Measures of Appropriateness and Value for Breast Surgeons and Their Patients: The American Society of Breast Surgeons Choosing Wisely ® Initiative

Abstract

BackgroundCurrent breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely® Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged.MethodsThe Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely® Campaign. The resulting list of “appropriateness” measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below.Results(1) Don’t routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don’t routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don’t routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don’t routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don’t routinely perform a double mastectomy in patients who have a single breast with cancer.ConclusionsThe ASBrS list for the Choosing Wisely® campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.

Expanding Implementation of ACOSOG Z0011 in Surgeon Practice

“…27 Given these observations and the lack of oncologic benefit to additional axillary surgery, the American Society of Breast Surgeons included omission of ALND in appropriate SLN-positive patients in their Choosing Wisely® Campaign. 11 …”

“…11 A review of the National Cancer Database reported on >74,000 patients who met Z0011 criteria with 1–2 positive nodes. The proportion of patients undergoing ALND dropped from 94% in 1998 to 77% in 2009 (the year before trial publication) to 44% in 2011 after release of the results (p<.001).…”

Meta-analysis of pre-operative magnetic resonance imaging (MRI) and surgical treatment for breast cancer

“…Previous meta-analyses focusing on preoperative MRI have reported solely on its detection capability 13 , or have indicated that MRI could increase mastectomy rates but with equivocal findings for some surgical outcomes 6 . It is not surprising then that guidelines give varying recommendations regarding use of pre-operative MRI in newly diagnosed BC and that there is persistent use of MRI for pre-operative surgical planning in BC 10;17–19 .…”

The Impact of Social Contagion on Physician Adoption of Advanced Imaging Tests in Breast Cancer

“…First introduced in breast cancer around 2000, the use of perioperative MRI among Medicare beneficiaries increased to 25% in 2008-2009 (22); PET scan use grew to more than 10% by 2006 (23). Though preoperative MRIs have a higher sensitivity for detection of additional breast lesions, randomized studies have not demonstrated survival differences (24,25), and concerns have been raised about the association between MRI and more aggressive surgical care and overdiagnosis (22,26), leading the American Society of Breast Surgeons to recommend against their routine use (27). The American Society of Clinical Oncology has recommended against routine PET scans for breast cancer with a low risk of metastasizing based on retrospective studies (28).…”