Choosing Wisely: Optimizing Routine Workup for the Newly Diagnosed Breast Cancer Patient

Purpose of Review: The American Board of Internal Medicine Foundation’s Choosing Wisely (CW) campaign has promoted a dialogue about avoiding unnecessary medical services since 2012. We review the evidence base, trends in utilization, and implications of CW recommendations relevant to the routine workup of newly diagnosed early stage breast cancer patients. Recent Findings: There are several CW recommendations addressing routine workup of newly diagnosed breast cancer: • Do not perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis - These studies are obtained in 10–20% of patients, especially those with Stage IIB disease • Do not routinely order breast MRI in new breast cancer patients with average risk - Evidence of long-term benefit to preoperative MRI is lacking, but approximately 1 in 4 breast cancer patients receive one, often leading to additional interventions • Do not routinely order specialized tumor gene testing in all new breast cancer patients - Evolving guidelines are expanding eligible populations for genetic assay driven clinical decision-making, with mixed implications for adjuvant chemotherapy utilization • Do not routinely use sentinel node biopsy in clinically node negative women ≥ 70 years of age with hormone receptor positive invasive breast cancer - The vast majority of such patients—85–90%— undergo sentinel node biopsy despite questions about the benefit of axillary staging in an elderly population Summary: CW recommendations offer a useful starting point for the discussion of optimal routine workup for breast cancer. Continued efforts are needed to define the marginal value of different tests and interventions and to develop mechanisms to incentivize and measure adoption of best practices. © 2018, Springer Science+Business Media, LLC, part of Springer Nature.