Patterns at hospitals vary
The authors of the study also examined hospital factors, which can heavily influence choice of procedure.
These results showed that the greatest reductions of the low-value breast cancer procedures occurred at academic research programs and high-volume surgical facilities. Elsewhere, the rates varied widely.
Interfacility rates of axillary lymph node dissection 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 rates ranged from 25% to 97%.
Being an outlier for use of one procedure did not necessarily translate to nonconformity for others. Factors such as a hospital’s volume of breast cancer cases or the type of facility did not appear to influence rates of axillary lymph node dissection or lumpectomy reoperation.
However, the rates of contralateral prophylactic mastectomy were significantly higher in high-volume centers and integrated network cancer programs, compared with community cancer programs (23% vs. 2%; P < .001).
Dr. Dossett said the lack of consistency was somewhat unexpected.
“We expected we would find some facilities were constantly good or bad at deimplementation or that there would be stronger associations between certain facility characteristics and performance,” she said. “That really wasn’t the case, and most facilities had mixed performance.”
Evidence may or may not influence trends
The authors speculate on why the low-value designation is in some cases being ignored.
The evidence regarding the risk for lymphedema related to axillary lymph node dissection procedure appears to have helped reduce its use, they note.
However, surgeons have been much less convinced of benefits in omitting sentinel lymph node biopsy, either because they are unfamiliar with the recommendations to avoid the procedure, or they may feel the procedure adds only minimal time and risk to a patient’s operation, the authors explain.
Patients may be convinced to opt to omit sentinel lymph node biopsy if they are properly counseled regarding the risks and benefits of the procedure, Dr. Dossett commented.
Dr. Yao added that, for elderly patients, age can play an important role in sentinel node biopsy.
“Patients’ life expectancy has increased over the years, and node status may impact adjuvant therapy decisions for these patients, even chemotherapy decisions,” she said.
Pressure to continue to perform contralateral prophylactic mastectomy is believed to be significantly patient driven, Dr. Dossett noted.
“I ultimately think the best way to reduce contralateral prophylactic mastectomy is to encourage women with small cancers to undergo breast-conserving surgery, i.e., lumpectomy, instead of mastectomy,” she explained.
“Once the decision for mastectomy is made, there is often a great deal of momentum towards a contralateral prophylactic mastectomy.”
“Contralateral prophylactic mastectomy is a personal preference that many surgeons are willing to do for their patients,” Dr. Yao explained.
“Although no survival benefit has been demonstrated for this procedure, patients find many other benefits that have nothing to do with survival.”
The authors and Dr. Yao have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
