Electronic Intervention May Decrease Low-Value Surgery in Breast Cancer

"The simple, user-friendly nudge provides a timely reminder to surgeons to consider the value of SLNB for each patient," according to Priscilla McAuliffe, MD, PhD.

An electronic health record (EHR)–based nudge intervention may limit the use of low-value sentinel lymph node biopsy (SLNB) among older patients with early-stage, cN0, hormone receptor (HR)–positive, HER2-negative breast cancer without impacting receipt of adjuvant treatment, according to findings from a nonrandomized trial (NCT06006910) published in JAMA Surgery.¹

Investigators administered SLNB to 46.9% (n = 91/194) of patients during the control period and 23.8% (n = 46/193) during the intervention period in which the nudge was implemented. When stratifying for race or ethnicity, there was no difference between periods. When adjusting for secular trends in SLNB use, intervention with the nudge correlated with a significant reduction in the use of SLNB (adjusted odds ratio [aOR], 0.26; 95% CI, 0.07-0.90; P = .03).

The rates of pathological node positivity were 8.8% for patients treated during the control period and 15.2% for those who received treatment during the intervention period. The decreases in the use of SLNB with the nudge intervention accompanied a reduction in the number of patients with symptoms warranting a referral for lymphedema evaluation. The referral rates were 6.2% for patients during the control period and 3.6% during the intervention period. Additionally, adjuvant system therapy recommendations did not appear to differ between the intervention and control groups.

Within the Epic EHR system, a nudge intervention column was implemented into the schedule. This nudge flagged patients based on their age, diagnosis code, and a new visit. This was indicated during the first outpatient surgical consultation by a caution signal or a red clipboard icon. When the surgeon clicked or hovered over the icon, it had them consider the omission of SLNB based on a detailed review of a core biopsy and ultrasonographic imaging.

“In breast cancer, there is a growing movement toward precisely treating each individual patient, [which is] what we call right-sized care. SLNB helps us determine if breast cancer has spread to the underarm lymph nodes, but it’s not necessary for every patient,” senior study author Priscilla McAuliffe, MD, PhD, an associate professor of surgery at the University of Pittsburgh and a breast surgical oncologist at the University of Pittsburgh Medical Center (UPMC) Hillman and UPMC Magee-Womens Hospital, said in a press release on these findings.² “The simple, user-friendly nudge provides a timely reminder to surgeons to consider the value of SLNB for each patient.”

Investigators conducted this hybrid type 1 effectiveness-implementation study to evaluate the feasibility and utility of an EHR-based nudge to limit the use of low-value SLNB.

The trial was conducted from October 2021 to October 2023 as part of the pre-intervention control period, in which 194 patients received treatment without the use of the electronic nudge. The nudge was deployed from October 2022 to October 2023; 193 patients received treatment during this intervention period. Investigators collected data based on EHRs at 8 outpatient clinics within an integrated system that included 7 breast surgical oncologists.

The trial’s primary end point was the rate of SLNB use after the nudge was integrated into the EHR. Secondary end points included the acceptability, appropriateness, and feasibility of the nudge intervention using a validated survey instrument.

The median patient age was 75 years (IQR 72-79) in both the control and intervention groups. Findings showed no significant differences in tumor characteristics between these groups.

Survey results indicated that the nudge intervention fulfilled the criteria for acceptability, appropriateness, and feasibility among the responding surgeons; aggregate scores exceeded 16 on a 20-point scale. Specifically, the scores for the intervention’s feasibility were the highest. Additionally, semi-structured interviews among the surgeons revealed 4 key themes related to the use of the nudge, including the intervention as a “reminder” for patient applicability of SLNB omission, logistics of the intervention’s implementation and engagement, patient perception and influence, and impact of axillary staging decision-making.

References

1. Carleton N, Radomski TR, Li D, et al. Electronic health record–based nudge intervention and axillary surgery in older women with breast cancer: a nonrandomized controlled trial. JAMA Surg. Published online July 17, 2024. doi:10.1001/jamasurg.2024.2407
2. Electronic prompt for surgeons may reduce breast cancer overtreatment. News release. UPMC. July 17, 2024. Accessed July 23, 2024. https://tinyurl.com/5n8hdu5d