The Choosing Wisely® campaign was developed by the American Board of Internal Medicine in 2011. The primary goal of this campaign is to encourage conversation between patients and their providers regarding what is “appropriate and necessary treatment” of common medical conditions—meaning it should be supported by evidence, have little risk of harm, and not be wasteful in terms of cost.
Choosing Wisely® guidelines discussing the management of women with breast cancer were released in 2016. While most women who present to a breast surgeon’s office have concerns about breast cancer, the truth remains that most complaints are benign (not cancer). This includes breast lumps, pain, infections, and changes in the skin or shape of the breast. As common as these conditions are, there is wide variation as to how they are treated.
In 2017, the American Society of Breast Surgeons was given the task of developing guidelines for five common benign conditions of the breast. The list of guidelines was released in January 2018.
- Don’t routinely drain non-painful fluid-filled breast cysts. Cysts are fluid-filled sacs in the breast that should only be drained if painful or have concerning features.
- Don’t routinely surgically excise biopsy-proven fibroadenomas that are smaller than 2cm in size. Fibroadenomas are benign solid lumps within the breast that should be removed only if they are large, causing pain, have concerning features, or increasing in size.
- Don’t routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it. An abscess is an infection that results in pockets of pus within the breast tissue. The first step in management should be to consider inserting a needle to remove fluid to clear the infection rather than surgery.
- Don’t perform screening mammography in asymptomatic patients with normal exams who have <5 years life expectancy. While mammograms have been shown to diagnose breast cancer earlier and improve survival, there is minimal benefit in women with life expectancy <5 years.
- Don’t routinely excise areas of pseudoangiomatous stromal hyperplasia (PASH) of the breast in women who are not having symptoms from it. PASH can present as either an abnormality on imaging or a palpable lump. Unless the area is suspicious or a woman has symptoms, it does not always require surgery.
The underlying theme of these guidelines is to determine whether surgery or invasive procedures are necessary. They are not exclusive and are only recommendations for managing these conditions. It is still important for women and their providers to have serious conversations about whether additional testing or procedures are necessary, along with the risks and benefits of each option. If you have developed any of these conditions, you are encouraged to discuss these guidelines with your care provider. Additional information can be found at the Choosing Wisely® website at http://www.choosingwisely.org/societies/american-society-of-breast-surgeons-benign-breast-disease/.