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Pesavento CM, Kazemi RJ, Kappelman A, Thompson JL, Jobin C, Wang T, Dossett LA. Pilot testing a patient decision aid as a strategy to reduce overtreatment for older women with early-stage breast cancer. Am J Surg 2024:115774. [PMID: 38834420 DOI: 10.1016/j.amjsurg.2024.115774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/23/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Despite national guidelines recommending omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (RT) in older women with early-stage, hormone receptor-positive (HR+) breast cancer, these practices persist. This pilot study assesses whether a decision aid can target patient-level determinants of low-value treatments. METHODS We adapted and pilot-tested a decision aid in women ≥70 years old with early-stage HR + breast cancer. Primary outcomes included acceptability and appropriateness of the decision aid. Secondary outcomes included treatment choice and satisfaction with decision. RESULTS Twenty-three patients enrolled in the trial. 19 completed survey one; 16 completed survey two. Primary outcomes demonstrated that 84% of patients agreed or strongly agreed the aid was acceptable and appropriate. Secondary outcomes demonstrated that 19% of patients underwent SLNB (below pre-intervention baseline), and 85% received adjuvant RT (change not statistically significant). CONCLUSIONS We demonstrate that a decision aid may effectively target patient-level factors contributing to overuse of low-value therapies.
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Affiliation(s)
- Cecilia M Pesavento
- University of Michigan Medical School, Ann Arbor, MI, USA; Vanderbilt University Medical Center, Department of Surgery, Nashville, TN, USA.
| | - Ruby J Kazemi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Abigail Kappelman
- University of Michigan Medical School, Ann Arbor, MI, USA; University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
| | - Jessica L Thompson
- Corewell Health West, Department of Cancer Health, Grand Rapids, MI, USA
| | | | - Ton Wang
- Duke University School of Medicine, Department of Surgery, Durham, NC, USA
| | - Lesly A Dossett
- University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA; University of Michigan, Department of Surgery, Ann Arbor, MI, USA
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Wang T, Dossett LA. Incorporating Value-Based Decisions in Breast Cancer Treatment Algorithms. Surg Oncol Clin N Am 2023; 32:777-797. [PMID: 37714643 DOI: 10.1016/j.soc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Given the excellent prognosis and availability of evidence-based treatment, patients with early-stage breast cancer are at risk of overtreatment. In this review, we summarize key opportunities to incorporate value-based decisions to optimize the delivery of high-value treatment across the breast cancer care continuum.
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Affiliation(s)
- Ton Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Tseng J, Bazan JG, Minami CA, Schonberg MA. Not Too Little, Not Too Much: Optimizing More Versus Less Locoregional Treatment for Older Patients With Breast Cancer. Am Soc Clin Oncol Educ Book 2023; 43:e390450. [PMID: 37327467 DOI: 10.1200/edbk_390450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Although undertreatment of older women with aggressive breast cancers has been a concern for years, there is increasing recognition that some older women are overtreated, receiving therapies unlikely to improve survival or reduce morbidity. De-escalation of surgery may include breast-conserving surgery over mastectomy for appropriate candidates and omitting or reducing extent of axillary surgery. Appropriate patients to de-escalate surgery are those with early-stage breast cancer, favorable tumor characteristics, are clinically node-negative, and who may have other major health issues. De-escalation of radiation includes reducing treatment course length through hypofractionation and ultrahypofractionation regimens, reducing treatment volumes through partial breast irradiation, omission of radiation for select patients, and reducing radiation dose to normal tissues. Shared decision making, which aims to facilitate patients making decisions concordant with their values, can guide health care providers and patients through complicated decisions optimizing breast cancer care.
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Affiliation(s)
| | - Jose G Bazan
- City of Hope Comprehensive Cancer Center, Duarte, CA
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Mott NM, Markovitz NH, Wang T, Hughes TM, Pilewskie M, Jagsi R, Dossett LA. Avoiding Overtreatment of Women ≥70 With Early-Stage Breast Cancer: A Provider-Level Deimplementation Strategy. J Surg Res 2023; 284:124-130. [PMID: 36566589 DOI: 10.1016/j.jss.2022.11.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION National guidelines recommend against routine axillary staging with sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy (RT) in women ≥70 y with early-stage, hormone receptor-positive, HER2-negative breast cancer and clinically negative axilla; however, these practices remain common. METHODS We conducted a prospective pilot study from August 2021 to 2022 using an intervention targeting breast surgeons and radiation oncologists in Michigan that aimed to reduce SLNB and RT in eligible patients. The intervention consisted of (1) a geriatric assessment, (2) an assessment of the patient's medical maximizing-minimizing preferences, and (3) a tailored script with counterpoints to reasons patients commonly seek SLNB or RT. At the end of the study period, participants completed a survey providing feedback with the primary outcomes being: acceptability, appropriateness, feasibility, and intention and motivation to use the materials based on validated measures. RESULTS Participants (n = 23) included 15 breast surgeons and 8 radiation oncologists. Collectively, the materials were used with 115 patients. Considering all materials holistically, acceptability, appropriateness, and feasibility of the intervention were high; participants also intended and were motivated to use the intervention. Scores across all measures were highest for the geriatric assessment and lowest for the tailored script. The major barriers to using the intervention were limited time and instances of disagreement on treatment recommendations among surgeons and radiation oncologists. CONCLUSIONS The omission of SLNB and adjuvant RT should be discussed in appropriately selected patients. A multifaceted provider-level deimplementation strategy may be an effective means for achieving this goal.
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Affiliation(s)
- Nicole M Mott
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Clinicopathological characteristics in women with breast cancer in extreme ages in Greece: A single centre experience. FORUM OF CLINICAL ONCOLOGY 2022. [DOI: 10.2478/fco-2021-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction
Breast cancer is the most common malignancy in Greek women. The highest incidence occurs in patients aged 40–70 years. However, the emergence of the disease in women under 40 and over 80 years old is a significant problem in everyday practice, because of the diagnostic and therapeutic challenges for these age groups. The objective of this study is to investigate clinicopathological characteristics of Greek women under 40 and over 80 diagnosed with breast cancer during 2019–2020 in a specialized Breast Cancer Surgical Centre, as well as the pathological characteristics of their disease and the therapeutic measures applied to these women.
Aim of the study
The aim of this study is to compare clinical and pathological characteristics of breast cancer in a group of Greek premenopausal women younger than 40 years of age with a group of elderly women older than 80 years old, who were treated in a surgical breast centre in Greece during the last two years.
Patients and Methods
During the last 2 years, 21 women under 40 and 22 women older than 80 were diagnosed with breast cancer in our Centre.
Results
Invasive ductal adenocarcinoma was the most frequent histological type for both Groups: Most younger women underwent surgery followed by chemotherapy, while the majority of older patients received hormonal therapy after surgery.
Conclusions
There were no statistically significant differences between women under 40 and women over 80 in the study sample regarding their clinicopathological characteristics. However, younger women underwent more therapeutic modalities (i.e.adjuvant treatments in addition to surgery) than older ones.
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Acceptability of a patient decision aid for women aged 70 and older with stage I, estrogen receptor-positive, HER2-negative breast cancer. J Geriatr Oncol 2021; 12:724-730. [PMID: 33678596 DOI: 10.1016/j.jgo.2021.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/11/2021] [Accepted: 02/26/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES A comprehensive decision aid (DA) for women ≥70 years with Stage I ER+/HER2-negative breast cancer was developed to support locoregional and systemic treatment decision-making. We aimed to test the acceptability of this novel DA in women newly-diagnosed with breast cancer. MATERIALS AND METHODS Women ≥70 diagnosed with Stage I, ER+/HER2- breast cancer were recruited from three Boston-area hospitals. They underwent baseline interviews after initial surgical consultation, reviewed the DA, and were surveyed <2 weeks later to determine DA acceptability (e.g., was it helpful?), changes in decisional conflict, stage of decision-making, and knowledge. Participants could optionally complete a three-month follow-up. Paired t-tests and McNemar's tests were used for statistical comparisons, and thematic analyses were conducted to identify themes in participants' open-ended comments. RESULTS Thirty-three of 56 eligible patients approached completed the baseline and acceptability surveys, and 25 completed the three-month follow-up. Participants' mean age was 74.7 years (±3.8). Nearly all participants (n = 31, 94%) strongly agreed that the DA was helpful and felt that the DA prepared them for treatment decision-making, with a mean decision preparation score of 4.1 (out of 5.0); 6% (n = 2) found it very anxiety provoking. Knowledge improved with a mean of 9.0 out of 14 questions correct at baseline to 10.6 correct on the acceptability survey (p < 0.0001). CONCLUSIONS A DA tailored to women ≥70 with Stage I, ER+, HER2- breast cancer increased knowledge and was perceived to be helpful by older women. A randomized controlled trial is needed to evaluate its efficacy.
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Wang T, Baskin A, Miller J, Metz A, Matusko N, Hughes T, Sabel M, Jeruss JS, Dossett LA. Trends in Breast Cancer Treatment De-Implementation in Older Patients with Hormone Receptor-Positive Breast Cancer: A Mixed Methods Study. Ann Surg Oncol 2021; 28:902-913. [PMID: 32651693 PMCID: PMC7796859 DOI: 10.1245/s10434-020-08823-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/21/2020] [Indexed: 12/20/2022]
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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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Alison Baskin
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jacquelyn Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Allan Metz
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Niki Matusko
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Tasha Hughes
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Michael Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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A Pre-Test-Post-Test Trial of a Breast Cancer Risk Report for Women in Their 40s. Am J Prev Med 2020; 59:343-354. [PMID: 32828322 DOI: 10.1016/j.amepre.2020.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/31/2020] [Accepted: 04/05/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk. STUDY DESIGN Pretest-Posttest trial. SETTING/PARTICIPANTS Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019. INTERVENTION Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest. MAIN OUTCOME MEASURES Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020. RESULTS Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician). CONCLUSIONS Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians. TRIAL REGISTRATION This study is registered at www.clinicaltrials.govNCT03180086.
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Jeon YW, You SH, Lee JE, Youn HJ, Lim W, Han JH, Park CH, Kim YS. Optimal treatment of breast cancer in women older than 75 years: a Korea Breast Cancer Registry analysis. Breast Cancer Res Treat 2019; 178:693-701. [PMID: 31493032 PMCID: PMC6817741 DOI: 10.1007/s10549-019-05426-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 08/27/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of this study was to investigate the therapeutic efficacy of adjuvant modalities for elderly Asian breast cancer patients using population-based data from the Korean Breast Cancer Registry database. METHODS We identified 53,582 patients who underwent curative surgery between January 2005 and December 2010. The primary end point was the comparison of overall survival between the administration or omission of adjuvant treatment modalities, including endocrine treatment, radiation therapy, and chemotherapy, in the elderly group (older than 75 years) compared with the control group (younger than 75 years). RESULTS Of the 53,582 patients analyzed, the total number of elderly patients was 901 (1.7%), and the number of control patients was 52,681 (98.3%). Although elderly patients were found to have larger tumor sizes (p = 0.024) and higher pathological stages (p < 0.001) than the control group, elderly patients were less likely to undergo adjuvant treatment compared to the control group. However, use of endocrine treatment in elderly patients with HR-positive breast cancer is associated with improved overall survival (OS) (adjusted OR 0.417; 95% confidence interval [CI] 0.240-0.726; p = 0.002). Furthermore, chemotherapy was associated with a significant improvement in OS in patients with stage II and III breast cancer (adjusted OR 0.657; 95% CI 0.462-0.934; p = 0.019). CONCLUSION Endocrine treatment and chemotherapy for elderly patients are associated with improved OS. Therefore, personalized decision-making based on the potential survival benefit of adjuvant treatment modalities should be made with the careful counseling of all elderly patients with breast cancer.
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Affiliation(s)
- Ye Won Jeon
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Sun Hyong You
- Department of Surgery, Park Surgrcal Clinic, Suwon, Korea
| | - Jong Eun Lee
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyun Jo Youn
- Department of Surgery, Chonbuk National University Medical School, Jeonju, Korea
| | - Woosung Lim
- Department of Surgery, Ewha Womans University Medical Center, Seoul, Korea
| | - Jai Hong Han
- Department of Surgery, Center for Breast Cancer, Reaserch Institute and Hospital, National Cancer Center, Goyang-si, Korea
| | - Chan Heun Park
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Seok Kim
- Department of Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, #271, Cheonbo-ro, Uijeongbu-City, Gyenggi-Do, 11765, Republic of Korea.
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