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In patients with breast cancer, screening, diagnostics, treatment, and surveillance all contribute to their outcome. Disparities in cancer care and outcomes have been attributed to several patient-specific factors, such as age, ethnicity/race, and socioeconomic status, in a myriad of studies. Some have attributed this disparity to a lack of access to healthcare, delayed diagnosis, number of comorbidities, and worse tumor biology, all potentially leading to lower breast cancer survival. In particular, the transition between active treatment and post-treatment care has been identified as a place where patients can be vulnerable to failing to receive recommended care, not only relating to their cancer care but also in a patient’s general medical care such as diabetes monitoring, etc. This was highlighted in the Institute of Medicine’s 2005 report ‘‘From Cancer Patient to Cancer Survivor: Lost in Transition.’’ Few studies have looked at the impact of social and economic factors in the utilization of post-treatment imaging during the survivorship period. After breast cancer treatment, patients are at increased risk of local recurrence in the ipsilateral breast, and a twofold increased risk of a second breast cancer in either breast. Routine breast imaging has the goal of earlier detection of either of these events. Local recurrence is considered an independent predictor of survival, with increased relative risks of developing distant metastases or breast cancer-related deaths when compared with patients without a recurrence. In this issue, Adesoye and coauthors examine the patterns of utilization and factors associated with the use of screening mammography and magnetic resonance imaging (MRI) using the National Cancer Data Base (NCDB), as well as manual chart abstraction for a random sample of over 9000 patients who had undergone surgery for stages II and III breast cancer in 2006–2007. Patient charts were audited for the subsequent 4 years to determine the frequency of both mammography and breast MRI. By combining data from the NCDB, which contains patient demographics including age, socioeconomic status, race, ethnicity, comorbidities, stage and treatment, and chart abstraction, to most accurately determine imaging frequency, the authors have assembled one of the more robust databases to explore issues of post-treatment surveillance. They found that in year 1 after surgery, only 69.5% of patients underwent mammography, and by year 4 the rate had declined to 61%. Age (\ 50 or[ 80 years), race (Black), lack of insurance or government insurance, and low socioeconomic status were associated with underutilization of surveillance imaging. In addition, women with nodepositive disease or larger tumors ([ 5 cm) also had lower rates of post-treatment imaging. Some of these patient groups would be considered at higher risk for locoregional recurrences, and one might expect better post-treatment imaging surveillance rates. Of note, even in groups without these risk factors for underutilization, one-quarter of patients did not receive recommended surveillance imaging. There was no difference in the use of imaging by hospital type, and academic teaching hospitals versus comprehensive community hospitals, versus community hospitals. A recent publication from the Commission on Cancer (CoC) and NCDB showed that risk-adjusted survival for stage III breast cancer varied by hospital type, with the best survivals at National Cancer Institute-designated comprehensive cancer centers and academic cancer centers, and poorer survival at community hospitals. The Author(s) 2018. This article is an open access publication

‘Under’ Surveillance: Impact of Race and Socioeconomic Status on Post-Treatment Breast Cancer Imaging