27 June 2016

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation. Things Providers and Patients Should Question have been chosen by various medical societies based on review of the evidence-based literature. The American Society of Breast Surgeons (ASBrS) has published their contributions to the campaign (open access) in the Annals of Surgical Oncology.

The 5 ASBrS measures include:

1.) Don’t routinely order breast magnetic resonance imaging (MRI) in new breast cancer patients
2.) Don’t routinely excise all the lymph nodes underneath the arm in patients having partial breast removal (lumpectomy) for breast cancer when only one or two contain cancer
3.) Don’t routinely order specialized tumor gene testing in all new breast cancer patients
4.) Don’t routinely reoperate on patients if the cancer is close to the edge of the excised lumpectomy tissue
5.) Don’t routinely perform a double mastectomy in patients who have single breast with cancer.

Rational for the measures is included in the manuscript, and are posted on the Choosing Wisely website.

As with the other Choosing Wisely lists, these are meant to spark discussions between patients and their physicians regarding the appropriate use of medical tests and procedures. In many areas of medicine, tests and procedures may be performed without good supportive evidence. There may be many valid reasons for straying from an evidence based practice, which is part of the art of medicine. In fact, the Choosing Wisely website specifically states that “these recommendations should not be used to establish coverage decisions or exclusions.” In addition, the ASBrS statement notes that the selections made “are not meant to infer that a test or procedure endorsed in our list is a ‘never should occur’ event.”

Individualizing care as much as possible is extremely important. However, that does not mean performing every available test just because it’s available. Patients and physicians need to realize that there are downsides to unnecessary testing. Physicians also need to remain educated about current practice, and not continue to make outdated recommendations simply because they may have “always done it that way.” A goal of the Choosing Wisely campaign is to ensure that when decisions are made, available evidence is considered and that the process is a collaborative one between patients and their physicians.