High Compliance With Choosing Wisely Breast Surgical Guidelines at a Safety-Net Hospital

Area of Science:

• Oncology
• Surgical Oncology
• Health Services Research

Background:

• Professional organizations developed guidelines to reduce low-value surgical procedures in breast cancer care.
• These guidelines target interventions such as re-excision for close margins, contralateral mastectomy, axillary lymph node dissection, and sentinel lymph node biopsy in specific patient groups.
• Variable adherence necessitates evaluating the implementation of these low-value care guidelines.

Purpose of the Study:

• To assess the implementation rates of guidelines aimed at reducing low-value surgical care for breast cancer patients.
• To evaluate the impact of these guidelines at a safety-net hospital serving a socioeconomically disadvantaged population.

Main Methods:

• Retrospective analysis of 195 breast cancer patients who underwent surgery between 2015 and 2020.
• Assessment of patient eligibility for omission of specific low-value surgical procedures.
• Comparison of trends before and after the addition of a fellowship-trained breast surgeon in 2018.

Main Results:

• No patients underwent re-excision for close invasive cancer margins.
• Contralateral mastectomy rates were 6.7% (3/45), and axillary lymph node dissection rates were 1.8% (3/169) among eligible patients.
• Sentinel lymph node biopsy (SLNB) was performed in 60% (9/15) of eligible patients aged ≥70 with early-stage, hormone-positive breast cancer, showing a downward trend from 71% to 50% post-2018.

Conclusions:

• De-implementation of low-value surgical care is feasible in community hospitals, including those serving vulnerable populations.
• Avoiding overtreatment enhances resource allocation and promotes social distributive justice in breast cancer care.
• Strategic use of health economic resources can be achieved while maintaining or improving patient outcomes.