Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California.
Department of Medicine, Alameda Health System - Highland Hospital, Oakland, California.
J Surg Res. 2022 Apr;272:96-104. doi: 10.1016/j.jss.2021.09.021. Epub 2021 Dec 22.
Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital.
We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test.
Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020.
De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.
专业组织最近为“明智选择”活动制定了避免低效益和过度手术的指南。这些指南包括浸润性癌接近切缘的再次切除术、单侧乳腺癌患者的双侧乳房切除术、局限性淋巴结疾病患者的腋窝淋巴结清扫术以及早期乳腺癌患者≥ 70 岁的前哨淋巴结活检术（SLNB）。由于对这些建议的遵守程度存在差异，我们评估了一家保障性医院低价值手术指南的实施率。
我们回顾性分析了 2015 年至 2020 年接受手术的乳腺癌患者。每位患者均评估了是否有资格放弃列出的手术。2018 年，一名接受过乳房外科医师培训的医师加入教职员工后，通过队列评估了趋势。使用 Fisher 精确检验比较了结果。
195 名患者中，无一例因浸润性癌接近切缘而行再次切除术。仅 6.7%的患者（3/45）接受了对侧乳房切除术，1.8%的符合条件的患者（3/169）接受了腋窝淋巴结清扫术。总体而言，60%的≥70 岁、Ⅰ期激素阳性乳腺癌患者（9/15）接受了 SLNB。2015-2018 年，符合条件的患者中有 71%接受了 SLNB，而 2019-2020 年则降至 50%。
即使在为社会经济地位较低的社区服务的社区医院，也可以实现对传统手术实践的去实施，这些实践被认为是低价值的护理，并朝着新的指南发展。通过避免过度治疗，医院可以实现有效的资源分配，在乳腺癌患者中实现社会分配公正，并确保在保护患者预后的同时，战略性地利用稀缺的卫生经济资源。
