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Original Investigation
February 3, 2021

Variations in Persistent Use of Low-Value Breast Cancer Surgery

Author Affiliations
  • 1Department of Surgery, Michigan Medicine, Ann Arbor
  • 2Center for Health Outcomes and Policy, Michigan Medicine, Ann Arbor
  • 3Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
  • 4University of Michigan School of Medicine, Ann Arbor
  • 5Department of Urology, Michigan Medicine, Ann Arbor
  • 6Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
JAMA Surg. Published online February 3, 2021. doi:10.1001/jamasurg.2020.6942
Key Points

Question  How do facility characteristics affect deimplementation of 4 low-value breast cancer operations in the Choosing Wisely campaign?

Findings  In this cohort study in response to national recommendations to avoid 4 low-value procedures, use of 2 procedures decreased significantly while 2 other procedures increased in use. Academic research programs and high-volume facilities demonstrated the greatest reduction in use, with significant interfacility variation for each low-value procedure.

Meaning  Facility-level characteristics were associated with use of low-value breast cancer operations.


Importance  Through 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.

Results  The 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 performance.

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    2 Comments for this article
    Deimplementation breast surgery
    robert Mansel, MD | University Hospital
    The paper by Wang et al is interesting in contrasting the performance of academic based centers to those of more community based centers. It may be the case that academic breast surgeons are more familiar with the detail of the key published evidence and work in a more evidence based multidisciplinary team, thus respond better to deimplementation strategies. This does not explain the rise in CPM procedures, but this may be a selection issue as CPM is technically more demanding and patients approach the procedure with high expectations in terms of cosmetic outcomes, resulting in patients selecting high volume academic centers because of perceived better outcomes.
    Professor Robert Mansel
    Emeritus Professor
    Cardiff University
    Challenges in Deimplementation of SLNB With Concurrent Omission of RT
    Neil Carleton, BS | University of Pittsburgh Medical Center
    We commend Wang et al for their recent work regarding deimplementation of low-value breast cancer surgery. Their analysis of National Cancer Database registry data show that deimplementation of sentinel lymph node biopsy (SLNB) remains an outlier amongst the four evaluated operations. Use of SLNB remains comparatively higher and is increasing, with little absolute differences between academic and non-academic centers, and between high and low volume settings. Deimplementation of SLNB is unique amongst the four operations investigated: (1) there is less evidence to support its omission, compared to the other procedures; and (2) it is the only operation for which there is a concurrent deimplementation recommendation, namely for post-lumpectomy radiation therapy (RT), for the same group of patients.

    Although the authors state that the four operations have similar bodies of evidence supporting deimplementation, for SLNB, the Society of Surgical Oncology’s (SSO) adoption of the Choosing Wisely guideline in 2016 cites as key data long-term follow-up of CALGB 9343 [2] and a small retrospective study by Chung et al [3]. Notably, CALGB 9343 was not specifically designed to detect differences in recurrence or survival for patients undergoing or omitting SLNB. Instead, a post-hoc analysis of CALGB 9343 showed a small increase in local recurrences with omission of SLNB, but it did not comment on these patients’ survival as the authors state. This lack of data could be a fundamental factor driving continued utilization of SLNB despite CALGB 9343 results and SSO’s adoption of the Choosing Wisely recommendation.

    Second, for patients meeting criteria to omit SLNB, concurrent recommendations support deimplementation of RT following lumpectomy. As the results of CALGB 9343 more strongly support omission of RT, it is notable that use of RT, while still high, is decreasing [4, 5]. Further evaluation of this could yield important considerations for SLNB deimplementation. Wang et al observed that deimplementation of SLNB was not correlated to deimplementation of other operations at these facilities, but we suggest that a similar facility-level analysis between SLNB and RT would be a useful comparison. Are the authors able to look at this?

    The quest to identify specific factors to guide deimplementation remains challenging. Analysis of patient-level, provider-level, and now facility-level factors for SLNB deimplementation has shown that, as patients largely defer to provider expertise, and with the absence of actionable steps at the facility-level, additional data to further solidify the body of evidence to target providers remains critical.

    Neil Carleton, BS
    Priscilla McAuliffe, MD, PhD
    Adrian Lee, PhD

    Women’s Cancer Research Center, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
    Division of Surgical Oncology, Department of Surgery, University of Pittsburgh School of Medicine, PA, USA

    1. Hughes KS et al, 2013, J Clin Oncol.
    2. Chung A et al, 2015, JAMA Surg.
    3. Wang T et al, 2021, Ann Surg Oncol.
    4. McAuliffe PF, Carleton N, et al, 2021, Cancer Res (4 Suppl):Abstract nr PS1-10.