Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study

Ton, Wang; Baskin, Alison S.; Miller, Jacquelyn; Metz, Allan K.; Matusko, Niki; Hughes, Tasha M.; Sabel, Michael S.; Jeruss, Jacqueline S.; Dossett, Lesly A.

doi:10.1245/s10434-020-08823-w

Cited by 25 publications

(19 citation statements)

References 26 publications

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“…Many individual-level factors (patient- and clinician-level) may contribute to the success of de-implementation interventions [ 63 ]. For example, patients’ perspectives and preferences [ 45 ], and trust in their clinicians [ 64 ] are key determinants of many practices in cancer care, and ignoring those factors in efforts to de-implement low-value care may jeopardize the de-implementation process. Prior research also showed that most patients overestimate the benefits and underestimate the harms of medical services [ 55 , 56 , 65 ].…”

Section: Discussionmentioning

confidence: 99%

De-implementing low-value care in cancer care delivery: a systematic review

et al. 2022

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Background Accumulating evidence suggests that interventions to de-implement low-value services are urgently needed. While medical societies and educational campaigns such as Choosing Wisely have developed several guidelines and recommendations pertaining to low-value care, little is known about interventions that exist to de-implement low-value care in oncology settings. We conducted this review to summarize the literature on interventions to de-implement low-value care in oncology settings. Methods We systematically reviewed the published literature in PubMed, Embase, CINAHL Plus, and Scopus from 1 January 1990 to 4 March 2021. We screened the retrieved abstracts for eligibility against inclusion criteria and conducted a full-text review of all eligible studies on de-implementation interventions in cancer care delivery. We used the framework analysis approach to summarize included studies’ key characteristics including design, type of cancer, outcome(s), objective(s), de-implementation interventions description, and determinants of the de-implementation interventions. To extract the data, pairs of authors placed text from included articles into the appropriate cells within our framework. We analyzed extracted data from each cell to describe the studies and findings of de-implementation interventions aiming to reduce low-value cancer care. Results Out of 2794 studies, 12 met our inclusion criteria. The studies covered several cancer types, including prostate cancer (n = 5), gastrointestinal cancer (n = 3), lung cancer (n = 2), breast cancer (n = 2), and hematologic cancers (n = 1). Most of the interventions (n = 10) were multifaceted. Auditing and providing feedback, having a clinical champion, educating clinicians through developing and disseminating new guidelines, and developing a decision support tool are the common components of the de-implementation interventions. Six of the de-implementation interventions were effective in reducing low-value care, five studies reported mixed results, and one study showed no difference across intervention arms. Eleven studies aimed to de-implement low-value care by changing providers’ behavior, and 1 de-implementation intervention focused on changing the patients’ behavior. Three studies had little risk of bias, five had moderate, and four had a high risk of bias. Conclusions This review demonstrated a paucity of evidence in many areas of the de-implementation of low-value care including lack of studies in active de-implementation (i.e., healthcare organizations initiating de-implementation interventions purposefully aimed at reducing low-value care).

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Section: Discussionmentioning

confidence: 99%

De-implementing low-value care in cancer care delivery: a systematic review

et al. 2022

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“…In conclusion, ultimately, clinicians have a responsibility to do no harm while also respecting patients' autonomy and right to make their own health care decisions. Part of the art of medicine is guiding shared decision making to support The most important factors influencing decision making were trust in their provider and a desire for peace of mind: "I wanted to know if it had spread or not, and the risk of it spreading, I wanted to know" 20 CPM should be discouraged in average-risk women with unilateral breast cancer 21 Before surgery, women who elected to have CPM had high levels of cancer distress (P 5 .04), cancer worry (P , .001), and body image distress (P , .001) than those who did not 22 Ovarian cancer Recommendation against screening for women with no family history of ovarian cancer 15.1% of women were screened despite the guideline recommendation; this was primarily motivated by patient desire for reassurance and peace of mind (93.1%) Providers reported being primarily motivated by patient requests (20.7%), improved patient outcomes (16.4%), and patient peace of mind (13.8%) 23 Thyroid cancer…”

Section: Recommendationsmentioning

confidence: 99%

Peace of Mind: A Role in Unnecessary Care?

Chen

Hughes

Dossett

et al. 2022

JCO

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Consider this excerpt from a real patient-surgeon conversation about treatment for a small, early-stage thyroid cancer and deliberating three equivalent treatment options: active surveillance, hemithyroidectomy, and total thyroidectomy. Patient: What do you recommend on my case? Surgeon: I could probably argue any of the three. I think, what I'm hearing from you is that peace of mind is important… Patient: Yes. Surgeon: If we're going to go down the surgery path, I would probably recommend a total. Patient: Mmm hmm.Surgeon: Knowing that it will definitively get the entire thyroid out so hopefully should give us peace of mind.Author affiliations and support information (if applicable) appear at the end of this article.

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“…Preliminary studies have shown a decrease in rates of ALND and lumpectomy re-excision at both institutional and national levels. 2,11,12 In contrast, other studies suggest more than 80% of women 70 years and older with HR+ breast cancer receive SLNB 2,[13][14][15] and that CPM rates for patients with unilateral cancer are increasing. 2,16 While previous studies have examined some tumor-level, patient-level, and clinicianlevel determinants of persistent use, 17 to our knowledge, variation of deimplementation across facilities and procedures has not been described.…”

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confidence: 93%

Variations in Persistent Use of Low-Value Breast Cancer Surgery

et al. 2021

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IMPORTANCEThrough the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation.OBJECTIVE To identify variation and determinants of persistent use of low-value breast cancer surgical care.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation.MAIN OUTCOMES AND MEASURES Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission. RESULTSThe total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another.CONCLUSIONS AND RELEVANCE Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and perfor...

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Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study

Cited by 25 publications

References 26 publications

De-implementing low-value care in cancer care delivery: a systematic review

De-implementing low-value care in cancer care delivery: a systematic review

Peace of Mind: A Role in Unnecessary Care?

Variations in Persistent Use of Low-Value Breast Cancer Surgery

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