EHR–Based Nudge Intervention for Surgeons to Reduce Breast Cancer Overtreatment

Sentinel lymph node biopsy (SLNB) is a critical surgical technique used to assess if breast cancer has spread to the underarm lymph nodes, although it's not necessary for all patients. Undergoing SLNB exposes patients to the risk of developing lymphedema, a permanent but treatable swelling in the arm or breast that can significantly affect their quality of life. For patients over 70 with early-stage estrogen-receptor positive breast cancer, routine SLNB is often discouraged due to the low risk of metastasis and favorable tumor characteristics. Despite this, many women in this demographic still receive this procedure even though it does not significantly guide treatment, improve survival, or come without potential side effects. To address this, researchers have created a new prompt, or ‘nudge,’ within the electronic health record (EHR) system to alert surgeons about older patients with early-stage breast cancer who could be at risk for unnecessary lymph node surgery.

Developed by researchers at the University of Pittsburgh Medical Center (UPMC, Pittsburgh, PA, USA), the "HER nudge" reminds surgeons to reassess the need for SLNB in older patients based on age and tumor biology. In a paper published in JAMA Surgery, the team observed a significant decline in the SLNB rate among targeted patients following the introduction of this nudge, indicating its capability to potentially reduce overtreatment. In a non-randomized clinical trial involving seven surgeons across eight surgical oncology clinics, SLNB was performed on 46.9% of eligible patients before the nudge and only 23.8% during the 12-month period after its implementation—a 49.3% reduction. This decline continued, with a further drop to 15.6% observed over an additional six months.

Surgeons participating in the trial rated the nudge as highly acceptable, appropriate, and feasible, appreciating its seamless integration into their existing workflow without the need for extra clicks or documentation. Additionally, the researchers used artificial intelligence to review patient records for mentions of lymphedema symptoms, finding that the rate of symptoms indicating a need for lymphedema evaluation fell from 6.2% to 3.6% post-nudge implementation.

“Our findings suggest that fewer lymph node surgeries resulting from the nudge will help reduce rates of lymphedema, but we need longer follow-up to be certain because this condition can take several years to appear,” said first author Neil Carleton, Ph.D., a student in Pitt’s Medical Scientist Training Program.

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