Access to breast reconstruction after mastectomy and patient perspectives on reconstruction decision making

IMPORTANCE

Most women undergoing mastectomy for breast cancer do not undergo breast reconstruction.

OBJECTIVE

To examine correlates of breast reconstruction after mastectomy and to determine if a significant unmet need for reconstruction exists.

DESIGN, SETTING, AND PARTICIPANTS

We used Surveillance, Epidemiology, and End Results registries from Los Angeles, California, and Detroit, Michigan, for rapid case ascertainment to identify a sample of women aged 20 to 79 years diagnosed as having ductal carcinoma in situ or stages I to III invasive breast cancer. Black and Latina women were oversampled to ensure adequate representation of racial/ethnic minorities. Eligible participants were able to complete a survey in English or Spanish. Of 3252 women sent the initial survey a median of 9 months after diagnosis, 2290 completed it. Those who remained disease free were surveyed 4 years later to determine the frequency of immediate and delayed reconstruction and patient attitudes toward the procedure; 1536 completed the follow-up survey. The 485 who remained disease free at follow-up underwent analysis.

EXPOSURES

Disease-free survival of breast cancer.

MAIN OUTCOMES AND MEASURES

Breast reconstruction at any time after mastectomy and patient satisfaction with different aspects of the reconstruction decision-making process.

RESULTS

Response rates in the initial and follow-up surveys were 73.1% and 67.7%, respectively (overall, 49.4%). Of 485 patients reporting mastectomy at the initial survey and remaining disease free, 24.8% underwent immediate and 16.8% underwent delayed reconstruction (total, 41.6%). Factors significantly associated with not undergoing reconstruction were black race (adjusted odds ratio [AOR], 2.16 [95% CI, 1.11-4.20]; P = .004), lower educational level (AOR, 4.49 [95% CI, 2.31-8.72]; P < .001), increased age (AOR in 10-year increments, 2.53 [95% CI, 1.77-3.61]; P < .001), major comorbidity (AOR, 2.27 [95% CI, 1.01-5.11]; P = .048), and chemotherapy (AOR, 1.82 [95% CI, 0.99-3.31]; P = .05). Only 13.3% of women were dissatisfied with the reconstruction decision-making process, but dissatisfaction was higher among nonwhite patients in the sample (AOR, 2.87 [95% CI, 1.27-6.51]; P = .03). The most common patient-reported reasons for not having reconstruction were the desire to avoid additional surgery (48.5%) and the belief that it was not important (33.8%), but 36.3% expressed fear of implants. Reasons for avoiding reconstruction and systems barriers to care varied by race; barriers were more common among nonwhite participants. Residual demand for reconstruction at 4 years was low, with only 30 of 263 who did not undergo reconstruction still considering the procedure.

CONCLUSIONS AND RELEVANCE

Reconstruction rates largely reflect patient demand; most patients are satisfied with the decision-making process about reconstruction. Specific approaches are needed to address lingering patient-level and system factors with a negative effect on reconstruction among minority women.

Shared decision making for treatment of cancer: challenges and opportunities

Treatment recommendations are based on complicated clinical information that is revealed variably over time after initial diagnosis. Integrating this information into a treatment plan is challenging, as different specialists direct the various treatments.

Impact of adjuvant chemotherapy on long-term employment of survivors of early-stage breast cancer

BACKGROUND

Many women with early-stage breast cancer are working at the time of diagnosis and survive without disease recurrence. The short-term impact of chemotherapy receipt on employment has been demonstrated, but the long-term impact merits further research.

METHODS

The authors conducted a longitudinal multicenter cohort study of women diagnosed with nonmetastatic breast cancer between 2005 and 2007, as reported to the population-based Los Angeles and Detroit Surveillance, Epidemiology, and End Results program registries. Of 3133 individuals who were sent surveys, 2290 (73%) completed a baseline survey soon after diagnosis and of these, 1536 (67%) completed a 4-year follow-up questionnaire.

RESULTS

Of the 1026 patients aged < 65 years at the time of diagnosis whose breast cancer did not recur and who responded to both surveys, 746 (76%) worked for pay before diagnosis. Of these, 236 (30%) were no longer working at the time of the follow-up survey. Women who received chemotherapy as part of their initial treatment were less likely to be working at the time of the follow-up survey (38% vs 27%; P = .003). Chemotherapy receipt at the time of diagnosis (odds ratio, 1.4; P = .04) was found to be independently associated with unemployment during survivorship in a multivariable model. Many women who were not employed during the survivorship period wanted to work: 50% reported that it was important for them to work and 31% were actively seeking work.

CONCLUSIONS

Unemployment among survivors of breast cancer 4 years after diagnosis is often undesired and appears to be related to the receipt of chemotherapy during initial treatment. These findings should be considered when patients decide whether to receive adjuvant chemotherapy, particularly when the expected benefit is low.

Long-term financial burden of breast cancer: experiences of a diverse cohort of survivors identified through population-based registries

PURPOSE

To evaluate the financial experiences of a racially and ethnically diverse cohort of long-term breast cancer survivors (17% African American, 40% Latina) identified through population-based registries.

METHODS

Longitudinal study of women diagnosed with nonmetastatic breast cancer in 2005 to 2007 and reported to the SEER registries of metropolitan Los Angeles and Detroit. We surveyed 3,133 women approximately 9 months after diagnosis and 4 years later. Multivariable models evaluated correlates of self-reported decline in financial status attributed to breast cancer and of experiencing at least one type of privation (economically motivated treatment nonadherence and broader hardships related to medical expenses).

RESULTS

Among 1,502 patients responding to both surveys, median out-of-pocket expenses were ≤ $2,000; 17% of respondents reported spending > $5,000; 12% reported having medical debt 4 years postdiagnosis. Debt varied significantly by race: 9% of whites, 15% of blacks, 17% of English-speaking Latinas, and 10% of Spanish-speaking Latinas reported debt (P = .03). Overall, 25% of women experienced financial decline at least partly attributed to breast cancer; Spanish-speaking Latinas had significantly increased odds of this decline relative to whites (odds ratio [OR], 2.76; P = .006). At least one privation was experienced by 18% of the sample; blacks (OR, 2.6; P < .001) and English-speaking Latinas (OR, 2.2; P = .02) were significantly more likely to have experienced privation than whites.

CONCLUSION

Racial and ethnic minority patients appear most vulnerable to privations and financial decline attributable to breast cancer, even after adjustment for income, education, and employment. These findings should motivate efforts to control costs and ensure communication between patients and providers regarding financial distress, particularly for vulnerable subgroups.

Providers of follow-up care in a population-based sample of breast cancer survivors

To describe which providers provide breast cancer survivorship care, we conducted a longitudinal survey of nonmetastatic breast cancer patients identified by the SEER registries of Los Angeles and Detroit. Multinomial logistic regression examined the adjusted odds of surgeon compared with a medical oncologist follow-up or primary care provider compared with medical oncologist follow-up, adjusting for age, race/ethnicity, insurance, tumor stage, receipt of chemotherapy, endocrine therapy use, and visit to a medical oncologist at the time of diagnosis. Results were weighted to account for sample selection and nonresponse. 844 women had invasive disease and received chemotherapy or endocrine therapy. 65.2 % reported medical oncologists as their main care provider at 4 years, followed by PCP/other physicians (24.3 %) and surgeons (10.5 %). Black women were more likely to receive their follow-up care from surgeons (OR 2.47, 95 % CI 1.16-5.27) or PCP/other physicians (OR 2.62, 95 % CI 1.47-4.65) than medical oncologists. Latinas were more likely to report PCP/other physician follow-up than medical oncologists (OR 2.33, 95 % CI 1.15-4.73). Compared with privately insured women, Medicaid recipients were more likely to report PCP/other physician follow-up (OR 2.52, 95 % CI 1.24-5.15). Women taking endocrine therapy 4 years after diagnosis were less likely to report surgeons or PCP/other physicians as their primary provider of breast cancer follow-up care. Different survivorship care patterns emerge on race/ethnicity and insurance status. Interventions are needed to inform patients and providers on the recommended sources of breast cancer follow-up.

Valuing cancer care: challenges and opportunities

Although payers are setting the pace with regard to innovations in health information technology and managed care techniques, they lack the power to apply them because of insufficient cost pressure on providers.

Racial and ethnic variation in partner perspectives about the breast cancer treatment decision-making experience

PURPOSE/OBJECTIVES

To characterize the perspectives of partners (husbands or significant others) of patients with breast cancer in the treatment decision-making process and to evaluate racial and ethnic differences in decision outcomes.

DESIGN

A cross-sectional survey.

SETTING

Los Angeles, CA, and Detroit, MI.

SAMPLE

517 partners of a population-based sample of patients with breast cancer four years post-treatment.

METHODS

A self-administered mailed questionnaire. Chi-square tests and logistic regression were used to assess associations between race and ethnicity and decision outcomes.

MAIN RESEARCH VARIABLES

Decision regret and three elements of the decision process: information received, actual involvement, and desired involvement.

FINDINGS

Most partners reported receiving sufficient information (77%), being involved in treatment decisions (74%), and having sufficient involvement (73%). Less-acculturated Hispanic partners were more likely than their Caucasian counterparts to report high decision regret (45% versus 14%, p<0.001). Factors significantly associated (p<0.05) with high decision regret were insufficient receipt of treatment information, low involvement in decision making, and a desire for more involvement.

CONCLUSIONS

Partners were generally positive regarding their perspectives about participating in the breast cancer treatment decision-making process. However, less acculturated Hispanic partners were most vulnerable to decision regret. In addition, high decision regret was associated with modifiable elements of the decision-making process.

IMPLICATIONS FOR NURSING

Attention should be paid to ensuring racial and ethnic minority partners are sufficiently involved in breast cancer treatment decisions and receive decision support.

Abstract P2-19-01: Impact of breast reconstruction approach on patient-reported satisfaction with cosmetic outcomes after mastectomy with and without radiotherapy

Background: The optimal approach to combining breast reconstruction with post-mastectomy radiation (RT) remains hotly debated. We evaluated the comparative effectiveness of different approaches using patient-reported outcomes from a longitudinal survey of patients identified through population-based registries.

Methods: We conducted a multicenter cohort study of women diagnosed with stage 0-III breast cancer from 2005-07, as reported to the Los Angeles and Detroit SEER registries. We surveyed 2290 women approximately 9 months after diagnosis and again after 4 years (n = 1536). The primary dependent variable was a composite measure of satisfaction with the cosmetic outcomes of reconstruction derived from 5 items (range 1-5; Cronbach's alpha 0.91). A linear regression model evaluated the impact of reconstruction type and timing, as well as interaction with RT, controlling for age, education, and marital status, after selection from a variety of sociodemographic and clinical variables (race/ethnicity chemotherapy, contralateral mastectomy, cancer stage, comorbidities, smoking, body-mass index, bra cup size, and geographic site).

Results: Of the 1450 patients who responded to both surveys and had not recurred, 222 received mastectomy and reconstruction, of whom 201 had complete variable information. There were 53 patients who had RT (among whom 53% had autologous technique and 47% had delayed timing) and 148 who did not (among whom 23% had autologous technique and 29% had delayed timing). Patients who received autologous reconstruction vs implants reported higher cosmetic satisfaction. Receipt of RT was associated with lower satisfaction. The adjusted scaled satisfaction score was 4.39 for patients receiving autologous reconstruction without RT, 4.09 for patients receiving autologous reconstruction and RT, 3.86 for patients receiving implant reconstruction without RT, and 2.71 for patients receiving implant reconstruction and RT. Patients who received RT and implant-based reconstruction had significantly lower satisfaction than the other 3 groups. Timing of reconstruction was not significantly associated with satisfaction, nor was there a significant interaction between timing and RT.

Linear Regression Model of Satisfaction with Reconstruction Outcomes (n = 201)CharacteristicCoefficient95% CIpIntercept3.86(3.37,4.35)&lt;0.001Recon type & RT status  &lt;0.001Autologous, no RT0.53(0.06,1.00) Autologous with RT0.23(-0.30,0.75) Implant, no RT00 Implant with RT-1.15(-1.84,-0.47) Reconstruction timing  0.97Immediate0.009(-0.44,0.45) Delayed00 Age (centered on 60)-0.02(-0.05, -0.001)0.04Married/partnered  0.06Yes-0.40(-0.82,0.02) No00 Education  0.35HS or less-0.23(-0.70,0.24) Some college-0.32(-0.77,0.13) College or more00 

Conclusions: In patients undergoing post-mastectomy RT, use of autologous reconstruction may mitigate some of the deleterious impact on cosmetic outcomes, but this requires confirmation in a larger dataset. This study had limited power to evaluate whether delaying reconstruction preferentially benefits radiated patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-19-01.

Informal decision support networks and treatment decisions for breast cancer

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Background: Although nearly 80% of breast cancer patients have someone with them during surgical consultations, there is little research that examines the extent, nature, or impact of informal decision support persons (DSPs) such as partner/spouse, other family members, or friends on breast cancer treatment decision making. Methods: Two data sources were used: 1) A population based sample of patients recently diagnosed in 2006/7 in the Detroit and Los Angeles SEER catchment areas completed a survey 9 months (N=1837, 72% response rate); and 2) A pilot survey study of a convenience sample of 150 breast cancer patients at three clinical sites surveyed within 18 months that examined more details on the extent and nature of informal decision support networks, including: a) quantity and type of DSPs involved in their treatments, b) number of appointments attended by DSPs, and c) patient-reported satisfaction with DSP’s involvement in treatment decision making. Results: Both a spouse/partner and another family member were very important in treatment decision-making for 33% of patients; a spouse/partner alone was very important for 19%; a family member alone was very important for 13%. A spouse/partner or friends were not important in treatment decision making for 24% of patients. Only 19% of patients reported that a friend was very important in treatment decision making. Friends were much more frequently endorsed among patients with family involvement (45%) vs those without family involvement (5%). Latina patients significantly more often reported that the opinion of a family member was very important vs. other race/ethnic groups (71% vs. 39%, p<0.001). Patients in the pilot study reported an average of 2.67 DSPs were involved in locoregional decision making (SD = 2.57 ) vs. an average of 0.8 (SD=1.03) for involvement in systemic treatment decision making. Conclusions: Many breast cancer patients rely on some informal decision support, but there is a very wide variation in the extent and nature of this support. Further work is needed to understand how to best incorporate DSPs into the treatment decision process. Additional findings will be presented to further describe the impact of informal treatment decision support for women with breast cancer.

Surgeons' knowledge and practices regarding the role of radiation therapy in breast cancer management

PURPOSE

Population-based studies suggest underuse of radiation therapy, especially after mastectomy. Because radiation oncology is a referral-based specialty, knowledge and attitudes of upstream providers, specifically surgeons, may influence patients' decisions regarding radiation, including whether it is even considered. Therefore, we sought to evaluate surgeons' knowledge of pertinent risk information, their patterns of referral, and the correlates of surgeon knowledge and referral in specific breast cancer scenarios.

METHODS AND MATERIALS

We surveyed a national sample of 750 surgeons, with a 67% response rate. We analyzed responses from those who had seen at least 1 breast cancer patient in the past year (n=403), using logistic regression models to identify correlates of knowledge and appropriate referral.

RESULTS

Overall, 87% of respondents were general surgeons, and 64% saw >10 breast cancer patients in the previous year. In a scenario involving a 45-year-old undergoing lumpectomy, only 45% correctly estimated the risk of locoregional recurrence without radiation therapy, but 97% would refer to radiation oncology. In a patient with 2 of 20 nodes involved after mastectomy, 30% would neither refer to radiation oncology nor provide accurate information to make radiation decisions. In a patient with 4 of 20 nodes involved after mastectomy, 9% would not refer to radiation oncology. Fewer than half knew that the Oxford meta-analysis revealed a survival benefit from radiation therapy after lumpectomy (45%) or mastectomy (32%). Only 16% passed a 7-item knowledge test; female and more-experienced surgeons were more likely to pass. Factors significantly associated with appropriate referral to radiation oncology included breast cancer volume, tumor board participation, and knowledge.

CONCLUSIONS

Many surgeons have inadequate knowledge regarding the role of radiation in breast cancer management, especially after mastectomy. Targeted educational interventions may improve the quality of care.

Patient-reported sources of breast cancer survivorship care four years after diagnosis

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Background: Breast cancer survivors remain “lost in transition” after active treatment due to changing needs and fragmented care. We sought to describe the patterns of breast cancer survivorship care in a diverse sample to identify factors associated with receipt of survivorship care by medical oncologists (med onc). Methods: We conducted a mailed survey to 2,290 women who resided in the Los Angeles and Detroit SEER registry catchment areas with a confirmed invasive breast cancer case from 6/05-2/07. Women were then surveyed approximately 4 years after diagnosis (n=1,536). On the follow-up survey, women were asked to identify their main provider of breast cancer follow up care: med onc, surgeon, primary care physician (PCP)/other physician. We examined the relationship between report of med onc as main provider of survivor care and: age, race/ethnicity, insurance, tumor stage, receipt of chemotherapy, and care by med onc reported on the baseline survey. Bivariate analyses and logistic regression were used to examine med onc-led survivorship care and the factors above. Results were weighted to account for sample selection and non-response. Results: 858 women had invasive disease at time of diagnosis: 65.2% reported med oncs as the main provider of survivorship care, followed by PCP/other physicians (24.3%) and surgeons (10.5%). Of the women who did not receive chemotherapy, 56% reported med onc-led survivorship care, compared with 79% of chemotherapy recipients. In multivariable logistic regression, black women were less likely than white women to report med onc-led survivorship care (OR 0.49, 95% CI 0.34-0.71). Privately-insured patients were more likely than Medicaid recipients to report med onc-led care (OR 2.00, 95% CI 1.16-3.45). Women with higher disease stage, those who received chemotherapy, and those who saw a med onc at baseline were significantly more likely to report med onc-led survivorship care. Conclusions: The oncology workforce shortage compels the identification of optimal and efficient survivorship care models. A mismatch may exist between chemotherapy receipt and med onc-led care. Our data suggest clear guidelines are needed to direct patients to the providers most appropriate to manage their care.

Desire for and use of genetic testing in a population-based sample of breast cancer patients

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Background: Prior research suggests that receipt of genetic testing to assess risk of disease in patients or their families is not limited to those who meet high-risk criteria (i.e., diagnosed at young age &/or with strong family history). There is little research from large population-based samples describing patterns and correlates of genetic testing receipt or reasons why patients undergo testing. Methods: We surveyed 2290 women newly diagnosed with breast cancer reported to the Detroit & Los Angeles SEER registries from 6/05-2/07. We merged these data to SEER and re-surveyed them again approximately 4 years later (n=1536). The primary outcomes were patient reports of a strong desire for genetic testing, participation in a discussion about genetic testing, and receipt of genetic testing. We also evaluated patient reports of reasons for getting tested. We compared dependent and independent factors using chi-square tests and used logistic regression to evaluate correlates of each outcome. Results: One third (33.9%) reported a strong desire to be tested, of whom 54% discussed testing with a health professional, & 46% were tested. A strong desire to be tested was associated with younger age (F=32.03, P<0.001), minority race (F=62.5, P<0.001), family history of breast &/or ovarian cancer (F=18.5, P<0.001) and worry about recurrence (OR: 1.8; 95% CI: 1.3-2.6). Overall, 19.3% were tested. Test receipt was significantly associated with younger age (F=26.8, P<0.001), higher education (OR: 1.8; 95% CI:1.13-2.71), and family history (F=25.1, P<0.001). Of those tested, reasons included: physician recommendation (61.8%), wanting more information about one’s own health (51.8%), wanting more information for family (54.2%), and family desire (13.6%). 7.8% of those not tested indicated it was because of the expense. Conclusions: Many women have a strong desire for genetic testing after diagnosis of breast cancer but often do not discuss testing with professionals. Desire for testing was correlated with pertinent clinical factors but also non-clinical factors such as minority race and worry about recurrence. Results suggest the continued need to address patient desire for testing and selection of appropriate patients for testing.

Racial and ethnic variation in employment and financial experiences of breast cancer survivors

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Background: Concerns exist regarding the employment and financial experiences of cancer survivors and whether they differ by race/ethnicity. Methods: In a longitudinal survey of women reported to the Los Angeles and Detroit SEER registries for nonmetastatic breast cancer, we compared experiences of 4-year survivors by race/ethnicity. Results: Overall, 31% of 1,536 respondents (68% response rate) felt their financial status was worse since diagnosis (63% attributed this to breast cancer). This varied by race/ethnicity: 41% of Spanish-speaking Latinas (SSL), 33% English-speaking Latinas (ESL), 23% blacks (B), and 29% whites (W), p<0.001. The median respondent had spent ≤$2000 on breast cancer medical expenses; 16% had spent >$5000. 12% had medical debt 4 yrs post-diagnosis: 17% of ESL, 14% B, 10% SSL, and 9% W (p=0.01). Minority respondents were more likely to report foregoing medical care due to cost and other privations due to their medical expenses (Table). Overall, 14% felt their employment status was worse since diagnosis, and 61% of these attributed this to breast cancer. 755 worked for pay some time after diagnosis, of whom 56% said it was at least somewhat important to work to keep health insurance (55% of SSL, 65% ESL, 65% B, 50% W, p=0.03); 24% would look for a new job if assured of comparable benefits (45% of SSL, 29% ESL, 22% B, 17% W, p<0.001); 7% had increased work hours to cover cancer-related expenses; 27% had decreased work hours due to cancer-related health issues; and 7% believed they had been denied job opportunities because of cancer. Conclusions: In this population-based sample of breast cancer survivors, job lock was common, and many women perceived being worse off with respect to finances and employment as a result of their breast cancer. Medical debt and privation varied significantly by race/ethnicity. [Table: see text]

Is contralateral prophylactic mastectomy (CPM) overused? Results from a population-based study

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Background: The growing rate of CPM among women diagnosed with breast cancer has raised concerns about potential for over-treatment yet, little is known about factors that affect the decisions for this surgical treatment option. Methods: We surveyed 2,245 women newly diagnosed with breast cancer and reported to the Detroit and Los Angeles SEER registries from 6/05-2/07. We merged these data to SEER and re-surveyed them again approximately 4 years later (n=1,525). The primary outcome was receipt of CPM. We modeled surgical treatment decision making in two stages: any mastectomy (including CPM) vs. lumpectomy, and CPM vs. unilateral mastectomy (UM) among mastectomy-treated patients. The primary independent variable was clinically significant risk of developing contralateral disease (family history of at least 2 family members with breast cancer and/or a positive genetic test). We also evaluated the degree to which worry about recurrence drove initial treatment decisions (very vs. somewhat/not at all) and controlled for race/ethnicity, age, stage and SEER site. Results: Of the 1,446 women who had not had a recurrence of breast cancer by the time 2 survey, 35% considered CPM and 7.4% received it. Among those who received a mastectomy for the affected breast the figures were 53% and 19%, respectively. About 70% of patients who received CPM were clinically at very low risk for contralateral disease. 90% of those who got CPM reported being very worried about recurrence when making their treatment decision, compared to 80% of those who received UM (p<0.05). Multivariate regression showed that receipt of CPM vs. UM was associated with having a family history (OR 5.1; 95% CI: 2.49-10.1) and a positive genetic test (OR: 10.93; 95% CI: 3.37-35.71), but was also associated with greater worry about recurrence (OR: 2.07; 95% CI: 1.01-4.51). Conclusions: Many women considered CPM despite the fact that very few of them had clinically significant risk of contralateral breast cancer. Most women who had CPM did not have a clinical indication for considering it and thus not expected to benefit in terms of disease free survival. More research is needed about the underlying factors driving decision-making for CPM.

Frequency of physician misconceptions that may drive underuse of radiotherapy (RT) in patients with breast cancer

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Background: Registry studies suggest underuse of RT for breast cancer, especially after mastectomy. Because radiation oncology is referral-based, knowledge and attitudes of upstream providers may influence patients’ RT decisions, including whether they even consider it. Methods: We surveyed a random sample of 750 medical oncologists (MO) and 750 surgeons (S) drawn from the AMA Masterfile in 2012; 895 responded. We analyzed responses to scenarios in which RT should be considered from the 766 (403 S, 363 MO) who had seen breast cancer patients in the past year. Results: Mean age was 52; 36% worked in a practice with an academic affiliation. 84% of MO and 64% of S saw more than 10 breast cancer patients in the previous year (p<0.001). 44% participated in multidisciplinary breast clinics. In a 45 yo T1cN0 ER+/PR+/HER2- patient receiving lumpectomy and tamoxifen, half of respondents substantially underestimated the 10-year risk of locoregional recurrence without RT. 19% of MO and 38% of S did not know that guidelines recommend RT in that case, but reassuringly, almost all would refer the patient to radiation oncology (97%). Referral to radiation oncology was less common for node-positive patients after mastectomy; however, in a T1cN1 patient with 2/20 nodes s/p mastectomy (in whom guidelines state that RT should be strongly considered), only 53% of MO and 34% of S recommend RT; 29% of MO and 43% of S would not refer to radiation oncology. If 4/20 nodes were involved (where RT is clearly guideline-recommended), 94% of MO but only 79% of S would recommend RT, and 9% of S would not refer to radiation oncology. The majority (53% of MO, 68% of S) substantially underestimated the risk of LRR in a patient with pN2 disease after mastectomy without RT. Fewer than half knew that the EBCTCG meta-analysis revealed a survival benefit from RT after lumpectomy (45%) or mastectomy (47% of MO, 32% of S, p<0.001). Only 66% of MO and 54% of S recognized the 10-year risk of RT-induced second malignancy to be <1%. Conclusions: Many MO and S who treat breast cancer patients have misconceptions relevant to RT decision-making. Educational interventions targeted towards referring providers may improve the quality of care received by breast cancer patients.

Attitudes toward and use of cancer management guidelines in a national sample of medical oncologists and surgeons

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Background: Previous studies have assessed physician perceptions of practice guidelines and identified barriers to adherence, including lack of knowledge, attitudes, and other factors. Little is known about attitudes toward and use of cancer management guidelines specifically. Methods: We surveyed a random sample of 750 medical oncologists and 750 surgeons drawn from the AMA Masterfile between January and June 2012. 896 responded; 130 of these reported that they had not seen breast cancer patients in the previous year and were asked not to complete the remainder of the survey. We analyzed responses from the remaining 766 (403 surgeons and 363 medical oncologists). Results: Mean participant age was 52; 36% worked in a practice with an academic affiliation. Attitudes towards clinical practice guidelines were generally favorable. Few (<3%) disagreed that guidelines were good educational tools or convenient, and only 12% felt that they were biased, although 24% felt they were oversimplified, 20% found them too rigid, and 20% perceived them as a challenge to physician autonomy. Most agreed that guidelines were intended to improve the quality of care (98%) but opinion split about whether they were intended to decrease costs (51% felt they were). NCCN guidelines were reported to influence the cancer management decisions of 96% of medical oncologists and 70% of surgeons (p<0.001), and ASCO guidelines influenced 65% of medical oncologists and 45% of surgeons (p<0.001). Many respondents looked at the NCCN guidelines at least every few months (93% of medical oncologists, 48% of surgeons, p<0.001). Most respondents reported they made guideline-concordant decisions in the majority of their cancer cases. Yet most respondents reported that they rarely refer patients to the patient versions of the NCCN guidelines (76% refer ¼ or fewer of their patients). When making a guideline-inconsistent recommendation, 17% do not routinely discuss the inconsistency with patients. Conclusions: Attitudes toward physician-directed cancer management guidelines are generally positive, and they are frequently used. However, physicians infrequently advise use of patient versions.