Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery

Abstract

stage breast cancer results in increased morbidity and cost without improving survival. Major surgical organizations participating in the Choosing Wisely campaign identified 4 breast cancer operations as low value: (1) axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiation, (2) re-excision for close but negative lumpectomy margins for invasive cancer, (3) contralateral prophylactic mastectomy in patients at average risk with unilateral cancer, and (4) sentinel lymph node biopsy in women 70 years or older with hormone receptor-positive cancer.OBJECTIVE To evaluate the extent to which these procedures have been deimplemented, determine the implications of decreased use, and recognize possible barriers and facilitators to deimplementation.EVIDENCE REVIEW A systematic review of published literature on use trends in breast surgery was performed in accordance with PRISMA guidelines. The Ovid, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for original research with relevance to the Choosing Wisely recommendations of interest. Eligible studies were examined for data about use, and any patient-level, clinician-level, or system-level factors associated with use.FINDINGS Concordant with recommendations, national rates of axillary lymph node dissection for patients with limited nodal disease have decreased by approximately 50% (from 44% in 2011 to 30% to 34% in 2012 and 25% to 28% in 2013), and national rates of lumpectomy margin re-excision have decreased by nearly 40% (from 16% to 34% before to 14% to 18% after publication of a consensus statement). Conversely, national rates of contralateral prophylactic mastectomy continue to rise each year, accounting for up to 30% of all mastectomies for breast cancer (range in all mastectomy cases: 2010-2012, 28%-30%; 1998, <2%), and rates of sentinel lymph node biopsy in women 70 years or older with low-risk breast cancer are persistently greater than 80% (range, 80%-88%). Factors associated with high rates of contralateral prophylactic mastectomy use are younger age, white race, increased socioeconomic status, and the availability of breast reconstruction; limited data exist on factors associated with high rates of sentinel lymph node biopsy in women 70 years or older. Successful deimplementation of axillary lymph node dissection and lumpectomy margin re-excision were associated with decreased costs and improved patient-centered outcomes.CONCLUSIONS AND RELEVANCE This review demonstrates variable deimplementation of 4 low-value surgical procedures in patients with breast cancer. Addressing specific patient-level, clinician-level, and system-level barriers to deimplementation is necessary to encourage shared decision-making and reduce overtreatment.

Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer

“…Despite recent guidelines and deimplementation efforts, CPM rates continue to rise nationwide with estimates ranging from 10% to 13% of all breast cancer procedures and 28%-30% of all mastectomy cases. 6 More troubling, this trend specifically has been observed in patients with early stage breast cancers who have excellent prognoses with breast-conserving therapy and often include older women who are the most vulnerable to the risks associated with CPM and the least likely to derive oncologic benefit. 7 Women with unilateral, small tumors (<20 mm) are often candidates for breast-conserving surgery (BCS), but for unclear reasons may choose to undergo unilateral mastectomy which can escalate to CPM.…”

Racial disparities in low‐value surgical care and time to surgery in high‐volume hospitals

“…Specifically, we were interested in racial differences in the utilization of low‐ value surgical care and surgical delays. Low‐value surgical procedures are defined as procedures with minimal to no clinical benefit 13 . The motivation behind focusing on these procedures was to better understand racial differences in the quality of surgical care.…”

“…Lowvalue surgical procedures are defined as procedures with minimal to no clinical benefit. 13 The motivation behind focusing on these procedures was to better understand racial differences in the quality of surgical care. Surgical delay was evaluated due to its association with increased disease-specific and overall survival.…”

Patient Perspectives on Treatment Options for Older Women With Hormone Receptor–Positive Breast Cancer

“…In national samples, more than 80% of women aged 70 years or older with HR-positive breast cancer underwent SLNB, and more than 65% received adjuvant radiotherapy. 1 , 9 , 10 , 11 Previous assessments of barriers to de-escalation of low-value breast cancer care have focused on clinician beliefs and attitudes. 12 , 13 Although clinicians cite patient preferences as a factor associated with overtreatment, evidence suggests that many older patients may actually prefer a less-aggressive treatment strategy.…”