Department of Surgery, University of Michigan, Ann Arbor.
Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
JAMA Surg. 2020 Aug 1;155(8):759-770. doi: 10.1001/jamasurg.2020.0322.
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.
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.
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.
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.
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.
早期乳腺癌的过度治疗会增加发病率和成本，而不会提高生存率。参与“明智选择”运动的主要外科组织确定了 4 种乳腺癌手术为低价值手术：（1）对于接受保乳术和放疗的有限淋巴结疾病患者进行腋窝淋巴结清扫，（2）对于浸润性癌保乳术切缘接近但为阴性的患者进行再次切除，（3）对于单侧癌症的平均风险患者进行对侧预防性乳房切除术，以及（4）对于激素受体阳性癌症的 70 岁或以上女性进行前哨淋巴结活检。
评估这些手术已被取消的程度，确定减少使用的影响，并认识到取消实施可能存在的障碍和促进因素。
根据 PRISMA 指南，对已发表的关于乳腺癌手术使用趋势的文献进行了系统评价。在 Ovid、Embase、Cumulative Index to Nursing and Allied Health Literature 和 Cochrane 数据库中，针对与明智选择建议相关的原始研究进行了搜索。对符合条件的研究进行了使用数据检查，并检查了任何与使用相关的患者水平、临床医生水平或系统水平因素。
与建议一致，接受有限淋巴结疾病患者腋窝淋巴结清扫术的全国比率已降低约 50%（从 2011 年的 44%降至 2012 年的 30%至 34%和 2013 年的 25%至 28%），而保乳术切缘再次切除术的全国比率已降低近 40%（从 16%降至 34%，在发表共识声明之前至 14%至 18%）。相反，每年对侧预防性乳房切除术的全国比率继续上升，占所有乳腺癌乳房切除术的 30%（所有乳房切除术病例范围：2010-2012 年，28%-30%；1998 年，<2%），而 70 岁或以上患有低危乳腺癌的女性进行前哨淋巴结活检的比率持续高于 80%（范围，80%-88%）。与对侧预防性乳房切除术使用率高相关的因素是年龄较小、白种人、社会经济地位提高和乳房重建的可用性；关于与 70 岁或以上女性的高比例前哨淋巴结活检相关的因素的数据有限。腋窝淋巴结清扫术和保乳术切缘再次切除术的成功取消实施与降低成本和改善以患者为中心的结果有关。
本综述表明，在乳腺癌患者中，有 4 种低价值的手术程序已进行了不同程度的取消实施。解决取消实施的特定患者水平、临床医生水平和系统水平障碍对于鼓励共同决策和减少过度治疗是必要的。
