Persistent Use of Low-Value Breast Cancer Surgeries Designated for Deimplementation by Choosing Wisely

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In a retrospective cohort study reported in JAMA Surgery, Wang et al found persistent use of low-value breast cancer surgeries designated for deimplementation by the Choosing Wisely program, with a wide interfacility variation in use of these procedures.

Study Details

The study used National Cancer Database data from women diagnosed with breast cancer between 2004 and 2016 to determine use of four low-value surgeries:

  • Axillary lymph node dissection for limited nodal disease in patients receiving lumpectomy and radiotherapy
  • Lumpectomy re-excision for close but negative margins for invasive cancer
  • Contralateral prophylactic mastectomy in average-risk women with unilateral cancer
  • Sentinel lymph node biopsy in clinically node-negative women age ≥ 70 with hormone receptor–positive cancer.

Changes in use across dates of evidence against use and across U.S. facilities were analyzed. Dates of evidence against use were around 2010 for axillary lymph node dissection, 2013 for reoperation after lumpectomy, 2007 for contralateral prophylactic mastectomy, and 2013 for sentinel lymph node biopsy in older women. 

Key Findings

The total cohort included 920,256 women with a median age of 63 years. Overall, 86% were White; 10%, Black; 3%, Asian; and 4.5%, Hispanic. Most women were insured (51% private and 47% public), lived in metropolitan or urban areas (88% and 11%), and were in the top half of income-earning households (65.5%).

Between 2004 and 2016, there were significant reductions in use of axillary lymph node dissection (63% to 14%) and lumpectomy reoperation (19% to 15%) in response to guidelines supporting deimplementation of these procedures, but rates of contralateral prophylactic mastectomy (11% to 26%) and sentinel lymph node biopsy in older women (78% to 87%) increased over the study period.

In analysis of use of the procedures between 2014 and 2016, there was significant interfacility variation for each procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy in older women rates ranged from 25% to 97%. Pearson correlation coefficients for each combination of two of the four procedures was < 0.11, indicating that facilities were not consistent in deimplementation across all four procedures; many facilities were high outliers in one procedure and low outliers in another.

Across the study period, the greatest reduction in use of the low-value surgeries occurred in academic research programs (eg, relative reductions of 79% for axillary lymph node dissection and 30% for lumpectomy reoperation) and high-volume facilities (eg, relative reductions of 79% for axillary lymph node dissection and 28% for lumpectomy reoperation).

The investigators concluded, “Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and performance.”

Lesly A. Dossett, MD, MPH, of the Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, is the corresponding author for the JAMA Surgery article.

Disclosure: The study was supported by grants from the National Cancer Institute and Agency for Healthcare Research and Quality. For full disclosures of the study authors, visit

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