ABSTRACT
BACKGROUND: Bilateral breast magnetic resonance imaging (MRI) is commonly used in the diagnostic workup of breast cancer (BC) to assess extent of disease and identify occult foci of disease. However, evidence for routine use of pre-operative MRI is lacking. Breast MRI is costly and can lead to unnecessary tests and treatment delays. Clinical care pathways (care paths) are value-based guidelines, which define management recommendations derived by expert consensus and available evidence based data. At Cleveland Clinic, care paths created for newly diagnosed BC patients recommend selective use of pre-operative MRI. We evaluated the number of pre-operative MRIs ordered before and after implementing an institution wide BC care paths in April 2014. METHODS: A retrospective review was conducted of BC cases during the years 2012, 2014, and part of 2015. Patient, tumor and treatment characteristics were collected. Pre-operative MRI utilization was compared before and after care path implementation. RESULTS: We identified 1,515 BC patients during the study period. Patients were more likely to undergo pre-operative MRI in 2012 than 2014 (OR: 2.77; P<0.001; 95% CI: 1.94-3.94) or 2015 (OR: 4.14; P<0.001; 95% CI: 2.51-6.83). There was a significant decrease in pre-operative MRI utilization between 2012 and 2014 (P<0.001) after adjustment for pre-operative MRIs ordered for care path indications. CONCLUSIONS: Implementation of online BC care paths at our institution was associated with a decreased use of pre-operative MRI overall and in patients without a BC care path indication, driving value based care through the reduction of pre-operative breast MRIs.
ABSTRACT
BACKGROUND: Breast cancer is the most frequently occurring cancer in women of reproductive age, and systemic treatments may adversely affect childbearing plans. Use of assisted reproductive technologies and therapies for ovarian protection improve fertility prospects. We evaluated whether patients had a documented fertility discussion (FD) with their oncology physician prior to therapy, what options were chosen, and if pregnancy was achieved. METHODS: A retrospective chart review from 2006 to 2014 was performed to evaluate women aged 40 years and younger who were diagnosed with breast cancer and treated with chemotherapy and/or antihormonal therapy. Patient demographics, treatment regimens, presence or absence of FD, in vitro fertilization (IVF) consultation, gonadotropin-releasing hormone (GnRH) agonist use, and subsequent successful pregnancy were analyzed. RESULTS: Among 303 patients meeting the inclusion criteria, 80 (26 %) had an FD with their physician documented; 71 of these 80 women (89 %) sought further fertility consultation and options. Sixteen (20 %) women were prescribed a GnRH agonist only for ovarian protection during chemotherapy, 50 (63 %) underwent IVF consultation only, and 5 (6 %) had both a GnRH agonist prescribed and an IVF consultation. The overall pregnancy rate was 7 % at a mean of 3 years post breast cancer treatment. Pregnancy after treatment was more common among those pursuing IVF consultation or prescribed a GnRH agonist. CONCLUSIONS: In treating young breast cancer patients, it is important to assess fertility desire, discuss treatment risks relating to fertility, and discuss preservation options. Although not every woman in this group desired pregnancy, 71/80 (89 %) women having a documented FD sought further fertility consultation and options.
