original

contribution
Quy
yumi
QUESTION ASKED: In patients with early-stage
breast cancer treated with curative intent, are
patients re-ceiving guideline-concordant follow-up
care with an oncology specialist, and which
demographic and tumor-specific factors influence
receipt of follow-up care?
SUMMARY ANSWER: Over the 5 years after diagnosis
of stage I or II breast cancer, 21.0% of patients dis-
continued follow-up visits and older patients, those who
were single (v married), and those with hormone
receptor–negative breast cancer were more likely to
discontinue follow-up care with an oncology specialist
provider. The number of patients who saw only a
medical oncologist increased each year, whereas visits
to only a radiation oncologist or surgeon decreased in
years 2 to 5 after diagnosis, and by year 5 the majority
of patients had fewer than two physician visits with an
oncology provider (Fig).
WHAT WE DID: Using the SEER-Medicare linked data
set, we evaluated patients diagnosed with stage I and II
breast cancer who underwent breast-conserving sur-
gery from 2002 to 2007 with follow-up until 2012. We
performed a multivariable logistic regression analysis to
determine factors associated with discontinuation of
follow-up care—defined as .12 months from the
previous physician visit without a visit claim from either
a surgeon, medical oncologist, or radiation oncologist.
BIAS, CONFOUNDING FACTOR(S), REAL-LIFE
IMPLICATIONS: Limitations of our study include a
restricted patient population, specifically women older
than age 65 years. We are unable to capture the reason
for dis-continuation in claims data and thus unable to
CORRESPONDING AUTHOR
Author affiliations
Dawn L. Hershman, MD, Columbia University Medical Center,
and disclosures are
161 Fort Washington Ave, Room 1068, New York, NY 10032; e-
available with the
mail: dlh23@cumc.columbia.edu.
complete article at
jop.ascopubs.org.
Accepted on August 1,
2018 and published at
jop.ascopubs.org on
November 8, 2018:
DOI https://doi.org/10.
1200/JOP.18.00229
determine if patients were not advised to follow up
with other providers or whether they discontinued
follow-up of their own volition.
Current practice guidelines for follow-up care for pa-
tients with breast cancer treated with curative intent vary
in their recommendations with regard to visit frequency
and with which providers patients should follow-up. We
found that certain factors, such as age, marital status,
stage of disease, and tumor type, influenced likelihood
of follow-up. Medical oncologists played a larger role in
follow-up for these patients compared with radiation
oncologists and surgeons. By year 5, the majority of
patients had fewer than two physician visits with an
oncology provider per year but there was still a subset
of patients seeing providers more than five times that
year.
Although our findings are descriptive in nature, it
il-lustrates that significant variation in follow-up
exists in older patients with breast cancer and
highlights the underlying need for more explicit
guidelines regarding follow-up care. Coordination
of care between providers may decrease
discontinuation rates and redundancy of visits and
will help improve quality of care patients receive.
60 2 physician visits
Visits to anOncology Provider )(%
2 physician visits
3 physician visits
50
4 physician visits
5 physician visits
40
30
20
10
0
Year 2 Year 3 Year 4 Year 5
FIG. Percentage of patients with a visit to an oncology provider
per year.
Volume 15, Issue 1 35
 CARE DELIVERY

original
contributio
nabstract
breast-conserving
surgery from 2002
to 2007 with follow-
up until 2012. We
defined
discontinuation of
follow-up as . 12
months from the
previous physician
visit without a visit
claim from either a
surgeon, medical
oncologist, or
radiation
oncologist. We
performed a
multivariable
logistic regression
and Cox
proportional
hazards regression
analysis to
determine factors
associated with the
discontinuation of
follow-up care.
RESULTS Of the
30,053 patients
enrolled in our
initial cohort,
25,781 (85.8%)
saw a medical
oncologist and
21,612 (71.9%)
saw a radiation
oncologist in the
first year in
addition to a
surgeon. Over the
5 years, 6,302
patients (21.0%)
discontinued
follow-up visits.
Discontinuation of
physician visits
increased with
increasing age.
Women with stage
II cancer (v stage I)
were less likely to
discontinue follow-
up visits (odds
ratio, 0.78; 95% CI,
0.73 to 0.83). Time
to early
discontinuation
was greater for
patients with
hormone receptor–
negative tumors
(hazard ratio, 1.14;
95% CI, 1.05 to
1.24). Women who
percent of patients
with early-stage
J Oncol Pract 15:e1-e9. © 2018 by American Society of Clinical Oncology

INTRODUCTION geared toward medical oncologists and little

In patients with early-stage breast cancer treated with direction is given to other providers who are also
curative intent, follow-up is recommended with the often involved in follow-up care. Whereas it is
purpose of early detection of local or systemic relapse clear that some sort of follow-up is needed, the
ASSOCIATED
as well as that of a second primary tumor.1 Wide
optimal frequency of follow-up and which provider
CONTENT
variation exists in the recommended frequency and
the patient should see is not well defined.
Appendix
Author affiliations duration of follow-up visits, as delineated in guidelines It is known that intensive follow-up strategies, such as
and support put forth by national and international organizations. For laboratory testing and imaging at regular intervals,
information (if example, ASCO recommends clinical examination results in higher costs without earlier detection of re-
applicable)
every 3 to 6 months for 3 years, every 6 to 12 months lapse, improvement in survival, or better quality of life
appear at the end
of this article. for the next 2 years, and then annually. 2 National for patients compared with routine clinician visits. 4-7
Accepted on August 1, Comprehensive Cancer Network guidelines liberalized However, there is currently no evidence that routine
2018 and published at clinical examination is of clinical benefit, and this
their recommendations in 2015 to allow more clinician
jop.ascopubs.org on
interpretation and flexibility for patient follow-up, but approach may actually be an inefficient way to detect
November 8, 2018:
DOI https://doi.org/10. before this recommended interval evaluation every 4 to recurrent disease.8 Important aims of follow-up care
1200/JOP.18.00229 3
6 months for 5 years. These guidelines are primarily include the detection of early local recurrences or

Volume 15, Issue 1 e1

 Quyyumi et al
contralateral breast cancer, evaluation of therapy-related
complications, and encouraging adherence to hormonal
therapy.9 The coordination of care and reduction in re-
dundancy of care in the breast cancer survivorship pop-
ulation have become issues of national importance to
improve overall quality of care and reduce costs.10-12
Patients with early-stage breast cancer are often
managed by a team of providers, including surgeons,
medical on-cologists, and radiation oncologists.
Follow-up care guidelines for these patients are not
evidence based and have an unknown effect on
cancer outcomes. The aims of the current study were
to use a large population-based database to evaluate
the patterns and predictors of pro-vider follow-up care
within the first 5 years after diagnosis and determine if
follow-up is concordant with current guidelines.
METHODS
Data Source
We analyzed data from the SEER-Medicare database. 13
SEER contains tumor registry data for 28% of the US
population and includes pathologic, staging, treatment,
demographic, and survival information.14 SEER is linked
with the Medicare database, which contains claims for
covered health care services for inpatients and
outpatients, diagnoses, and billed services from the time
of a person’s Medicare eligibility until death.15
Cohort Selection
We identified all women age $ 65 years who were di-
agnosed with stage I and II breast cancer who underwent
breast-conserving surgery within 6 months of diagnosis,
between January 1, 2002, and December 31, 2007, and
were observed through December 31, 2012. Surgery was
determined by examination of current procedural termi-
nology (CPT) procedure codes with the corresponding
date of the procedure. Only patients who were alive for 5
years after diagnosis were included. Stage III patients
were ex-cluded because of the high rate of cancer
recurrence in this population. Patients who underwent
mastectomy were excluded as they are not routinely seen
by a radiation oncologist. We excluded patients who were
not covered by Medicare Parts A and B or who were
enrolled in health maintenance organizations from 12
months before the date of diagnosis to 5 years after the
date of diagnosis. We also required that breast cancer be
the patient’s first cancer diagnosis. If a patient developed
a second malignancy less than 6 months after breast
cancer diagnosis, the patient was excluded.
Clinical and Demographic Characteristics
We evaluated the following variables: age at diagnosis (65 to
69, 70 to 74, 75 to 79, and $ 80 years), race/ethnicity (black,
white, Hispanic, other), marital status (unmarried, married,
unknown), tumor stage, area of residence (urban,
e2 © 2018 by American Society of Clinical Oncology
rural), tumor grade (low, high, unknown), hormone re-ceptor
status (positive, negative, unknown), and year of diagnosis.
We used the Klabunde adaptation of the Charlson
comorbidity index, which yields an overall comorbidity score
on the basis of 15 comorbid disease categories, calculated
from International Classification of Diseases, 9th Revision,
codes, Healthcare Common Pro-cedure Coding System
codes, and surgery codes in the Medicare database and
expressed as a score of 0, 1, or $ 2. 16 Socioeconomic status
was evaluated from the SEER-Medicare database using ZIP
codes and median annual household income to create an
aggregate socioeconomic score that was then stratified into
quintiles.17
Primary End Point: Discontinuation of Follow-Up
We defined discontinuation of follow-up care as . 12 months
from the previous physician visit without a visit claim from
either a surgeon, medical oncologist, or radi-ation oncologist.
Physician visits were identified using Medicare National
Claims History and CPT codes that in-cluded physician
claims for inpatient and outpatient visits. The Outpatient
Standard Analytic File database was also used to gather
office visit data and includes a CPT pro-cedure code with
accompanying date. Surgeon visits were defined as a visit to
the same surgeon who performed the original lumpectomy.
Medical oncology and hematology/ oncology were included
to define a medical oncology visit. Radiation oncologists
were identified as physicians who were listed with a specialty
of radiation oncology or di-agnostic radiologist. As described
previously,18 not all pa-tients who receive radiation therapy
are captured under a radiation oncologist and we considered
only physicians who had Medicare claims with a radiation
therapy CPT code as practicing radiation oncology.
Statistical Analysis
We used multivariable logistic regression models to analyze
the association between patient demographic and tumor-
specific factors and discontinuation of follow-up care over the
5 years after diagnosis. Results are reported as odds ratios
(ORs) with 95% CIs, with an OR . 1 indicating an increased
likelihood of discontinuation. We developed a Cox
proportional hazards regression model to determine the
effect of each variable on the time to early discontin-uation of
physician follow-up visits. Patients who initiated
chemotherapy . 1 year after diagnosis or patients with a
diagnosis of a later stage of breast cancer . 6 months after
diagnosis were censored because of a concern about re-
currence of cancer and having a higher risk tumor. Those
patients who developed a second malignancy . 6 months
after their breast cancer diagnosis were also censored. We
estimated the probability of early discontinuation at various
time points using the Kaplan-Meier method and compared
early discontinuation between various groups. All analyses
were performed using SAS (SAS/STAT User’s Guide,
Volume 15, Issue 1
 Factors Associated With Follow-Up Care in Breast Cancer
Version 9.4; SAS Institute, Cary, NC ). All statistical
tests were two sided, with an a of .05.
RESULTS
We identified 30,053 women age $ 65 years who were
diagnosed with stage I and II breast cancer who
underwent breast-conserving surgery within 6 months of
diagnosis. In addition to the surgeon, 25,781 patients
(85.8%) saw a medical oncologist and 21,612 (71.9%)
saw a radiation oncologist in the first year. Sixty-six
percent of patients visited all three providers over the first
year. The charac-teristics of patients who saw a medical
oncologist were similar to those of patients who did not.
The mean number of total physician visits for years 2 to 5
were 4.2, 3.1, 2.5, and 2.1, respectively. The overall
mean number of surgeon visits was 2.1, mean number of
oncology visits was 9.0, and mean number of radiation
oncology visits was 2.2 over years 2 to 5.
Over the five years, 6,302 women (21.0%) discontinued
follow-up visits—that is, went . 12 months without seeing
any provider. The number of patients who saw only a
medical oncologist increased each year—22.8% in year 2
to 32.7% in year 5—whereas radiation oncology and
surgeon visits decreased. Visits to a radiation oncologist
only decreased from 2.4% in year 2 to 1.5% in year 5.
The percentage of patients with a visit only to a surgeon
de-creased from 9.4% to 5.4% over years 2 to 5. Patients
were less likely to see all three physicians annually, over
time— 15.1% in year 2 and 2.9% in year 5 (Appendix Fig
A1, online only).
We evaluated patients who visited a provider two or more
times per year as that is the minimum recommended visit
frequency.3 For each oncology specialist, the proportion
of patients with two or more physician visits decreased
an-nually. The percentage of patients who saw a surgeon
at least biannually decreased from 27.0% in year 2 to
7.4% in year 5. Similarly, the number of patients who saw
a radi-ation oncologist at least biannually decreased from
22.6% in year 2 to 4.2% in year 5. Each year, medical
oncologist visits were notably higher than those of the
other two providers. In year 2, 65.5% of patients saw a
medical oncologist at least biannually, whereas in year 5,
44.1% saw the same provider (Appendix Fig A1). After
year 2, the majority of patients saw any oncology provider
fewer than two times per year. However, there was a
subset of patients who saw an oncology specialist five or
more times over years 2 to 5 after diagnosis (Fig 1). By
year 5 after diagnosis, the majority of patients had fewer
than two physician visits with an oncology provider.
Factors Associated With Early Discontinuation
Demographic variables and tumor characteristics associ-
ated with early discontinuation are shown in Table 1. In a
multivariable model evaluating factors that resulted in any
discontinuation over the 5-year period, patients were more
Journal of Oncology Practice
e3
60 2 physician visits
Visits to an Oncology Provider (%)
2 physician visits
3 physician visits
50
4 physician visits
5 physician visits
40
30
20
10
0
Year 2 Year 3 Year 4 Year 5
FIG 1. Percentage of patients with a visit to an oncology provider
per year.
likely to discontinue physician visits with increasing age.
Conversely, women with higher-stage cancer were less likely
to discontinue follow-up (OR, 0.78; 95% CI, 0.73 to 0.83).
Patients with low-grade tumor were more likely to
discontinue follow-up compared with those with high-grade
cancer (OR, 1.09; 95% CI, 1.02 to 1.18). Women who were
diagnosed in later years were less likely to discontinue
seeing any of the three physicians (OR, 0.97; 95% CI, 0.95
to 0.98). Race, socioeconomic status, and marital status
were not associated with discontinuation of physician follow-
up. A proportional hazards model evaluating time to
discontinuation demonstrated similar trends with regard to
the association between age, diagnosis year, stage, and
grade with early discontinuation. Patients with hormone
receptor–negative breast cancer were more likely to dis-
continue follow-up (HR, 1.14; 95% CI, 1.05 to 1.24).
Time to Early Discontinuation
Figure 2 shows Kaplan-Meier curves of time to early dis-
continuation among patients who saw each provider the first
year after diagnosis. Among those patients who were seen
by medical oncology the first year after diagnosis, we
evaluated the time to early discontinuation from medical
oncology. Patients who saw all three providers the first year
(top curve) had the lowest likelihood of discontinuation with
any provider compared with the other groups. Compared
with those patients who saw medical oncology or all three
providers the first year, patients with a visit to radiation
oncology or a surgeon had a higher probability of having a
12-month gap in seeing that provider at the end of 5 years.
DISCUSSION
In this analysis of patients age $ 65 years with early-stage
breast cancer who underwent lumpectomy, we found that
21.0% of women discontinued follow-up visits with either
medical oncology, radiation oncology, and surgery in the first
5 years after diagnosis. Discontinuation of clinical
 Quyyumi et al
TABLE 1. Multivariable Analysis of Factors Associated With Discontinuation of Follow-Up Care

Discontinued Did Not Discontinue Odds Ratio Hazard Ratio

Characteristic Total Follow-Up Follow-Up (95% CI) (95% CI)
Total 30,053 6,302 (21.0) 23,751 (79.0)
Age, years
65-69 6,687 (22.2) 1,276 (19.1) 5,411 (80.9) 1 1
70-74 7,689 (25.6) 1,577 (20.5) 6,112 (79.5) 1.09 (1.00 to 1.84)* 1.11 (1.03 to 1.20)*
75-79 7,435 (24.7) 1,570 (21.1) 5,855 (78.9) 1.12 (1.04 to 1.22)* 1.21 (1.12 to 1.30)*
$ 80 8,252 (27.5) 1,879 (22.8) 6,373 (77.2) 1.25 (1.15 to 1.36)* 1.68 (1.56 to 1.80)*
Diagnosis year 0.97 (0.95 to 0.98)* 0.96 (0.94 to 0.98)*
Race
White 26,994 (89.8) 5,682 (21.0) 21,312 (79.0) 1 1
Black 1,732 (5.8) 324 (18.7) 1,408 (81.3) 0.89 (0.78 to 1.02) 0.91 (0.81 to 1.02)
Hispanic 283 (0.9) 69 (24.4) 214 (75.6) 1.21 (0.92 to 1.59) 1.22 (0.96 to 1.55)
Other 1,044 (3.5) 227 (21.7) 817 (78.3) 1.06 (0.91 to 1.23) 1.03 (0.90 to 1.18)
Marital status
Married 13,693 (45.6) 2,809 (20.5) 10,884 (79.5) 1 1
Single 15,475 (51.5) 3,298 (21.3) 12,177 (78.7) 1.02 (0.96 to 1.08) 1.09 (1.03 to 1.15)*
Unknown 885 (2.9) 195 (22.0) 690 (78.0) 1.08 (0.91 to 1.27) 1.15 (0.99 to 1.33)
Residency
Urban 27,132 (90.3) 5,692 (21.0) 21,440 (79.0) 1 1
Rural 2,921 (9.7) 610 (20.9) 2,311 (79.1) 1.00 (0.90 to 1.10) 1.02 (0.93 to 1.12)
Comorbidity (CCS)
0 18,201 (61.6) 3,944 (21.7) 14,257 (78.3) 1 1
1 7,381 (25.0) 1,561 (21.2) 5,820 (78.8) 1.00 (0.94 to 1.07) 1.03 (0.97 to 1.10)
$2 3,985 (13.5) 791 (19.8) 3,194 (80.2) 0.92 (0.85 to 1.01) 1.07 (0.99 to 1.16)
SES
0 (low) 6,966 (23.2) 1,448 (20.8) 5,518 (79.2) 1 1
1 6,886 (22.9) 1,446 (21.0) 5,440 (79.0) 1.00 (0.91 to 1.08) 0.99 (0.92 to 1.07)
2 4,763 (15.9) 1,046 (22.0) 3,717 (78.0) 1.06 (0.96 to 1.16) 1.03 (0.94 to 1.12)
3 7,103 (23.6) 1,473 (20.7) 5,630 (79.3) 0.98 (0.89 to 1.06) 0.95 (0.88 to 1.03)
4 (high) 4,322 (14.4) 885 (20.5) 3,437 (79.5) 0.97 (0.88 to 1.07) 0.96 (0.87 to 1.04)
Tumor stage
1 20,744 (69.0) 4,615 (22.2) 16,129 (77.8) 1 1
2 9,309 (31.0) 1,687 (18.1) 7,622 (81.9) 0.78 (0.73 to 0.83)* 0.83 (0.78 to 0.88)*
Tumor grade
High 6,749 (22.5) 1,305 (19.3) 5,444 (80.7) 1 1
Low 21,158 (70.4) 4,526 (21.4) 16,632 (78.6) 1.09 (1.02 to 1.18)* 1.07 (1.00 to 1.15)*
Unknown 2,146 (7.1) 471 (22.0) 1,675 (78.0) 1.11 (0.98 to 1.25) 1.11 (1.00 to 1.24)
ER/PR status
Positive 23,643 (78.7) 4,923 (20.8) 18,720 (79.2) 1 1
Negative 3,497 (11.6) 718 (20.5) 2,779 (79.5) 1.06 (0.97 to 1.17) 1.14 (1.05 to 1.24)*
Unknown 2,913 (9.7) 661 (22.7) 2,252 (77.3) 1.09 (0.99 to 1.20) 1.19 (1.10 to 1.29)*

NOTE. Data are given as No. (%) unless otherwise noted.

Abbreviations: CCS, Charlson comorbidity score; ER, estrogen receptor; PR, progesterone receptor; SES,
socioeconomic status. *P , .05

e4 © 2018 by American Society of Clinical Oncology Volume 15, Issue 1

 Factors Associated With Follow-Up Care in Breast Cancer
1.0
0.8
Probability
0.6
Surviva l
0.4
0
. The primary reason for follow-up care in patients with early-
2 stage breast cancer who have undergone curative treat-ment
Censored
0 1 2 3
Years
FIG 2. Time to early discontinuation of follow-up visits by specialty.
follow-up decreased with each subsequent year of di-
agnosis. In addition, older patients and those with
hormone receptor–negative cancer and low-grade
tumors were more likely to discontinue follow-up visits.
Patients with higher-stage disease were less likely to
discontinue seeing a physician.
Whereas numerous guidelines exist for the follow-up of
patients with breast cancer after initial treatment, there is
vast heterogeneity among them, and evidence in the lit-
erature is lacking as to the best approach. We found that
patients were more likely to follow-up with a medical on-
cologist compared with a radiation oncologist or surgeon as
time progressed. In a SEER-Medicare analysis of patients
with early-stage breast cancer, Neuman and colleagues 19
showed that medical oncologists are more likely to observe
patients who would be eligible for systemic therapy, but
patients who are poor candidates for systemic therapy— that
is, because of age or comorbidities—are instead more likely
to receive follow-up care by a surgeon, radiation oncologist,
and/or primary care provider. By delving into why different
types of oncologists participate in follow-up care and their
perceived roles, Neuman et al found that nonmedical
oncologists were more selective in the patients they
observed, focusing on those who would benefit most from
their specific skillset of locoregional assessment. 20 Our
findings are consistent with prior work that demonstrated
that, nationally, surgeons provide less breast cancer sur-
vivorship care compared with medical oncologists and
primary care providers.21
There is a paucity of data that evaluate factors that are
associated with the early discontinuation of follow-up care in
patients with cancer. In the primary care setting, Goldman et
al22 demonstrated that certain variables had independently
significant associations with future appointment-keeping
behavior, including the patient’s age, race, and physician-
cited psychological or social problems. We found that
discontinuation of follow-up visits increased
Journal of Oncology Practice
as age increased. In a prior SEER-Medicare study of pa-
Type of Physician
All tients with early-stage breast cancer, younger age was
Oncol
shown to be associated with more frequent follow-up
visits with an oncology specialist.23 Older survivors of
Radiol
Surgeon
breast cancer represent a potentially vulnerable
population, as they may have functional limitations 24 that
could limit ac-cess to suitable health care and appropriate
follow-up may help reduce adverse outcomes.
is to detect a locoregional or distant recurrence of the tumor.
Prior studies have established that intensive testing is not
4 5 recommended as it does not improve the chances of survival
and increases cost.4,25 Since the 1990s, ASCO has
published recommendations against the routine assess-ment
of tumor markers for the detection of recurrence of
disease.26-28 Although there is no evidence from random-ized
controlled trials that the earlier detection or treatment of
asymptomatic, metastatic breast cancer recurrence improves
clinical outcomes, some suggest that patients with early and
limited metastatic recurrence may be cured. 29,30 Follow-up
with an oncology provider and clinical examination per
guidelines may be useful to detect re-currences early, but
whether this improves survival out-comes has not been
proven.
Not all patients have an equal risk of developing locore-
gional recurrences. Those with high-risk characteristics, such
as larger tumors or more lymph node involvement,
correspond to higher locoregional recurrence rates. 31 De-
spite having a higher rate of recurrence and a more ag-
gressive clinical course,32 we found that patients with
hormone receptor–negative tumors who are ineligible for
hormone therapy are more likely to discontinue follow-up
(HR, 1.14; 95% CI, 1.05 to 1.24). An important aspect of
follow-up is monitoring for adverse effects and adherence to
endocrine therapy, which is recommended for at least 5
years.33 Adverse effects from hormonal treatment are
common and can frequently result in nonadherence to
therapy.34,35 Future studies may assess the association
between loss of follow-up and hormone therapy adherence.
In a multivariable analysis of patients with hormone
receptor–positive disease, we found that similar factors were
associated with discontinuation of follow-up care compared
with our overall cohort. In our patient cohort, by year 5, the
majority of patients had more than two visits with a medical
oncologist compared with a surgeon or radiation oncologist.
Unlike patients with hormone receptor–positive breast
cancer, those patients who are ineligible for hor-mone
therapy may not be motivated to follow-up with medical
oncology or other oncology providers.
There are several potential adverse effects of frequent
follow-up of patients with early-stage breast cancer. This
includes possible financial burdens of traveling to ap-
pointments and missed work. Quality of life, including
psychological distress and anxiety with more intensive
e5
 Quyyumi et al

follow-up, is also a concern; however, in one randomized
controlled trial that compared intensive with standard
surveillance follow-up strategies in patients with early-stage
breast cancer, no difference in health-related quality of life
was detected between the two groups. 6 In our patient cohort,
a subset of women saw providers more than two times each
year in the years after diagnosis. Whereas the majority of
patients visited medical oncology, there was a percentage of
patients who saw radiation oncology and surgery more
frequently than what is recommended by guidelines. By year
5, approximately 11% of patients were seeing an oncology
specialist five or more times. Given the limitations of the
SEER-Medicare data set, we are unable to delineate the
reasons behind frequent follow-up. Improved definition and
guidance regarding a particular provider’s role during follow-
up is needed to reduce redundancy and improve the
effectiveness of follow-up care.
Although the SEER-Medicare registry data are compre-
hensive, this study has a few limitations. Our study includes
a restricted patient sample, specifically, nondisabled pa-
tients older than age 65 years. Whereas findings cannot be
generalized to a younger population, more than 50% of
patients with breast cancer are older than age 65 years 36;
therefore, our results are relevant to the majority of women.
We are also unable to determine the reason for discon-
tinuation of follow-up. It is difficult to distinguish whether
patients were not advised to follow-up with other providers
or whether they discontinued follow-up of their own
volition. As such, there may be reasons for
discontinuation that are not captured with claims data.
Prior research has dem-onstrated that follow-up with a
primary care physician who has been provided guidelines
on follow-up results in similar outcomes. 37,38 Current
guidelines recommend follow-up care with an oncology
specialist, and our goal was to as-sess compliance with
those guidelines. Future studies should better ascertain
how primary care physicians and midlevel providers can
participate in the follow-up care of patients with breast
cancer as trends in practice continue to evolve.
In summary, significant variation exists in the follow-up care
of older patients with breast cancer treated with curative
intent. Current practice guidelines are directed toward
oncology specialists and suggest frequent follow-up with a
provider but are not explicit in their recommendations with
regard to the level of care that should be provided during
follow-up visits. Coordination of follow-up care between
oncology specialists and other providers may reduce dis-
continuation rates as well as the redundancy of visits,
thereby increasing clinical efficiency. Identifying patients who
are at risk for early discontinuation of follow-up will eventually
allow for the promotion of public health initiatives to improve
access to care. More research is needed to determine the
optimal follow-up for maintaining adherence to therapy,
reducing over-testing, and decreasing cost.

AFFILIATIONS Provision of study materials or patients: Dawn L. Hershman

1
Columbia University College of Physicians and Surgeons, New York, NY
2
Columbia University Mailman School of Public Health, New York, NY
CORRESPONDING AUTHOR
Dawn L. Hershman, MD, Columbia University Medical Center, 161
Fort Washington Ave, Room 1068, New York, NY 10032; e-mail:
dlh23@ cumc.columbia.edu.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF
INTEREST AND DATA AVAILABILITY STATEMENT
Disclosures provided by the authors and data availability statement
(if applicable) are available with this article at DOI
https://doi.org/10.1200/ JOP.18.00229.
AUTHOR CONTRIBUTIONS
Conception and design Farah F. Quyyumi, Dawn L.
Hershman Financial support: Dawn L. Hershman
Administrative support: Grace C. Hillyer
Collection and assembly of data: Donna Buono, Cynthia W. Law
Data analysis and interpretation: Farah F. Quyyumi, Dawn L.
Hershman, Jason D. Wright, Melissa K. Accordino, Donna Buono,
Alfred I. Neugut Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
ACKNOWLEDGMENT
Supported by a grant from the American Society of Clinical Oncology/
Breast Cancer Research Foundation (to D.L.H.) and Grant No. R01-
CA169121 from the National Cancer Institute (to J.D.W.). This study
used the linked SEER-Medicare database. The interpretation and
reporting of these data are the sole responsibility of the authors. The
authors acknowledge the efforts of the National Cancer Institute; the
Office of Research, Development, and Information, CMS; Information
Management Services; and the SEER Program tumor registries in the
creation of the SEER-Medicare database

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 Quyyumi et al

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Factors Associated With Follow-Up Care Among Women With Early-Stage Breast Cancer
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are
self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For
more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jop/site/ifc/journal-policies.html.

Jason D. Wright Alfred I. Neugut

Consulting or Advisory Role: Clovis Oncology, Tesaro Stock and Other Ownership Interests: Stemline Therapeutics
Consulting or Advisory Role: Pfizer, Otsuka, United Biosource
Melissa K. Accordino Corporation, EHE International
Honoraria: Sermo, Sermo (I), M3 Expert Testimony: Hospira

No other potential conflicts of interest were reported.

e8 © 2018 by American Society of Clinical Oncology Volume 15, Issue 1

 Factors Associated With Follow-Up Care in Breast Cancer

APPENDIX

70 Year 2
Year 3

(%)
60 Year 4
Year 5
50
Physician Visits
40

30

20

10
0

All MDs MO Only RO Only Surgery Only MO RO Surgeon

FIG A1. Percentage of physician visits by specialty (left) and percentage of patients with two or more physician
visits per year (right). All MDs, medical oncologist, radiation oncologist, and surgeon; MO, medical oncologist; RO,
radiation oncologist.

Journal of Oncology Practice e9