Surveillance after primary therapy for breast carcinoma – what motivates clinical experts?

PURPOSE: Breast cancer is the most common cancer among American women except for skin cancer. About 1 in 8 women develop breast cancer in their lifetime. Breast carcinoma is diagnosed in over 200,000 patients annually in the U.S. Most receive curative-intent treatment. There are over 2.5 million women with a history of breast cancer now alive who are eligible for surveillance. The American Society of Clinical Oncology (ASCO) has published evidence-based guidelines for surveillance after primary breast cancer treatment. However, we have demonstrated dramatic variation in the actual practice patterns of ASCO clinicians. We sought to evaluate potential factors that motivate these experts in designing their own surveillance strategies. METHODS: We sent an e-mail survey instrument with 11 questions about potential motivating factors to the 3245 ASCO members who had indicated that breast cancer was a major focus of their clinical practice. Responses were submitted on a 10-level Likert scale. The percentage of responses for each point on the scale for each of the 11 putative motivating factors was tabulated. The motivation factors were ranked as least or most important depending on the percentage of responses on the Likert scale score. The least important motivating factor was the one with the highest percentage score of 1. The most important motivating factor was the one with the highest percentage score of 10. RESULTS: 1013 responses (31%) were submitted, of which 734 (73%) were evaluable. “Avoidance of medical malpractice lawsuits” was the weakest motivating factor (26% with a score of 1). “Detection of a second primary breast cancer” was the strongest motivating factor (53% with a score of 10). CONCLUSIONS: We believe our study is the first of its kind to evaluate factors that potentially motivate expert clinicians in selecting their surveillance strategies after primary treatment of breast cancer. Understanding these factors may permit the development of strategies to reduce non-compliance with evidence-based guidelines and minimize the present variation in practice patterns. This should reduce overuse, underuse and/or misuse of costly resources, which will be particularly important in the national healthcare system now being implemented.