American Society of Breast Surgeons – Benign Breast Disease

Five Things Physicians and Patients Should Question

Released January 8, 2018

  1. 1

    Don’t routinely excise areas of psuedoangiomatous stromal hyperplasia (PASH) of the breast in patients who are not having symptoms from it.

    PASH is a benign breast condition that can present as either an abnormality on imaging or a palpable mass. Unless the lesion is suspicious or a patient has symptoms, a diagnosis of PASH on needle biopsy does not necessitate surgical removal.

  2. 2

    Don’t routinely surgically excise biopsy proven fibroadenomas that are smaller than 2 centimeters in size.

    Fibroadenomas are non-cancerous solid masses within the breast that should be removed only if they are large, bothersome to the patient, or increasing in size. If a needle biopsy shows that a mass less than 2 centimeters in size is a fibroadenoma, with no other concerning features, it does not have to be surgically removed.

  3. 3

    Don’t routinely operate for a breast abscess without an initial attempt to percutaneously aspirate or drain it.

    An abscess is an infection of the breast tissue, forming pockets of pus that can be painful. Many times these can be treated by placing a large needle in the pocket and draining the fluid instead of performing an operation where an incision is made and the fluid removed. The needle removal of the fluid forms less scar and sometimes avoids an operation.

  4. 4

    Don’t perform screening mammography in asymptomatic patients with normal exams who have less than 5-year life expectancy.

    Mammography identifies breast cancers at early stages and has demonstrated benefits in reducing mortality and morbidity from a breast cancer diagnosis. There is minimal benefit of screening mammography in women with life expectancies of <5 years. Additionally, there is a risk of false positives and potential procedures that do not provide patients improved outcomes.

  5. 5

    Don’t routinely drain non-painful fluid-filled breast cysts.

    Breast cysts are common. They are harmless fluid filled sacs. If an ultrasound (sonogram) confirms that a breast mass is a simple cyst, it does not need to be drained unless it is bothersome to the patient or if there are concerns it could be something other than a cyst or has complex characteristics.

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 Society of Breast Surgeons is the primary leadership organization for general surgeons who treat patients with breast disease, and is committed to continually improving the practice of breast surgery by serving as an advocate for surgeons who seek excellence in the care of breast patients. This mission is accomplished by providing a forum for the exchange of ideas and by promoting education, research and the development of advanced surgical techniques.

Founded in 1995, the Society now has more than 3,000 members throughout the United States and in 52 countries around the world.

For more information, visit www.breastsurgeons.org.

How This List Was Created

The American Society of Breast Surgeons (ASBrS) Patient Safety and Quality Committee (PSQC) received approval from the ASBrS Board of Directors to create and rank a list of “appropriateness” domains of benign breast care to be submitted to the ABIM Foundation’s Choosing Wisely Campaign. The PSQC discussed the goals of the Choosing Wisely campaign and solicited candidate measures from its members starting in August, 2016. The PSQC members were asked to identify measures that addressed the goals of Choosing Wisely. Committee members were provided with a full description of the Choosing Wisely campaign and its goals, as well as its emphasis on decreasing “unnecessary” tests and interventions. Specific recommendations were made to consider domains of care that reflected “appropriateness”, “waste”, and “value” as noted in recent publications, randomized trials, and meta analyses.

Committee members were instructed to rank candidate choices specifically as follows:

Voting will occur on a Likert-type scale delineated below:

Rank each Quality Measure (QM) from 1–9. Nine is the highest score for “validity”, 1 is the lowest. Do not give a “lower rank” to a candidate QM because you are concerned about feasibility of measurement, or risk adjustment. Do not assign your numerical score to “weight” your answer with more influence on the final score compared to other panelists; ie. if you believe a “choice’s” score is 4, but you believe other panelists will assign a score “too high”, you should assign a “4”, not a “1,2 or 3”.

Formal definition provided by RAND for “validity”: adherence to this QM is critical to provide quality patient care, regardless of cost or feasibility. Not providing this level of care is a “breach” in care and unacceptable. Level of validity is your personal judgment, not what others believe (or don’t believe) is important. In other words, the strength of this process is that you all are experts and it is natural that opinions may differ. You must provide your opinion. The QM should apply to the average patient in the average hospital with the average physician. Do not be distracted by the special situation in which the QM being ranked may be of different importance in a specific unusual situation. The QM may provide benefit not always to the individual patient, but rather to overall breast care. 1=definitely not valid. 9=valid. 5=uncertain validity.

After creation of a list of 28 candidate measures, two rounds of modified Delphi process ranking were performed electronically—October, 2016 and December, 2016—following the iterative and analytic methodology in the RAND UCLA Ranking manual.*

After each round of ranking, a spreadsheet with ranking results was provided to committee members. Inter-round electronic communication followed with opportunities for participants to discuss the choices, lobby for either or decreasing a choices “rank”, and review areas of significant discordance between participants. After the second round of ranking, the remaining 20 candidate measures all had a median appropriateness score of 7. Subsequently, high scoring items were chosen to inform the final list of 5 choices; these were chosen to reflect the values of the Choosing Wisely Campaign, have broad applicability and impact, and that were consistent with the mission of ASBrS. The final list of 5 choices was distributed to the entire PSQC twice by email for further vetting and a final round of discussion occurred on February 8, 2017.

* The RAND/UCLA Appropriateness Method User’s Manual 2008. Accessible April 3, 2017 at www.rand.org/pubs/monograph_reports/MR1269.

Conflict of Interest (COI):
General COI for the ASBrS PSQC and the ASBrS Board of Directors are on file with the ASBrS staff. The Chair of the PSQC reviewed, then asked for an update of COI before, during and after the ranking process was completed and determined there were no COI for the process or the result.

ASBrS Patient Safety and Quality Committee Members:

  • Roshni Rao MD Co-Chair, New York Presbyterian/Columbia University, New York, NY
  • Jeffrey Landercasper MD Co-Chair, Gundersen Medical Foundation, La Crosse, WI
  • Lisa Bailey MD, Bay Area Breast Surgeons, Inc., Oakland, CA
  • Tiffany S. Berry MD, Norton Healthcare, Louisville, KY
  • Robert R. Buras MD, Anne Arundel Medical Center, Annapolis, MD
  • Steven L Chen MD, MBA, OasisMD, San Diego, CA
  • Amy C. Degnim MD, Mayo Clinic, Rochester, MN
  • Oluwadamilola “Lola” Fayanju, MD, Duke University School of Medicine/Duke Cancer Institute, Durham, NC
  • Joshua Froman MD, Mayo Clinic Health System, Owatonna, MN
  • Jennifer Gass MD, Women and Infants Hospital, Providence, RI
  • Negar Golesorkhi, MD, Sentara Northern Virginia Medical Center, Woodbridge, VA
  • Caprice Greenberg MD, University of Wisconsin School of Public Health and Medicine, Madison, WI
  • Starr Koslow Mautner MD, Miami Cancer Institute, Baptist Health South Florida, Miami, FL
  • Helen Krontiras MD, University of Alabama at Birmingham, Birmingham, AL
  • Kandice Ludwig MD, Indiana University School of Medicine, Indianapolis, IN
  • Ayemoethu Ma MD, Mount Sinai St. Luke’s, New York, NY
  • Michelle Sowden DO, University of Vermont, Burlington, VT
  • Barbara Wexelman MD, Trihealth Cancer Institute, Cincinnati, OH
  • Lee Wilke MD, University of Wisconsin at Madison, Madison, WI

Sources

  1. Raj SD, Sahani VG, Adrada BE, et al. Pseudoangiomatous Stromal Hyperplasia of the Breast: Multimodality Review With Pathologic Correlation. Curr Probl Diagn Radiol. 2017;46: 130-135.

    Virk RK, Khan A. Pseudoangiomatous stromal hyperplasia: an overview. Arch Pathol Lab Med. 2010;134: 1070-1074.

  2. Amin AL, Purdy AC, Mattingly JD, Kong AL, Termuhlen PM. Benign breast disease. Surg Clin North Am. 2013;93: 299-308.

    Gould DJ, Salmans JA, Lassinger BK, et al. Factors associated with phyllodes tumor of the breast after core needle biopsy identifies fibroepithelial neoplasm. J Surg Res. 2012;178: 299-303.

  3. Lam E, Chan T, Wiseman SM. Breast abscess: evidence based management recommendations. Expert Rev Anti Infect Ther. 2014;12: 753-762.

    Trop I, Dugas A, David J, et al. Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up. Radiographics. 2011;31: 1683-1699.

    Naeem M, Rahimnajjad MK, Rahimnajjad NA, Ahmed QJ, Fazel PA, Owais M. Comparison of incision and drainage against needle aspiration for the treatment of breast abscess. Am Surg. 2012;78: 1224-1227.

  4. Schonberg MA, Breslau ES, McCarthy EP. Targeting of mammography screening according to life expectancy in women aged 75 and older. J Am Geriatr Soc. 2013;61: 388-395.

    Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014;311: 1336-1347.

  5. Amin AL, Purdy AC, Mattingly JD, Kong AL, Termuhlen PM. Benign breast disease. Surg Clin North Am. 2013;93: 299-308.

    Berg WA, Sechtin AG, Marques H, Zhang Z. Cystic breast masses and the ACRIN 6666 experience. Radiol Clin North Am. 2010;48: 931-987.

    Sanders LM, Lacz NL, Lara J. 16 year experience with aspiration of noncomplex breast cysts: cytology results with focus on positive cases. Breast J. 2012;18: 443-452.