Trends in utilization of sentinel node biopsy and adjuvant radiation in women ≥ 70

Gunn, Jinny; Lemini, Riccardo; Partain, Kristin N.; Yeager, Tamanie; Almerey, Tariq; Attwood, Kristopher; Bagaria, Sanjay P.; Gabriel, Emmanuel

doi:10.1111/tbj.13750

Cited by 6 publications

(6 citation statements)

References 22 publications

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“…Other studies have shown a range from 36.8%-52.8% radiation omission in the elderly. 36,37 Widespread adoption of the de-escalation of breast radiation would save costs and decrease morbidity and inconvenience for patients who stand not to benefit in overall survival.…”

Section: Discussionmentioning

confidence: 99%

Think Globally, Start Locally: Value-Based Breast Cancer Care for Newly Diagnosed Patients in A Safety-Net Medical Center

Ugarte

Khoury

Gyawali

et al. 2022

International Journal of Cancer Care and Delivery

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We assessed the efficacy of a multidisciplinary, patient-focused approach emphasizing appropriate use of medical resources among a population of breast cancer patients at our safety-net hospital. MethodsA multidisciplinary program coordinated and provided value-based care. Surgery, oncology, and navigation were physically co-located. Real time decisions were made by medical and surgical oncologists. Focused institution-specific protocols initiated in 2018, advised against four specific cancer resources that our team had determined as lower-value: imaging tests for indications not recommended in NCCN guidelines, inappropriate Oncotype Dx testing, radiation for patients ≥65 years with stage I hormone-positive disease, and administration of pertuzumab and neratinib as adjuvant therapy in HER2+ breast cancer patients. Time to treatment and rates of use of these resources were monitored. ResultsNewly diagnosed breast cancer patients from 2015-2019 were compared to the pre-protocol era (2015)(2016)(2017). Time from first breast clinic visit to oncology appointment decreased 39 days (60% decrease, median of 63.0 vs 22.5 days, p<0.001), no patients ≥65 years with stage I hormone-positive breast cancer in 2018-2019 received radiation therapy, and rates of ordering of CT, PET, and bone scans for asymptomatic patients decreased by 80%. Overall survival did not differ by cohort protocol category/treatment choices (p=0.69) Compared to the pre-protocol cohort, the post-protocol cohort did not have a significantly lower risk of death (Hazard Ratio 0.66, 95% Confidence Interval 0. 08-5.38, p=0.69). Overall breast cancer care cost decreased by $3,675,374 between 2018 and 2019 versus 2015 to 2017. ConclusionsAfter initiating a breast cancer program focused on reducing rates of use of four commonly excessively ordered breast cancer resources our team identified as lower-value, care at our safety-net hospital achieved high compliance with NCCN maging guidelines and also reduced use of a low-value diagnostic test, and low-value radiation and chemotherapy.

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Section: Discussionmentioning

confidence: 99%

Think Globally, Start Locally: Value-Based Breast Cancer Care for Newly Diagnosed Patients in A Safety-Net Medical Center

Ugarte

Khoury

Gyawali

et al. 2022

International Journal of Cancer Care and Delivery

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“…Gunn et al suggest academic specialists may be more familiar with the nuances of the CALGB‐9343 trial (the basis for omission of SLNB in women ≥70 with small hormone positive cancers), thereby leading to more selective patient criteria to omit SLNB 51 . Additionally, other specialists, such as radiation or medical oncologist, may advocate for SLNB as omission of nodal tissue leads to less complete pathologic staging which may influence their adjuvant treatment planning 51 . Nevertheless, recent evidence reports minimal benefit from adjuvant chemoradiation in this population given the higher likelihood of death from comorbidities 51 .…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, other specialists, such as radiation or medical oncologist, may advocate for SLNB as omission of nodal tissue leads to less complete pathologic staging which may influence their adjuvant treatment planning 51 . Nevertheless, recent evidence reports minimal benefit from adjuvant chemoradiation in this population given the higher likelihood of death from comorbidities 51 . Smith et al also reports that most surgeons are unaware of these guidelines and are more likely to decide on axillary surgery based on functional rather than chronological age 49 .…”

Section: Discussionmentioning

confidence: 99%

“…51 Nevertheless, recent evidence reports minimal benefit from adjuvant chemoradiation in this population given the higher likelihood of death from comorbidities. 51 Smith et al also reports that most surgeons are unaware of these guidelines and are more likely to decide on axillary surgery based on functional rather than chronological age. 49 Our results, which are consistent with prior studies, indicate that regardless of nSES, the majority of breast cancer patients ≥70 years with small clinically node negative breast cancers are undergoing SLNB.…”

Section: Low Value Surgical Carementioning

confidence: 99%

“…50 Interestingly, patients treated at comprehensive community programs had a lower likelihood of receiving SLNB compared to academic programs. 51 Gunn et al suggest academic specialists may be more familiar with the nuances of the CALGB-9343 trial (the basis for omission of SLNB in women ≥70 with small hormone positive cancers), thereby leading to more selective patient criteria to omit SLNB. 51 Additionally, other specialists, such as radiation or medical oncologist, may advocate for SLNB as omission of nodal tissue leads to less complete pathologic staging which may influence their adjuvant treatment planning.…”

Section: Low Value Surgical Carementioning

confidence: 99%

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Neighborhood socioeconomic status and low‐value breast cancer care

Chen

Bhattacharyya

et al. 2022

Journal of Surgical Oncology

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Background The objective of this study is to examine the association between neighborhood socioeconomic status (nSES) and receipt of low‐value breast cancer procedures. Methods Patients with breast cancer diagnosed between 2010 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER) Program. Low value procedures included: (1) axillary lymph node dissection (ALND) for patients with limited nodal disease receiving breast conservation therapy (BCT); (2) contralateral prophylactic mastectomies (CPM); and (3) sentinel lymph node biopsies (SLNB) in patients ≥70 years old with clinically node negative early‐stage hormone‐positive breast cancer. The cohort was divided by nSES. Univariable and multivariable logistic regression analysis compared the groups. Results The study included 412 959 patients. Compared to patients in high nSES areas, residing in neighborhoods with low nSES (odd ratio [OR] 2.20, 95% confidence interval [CI] 2.0−2.42) and middle nSES (OR 1.42, 95% CI 1.20−1.56) was associated with a higher probability of undergoing low value ALND. Conversely, patients in low SES neighborhoods were less likely to receive low value SLNB (OR 0.89, 95% CI 0.85−0.94) or CPM than (low nSES OR 0.75, 95% CI 0.73−0.77); middle nSES OR 0.91 (0.89−0.92) those in high SES neighborhoods. Conclusion In the SEER Program, low nSES was associated with a lower probability of low value procedures except for ALND utilization.

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A scoping review characterizing "Choosing Wisely®" recommendations for breast cancer management

Shah

Surujballi

Awan

et al. 2020

Breast Cancer Res Treat

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Purpose Choosing Wisely (CW)® was created by the American Board of Internal Medicine (ABIM) to promote patient-physician conversations about unnecessary medical interventions. Similarly, other countries created their own panels of experts called "CW® campaigns" which review recommendations submitted by that country's oncology societies. We performed a scoping review to consolidate CW® recommendations from different groups with respect to breast cancer care. Methods A systematic search of Medline and Embase was designed by an information specialist for publications presenting CW® recommendations for breast cancer care practices from 2011-2020. We also reviewed the websites of all CW® campaigns and reference sections of each CW® recommendation. Two reviewers independently screened studies for inclusion and performed data extraction. Findings were summarized narratively. Results Review of ABIM CW® recommendations showed 19 breast cancer-related recommendations pertaining to; screening (n = 4), radiological staging (n = 2), treatment (n = 10), surveillance (n = 2), and miscellaneous (genetic testing; n = 1). Of 22 countries with CW® campaigns, 10 published recommendations for breast cancer. Over half (57%) of recommendations were supported by more than one country. No recommendations were refuted between campaigns. Two campaigns developed 3 novel recommendations on new topics, including chemotherapy in ductal carcinoma in situ (Italy) and comparison of screening imaging modalities (Portugal). Conclusions CW® recommendations focus on reducing overutilization of investigations and treatments. There was a high rate of consensus between different CW® campaigns. As health care systems globally move attention to reduce low-value care, further studies are required to address adherence to these current recommendations and develop new recommendations.

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Trends in utilization of sentinel node biopsy and adjuvant radiation in women ≥ 70

Cited by 6 publications

References 22 publications

Think Globally, Start Locally: Value-Based Breast Cancer Care for Newly Diagnosed Patients in A Safety-Net Medical Center

Think Globally, Start Locally: Value-Based Breast Cancer Care for Newly Diagnosed Patients in A Safety-Net Medical Center

Neighborhood socioeconomic status and low‐value breast cancer care

A scoping review characterizing "Choosing Wisely®" recommendations for breast cancer management

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