New Breast Health “Don’t”s Added to Choosing Wisely

Rita Singhal, MD, MPH

March-April 2018

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Choosing WiselyTM recommendations have recently grown to include more society recommendations of practices to avoid in the management of benign breast disease and breast cancer screening. The recommendations from the American Society of Breast Surgeons (ASBS), the Society of Surgical Oncology (SSO), and the American Society of Clinical Oncology (ASCO) that are relevant to primary care are listed below and have also been added to the Rx for Prevention, Women’s Health Choosing Wisely Recommendations. The table, “Summary of Choosing Wisely Women’s Health Care ‘Don’ts’,” is included at the end of this article and available here for printing on one page.

  1. Don’t routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size. (ASBS) Fibroadenomas are a benign breast condition that do not need to be surgically removed unless they are large, increasing in size, or bothersome to the patient.1

  2. Don’t routinely drain non-painful fluid-filled breast cysts. (ASBS) An ultrasound-confirmed simple breast cyst does not need to be drained unless there are concerning features such as complex characteristics or if it is bothersome to the patient.1

  3. Don’t routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it.(ASBS) For a breast abscess, initial treatment should be an attempt to remove fluid with a needle to minimize scarring and avoid more invasive procedures.1

  4. Don’t routinely use breast MRI for breast cancer screening in average risk women. (SSO) Average risk women should be routinely screened using mammography. Breast MRI should be reserved for women at increased risk which includes, but is not limited to, the following: known BRCA gene mutation carriers, those with a lifetime risk for breast cancer greater than 20%, or those who received mantle radiation before the age of 30.2

  5. Don’t perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy. (ASBS) The breast cancer mortality reduction benefit from screening mammography is minimal in women with life expectancies of less than five years. In addition, mammography carries a risk of false positives and the need for follow-up procedures with no improved outcomes for patients.1

  6. Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent. (ASCO) Surveillance in breast cancer patients does not require routine imaging or serum tumor marker measurements in asymptomatic patients that have been treated with curative intent. False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.3
 

Summary of Choosing Wisely Women’s Health Care "Don’t's"*

 

Hormonal Contraceptives
  • Don’t require a pelvic exam or other physical exam before prescribing.
Irregular or Abnormal Menstrual Bleeding
  • Don’t obtain FSH levels in women in their 40s to identify menopause transition as a cause of irregular or abnormal menstrual bleeding.
Cervical Cancer Screening and Abnormal Cytology Management.**
  • Don’t screen women younger than 21 years.
  • Don’t screen women who have had a hysterectomy for non-cancer disease.
  • Don’t screen women younger than 30 years with HPV testing, either alone or in combination with cytology.
  • Don’t perform annual screening for average-risk women between the ages 30-65.
  • Don’t screen women older than 65 years who have had adequate prior screening and are not at high-risk.
  • Don’t perform Pap tests for surveillance of women with a history of endometrial cancer.
  • Don’t treat women with mild dysplasia of less than 2 years’ duration.

**These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).

Ovarian Cancer Screening
  • Don’t screen for ovarian cancer in asymptomatic women at low/average risk.
Breast Cancer Screening
  • Don’t routinely use breast MRI for breast cancer screening in average risk women.
  • Don’t perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy.
  • Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
General Cancer Screening
  • Don’t recommend cancer screening in adults with life expectancy of less than 10 years.
Osteoporosis Screening
  • Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 with no risk factors.
Management of Benign Breast Disease
  • Don’t routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size.
  • Don’t routinely drain non-painful fluid-filled breast cysts.
  • Don’t routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it.

 

*Choosing Wisely Clinician Lists www.choosingwisely.org/clinician-lists

Click here to download a one-page printable version of this table.

 

As part of the Choosing Wisely campaign, specialty societies, including the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), the Society of Gynecologic Oncology (SGO), the Society of General Internal Medicine (SGIM), American Society of Breast Surgeons (ASBS), Society of Surgical Oncology (SSO), and American Society of Clinical Oncology (ASCO) have developed evidence-based recommendations for what care should not be routinely provided. In developing these recommendations, the goal was to follow the primary tenet of medicine: first, do no harm.

 

References

  1. American Society of Breast Surgeons - Benign Breast Disease: Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/american-society-of-breast-surgeons-benign-breast-disease/. Released January 8, 2018. Accessed February 14, 2018.
  2. Society of Surgical Oncology: Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/society-of-surgical-oncology/. Released July 12, 2016. Accessed February 14, 2018.
  3. American Society of Clinical Oncology: Ten Things Physicians and Patients Should Question. http://www.choosingwisely.org/societies/american-society-of-clinical-oncology/. Released April 4, 2012 (1-5) and October 29, 2013 (6-10). Accessed February 14, 2018.
 

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Author Information:

Rita Singhal, MD, MPH
Medical Director
Office of Women’s Health

County of Los Angeles
Department of Public Health

risinghal@ph.lacounty.gov

publichealth.lacounty.gov/owh/


Rx for Prevention, 2018
March-April;8(2).


Published: March 15, 2018