Past
Most older women with breast cancer have early-stage, hormone receptor-positive (HR+) tumors, a favorable biology with an excellent long-term prognosis. At the same time, older women are more vulnerable to toxicities of cancer treatment. In this setting, several studies have investigated the safety of omitting previously routine therapies. In 2013, the Cancer and Leukemia Group B (CALGB) 9343 trial demonstrated that women ≥ 70 years-old who underwent post-lumpectomy radiotherapy with or without axillary staging experienced no additional survival benefit compared to women treated with lumpectomy and endocrine therapy alone.1 As part of national campaigns to reduce low-value services, organizations including the Society of Surgical Oncology (SSO) and the National Comprehensive Cancer Network (NCCN) now recommended against the routine use of SLNB and post-lumpectomy radiotherapy since at least 2016 in these patients.
Present
Both SLNB and post-lumpectomy radiotherapy continue to be utilized at high rates in patients eligible for omission.2 Current literature has investigated this quality gap from both providers’ and patients’ perspectives. The single-item maximizer-minimizer elicitation question (MM1) is a recently validated question that can categorize an individual as a medical “maximizer” who generally pursues intervention regardless of necessity or a “minimizer” who generally refuses intervention unless absolutely necessary.3 In this study, we analyzed the relationship between older women’s maximizing-minimizing (MM) scores as determined by the MM1 and their preferences for surgery, axillary staging, chemotherapy, and radiotherapy in the case of early-stage, HR+ breast cancer.4
Future
We demonstrated a clear association between medical MM preferences in older women and their preferences for low-value breast cancer treatment options. While there exists an ethical tension between eliminating low-value care and maintaining patient autonomy, we believe physicians have an obligation to practice evidence-based medicine, reduce healthcare waste, and prevent patient harm. Addressing patients’ maximizing-minimizing preferences through the MM1 may offer a patient-centered approach to de-implementation by actively involving the patient in conversations surrounding low-value care. The best strategy to address MM preferences is an area of future research and may require targeted messages and directed counseling to patients based on their MM1 scores.
Acknowledgments
This project was supported by an internal grant from the University of Michigan Rogel Cancer Center. Dr. Dossett is supported by a grant from the Agency for Healthcare Research and Quality (AHRQ; 5 K08 HS026030-02). Dr. Wang, one of the co-investigators, is supported by a grant from the National Cancer Institute (NCI; T32 CA009672).
Footnotes
Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
References
- 1.Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–2387. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Wang T, Baskin A, Dossett LA. De-Implementation of the Choosing Wisely® recommendations for low-value breast cancer surgery: a systematic review [published online ahead of print, 2020 Jun 3]. JAMA Surg. 2020. 10.1001/jamasurg.2020.0322. [DOI] [PMC free article] [PubMed]
- 3.Scherer LD, Zikmund-Fisher BJ. Eliciting medical maximizing-minimizing preferences with a single question: development and validation of the MM1. Med Decis Making. 2020;40(4):545–550. [DOI] [PubMed] [Google Scholar]
- 4.Mott N, Wang T, Miller J, Berlin NL, Hawley S, Jagsi R, et al. Medical maximizing-minimizing preferences in relation to low-value services for older women with hormone-receptor positive breast cancer—a qualitative study. Ann Surg Onc. (In press, 2020). [DOI] [PMC free article] [PubMed]