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J Am Coll Radiol. 2020 Jan 28. pii: S1546-1440(19)31483-8. doi: 10.1016/j.jacr.2019.12.020. [Epub ahead of print]

Facility Variability in Examination Indication Among Women With Prior Breast Cancer: Implications and the Need for Standardization.

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Kaiser Permanente Washington Health Research Institute, Seattle, Washington. Electronic address:
Kaiser Permanente Washington Health Research Institute, Seattle, Washington.
Department of Radiology, University of Washington School of Medicine, Seattle, Washington.
Department of Radiology, University of North Carolina, Chapel Hill, North Carolina.
Departments of Medicine and Epidemiology and Biostatistics, General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, San Francisco, California.
Kaiser Permanente Washington Health Research Institute, Seattle, Washington; University of California, Davis, Department of Public Health Sciences, School of Medicine, Davis, California.
Division of Medical Oncology, University of Washington School of Medicine, Seattle, Washington.
University of Illinois at Chicago School of Public Health, Chicago, Illinois.
University of Vermont College of Medicine, Department of Surgery, Burlington, Vermont.
The Dartmouth Institute for Health Policy and Clinical Practice and Department of Biomedical Data Science, Department of Medicine, and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.



We sought to identify and characterize examinations in women with a personal history of breast cancer likely performed for asymptomatic surveillance.


We included surveillance mammograms (1997-2017) in asymptomatic women with a personal history of breast cancer diagnosed at age ≥18 years (1996-2016) from 103 Breast Cancer Surveillance Consortium facilities. We examined facility-level variability in examination indication. We modeled the relative risk (RR) and 95% confidence intervals (CIs) at the examination level of a (1) nonscreening indication and (2) surveillance interval ≤9 months using Poisson regression with fixed effects for facility, stage, diagnosis age, surgery, examination year, and time since diagnosis.


Among 244,855 surveillance mammograms, 69.5% were coded with a screening indication, 12.7% short-interval follow-up, and 15.3% as evaluation of a breast problem. Within a facility, the proportion of examinations with a screening indication ranged from 6% to 100% (median 86%, interquartile range 79%-92%). Facilities varied the most for examinations in the first 5 years after diagnosis, with 39.4% of surveillance mammograms having a nonscreening indication. Within a facility, breast conserving surgery compared with mastectomy (RR = 1.64; 95% CI = 1.60-1.68) and less time since diagnosis (1 year versus 5 years; RR = 1.69; 95% CI = 1.66-1.72; 3 years versus 5 years = 1.20; 95% CI = 1.18-1.23) were strongly associated with a nonscreening indication with similar results for ≤9-month surveillance interval. Screening indication and >9-month surveillance intervals were more common in more recent years.


Variability in surveillance indications across facilities in the United States supports including indications beyond screening in studies evaluating surveillance mammography effectiveness and demonstrates the need for standardization.


Breast Cancer Surveillance Consortium; Breast cancer screening; breast cancer surveillance; breast carcinoma; mammography indication


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