Significant Interfacility Variation Found in Implementation of Low-Value Breast Cancer Procedures

In Clinical Studies News by Barbara Jacoby

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By: Matthew Fowler


Data examining 4 low-value breast cancer procedures found an association between facility-level characteristics and the use of these procedures, suggesting a need for de-implementation targeting efforts in various facilities.

A number of facility-level characteristics were associated with the use of low-value breast cancer procedures, and interfacility variation presented an opportunity for formal de-implementation efforts targeting these low-value operations, according to data published in JAMA Surgery.

Research from the Choosing Wisely campaign identified 4 low-value breast cancer operations with the goal of finding variation and determinants of persistent use of these surgical operations among different facilities.

“Hospitals were not uniform in their de-implementation performance across all 4 procedures, suggesting that success at reducing overtreatment is not an inherent trait associated with a particular hospital,” wrote the investigators. “Significant interfacility variation demonstrates a performance gap for many centers and room for formal de-implementation efforts targeting each procedure.”

When examining the low-value breast cancer procedures, the research team found a significant de-implementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines that supported the exclusion of these specific procedures. Conversely, the team found an increase in the rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy for older women over this period.

When focusing on the facilities themselves, the research team found significant interfacility variation in the implementation of low-value breast cancer procedures. Specifically, rates for facility-level axillary lymph node dissection ranged from 7% to 47%, lumpectomy reoperation ranged from 3% to 62%, contralateral prophylactic mastectomy ranged from 9% to 67%, and sentinel lymph node biopsy ranged from 25% to 97%.

Further, it was determined that academic research programs and high-volume facilities decreased their use of these low-value procedures the most.

Overall, Pearson correlations for each combination of 2 of the 4 procedures determined that facilities were not consistent in de-implementing these low-value procedures across the board.

“Despite similar evidence and national recommendations supporting the omission of 4 low-value breast cancer procedures, only 2 have been successfully de-implemented,” wrote the investigators. “Several facility-level characteristics were associated with de-implementation performance, with academic research facilities and facilities with a high volume of patients with breast cancer demonstrating the greatest reduction in use of these low-value procedures.”

The population examined included 920,256 women with a median age of 63 years found via the National Cancer Database between 2004 and 2016. Of the total cohort, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. More, a majority of women reported having private insurance (51% private and 47% public), lived in a metropolitan or urban area (88% and 11%, respectively), and were from the top half of income-earning households (65.5%).

As for limitations, the research team explained that the National Cancer Database is limited by its retrospective design, meaning eligible patients were determined via surrogate measures. More, the team notes that the “ideal rate of de-implementation has not been established,” suggesting that there are other factors at play that the National Cancer Database cannot quantify.

“This is the first study to explore facility-level variation and determinants of differential de-implementation of low-value surgery in a single disease,” wrote the investigators. “We identify 3 findings to inform future efforts to reduce over-treatment.”


Wang T, Bredbeck BC, Sinco B, et al. Variations in persistent use of low-value breast cancer surgery. JAMA Surg. doi:10.1001/jamasurg.2020.6942