Researchers have developed a novel prompt, embedded in electronic health records, to flag older patients with early-stage breast cancer who may be at risk of unnecessary sentinel lymph node biopsy, according to a recent study published by Carleton et al in JAMA Surgery.
Background
“In breast cancer, there is a growing movement toward precisely treating each individual patient, what we call right-sized care,” explained senior study author Priscilla McAuliffe, MD, PhD, Associate Professor of Surgery at the University of Pittsburgh and a breast surgical oncologist at the UPMC Hillman Cancer Center and UPMC Magee-Womens Hospital. “[Sentinel lymph node biopsy] helps us determine if breast cancer has spread to the underarm lymph nodes, but it’s not necessary for every patient. The simple, user-friendly nudge provides a timely reminder to surgeons to consider the value of [sentinel lymph node biopsy] for each patient,” she added.
One of the American Board of Internal Medicine Choosing Wisely recommendations—adopted by the Society of Surgical Oncology—currently advocates against routine sentinel lymph node biopsy among patients aged 70 years and older with early-stage estrogen receptor–positive breast cancer as a result of the low risk of metastasis and favorable tumor biology. Nonetheless, a majority of these patients may still undergo the procedure even though it does not provide critical treatment-guiding information, is not associated with a survival benefit, and may have side effects.
“Patients who undergo [sentinel lymph node biopsy] are at risk of developing a serious complication called lymphedema, a permanent but treatable swelling of the arm or breast that can greatly impact quality of life,” stressed lead study author Neil Carleton, PhD, a student in the Medical Scientist Training Program at the University of Pittsburgh. “As patients get older, they also have more challenges recovering from surgery and anesthesia, so if a patient isn’t likely to benefit from [sentinel lymph node biopsy], we want to avoid it whenever possible,” he suggested.
In a previous study, researchers found that the recommendation against routine use of sentinel lymph node biopsy in older patients with early-stage breast cancer could be extended to postmenopausal patients who are over 55.
Study Methods and Results
In the recent study, a multidisciplinary team of researchers developed and evaluated the electronic health record–based nudge designed to remind treating surgeons to consider the value of sentinel lymph node biopsy in patients flagged as potentially eligible to forgo the procedure based on their age and tumor biology. To test the effectiveness of their novel approach, they then launched a nonrandomized clinical trial involving seven surgeons who worked across eight surgical oncology clinics.
The surgeons performed sentinel lymph node biopsy in 46.9% of the eligible patients throughout the 12-month period prior to implementation of the nudge. However, during the 12-month intervention period, the researchers found that the procedure was performed in just 23.8% of the eligible patients—a reduction of 49.3%. During an additional 6-month follow-up period, the rate dropped further to 15.6%.
In surveys completed after the 12-month intervention period, the participating surgeons rated the nudge as highly acceptable, appropriate, and feasible. The surgeons also appreciated that the prompt didn’t require additional clicks or paperwork as well as how easily it was integrated into their workflow.
After using artificial intelligence technology developed by Realyze Intelligence to analyze patient records for language potentially indicating lymphedema symptoms, the researchers noted that the rate of patients who experienced symptoms worthy of referral for a lymphedema evaluation decreased from 6.2% to 3.6% after the nudge was implemented.
Conclusions
“Our findings suggest that fewer [sentinel lymph node biopsies] resulting from the nudge will help reduce rates of lymphedema, but we need longer follow-up to be certain, because this condition can take several years to appear,” underscored Dr. Carleton.
The researchers emphasized that their simple reminder could significantly improve individualized care and reduce overtreatment among older patients with breast cancer. They plan to implement the nudge to physicians at the UPMC Hillman Cancer Center in the hopes that it will improve care for more patients across the health-care system—including patients seen in community settings who are often excluded from clinical trials.
Disclosure: The research in this study was supported in part by the National Institutes of Health, the UPMC Hillman Cancer Center Biostatistics Facility, and UPMC eRecord Ambulatory Decision Support and Analytics. For full disclosures of the study authors, visit jamanetwork.com.
