American College of Surgeons

Five Things Physicians and Patients Should Question

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1

Don’t perform axillary lymph node dissection for clinical stages I and II breast cancer with clinically negative lymph nodes without attempting sentinel node biopsy.

Sentinel node biopsy is proven effective at staging the axilla for positive lymph nodes and is proven to have fewer short and long term side effects, and in particular is associated with a markedly lower risk of lymphedema (permanent arm swelling).

When the sentinel lymph node(s) are negative for cancer, no axillary dissection should be performed.

When one or two sentinel nodes are involved with cancer that is not extensive in the node, the patient received breast conserving surgery and is planned to receive whole breast radiation and stage appropriate systemic therapy, axillary node dissection should not be performed.

2

Avoid the routine use of “whole-body” diagnostic computed tomography (CT) scanning in patients with minor or single system trauma.

Aggressive use of “whole-body” CT scanning improves early diagnosis of injury and may even positively impact survival in polytrauma patients.  However, the significance of radiation exposure as well as costs associated with these studies must be considered, especially in patients with low energy mechanisms of injury and absent physical examination findings consistent with major trauma.

3

Avoid colorectal cancer screening tests on asymptomatic patients with a life expectancy of less than 10 years and no family or personal history of colorectal neoplasia.

Screening for colorectal cancer has been shown to reduce the mortality associated with this common disease; colonoscopy provides the opportunity to detect and remove adenomatous polyps, the precursor lesion to many cancers, thereby reducing the incidence of the disease later in life.

However, screening and surveillance modalities are inappropriate when the risks exceed the benefit.

The risk of colonoscopy increases with increasing age and comorbidities.

The risk/benefit ratio of colorectal cancer screening or surveillance for any patient should be individualized based on the results of previous screening examinations, family history, predicted risk of the intervention, life expectancy and patient preference.

4

Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest X-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2 percent of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary diseases in patients older than age 70 who has not had chest radiography within six months.

5

Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94 percent in experienced hands. Recognizing that expertise may vary, strategies including improving diagnostic expertise in community based ultrasound and the development of evidence-based clinical decision rules are realistic goals in improving diagnosis without the use of CT scan.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.

How this list was created: The American College of Surgeons (ACS) solicited recommendations for the ABIM Foundation’s Choosing Wisely® campaign from the Commission on Cancer, Committee on Trauma, and the Advisory Councils for Colon and Rectal Surgery, General Surgery, and Pediatric Surgery. The committees were provided with a description of the campaign’s initiative, a link to the Choosing Wisely website, and published recommendations from organizations already participating in the campaign were referenced and reviewed during discussions. All of the recommendations collected from the ACS committees were reviewed, and five items were identified. The ACS’ disclosure and conflict of interest policy can be found at www.facs.org.

Participating ACS Committees:

Advisory Council for Colon and Rectal Surgery

  • Chair: Thomas E. Read, MD, FACS, Burlington, MA

Advisory Council for General Surgery

  • Chair: E. Christopher Ellison, MD, FACS, Columbus, OH

Advisory Council for Pediatric Surgery

  • Chair: Mary E. Fallat, MD, FACS, Louisville, KY
  • Immediate Past Chair: Thomas F. Tracy Jr., MD, FACS, Providence, RI

Commission on Cancer

  • Chair: Daniel P. McKellar, MD, FACS, Greenville, OH

Committee on Trauma

  • Chair: Michael F. Rotondo, MD, FACS, Greenville, NC

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