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Review
June 3, 2020

Deimplementation of the Choosing Wisely Recommendations for Low-Value Breast Cancer Surgery: A Systematic Review

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
JAMA Surg. Published online June 3, 2020. doi:10.1001/jamasurg.2020.0322
Key Points

Question  Has low-value breast cancer surgery been successfully deimplemented?

Findings  Rates of axillary lymph node dissection in patients with limited nodal disease and re-excision of close but negative margins after lumpectomy have significantly decreased over time, reflecting changes in practice concordant with current evidence and recommendations; conversely, rates of contralateral prophylactic mastectomy in patients at average risk with unilateral cancer and sentinel lymph node biopsy in patients 70 years or older with hormone receptor–positive cancer remain elevated, despite recommendations against their routine use. This review identifies some of the patient-level, tumor-level, and facility-level factors that contribute to this differential deimplementation.

Meaning  Efforts toward the reduction of low-value breast cancer surgery have been variably influential; areas of incomplete deimplementation can provide insight into potential barriers at guideline, patient, clinician, and system levels contributing to the persistent use of some procedures.

Abstract

Importance  Overtreatment of early-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.

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