Article Title

Use of Imaging for Staging of Localized Breast Cancer in Two Integrated Health Care Systems: Adherence to a Choosing Wisely Recommendation

Publication Date



breast cancer, diagnosis, staging


Background/Aims: The initial American Society of Clinical Oncology “Top 5” list, created as part of the Choosing Wisely campaign, recommends against use of imaging for staging of localized breast cancer in asymptomatic women at low risk for metastasis. The objective of this study was to measure and compare use of imaging for staging in two large integrated health care systems, Kaiser Permanente (KP) and Intermountain Healthcare (IH). We also sought to distinguish whether imaging was used for routine staging or for diagnostic purposes.

Methods: We identified stage 0–IIB breast cancer patients diagnosed between January 1, 2010, and December 31, 2012, with first primary malignancy from tumor registries in three KP regions (Southern California, Northwest, and Mid-Atlantic) and IH. Using the KP and IH electronic health records, we identified use of imaging tests (positron emission tomography, computerized tomography [CT], bone scan) during the staging window, defined as 30 days prior to diagnosis up to initial cancer-directed surgery. We performed chart abstraction on a stratified random sample of patients who received an imaging test to identify clinical indication.

Results: For the total sample of 10,014, mean age at diagnosis was 60 years (range 22–99), with 21% stage 0, 47% stage I and 32% stage II. Overall, 8% of patients (n=792) received at least one imaging test during the staging window, including 8% at KP and 6% at IH (P=0.0005). The most commonly used service was CT, with 82% of imaging services. Chart abstraction (n=129) revealed that overall, almost half of all imaging tests (48%) were performed to evaluate a symptom, sign or prior imaging finding, including 55% at KP and 32% at IH. Symptoms and signs included chest pain, weight loss and palpable masses.

Discussion: Use of imaging for staging of low-risk breast cancer was very low in both health care systems, with clinically trivial differences between them. Approximately half of imaging services were in response to a sign or symptom. Strategies to reduce use of imaging for staging of localized breast cancer within these health care systems are unlikely to yield meaningful improvement.