Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
Ann Surg Oncol. 2021 Feb;28(2):902-913. doi: 10.1245/s10434-020-08823-w. Epub 2020 Jul 10.
Guidelines allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 years of age with hormone receptor-positive (HR +) breast cancer. Despite this, national data suggest these procedures have not been widely de-implemented.
Our objectives were to evaluate trends in SLNB and post-lumpectomy radiotherapy utilization in patients who are eligible for omission, and evaluate patient preferences as a target for de-implementation of low-value care.
We performed a sequential explanatory mixed-methods study by first analyzing an institutional database of patients ≥ 70 years of age with HR + breast cancer who received surgical treatment from 2014 to 2018. Based on the quantitative data, we conducted semi-structured interviews with women identified as high or low utilizers of breast cancer treatments to elicit patient perspectives on de-implementation.
SLNB and post-lumpectomy radiotherapy were performed in 68% and 43% of patients, respectively, who met the criteria for omission. There was a significant decrease in SLNB rates from 2014 to 2018. Forty-nine percent of patients were classified as high utilizers and 26% were classified as low utilizers. Qualitative analysis found that the most important factors influencing decision making regarding SLNB and post-lumpectomy radiotherapy omission for both high and low utilizers were trust in their provider and a desire for peace of mind.
Despite efforts to de-implement low-value care, older women with HR + breast cancer remain at risk of overtreatment. Patient perspectives suggest that multi-level de-implementation strategies will need to target provider practice patterns and patient-provider communication to promote high-quality decision making and reduction in breast cancer overtreatment.
指南允许对激素受体阳性（HR+）乳腺癌且年龄≥70 岁的女性免除前哨淋巴结活检（SLNB）和保乳术后放疗。尽管如此，国家数据表明这些程序尚未广泛取消。
我们的目的是评估符合豁免条件的患者 SLNB 和保乳术后放疗的使用趋势，并评估患者偏好作为降低低价值护理的目标。
我们首先对 2014 年至 2018 年接受手术治疗的 HR+乳腺癌且年龄≥70 岁的患者进行了一项机构数据库的序贯解释性混合方法研究。根据定量数据，我们对被确定为高或低使用乳腺癌治疗方法的女性进行了半结构化访谈，以了解患者对取消的看法。
符合豁免标准的患者中，分别有 68%和 43%的患者接受了 SLNB 和保乳术后放疗。2014 年至 2018 年，SLNB 率显著下降。49%的患者被归类为高使用者，26%的患者被归类为低使用者。定性分析发现，影响 SLNB 和保乳术后放疗豁免决策的最重要因素是对提供者的信任和寻求安心。
尽管努力降低低价值护理的风险，但 HR+乳腺癌的老年女性仍有过度治疗的风险。患者观点表明，多层次的取消策略需要针对提供者的实践模式和患者提供者的沟通，以促进高质量的决策制定和减少乳腺癌的过度治疗。
