When It Comes To Breast Cancer, Doing More Tests Doesn’t Necessarily Mean Better Outcomes

When it comes to our health and our health care, we love the numbers. Sometimes, we even fall in love with the numbers, assuming that the numbers tell us the whole story when in fact that may not be the case. Cholesterol numbers, blood pressure numbers, body mass index, whatever. As patients and consumers, we are frequently defined by our numbers.

But what happens when those numbers and other medical tests such as CT scans really don’t tell the story we think they do? The recent evolution of prostate specific antigen (PSA) is a case in point: for decades we believed the numbers saved many lives. Turns out PSA did save some lives, but not as many as we thought and at the considerable financial and human expense of treating many men who probably did not benefit.

So in that vein an article and editorial in a recent issue of the Journal of Clinical Oncology makes the point that just because we have numbers does not really mean they offer us the scientific certainty about the course of cancer we may think they do.

The research reviews the use of various biomarkers (called serum tumor markers, or STMs) and imaging tests (CT and PET scans) in women with metastatic breast cancer. The researchers looked at Medicare data from 2002 and 2011 to find women who received more than 12 blood tests with biomarkers (CEA, CA 15-3, CA 27.29) and/or more than four CTs and/or PET scans in a 12-month period and compared outcomes with women who received fewer tests over that same period of time.  Their goal was to determine whether those who had more testing did better than those who had fewer tests.

It turns out about 40% of the women older than 65 with metastatic breast cancer had both the blood tests and imaging studies done periodically to monitor the progress of their disease. Of this group, about 1 in 3 had the status of their breast cancer monitored very frequently during the 12 month segments. The annual costs of treating those who were tested frequently was almost 60% more than the cost of treating compared women with the same illness but who didn’t have all those studies.

All this would be irrelevant if frequent testing led to improved quality and/or years of life. But the authors found no such thing. Overall survival was not improved by frequent disease monitoring. Moreover, they point out there aren’t any generally accepted guidelines that tell health professionals which tests to order and how frequently they should be done so we really don’t know the right answer to how often these tests are necessary.

The conclusion?

From the authors:

“Currently, in the metastatic setting, there is no evidence to suggest that more frequent testing is associated with better outcomes…Furthermore, in women with early-stage breast cancer, surveillance testing, which can result in earlier treatment initiation, does not affect survival.”  

The editorial that accompanied the research report essentially agreed with the report’s authors:

“Despite its availability for more than two decades and provision of prognostic information, no evidence indicates that STM (serum tumor markers) monitoring changes the course of the disease. Since 1999, ASCO (American Society of Clinical Oncology) has recommended explicitly against STM use for surveillance after treatment of early-stage breast cancer, yet 42% of Medicare-age breast cancer survivors undergo STM assessment an average of almost three times a year, which results in 20% higher medical costs with no known impact on survival. Similarly, ASCO has recommended against the routine use of STMS in MBC (metastatic breast cancer) in the absence of other measureable disease since 2006, with all subsequent updates confirming this initial guideline.”

This appears to be a lesson we keep on learning: we have tests, we do tests, we think tests help us make better decisions by “staying on top” of someone’s cancer, and sometimes we find out—when the evidence is finally looked at carefully—that the tests really don’t make a difference.

No one likes to think of costs when it comes to medical care and especially when saving lives. But while a lab test or an imaging study may not make a difference to our care or the outcome of our illness it certainly does make a difference to our pocketbook. And even worse, it may give us a false sense of comfort when it doesn’t accurately reflect a change in our disease, or send us down another perhaps more toxic path of treatment when it wouldn’t make a difference to do so.

Those are all very serious questions that must be answered.

Many years ago we routinely did bone scans to follow women diagnosed and treated for primary breast cancer. We firmly believed that if we found a new bone lesion early and started therapy immediately at the first evidence the disease had recurred and spread we would save lives. We were wrong. The evidence showed us it didn’t make a difference, so we stopped doing the test.

Years later, we are still learning the same lessons. Sometimes doing lots of tests makes all of us feel better. It helps us feel in control. It helps us feel that we are going to be able to change the course of our illness and treatment at the earliest moment and as a result improve our outcome. But despite all of those considerations, we need to look at the evidence and understand that sometimes that just is not the case.

There are no easy answers to these questions. Health professionals and patients alike have their own thoughts and their own expectations, and there is no question that each personal situation is different sometimes requiring stepping outside the guidelines or currently accepted practice.

However, even understanding that consideration, we also need to realize that just because we can do something doesn’t mean we should, or that it really makes a difference. We need to look at the evidence, we need to understand the evidence, we need to listen to the evidence and let that be our guide—especially and most importantly when the message the evidence offers differs from what we think we already know.

Easy to say, difficult to do. It is a lesson we keep on learning. Maybe it’s time we paid attention to the message.


J. Leonard Lichtenfeld's Biography

Dr. Len

J. Leonard Lichtenfeld, MD, MACP: Dr. Lichtenfeld currently serves as Deputy Chief Medical Officer for the American Cancer Society in the Society's Office of the Chief Medical Officer located at the Society's Corporate Center in Atlanta. Dr. Lichtenfeld joined the Society in 2001 as a medical editor, and in 2002 assumed responsibility for managing the Society's then newly created Cancer Control Science Department which included the prevention and early detection of cancer, emerging cancer science and trends, health equity, quality of life for cancer patients, the science of cancer communications and the role of nutrition and physical activity in cancer prevention and cancer care.  In 2014, Dr. Lichtenfeld assumed his current role in the Office of the Chief Medical Officer where he provides extensive support to a number of Society colleagues and activities. As a result of his over four decades of experience in cancer care, Dr. Lichtenfeld is frequently quoted in the print and electronic media regarding the Society's positions on a number of important issues related to cancer. He has testified regularly in legislative and regulatory hearings, and participated on numerous panels regarding cancer care, research, advocacy and related topics. He has served on a number of advisory committees and boards for organizations that collaborate with the Society to reduce the burden of cancer nationally and worldwide. He is well known for his blog (www.cancer.org/drlen) which first appeared in 2005 and which continues to address many topics related to cancer research and treatment. A board certified medical oncologist and internist who was a practicing physician for over 19 years, Dr. Lichtenfeld has long been engaged in health care policy on a local, state, and national level.  He is active in several state and national medical organizations and has a long-standing interest in professional legislative and regulatory issues related to health care including physician payment, medical care delivery systems, and health information technology. Dr. Lichtenfeld is a graduate of the University of Pennsylvania and Hahnemann Medical College (now Drexel University College of Medicine) in Philadelphia.  His postgraduate training was at Temple University Hospital in Philadelphia, Johns Hopkins University School of Medicine and the National Cancer Institute in Baltimore. He is a member of Alpha Omega Alpha, the national honor medical society.  Dr. Lichtenfeld has received several awards in recognition of his efforts on behalf of his colleagues and his professional activities.  He has been designated a Master of the American College of Physicians in acknowledgement of his contributions to internal medicine.  Dr. Lichtenfeld is married, and resides in Atlanta and Thomasville, Georgia.

6 thoughts on “When It Comes To Breast Cancer, Doing More Tests Doesn’t Necessarily Mean Better Outcomes

  1. I’m very concerned about the attempt to increase the age for first mammograms. It’s frightening to think that the youth of our age could develope breast cancer or even fibrous tissue and not be aware. My daughter in law is 35 yrs old. She was told she had fibrous tissue 3 years ago. In Dec of 2015 she was diagnosed with Stage 3 breast cancer and is HERS 2 positive. She had both breasts removed and 20 lymph nodes removed. She will continue Chemo, HERS 2 tx and Radiation for the next year. She and my son have 3 boys. Ages 6, 10 and 12. 3 years ago this could have been prevented with more diagnostic equipment and the ability to have these tests done without cost to the patient.

    Whatever it takes to get the attention of government and insurance review boards, we need to do it.

  2. Dr. Len,

    Just read your article, “when it comes to cancer, doing more tests etc”. I am a husband of a 3 year metastatic breast cancer patient who has gone through estrogen targeted drugs, a clinical trial, taxol and most recently AC chemo. And yes there has been constant testing and PETs and CT scans. She is about to go on Ibrance and we continue to be hopeful. Hopeful in the sense that yes, it will extend her life as at this time, she looks and feels pretty well and has a great attitude. In all this, I am realistic, that withstanding some remarkable development, the BC will take her life. The treatment and constant testing has kept her oncologist on top of her disease. I dare say, and responding to the article, that without all of the referenced testing, she would have already succumbed to this disease. So, I respectfully disagree with the message of the article – it’s not just about the money. Hope is not to be confused with being naïve and must always be a part of the treatment.

    1. I am glad to know your wife is doing well. The article I discussed examined evidence on whether certain tests done frequently, especially blood tests, make a difference in outcomes. Unfortunately, the evidence doesn’t always show they do. There are tests which are considered useful, some not useful, and some can be overused. I certainly cannot comment on any individual situation, however we all need to have a better understanding of what truly makes a difference in the care of our patients. And I certainly agree: hope remains a very important part of a cancer journey.

      1. I have to agree with Bernard. In addition to hope is piece of mind. I am a 3 year breast cancer survivor. My initial oncologist performed blood tests to monitor tumor markers every 6 months. I recently changed oncologists and the new doctor does not perform any ongoing screening tests. As a patient, I don’t care about the cost, I prefer to have the reassurance of knowing the numbers are in line – at least until the next checkup.

  3. Dear Dr Len:
    I was diagnosed with early invasive positive ER/PR breast cancer. My Oncotype was 23. I underwent 4 rounds of T and C chemo and 20 radiation treatments after a partial mastectomy. I am being told that if I become symptomatic, then tests will be done. I was never symptomatic to begin with. I have 2 daughters in their 40’s and 12 grand daughters. I was told they don’t need any genetic testing i.e. BRCA 1 or 2. Not one familial female has had breast cancer on both sides of my parental history. However their paternal grandmother had breast cancer, of which, the information was not shared with my dauighters as to what type of cancer. Should my daughters and granddaughters undergo genetic testing for the breast cancer gene? Thank you

    1. There are too many details that are important in answering your question whether you should be tested for BRCA or other genetic abnormalities that can result in an increased risk for breast cancer. Since you are the person with the illness, it would be you who could be tested. Your daughters should be tested if you are positive. If you have questions about genetic testing you can contact our cancer information service at 800 227 2345, and of course you should discuss your concerns with your health care professional. In some situations where there is a strong family history of cancer, a consultation with a genetic counselor would be appropriate.

      It is important to remember that it is the family history of ALL types of cancer–going as far back and “out” (aunts, uncles, grandparents, cousins, etc) that help us understand whether genetic testing is appropriate for any one person.

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