American Society of Breast Surgeons – Benign Breast Disease

View all recommendations from this society

January 8, 2018

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.

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.

How The 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

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


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.