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Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Introduction

Guidelines allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 years of age with hormone receptor-positive (HR +) breast cancer. Despite this, national data suggest these procedures have not been widely de-implemented.

Objectives

Our objectives were to evaluate trends in SLNB and post-lumpectomy radiotherapy utilization in patients who are eligible for omission, and evaluate patient preferences as a target for de-implementation of low-value care.

Methods

We performed a sequential explanatory mixed-methods study by first analyzing an institutional database of patients ≥ 70 years of age with HR + breast cancer who received surgical treatment from 2014 to 2018. Based on the quantitative data, we conducted semi-structured interviews with women identified as high or low utilizers of breast cancer treatments to elicit patient perspectives on de-implementation.

Results

SLNB and post-lumpectomy radiotherapy were performed in 68% and 43% of patients, respectively, who met the criteria for omission. There was a significant decrease in SLNB rates from 2014 to 2018. Forty-nine percent of patients were classified as high utilizers and 26% were classified as low utilizers. Qualitative analysis found that the most important factors influencing decision making regarding SLNB and post-lumpectomy radiotherapy omission for both high and low utilizers were trust in their provider and a desire for peace of mind.

Conclusions

Despite efforts to de-implement low-value care, older women with HR + breast cancer remain at risk of overtreatment. Patient perspectives suggest that multi-level de-implementation strategies will need to target provider practice patterns and patient-provider communication to promote high-quality decision making and reduction in breast cancer overtreatment.

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Authors and Affiliations

  1. Department of Surgery, University of Michigan, Ann Arbor, MI, USA

    Ton Wang MD, Niki Matusko BS, Tasha Hughes MD, MPH, Michael Sabel MD, Jacqueline S. Jeruss MD, PhD & Lesly A. Dossett MD, MPH

  2. Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA

    Ton Wang MD, Jacquelyn Miller MA, Tasha Hughes MD, MPH & Lesly A. Dossett MD, MPH

  3. University of Michigan Medical School, Ann Arbor, MI, USA

    Alison Baskin BA & Allan Metz BS

Authors
  1. Ton Wang MD
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  2. Alison Baskin BA
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  3. Jacquelyn Miller MA
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  4. Allan Metz BS
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  5. Niki Matusko BS
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  6. Tasha Hughes MD, MPH
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  7. Michael Sabel MD
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  8. Jacqueline S. Jeruss MD, PhD
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  9. Lesly A. Dossett MD, MPH
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Corresponding author

Correspondence to Lesly A. Dossett MD, MPH.

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Disclosures

Alison Baskin, Jacquelyn Miller, Allan Metz, Niki Matusko, Tasha Hughes, Michael Sabel, and Jacqueline S. Jeruss have no disclosures to declare. Dr. Lesly Dossett is supported by a grant from the Agency for Healthcare Research and Quality (AHRQ; 5 K08 HS026030-02), and Dr. Ton Wang is supported by a grant from the National Cancer Institute (NCI; T32 CA009672).

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Wang, T., Baskin, A., Miller, J. et al. Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study. Ann Surg Oncol 28, 902–913 (2021). https://doi.org/10.1245/s10434-020-08823-w

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  • DOI: https://doi.org/10.1245/s10434-020-08823-w

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