American Society of Breast Surgeons "Choosing Wisely" Choices: An initiative of the American Board of Internal Medicine Foundation

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Five Things Physicians and Patients Should Question*

1) Do not routinely order breast MRI in new breast cancer patients.
After a new diagnosis of breast cancer, breast MRI can be useful in selected patients to aid treatment decisions. However, there is a lack of evidence that routine use of MRI lessens cancer recurrence, death from cancer, or the need for re-operation after lumpectomy surgery. The routine use of MRI is associated with an increased need for subsequent breast biopsy procedures, increased mastectomy rates, delays in time to treatment and higher cost of care.

2) Do not routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer.
After a new diagnosis of invasive breast cancer, most patients undergoing partial breast removal (lumpectomy) benefit from a “sentinel node (SN) biopsy” a procedure that removes a small number of lymph nodes beneath the arm. In the past, patients found to have cancer in any SN underwent extra surgery to remove more nodes. Recent evidence suggests further node surgery is not necessary in patients with cancer found in fewer than three SN, if the patient receives other recommended cancer treatments.

3) Do not routinely order specialized gene testing in all new breast cancer patients.
There are multiple new “multi-gene signature” tests that provide selected patients with information about their risk of dying of cancer or the likelihood they will benefit from chemotherapy. These tests are helpful in selected patients. There is no evidence that they should be used routinely. These tests should not be done in patients who indicate the test results would not change their choice of treatment.

4) Do not routinely re-operate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue.
Patients undergoing partial breast removal (lumpectomy) of the breast for invasive cancer benefit from re-operation to excise more breast tissue if microscopic review of the lumpectomy breast tissue indicates cancer cells at the tissue edge. However, if cancer cells are close to the edge, but not at the actual edge, then recent evidence suggests it is safe to avoid re-operation.

5) Do not routinely perform a double mastectomy in patients who have a single breast with cancer.
After a new diagnosis of breast cancer in a single breast, many patients desire removal of both breasts, believing their cancer risk in the other breast is high and their cancer cure rate will be improved with double mastectomy. Double mastectomy should not be routinely performed in these patients until they have been provided with adequate understandable information about the generally low risk they will develop cancer in the other breast and the minimal effectiveness, if any, of double mastectomy improving their life expectancy.

* “These items are provided solely for informational purposes and are not intended to replace a medical professional’s independent judgment or as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their healthcare provider. New evidence may emerge following the development of these items. The American Society of Breast Surgeons is not responsible for any injury or damage arising out of or related to any use of these items or to any errors or omissions.” (Accessible at http://www.choosingwisely.org/clinician-lists/)

Measures of Appropriateness and Value for Breast Surgeons and Their Patients: The American Society of Breast Surgeons Choosing Wisely Initiative  Landercasper, J et al. Ann Surg Oncol (2016). doi:10.1245/s10434-016-5327-8
http://link.springer.com/article/10.1245/s10434-016-5327-8/fulltext.html