Which breast cancer decisions remain non-compliant with guidelines despite the use of computerised decision support?
BACKGROUND
Despite multidisciplinary tumour boards (MTBs), non-compliance with clinical practice guidelines is still observed for breast cancer patients. Computerised clinical decision support systems (CDSSs) may improve the implementation of guidelines, but cases of non-compliance persist.


METHODS
OncoDoc2, a guideline-based decision support system, has been routinely used to remind MTB physicians of patient-specific recommended care plans. Non-compliant MTB decisions were analysed using a multivariate adjusted logistic regression model.


RESULTS
Between 2007 and 2009, 1624 decisions for invasive breast cancers with a global non-compliance rate of 8.3% were analysed. Patient factors associated with non-compliance were age>80 years (odds ratio (OR): 7.7; 95% confidence interval (CI): 3.7-15.7) in pre-surgical decisions; microinvasive tumour (OR: 5.2; 95% CI: 1.5-17.5), surgical discovery of microinvasion in addition to a unique invasive tumour (OR: 4.2; 95% CI: 1.4-12.5), and prior neoadjuvant treatment (OR: 4.2; 95% CI: 1.1-15.1) in decisions with recommendation of re-excision; age<35 years (OR: 4.7; 95% CI: 1.9-11.4), positive hormonal receptors with human epidermal growth factor receptor 2 overexpression (OR: 15.7; 95% CI: 3.1-78.7), and the absence of prior axillary surgery (OR: 17.2; 95% CI: 5.1-58.1) in adjuvant decisions.


CONCLUSIONS
Residual non-compliance despite the use of OncoDoc2 illustrates the need to question the clinical profiles where evidence is missing. These findings challenge the weaknesses of guideline content rather than the use of CDSSs.
UPMC, UFR de Médecine, Sorbonne Universités, 91 boulevard de l'hôpital, 75013 Paris, France. brigitte.seroussi@tnn.aphp.fr
B
B
Séroussi
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Laouénan
J
J
Gligorov
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S
Uzan
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Mentré
J
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Bouaud
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000628:therapy*; D003658:Decision Making, Computer-Assisted; D003661:Decision Support Techniques; D005103:Expert Systems; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000592:standards*