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Key words: breast cancer, follow-up
care, abdominal echogram, bone

scan.

Financial disclosure: This work was

supported by funding from the Agen-

zia Sanitaria e Sociale Regionale, Re-

gione Emilia-Romagna, Italy.

Correspondence to: Maurizio Leoni,

Ospedale S Maria delle Croci, Via Ran-

di 5, 48100 Ravenna, Italy.

Tel +39-333-7235194;

fax +39-051-6397053; 

email m.leoni@ausl.ra.it

Received March 14, 2012;

accepted August 6, 2012.

Variation among local health units in follow-up
care of breast cancer patients in Emilia-Romagna,
Italy
Maurizio Leoni1,5, Radha Sadacharan2, Daniel Louis2, Fabio Falcini3,
Carol Rabinowitz2, Luca Cisbani3, Rossana De Palma3, Elaine Yuen4, 
and Roberto Grilli5

1Ospedale Civile Ravenna, Ravenna, Italy; 2Jefferson Medical College, Thomas Jefferson University,
Philadelphia, PA, USA; 3Registro Tumori, Forlì, Italy; 4Jefferson School of Population Health, 
Thomas Jefferson University, Philadelphia, PA, USA; 5Agenzia Sanitaria e Sociale Regionale, Regione
Emilia-Romagna, Italy

ABSTRACT

Aims and background. This study examines the patterns of follow-up care for breast
cancer survivors in one region in Italy.

Methods and study design. This retrospective analysis included 10,024 surgically
treated women, with incident cases of breast cancer in the years 2002-2005 who were
alive 18 months after their incidence date. Rates of use of follow-up mammograms,
abdominal echogram, bone scans and chest x-rays were estimated from administra-
tive data and compared by Local Health Unit (LHU) of residence. Logistic regression
analyses were performed to assess possible “overuse”, accounting for patient age,
cancer stage, type of surgery and LHU of residence.

Results. A total of 7168 (72.1%) women received a mammogram within 18 months of
their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%)
had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal
echograms, bone scans and chest x-rays were substantially higher in the population
of breast cancer survivors than in the general female population. Taking account of
patient age, cancer stage at diagnosis and type of surgery, multivariate analyses
demonstrated significant variation in the use of these tests by LHU of residence. 

Conclusions. The observed variation in the use of abdominal echograms, bone scans
and chest x-rays supports the conclusion that there is substantial misuse of these
tests in the population of postsurgical breast cancer patients in the Emilia-Romagna
region in Italy. In the absence of a documented survival benefit, overtesting has both
a human and financial cost. We recommend additional review of the methods of fol-
low-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of
developing, disseminating and evaluating the implementation of specific guidelines
targeting primary care physicians and oncologists providing care to breast cancer
survivors. Patient education materials may also help to reduce unnecessary testing. 

Tu mo ri, 99: 30-34, 2013