Barriers and Facilitators to De-Implementation of the Choosing Wisely® Guidelines for Low-Value Breast Cancer Surgery

Smith, Margaret E.; Vitous, C. Ann; Hughes, Tasha M.; Shubeck, Sarah P.; Jagsi, Reshma; Dossett, Lesly A.

doi:10.1245/s10434-020-08285-0

Cited by 52 publications

(51 citation statements)

References 54 publications

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“…Such guidelines and directives can encourage and legitimise decisions to avoid active treatment, but can be difficult to implement in practice: evidence about treatment value at population level may be seen as uninformative for individual-level decisions. 17 Here, shared decision-making can play an important role. For example, in cancer treatment decisions, conversations supported by decision tools can help in assessing the value of treatment for an individual patient and can enable discussion about goals of care and the appropriateness of active (or more aggressive) intervention.…”

Section: How Can We Reduce Antibiotic Overuse?mentioning

confidence: 99%

Antibiotic overuse: managing uncertainty and mitigating against overtreatment

Tarrant

Krockow

2021

BMJ Qual Saf

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Section: How Can We Reduce Antibiotic Overuse?mentioning

confidence: 99%

Antibiotic overuse: managing uncertainty and mitigating against overtreatment

Tarrant

Krockow

2021

BMJ Qual Saf

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“…[27][28][29][30] Recent studies have described the challenges in deimplementation of SLNB, citing surgeons who described a "lack of familiarity" with or skepticism toward the recommendation as the key reasons for continued high rates of SLNB use. 31 Other barriers to deimplementation include malpractice concerns, patient demands, and the need for additional evidence before changing practice. 32 These results suggest that further studies are needed to support deimplementation.…”

Section: Discussionmentioning

confidence: 99%

Outcomes After Sentinel Lymph Node Biopsy and Radiotherapy in Older Women With Early-Stage, Estrogen Receptor–Positive Breast Cancer

et al. 2021

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IMPORTANCE Overtreatment of early-stage breast cancer with favorable tumor biology in older patients may be harmful without affecting recurrence and survival. Guidelines that recommend deimplementation of sentinel lymph node biopsy (SLNB) (Choosing Wisely) and radiotherapy (RT) (National Comprehensive Cancer Network) have been published. OBJECTIVE To describe the use rates and association with disease recurrence of SLNB and RT in older women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained patient and clinical data from an integrated cancer registry and electronic health record of a single health care system in Pennsylvania. The cohort was composed of consecutive female patients 70 years or older who were diagnosed with early-stage, estrogen receptor-positive, ERBB2 (formerly HER2)-negative, clinically node-negative breast cancer from January 1, 2010, to December 31, 2018, who were treated at 15 community and academic hospitals within the health system. EXPOSURES Sentinel lymph node biopsy and adjuvant RT. MAIN OUTCOMES AND MEASURES Primary outcomes were 5-year locoregional recurrence-free survival (LRFS) rate and disease-free survival (DFS) rate after SLNB and after RT. Secondary outcomes included recurrence rate, subgroups that may benefit from SLNB or RT, and use rate of SLNB and RT over time. Propensity scores were used to create 2 cohorts to separately evaluate the association of SLNB and RT with recurrence outcomes. Cox proportional hazards regression model was used to estimate hazard ratios (HRs). RESULTS From 2010 to 2018, a total of 3361 women 70 years or older (median [interquartile range {IQR}] age, 77.0 [73.0-82.0] years) with estrogen receptor-positive, ERBB2-negative, clinically nodenegative breast cancer were included in the study. Of these women, 2195 (65.3%) received SLNB and 1828 (54.4%) received adjuvant RT. Rates of SLNB steadily increased (1.0% per year), a trend that persisted after the 2016 adoption of the Choosing Wisely guideline. Rates of RT decreased slightly (3.4% per year). To examine patient outcomes and maximize follow-up time, the analysis was limited to cases from 2010 to 2014, identifying 2109 patients with a median (IQR) follow-up time of 4.1 (2.5-5.7) years. In the propensity score-matched cohorts, no association was found between

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“…16 Many factors that could be influencing surgeons to perform SLNB are contributing to surgeon adherence to guidelines. First, surgeons are likely recommending SLNB based on functional status and not age, 17 and are therefore using a higher age cut-off than 70 years. This would explain why surgeons are much more likely to recommend SLNB in a 75-year-old with or without comorbidities, compared with an 85-year-old.…”

Section: Discussionmentioning

confidence: 99%

Controversial Areas in Axillary Staging: Are We Following the Guidelines?

et al. 2021

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Background Sentinel lymph node biopsy (SLNB) has been the standard of care for clinically node-negative women with invasive breast cancer (IBC); however, there is less agreement on whether to perform SLNB when the risk of metastasis is low or when it does not affect survival or locoregional control. Methods An Institutional Review Board-approved survey was sent to members of the American Society of Breast Surgeons asking in which scenarios surgeons would recommend SLNB. Descriptive statistics and multivariable analysis were performed using SPSS software. Results There was a 23% response rate; 68% identified as breast surgical oncologists, 6% as surgical oncologists, 24% as general surgeons, and 2% as other. The majority practiced in a community setting (71%) versus an academic setting (29%). In a healthy female with clinical T1N0 hormone receptor-positive (HR+) IBC, 83% favored SLNB if the patient was 75 years of age, versus 35% if the patient was 85 years of age. Academic surgeons were less likely to perform axillary staging in a healthy 75-year-old (odds ratio [OR] 0.51 [0.32–0.80], p = 0.004) or a healthy 85-year-old (OR 0.48 [0.31–0.74], p = 0.001). For DCIS, 32% endorsed SLNB in women undergoing lumpectomy, with breast surgical oncologists and academic surgeons being less likely to endorse this procedure (OR 0.54 [0.36–0.82], p = 0.028; and OR 0.53 [0.34–0.83], p = 0.005, respectively). Conclusions Despite studies showing that omitting SLNB in older patients with HR+ IBC does not impact regional control or survival, most surgeons are still opting for axillary staging. In addition, one in three are performing SLNB for lumpectomies for DCIS. Breast surgical oncologists and academic surgeons were more likely to be practicing based on recent data and guidelines. Practice patterns are changing but there is still room for improvement.

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Barriers and Facilitators to De-Implementation of the Choosing Wisely® Guidelines for Low-Value Breast Cancer Surgery

Cited by 52 publications

References 54 publications

Antibiotic overuse: managing uncertainty and mitigating against overtreatment

Antibiotic overuse: managing uncertainty and mitigating against overtreatment

Outcomes After Sentinel Lymph Node Biopsy and Radiotherapy in Older Women With Early-Stage, Estrogen Receptor–Positive Breast Cancer

Controversial Areas in Axillary Staging: Are We Following the Guidelines?

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