A recent study published in JAMA Surgery suggests that implementing a prompt or “nudge” in electronic health records (EHRs) could effectively reduce the rate of overtreatment among older patients with early-stage breast cancer.
Conducted as an observational, nonrandomized study (NCT06006910), the research indicated that patients treated after the deployment of the nudge (n = 193) underwent sentinel lymph node biopsy at a rate of 23.8%, compared to 46.9% among those treated before the nudge (n = 194). This represented a significant decrease of 23.1% (95% CI, –32.9% to –13.8%) in the unadjusted rate of sentinel lymph node biopsy during the intervention period compared to the control period. After adjusting for potential confounders, the odds ratio was 0.35 (95% CI, 0.23-0.55; P < .001), indicating a substantial reduction in biopsy rates post-nudge deployment.
Dr. Priscilla F. McAuliffe, a breast surgical oncologist at UPMC Hillman Cancer Center and assistant professor at the University of Pittsburgh School of Medicine, emphasized the importance of tailored care in breast cancer treatment. She noted that while sentinel lymph node biopsy is crucial for staging, it may not be necessary for every patient, and the nudge serves as a timely reminder to consider its value.
The study, classified as a hybrid type 1 effectiveness-implementation trial, assessed the feasibility, acceptability, and appropriateness of the EHR-based nudge intervention across eight surgical oncology clinics within a single health care system from October 2021 to October 2023. Eligible patients, aged 70 or older with hormone receptor-positive/HER2-negative, early-stage breast cancer, received a prompt during their initial consultation, recommending reconsideration of sentinel lymph node biopsy based on clinical factors.
Results also indicated a sustained reduction in biopsy rates beyond the intervention period, with a mean rate of 15.6% observed six months post-intervention. Furthermore, the incidence of lymphedema-related symptoms potentially necessitating evaluation decreased from 6.2% in the control period to 3.6% during the intervention period, highlighting additional benefits of the nudge strategy.
Neil Carleton, the study’s lead author and a graduate student at Pitt’s Medical Scientist Training Program, underscored the impact on patient outcomes, noting that avoiding unnecessary procedures can mitigate risks associated with lymph node surgeries, such as lymphedema. He stressed the need for continued monitoring to fully assess long-term implications.
The findings suggest that integrating clinical decision support tools like nudges into EHRs can effectively enhance treatment precision and patient safety in breast cancer care. Further research is warranted to validate these results and explore broader implementation across diverse healthcare settings.
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