Society of Surgical Oncology

Five Things Physicians and Patients Should Question

Released July 12, 2016; updated June 20, 2019; updated November 13, 2020; updated July 27, 2021

  1. 1

    Don’t routinely use sentinel node biopsy in clinically node negative women ≥70 years of age with early stage hormone receptor positive, HER2 negative invasive breast cancer.

    Endocrine therapy is standard treatment for all patients with hormone receptor positive breast cancer. The omission of sentinel lymph node biopsy in patients with non-palpable axillary lymph nodes in those women ≥70 years of age treated with endocrine therapy does not result in increased rates of locoregional recurrence and does not impact breast cancer mortality. Patients ≥ 70 years of age with early-stage, hormone receptor positive, HER2 negative breast cancer and no palpable axillary lymph nodes can be safely treated without axillary staging. Axillary staging can be individually considered, if the results may impact radiation therapy recommendations and/or systemic therapy decisions.

  2. 2

    Don’t routinely use breast MRI for breast cancer screening in average risk women.

    MRI screening should be reserved for those at increased risk of developing breast cancer. Women considered at high risk include: known BRCA gene mutation carriers; untested first-degree relatives of known BRCA gene mutation carriers; those with moderate penetrance gene mutations including CHEK2, PALB2, ATM, PTEN, CDH1 and p53; those with a lifetime risk exceeding 20% as measured by risk-assessment tools based primarily on family history of breast cancer; and those with a clinical history associated with a significant risk for breast cancer, including women who received mantle radiation before the age of 30. MRI for screening after treatment for breast cancer is not indicated in women who would otherwise be considered average risk.

  3. 3

    Don’t obtain routine blood work (e.g., CBC, liver function tests) other than a CEA level for surveillance for colorectal cancer.

    Due to lack of sensitivity and accuracy in detecting early recurrences, current evidence does not support measurement of CBC or liver function tests for surveillance following colorectal cancer treatment. Although evidence is not unequivocal, surveillance regimens that include serial carcinoembryonic antigen (CEA) testing have been associated with improved survival.

    Depending on the stage of non-metastatic disease, accepted components for colorectal cancer surveillance following standard radical resection include a combination of history and physical examination; CEA; CT of the chest, abdomen and pelvis; and colonoscopy at variable intervals depending on stage and risk of recurrent disease.

  4. 4

    Don’t perform routine PET-CT in the initial staging of localized colon or rectal cancer or as part of routine surveillance for patients who have been curatively treated for colon or rectal cancer.

    A CT of the chest, abdomen and pelvis with IV and PO contrast provides excellent staging and standard PET imaging does not significantly improve diagnostic accuracy or outcomes as part of the initial workup or surveillance testing. Use of PET does not eliminate the need for recommended staging CT but does increase costs.

  5. 5

    Don’t routinely order imaging studies for initial staging purposes prior to surgery on a patient with clinically localized primary cutaneous melanoma unless there is suspicion for metastatic disease based on history and/or physical exam.

    Routine imaging studies for localized melanoma including chest radiographs, brain MRI, cross-sectional imaging and PET/CT are insensitive at the lower limits of resolution and do not significantly improve staging of these patients. There is a low risk of metastases and also a risk of detecting findings unrelated to the melanoma (e.g., false positive findings or incidental, unrelated findings). Imaging should be performed if there are concerning findings on history and physical exam, and such tests should be driven by symptoms.

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.

Founded in 1940 as the James Ewing Society, the Society of Surgical Oncology® is the preeminent organization for surgeons, scientists and health care specialists dedicated to advancing the treatment of cancer through leading edge scientific research and surgical techniques. The Society’s 2,800 U.S. and international members are at the forefront of the field, representing premier universities, hospitals and cancer centers from around the globe; in addition to its domestic initiatives, the Society has entered into agreements with six international surgical societies to advance collaborative cancer care education globally. The Society’s focus on all solid tumor disease sites is reflected in its Annual Cancer Symposium, monthly scientific journal (Annals of Surgical Oncology), education initiatives and committee structure. The mission of the Society of Surgical Oncology is to improve multidisciplinary patient care by advancing the science, education and practice of cancer surgery worldwide. For more information, visit

How This List Was Created

The Society of Surgical Oncology (SSO) maintains disease site workgroups (DSWGs) to represent the various disease sites associated with surgical oncology. The DSWGs are comprised of experts in the following disease sites: gastrointestinal, melanoma/sarcoma, breast, hepatobiliary, endocrine/head & neck, colorectal and peritoneal surface malignancy. The SSO Quality Committee initiated the Choosing Wisely measure development process by asking the DSWGs to identify tests or procedures commonly used in their respective areas of expertise whose necessity should be questioned and discussed. The Quality Committee received submissions from six disease sites; however, because the list was limited to five measures, the Committee felt it was precluded from incorporating measures representing all disease sites. As a means of refining the list of Choosing Wisely measures, the Quality Committee elected to include the five measures impacting the largest number of patients. The draft list was reduced significantly – eliminating the gastrointestinal, endocrine, hepatobiliary, sarcoma and peritoneal surface malignancies measures. The five measures were selected from the breast, colorectal and melanoma sets. These five measures were submitted to and approved by the SSO Executive Council.

Quality Committee Members

  • Sandra Wong, MD, MS, Chair
  • David Shibata, MD, Vice Chair
  • Dave Bentrem, MD
  • Ned Carp, MD
  • Fabian Johnston, MD, MHS
  • Tari King, MD
  • Larissa Temple, MD
  • Sharon Weber, MD


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