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.

Surgeon-level variation in patients' appraisals of their breast cancer treatment experiences

BACKGROUND AND PURPOSE

While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.

METHODS

Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.

RESULTS

Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.

CONCLUSIONS

Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample

PURPOSE

Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample.

PATIENTS AND METHODS

Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt.

RESULTS

The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt.

CONCLUSION

In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

The influence of non-clinical patient factors on medical oncologists' decisions to recommend breast cancer adjuvant chemotherapy

The extent to which medical oncologists consider non-clinical patient factors when deciding to recommend adjuvant chemotherapy is unknown. Medical oncologists who treated a population-based sample of early stage breast cancer patients reported to the Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries 2005-2007 were asked how strongly they consider a patient's ability to follow instructions, level of social support, and level of work support/flexibility in decisions to recommend adjuvant chemotherapy. Responses of 4 (Quite strongly) or 5 (Very strongly) on a five-point Likert scale defined strong consideration. Associations between oncologist/practice characteristics and strong consideration of each non-clinical factor were examined. 134 oncologists (66 %) reported strong consideration of one or more factor. Ability to follow instructions was strongly considered by 120 oncologists (59 %), social support by 78 (38 %), and work support/flexibility by 73 (36 %). Larger percent of practice devoted to breast cancer was associated with lower likelihood of strongly considering ability to follow instructions [odds ratio (OR) 0.98, 95 % confidence interval (CI) 0.97-0.99; P = 0.04]. Increased years in practice was associated with lower likelihood of strongly considering social support (OR 0.96, CI 0.93-0.99; P = 0.011), while non-white race (OR 2.1, CI 1.03-4.26; P = 0.041) and tumor board access (OR 2.04, CI 1.01-4.12; P = 0.048) were associated with higher likelihood. Non-white race was associated with strongly considering work support/flexibility (OR 2.44, CI 1.21-4.92; P = 0.013). Tumor board access (OR 2, CI 1.00-4.02; P = 0.051) was borderline significant. Non-clinical patient factors play a role in medical oncologist decision-making for breast cancer adjuvant chemotherapy recommendations.

The involvement of partners in breast cancer treatment decision making

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Background: Incorporating partners into treatment decision making is an important element of patient-centered care, yet little is known about the role of partners in the decision process. Methods: We surveyed 503 partners of a population-based sample of breast cancer survivor 4 years after diagnosis (RR= 76%, N=382).The outcome was partners’ reports of decision regret. Independent variables included decision making process measures (partners’ reports of sufficient treatment information receipt and sufficient involvement in decision making), race/ethnicity, age, education and income. Multivariable logistic regression was used to assess associations between decision regret and race/ethnicity, controlling for other variables. Results: 49% of partners were white, 14% African American, 15% more-acculturated Latino, and 18% less-acculturated Latino. One quarter (26%) of partners reported that they received insufficient information and one third (35%) desired more involvement in decision-making. Compared to whites, less-acculturated Latino partners more often reported that they received insufficient information (41% vs. 18%, p<0.05) and desired more involvement in decision-making (49% vs. 14%, p<0.001). Overall 30% of partners reported high decision regret. Multivariate analyses showed factors associated with high decision regret were less-acculturated Latinos, insufficient information receipt and desire for more involvement (Table). Conclusions: Most partners of breast cancer survivors reported low decision regret and positively appraised their involvement in the decision process. Less acculturated Latinos reported more dissatisfaction with the decision process. Findings suggest the need for culturally appropriate treatment decision support interventions that include partners. [Table: see text]

Improving the quality of breast cancer surgical treatment decisions

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Background: Ensuring breast cancer treatment decisions are high quality (i.e., informed and preference-concordant) is a key component of patient centered care. Methods: A web-based decision tool, including an interactive preference clarification exercise, was developed over a one-year period with input from health communication experts, clinicians, and women with breast cancer. Newly diagnosed early stage breast cancer patients from two cancer centers were recruited and randomized to view the tool before or after completing a survey. Mean scores for key outcome measures, including surgical treatment knowledge (4 true/false questions), decision satisfaction (12 questions each with a 5-point Likert scale from strongly agree to strongly disagree), and preference-concordant decisions, were compared between the groups using t-tests. Concordance between preferences and surgical choices was evaluated using the chi-square test. Results: 110 subjects were recruited and 105 completed the study. Their mean age was 57 years, 60% had a college degree or more, and 81% were white. Those viewing the website first had higher scores on several decision outcomes than those taking the survey first (Table). Knowledge scores were also higher among those viewing the website before the survey (3.0 vs. 2.61, p=.23). The risk of recurrence was the most important treatment attribute, followed by retaining the natural breast, in both groups. Concordance between treatment choice and computer generated treatment was 65% for website first and 61% for survey first groups. Conclusions: A tool focused on improving knowledge and preference-concordant decisions produced positive results on breast cancer surgical treatment decision making. Further work should assess the impact of the tool in larger and more diverse populations. [Table: see text]

Coordination of breast cancer care between radiation oncologists and surgeons: a survey study

PURPOSE

To assess whether radiation oncologists and surgeons differ in their attitudes regarding the local management of breast cancer, and to examine coordination of care between these specialists.

METHODS AND MATERIALS

We surveyed attending surgeons and radiation oncologists who treated a population-based sample of patients diagnosed with breast cancer in metropolitan Detroit and Los Angeles. We identified 419 surgeons, of whom 318 (76%) responded, and 160 radiation oncologists, of whom 117 (73%) responded. We assessed demographic, professional, and practice characteristics; challenges to coordinated care; and attitudes toward management in three scenarios.

RESULTS

92.1% of surgeons and 94.8% of radiation oncologists indicated access to a multidisciplinary tumor board. Nevertheless, the most commonly identified challenge to radiation oncologists, cited by 27.9%, was failure of other providers to include them in the treatment decision process early enough. Nearly half the surgeons (49.7%) stated that few or almost none of the breast cancer patients they saw in the past 12 months had consulted with a radiation oncologist before undergoing definitive surgery. Surgeons and radiation oncologists differed in their recommendations in management scenarios. Radiation oncologists were more likely to favor radiation than were surgeons for a patient with 3/20 lymph nodes undergoing mastectomy (p = 0.03); surgeons were more likely to favor more widely clear margins after breast conservation than were radiation oncologists (p = 0.001).

CONCLUSIONS

Despite the widespread availability of tumor boards, a substantial minority of radiation oncologists indicated other providers failed to include them in the breast cancer treatment decision-making process early enough. Earlier inclusion of radiation oncologists may influence patient decisions, and interventions to facilitate this should be considered.

Dissemination of Quality-of-Care Research Findings to Breast Oncology Surgeons

PURPOSE

In this era of rapidly evolving clinical knowledge, clinicians need to be aware of current research and how it might affect their practice. The Internet is a widely available, under-assessed tool for providing this information. In this two-phase pilot study, a novel Web site (www.cansortsurgeons.org) was developed to specifically disseminate relevant clinical information to community breast oncology surgeons.

METHODS

The first phase targeted a sample of community surgeons identified from Surveillance, Epidemiology, and End Results catchment areas in Los Angeles, CA and Detroit, MI. The second phase broadened availability by linking the site through the American College of Surgeons (ACoS) Commission on Cancer (CoC) homepage. An eight-question, Web-based survey was used to obtain feedback regarding the Web site's utility and potential application to clinical practice. Journal continuing medical education credit was also offered through ACoS.

RESULTS

For phase 1, of the 315 community surgeons invited to view the site, 114 (36%) participated in the study and 98 (86%) responded to the survey. Overall, there was a strongly supportive response, with 79 (81%) recommending the site to other clinicians. For phase 2, of the 516 site hits, 411 came from the ACoS site. Only 10 individuals completed the survey during this phase, but all positively endorsed the utility of the site.

CONCLUSION

The implication for clinical practice is that the Internet is a useful tool for providing relevant clinical research to providers. In the future, this could be tailored to an individual's needs, aiding synthesis and, hopefully, improving the quality of clinical care.

Employment of nurse practitioners and physician assistants in breast cancer care

PURPOSE

We sought to examine the employment of nurse practitioners (NPs) and physician assistants (PAs) in surgical, medical, and radiation oncology practices and to identify correlates of NP and PA employment.

METHODS

We conducted a mailed survey of attending surgeons, medical oncologists, and radiation oncologists who cared for a population-based sample of women diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles, CA, and Detroit, MI. In addition to information about whether practices employed NPs and/or PAs, physician and practice characteristics were obtained. We estimated the likelihood of the employment of NPs and PAs with multivariable logistic regression.

RESULTS

Overall, 39.6% of physicians reported that NPs and PAs were employed in their practice, although there were significant differences across specialty: medical oncologists (56.3%), radiation oncologists (40.0%), and surgeons (28.7%; P < .01). The likelihood of NP and PA employment increased for medical oncologists (compared with surgeons; odds ratio [OR], 2.63; 95% CI, 1.73 to 3.99), physicians with 10 or fewer years in practice (OR, 1.94; 95% CI, 1.18 to 3.16), and practices with university affiliations (OR, 2.20; 95% CI, 1.44 to 3.37). Physicians with fewer than 25% of their patients diagnosed with breast cancer (OR, 0.48; 95% CI, 0.25 to 0.92) and practices with fewer than three physicians (OR, 0.14; 95% CI 0.09, to 0.24) were less likely to employ NPs and PAs.

CONCLUSIONS

NP and PA employment was higher with newer physicians and in more heavily resourced practices. Employment of NPs and PAs was relatively modest, which suggests an opportunity for physicians to employ these providers to alleviate workloads.

Underascertainment of radiotherapy receipt in Surveillance, Epidemiology, and End Results registry data

BACKGROUND

Surveillance, Epidemiology, and End Results (SEER) registry data have been used to suggest underuse and disparities in receipt of radiotherapy. Prior studies have cautioned that SEER may underascertain radiotherapy but lacked adequate representation to assess whether underascertainment varies by geography or patient sociodemographic characteristics. The authors sought to determine rates and correlates of underascertainment of radiotherapy in recent SEER data.

METHODS

The authors evaluated data from 2290 survey respondents with nonmetastatic breast cancer, aged 20 to 79 years, diagnosed from June of 2005 to February 2007 in Detroit and Los Angeles and reported to SEER registries (73% response rate). Survey responses regarding treatment and sociodemographic factors were merged with SEER data. The authors compared radiotherapy receipt as reported by patients versus SEER records. The authors then assessed correlates of radiotherapy underascertainment in SEER.

RESULTS

Of 1292 patients who reported receiving radiotherapy, 273 were coded as not receiving radiotherapy in SEER (underascertained). Underascertainment was more common in Los Angeles than in Detroit (32.0% vs 11.25%, P < .001). On multivariate analysis, radiotherapy underascertainment was significantly associated in each registry (Los Angeles, Detroit) with stage (P = .008, P = .026), income (P < .001, P = .050), mastectomy receipt (P < .001, P < .001), chemotherapy receipt (P < .001, P = .045), and diagnosis at a hospital that was not accredited by the American College of Surgeons (P < .001, P < .001). In Los Angeles, additional significant variables included younger age (P < .001), nonprivate insurance (P < .001), and delayed receipt of radiotherapy (P < .001).

CONCLUSIONS

SEER registry data as currently collected may not be an appropriate source for documentation of rates of radiotherapy receipt or investigation of geographic variation in the radiation treatment of breast cancer.

Correlates of worry about recurrence in a multiethnic population-based sample of women with breast cancer

BACKGROUND

Worry about recurrence (worry) is a persistent concern of breast cancer survivors. Little is known about whether race/ethnicity or healthcare experiences are associated with worry.

METHODS

Women with nonmetastatic breast cancer diagnosed from June 2005 to February 2007 and reported to Detroit or Los Angeles Surveillance, Epidemiology, and End Results registries were surveyed (mean 9 months postdiagnosis); 2290 responded (73%). Latinas and African Americans were oversampled. A worry scale was constructed as the mean score of 3 items (on 5-point Likert, higher = more worry): worry about cancer returning to the same breast, occurring in the other breast, or spreading to other parts of the body. Race/ethnicity categories were white, African American, and Latina (categorized into low vs high acculturation). The worry scale was regressed on sociodemographics, clinical/treatment, and healthcare experience factors (eg, care coordination collapsed into low, medium, high).

RESULTS

Low acculturated Latinas reported more worry and African Americans less worry than whites (P < .001). Other factors independently associated with more worry were younger age, being employed, more pain and fatigue, and radiation (Ps < .05). With all factors in the model, less worry was associated (all Ps < .05) with greater ease of understanding information (2.89, 2.99, 2.81 for low, medium, high), better symptom management (3.19, 2.89, 2.87 for low, medium, high), and more coordinated care (3.36, 2.94, 2.82 for low, medium, high). Race/ethnicity remained significant controlling for all factors (P < .001).

CONCLUSIONS

Less acculturated Latina breast cancer patients are vulnerable to high levels of worry. Interventions that improve information exchange, symptom management, and coordinating care hold promise in reducing worry.

How confident are internal medicine residents in rheumatology versus other common internal medicine clinical skills: an issue of training time or exposure?

The objective of this study was to determine self-confidence of internal medicine (IM) residents regarding rheumatology clinical skills and factors that may affect their confidence. Permission was sought to e-mail a web-based survey to IM residents at all 13 English language Canadian internal medicine programs. Residents were asked to rank self-confidence in rheumatology, cardiology, respirology, and gastroenterology skills. Further questions included site and year of training, career interests, rheumatology experiences, learning opportunities, and assessment frequency. These factors were analyzed by univariate and multivariate analyses. Two hundred sixteen residents (21.8%) from all 13 sites responded to the survey. Resident self-confidence in rheumatology diagnoses was 5.24/10, lower than all three comparator subspecialties. Increasing teaching exposure had a more significant impact on confidence in rheumatology than on comparator subspecialties. Increasing year of training had no association with higher self-confidence for rheumatology, in contrast to the increase in confidence seen with increased year of training for each comparator subspecialty. Further analysis demonstrated that the completion of a rheumatology rotation, increasing learning opportunities, annual assessment, and career interest were associated with greater resident self-confidence. Resident self-confidence for rheumatology skills is cautious at best and is lower than other common subspecialties. Self confidence improves with targeted rheumatology clinical experience and teaching, but does not improve solely with higher year of IM training. Furthermore, the impact of rheumatology teaching is greater than that of other common IM subspecialties. This information is critical to the planning and implementation of effective rheumatology curricula within internal medicine residency programs.

Perceptions of care coordination in a population-based sample of diverse breast cancer patients

OBJECTIVE

To identify factors associated with perceptions of care coordination in a diverse sample of breast cancer patients.

METHODS

Breast cancer patients reported to the metropolitan SEER registries of Detroit or Los Angeles from 6/05 to 2/07 were surveyed after diagnosis (N=2268, RR=72.4%). Outcomes were two dichotomous measures reflecting patient appraisal of care coordination during their treatment experience. Primary independent variables were race/ethnicity (white, African American, Latina-high acculturated, Latina-low acculturated) and health literacy (low, moderate, high). Logistic regression was used to evaluate factors associated with both measures of care coordination.

RESULTS

2148 subjects were included in the analytic dataset. 16.4% of women perceived low care coordination and 12.5% reported low satisfaction. Race/ethnicity was not significantly associated with care coordination. Women with low subjective health literacy were 3-4 times as likely as those with high health literacy to perceive low care coordination and low satisfaction with care coordination (OR=3.88; 95% CI: 2.78-5.41; OR=3.19 95% CI: 2.25-4.52, respectively).

CONCLUSIONS

Many breast cancer patients positively appraised their care coordination, but patients with low health literacy perceived low care coordination.

PRACTICE IMPLICATIONS

Providers should be aware of the health literacy deficits that may contribute to their patients' attitudes towards their breast cancer care coordination.

Patterns and correlates of adjuvant radiotherapy receipt after lumpectomy and after mastectomy for breast cancer

PURPOSE

To use patient self-report to provide more valid estimates of whether radiotherapy (RT) is underutilized than possible with registry data, as well as to evaluate for disparities and the influence of preferences and provider interactions.

METHODS

We considered 2,260 survey respondents who had nonmetastatic breast cancer, were age 20 to 79 years, were diagnosed between July 2005 and February 2007 in Detroit and Los Angeles, and reported to Surveillance, Epidemiology and End Results (SEER) registries (72% response rate). Survey responses were merged with SEER data. We assessed rates and correlates of RT receipt among all patients with invasive cancer receiving breast-conserving surgery (BCS) and among patients undergoing mastectomy with indications for RT (ie, positive lymph nodes or T3-4 tumors).

RESULTS

Among 904 patients undergoing BCS with strong indications for RT, 95.4% received RT, and 77.6% received RT among the 135 patients undergoing mastectomy with strong indications (P < .001). Among 114 patients undergoing BCS with weaker indications (ie, elderly) for RT, 80.0% received treatment, and 47.5% received RT among the 164 patients undergoing mastectomy with weaker indications (T1N1, T2N1, or T3N0 disease; P < .001). On multivariate analysis, surgery type (P < .001), indication strength (P < .001), age (P = .005), comorbidity (P < .001), income (P = .03), patient desire to avoid RT (P < .001), level of surgeon involvement in decision to have radiation (P < .001), and SEER site (P < .001) were significantly associated with likelihood of RT receipt.

CONCLUSION

RT receipt was consistently high across sociodemographic subgroups after BCS but was lower after mastectomy, even among patients with strong indications for treatment, in whom clinical benefit is similar. Surgeon involvement had a strong influence on RT receipt.

What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates

BACKGROUND

Re-excision is common in breast-conserving surgery (BCS), partly due to lack of consensus on margin definitions. A population-based surgeon sample was used to determine current attitudes toward margin width and identify characteristics associated with margin choice.

METHODS

Breast cancer patients treated from 2005 to 2007 were identified from Los Angeles and Detroit Surveillance, Epidemiology, and End Results (SEER) registries. Pathology reports were used to identify their surgeons, who were surveyed (n = 418). Response rate was 74.6% (n = 312). Mean surgeon age was 51.9 years, 17.8% were female, and mean number of years in practice was 18.5.

RESULTS

Wide variation in margin selection was noted among surgeons, and did not differ for invasive cancer and ductal carcinoma in situ (DCIS). In a scenario of T1 invasive cancer, 11% of surgeons endorsed margins of tumor not touching ink (TNTI), 42% of 1-2 mm, 28% of > or =5 mm, and 19% >1 cm as precluding need for re-excision before radiotherapy. On multivariate analysis, having 50% or more of practice devoted to breast cancer independently predicted smaller margin choice (p = 0.03). For a patient with a 1.4-cm grade 2 estrogen receptor (ER)-positive DCIS without radiotherapy (RT) planned, 3% of surgeons chose TNTI, 12% 1-2 mm, 25% > or =5 mm, and 61% >1 cm as sufficient without re-excision. In the scenario of DCIS without RT, breast specialization independently predicted larger margin choice (p = 0.03). Gender and years in practice were not predictive of margin choice.

CONCLUSIONS

Wide variation in BCS margin definition exists. Variation is similar for invasive cancer and DCIS with RT, with more specialized surgeons choosing smaller margins. In DCIS without RT, more specialized surgeons favored larger margins. A standardized margin definition may significantly affect re-excision rates.

Racial/ethnic differences in quality of life after diagnosis of breast cancer

INTRODUCTION

Most studies on quality of life of breast cancer survivors have not had adequate representation of ethnic minorities. The purpose of this study was to determine whether racial/ethnic differences in quality of life exist between white, African American, and Latina women in the early stages of survivorship.

METHODS

2268 women were identified by two Surveillance, Epidemiology and End Results (SEER) registries (6/05-2/07) and asked to complete a survey (mean 9 months post-diagnosis, 72.1% response rate). Latina and African American women were over-sampled. Regression models compared quality of life across race/ethnicity (white, African American, Latina [low vs. high acculturation]), sequentially controlling for sociodemographics, clinical, and treatment factors.

RESULTS

There were significant racial/ethnic differences in quality of life controlling for sociodemographics, clinical factors and treatment factors. Lower acculturated Latinas compared to whites had significantly lower functional well-being, emotional well-being, and breast cancer concerns (p values < 0.05). African Americans had significantly higher emotional well-being than whites. Age, co-morbidities, cancer stage, and chemotherapy also influenced quality of life. A significant interaction was found between race/ethnicity and age for physical well-being (p = 0.041) and for emotional well-being (p = 0.042). Specifically, racial/ethnic differences were only observed among older women (>or=50 years), with less acculturated Latinas reporting the lowest quality of life.

CONCLUSIONS

Racial/ethnic differences in quality of life exist during the cancer survivorship period. Latinas with low acculturation are a particularly vulnerable subgroup.

IMPLICATIONS

Greater attention should be devoted to identifying women disproportionately affected by breast cancer and developing interventions targeting their unique survivorship concerns.

Attracting internal medicine trainees to rheumatology: where and when programs should focus efforts

OBJECTIVE

To determine where and when efforts should be focused to increase recruitment of rheumatology trainees from internal medicine (IM) programs.

METHODS

(1) We calculated the percentage of trainees at each of the 13 English-speaking Canadian IM-accredited programs who entered a rheumatology training program in Canada from 2005 to 2007. We then correlated this with the opportunity they would have had to do a rheumatology rotation in each of their 3 postgraduate years of IM training. (2) We calculated the overall percentage of residents who remained at the same training institution after their IM program, 2005-2007, comparing this to 4 similar-size subspecialty training programs.

RESULTS

Among IM trainees, 3.5% began rheumatology training in Canada. There was a positive relationship at the postgraduate year 1 (PGY1) level between more rheumatology opportunities and chance of entering rheumatology (r(2) = 0.35, p < 0.05), but not at the PGY2 or PGY3 level. Among rheumatology trainees, 78% remained at the training institution where they completed IM training, more than the 70% of gastroenterology trainees, 68% of nephrology trainees, 67% of endocrinology trainees, and 76% of infectious diseases trainees.

CONCLUSION

The opportunity for a rheumatology rotation in the first year of IM training increases the likelihood the trainee may choose rheumatology as a career. Further, most rheumatology trainees continue at the same institution as their IM training, more than other subspecialties. This information may assist recruitment efforts to increase numbers of rheumatology trainees and the overall rheumatology workforce. These data warrant reevaluation of IM programs of study in order to influence trainee career choices and plan better for future workforce requirements in all IM fields.

Surgeon recommendations and receipt of mastectomy for treatment of breast cancer

CONTEXT

There is concern that mastectomy is overused in the United States.

OBJECTIVES

To evaluate the association of patient-reported initial recommendations by surgeons and those given when a second opinion was sought with receipt of initial mastectomy; and to assess the use of mastectomy after attempted breast-conserving surgery (BCS).

DESIGN, SETTING, AND PATIENTS

A survey of women aged 20 to 79 years with intraductal or stage I and II breast cancer diagnosed between June 2005 and February 2007 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results registries for the metropolitan areas of Los Angeles, California, and Detroit, Michigan. Patients were identified using rapid case ascertainment, and Latinas and blacks were oversampled. Of 3133 patients sent surveys, 2290 responded (73.1%). A mailed survey was completed by 96.5% of respondents and 3.5% completed a telephone survey. The final sample included 1984 female patients (502 Latinas, 529 blacks, and 953 non-Hispanic white or other).

MAIN OUTCOME MEASURES

The rate of initial mastectomy and the perceived reason for its use (surgeon recommendation, patient driven, medical contraindication) and the rate of mastectomy after attempted BCS.

RESULTS

Of the 1984 patients, 1468 had BCS as an initial surgical therapy (75.4%) and 460 had initial mastectomy, including 13.4% following surgeon recommendation and 8.8% based on patient preference. Approximately 20% of patients (n = 378) sought a second opinion; this was more common for those patients advised by their initial surgeon to undergo mastectomy (33.4%) than for those advised to have BCS (15.6%) or for those not receiving a recommendation for one procedure over another (21.2%) (P < .001). Discordance in treatment recommendations between surgeons occurred in 12.1% (n = 43) of second opinions and did not differ on the basis of patient race/ethnicity, education, or geographic site. Among the 1459 women for whom BCS was attempted, additional surgery was required in 37.9% of patients, including 358 with reexcision (26.0%) and 167 with mastectomy (11.9%). Mastectomy was most common in patients with stage II cancer (P < .001).

CONCLUSION

Breast-conserving surgery was recommended by surgeons and attempted in the majority of patients evaluated, with surgeon recommendation, patient decision, and failure of BCS all contributing to the mastectomy rate.

Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population- based study

PURPOSE

There is concern that minority women have limited access to breast reconstruction. We described patterns of use, experiences with clinicians, and patients' satisfaction with treatment decisions for women of different race/ethnicities.

METHODS

A total of 3,252 patients with breast cancer from Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries were surveyed near the time of diagnosis (n = 2,260, response rate 72.2%). The primary outcomes were receipt of reconstruction, access to information about reconstruction, and decisional satisfaction. The primary independent variable was race/ethnicity (white, African American [AA], highly acculturated Latina [Latina-high], and less acculturated Latina [Latina-low]). Control variables included other sociodemographic and clinical factors. chi(2) and multivariate logistic regression were used for the analyses.

RESULTS

Receipt of reconstruction varied significantly by patient race/ethnicity-40.9% of whites, 33.5% of AAs, 41.2% of Latina-high, and only 13.5% of Latina-low (P < .001)-and persisted when we controlled for demographic and clinical factors. Minority women were significantly less likely than whites to see a plastic surgeon before initial surgery and were more likely to desire more information about reconstruction (17.0% of whites v 27.0% of AAs, 30.0% of Latina-high, and 55.9% of Latina-low; P < .001). Decisional satisfaction was lowest among minority women without reconstruction (P < .001).

CONCLUSION

Minority women, particularly less acculturated Latinas, had low receipt of breast reconstruction, which may be related to limited information about the procedure and less access to plastic surgeons. Greater desire for information and lower satisfaction with surgical decisions among these patients motivate greater attention to treatment support for these patients.

Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients

BACKGROUND

Few studies have evaluated the association between patient decision involvement and surgery received among racially and ethnically diverse patients or patients' attitudes about surgery and the role of family and friends in surgical treatment choices.

METHODS

Women diagnosed with nonmetastatic breast cancer from June 2005 through February 2007 and reported to the Los Angeles or Detroit Surveillance, Epidemiology, and End Results registries were mailed a survey after diagnosis (N = 3133). Latina and African American women were oversampled. The response rate was 72.4%. The analytic sample (N = 1651) excluded those with stage IIIA or higher disease, self-reported clinical contraindications to breast-conserving surgery with radiation, and unclear race or ethnicity. The dependent variable was receipt of mastectomy initially. The primary independent variables were patient involvement in decision making, race or ethnicity, attitudes about recurrence, the effects of radiation, the impact of surgery on body image, and the role of others in decision making. Latinas were categorized as low or high acculturated. The association between patient involvement in decision making and the receipt of mastectomy was evaluated using logistic regression while controlling for other independent variables. All statistical tests were two-sided.

RESULTS

The analytic sample was 23.9% Latina (12.0% low acculturated, 11.9% high acculturated), 27.1% African American, and 48.9% white, and 17.2% received a mastectomy initially. For each racial or ethnic group, more women who reported a patient-based decision received mastectomy than those who reported a shared or surgeon-based decision (P = .022 for low-acculturated Latinas, P < .001 for other groups). Women who reported that concerns about recurrence or radiation effects were very important in their surgery decision were more likely to receive mastectomy than those less concerned (for recurrence concerns, estimated relative risk [RR] = 1.66, 95% confidence interval [CI] = 1.28 to 2.10; for radiation concerns, estimated RR = 2.35, 95% CI = 1.88 to 2.85). Women who reported that body image concerns and their spouse's opinion were very important in their surgery decision less often received mastectomy than those less concerned about body image or who placed less weight on their spouse's opinion (for body image concerns, estimated RR = 0.47, 95% CI = 0.30 to 0.74; for spouse's opinion, estimated RR = 0.53, 95% CI = 0.36 to 0.78).

CONCLUSION

Greater patient involvement in decision making was associated with receipt of mastectomy for all racial and ethnic groups. Patient attitudes about surgery and the opinions of family and friends contribute to surgical choices made by women with breast cancer.

Latinas and breast cancer outcomes: population-based sampling, ethnic identity, and acculturation assessment

PURPOSE

Latinas and African-Americans with breast cancer, especially those of lower socioeconomic status and acculturation, have been underrepresented in studies assessing treatment satisfaction, decision-making, and quality of life. A study was designed to recruit a large and representative sample of these subgroups.

MATERIALS AND METHODS

Incident cases were selected by rapid case ascertainment (RCA) in the Los Angeles Surveillance, Epidemiology, and End Results Registry from 2005 to 2006, with oversampling of Latinas and African-Americans. Patients were mailed a questionnaire and $10 incentive 5 to 6 months after diagnosis; nonrespondents were contacted by telephone. Multivariate analysis was used to assess possible response bias. The RCA definition of Hispanic origin was validated by self-reports. The Short Acculturation Scale for Hispanics index for Latina respondents was used.

RESULTS

One thousand six hundred and ninety-eight eligible breast cancer cases were selected and 1,223 participated, for a response rate of 72.0%, which varied little by race/ethnicity. Age, race/ethnicity, and clinical factors were not associated with response; however, respondents were slightly more likely to be married and from higher socioeconomic status census tracts than nonrespondents. The RCA definition of Hispanic identity was highly sensitive (94.6%) and specific (90.0%). Lower acculturation was associated with lower education and literacy among Latinas.

DISCUSSION

High response rates among all subgroups were achieved due to the use of RCA, an incentive, extensive telephone follow-up, a native Spanish-speaking interviewer, and a focused questionnaire. The low acculturation index category identified a highly vulnerable subgroup. This large sample representing subgroups with greater problems will provide a basis for developing better interventions to assist these women.

Postmastectomy radiotherapy for breast cancer: patterns, correlates, communication, and insights into the decision process

BACKGROUND

Given accumulating evidence supporting postmastectomy radiotherapy (PMRT) in selected patients, it is important to evaluate patterns and correlates of PMRT utilization, including communication and attitudinal factors.

METHODS

The authors surveyed 2382 patients diagnosed with breast cancer in 2002 and reported to the Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries (n=1844, 77.4% response rate). Analyses were restricted to patients with nonmetastatic invasive breast cancer treated by mastectomy who had decided whether or not to undergo PMRT (n=396). The authors assessed rates of explanation, recommendation, and receipt of radiation by indication grouping, defined primarily by the 2001 American Society of Clinical Oncology guidelines. They evaluated correlates of PMRT receipt, including tumor and sociodemographic characteristics. They also explored patients' self-reported reasons for nonreceipt of PMRT.

RESULTS

The adjusted proportion in each indication group reporting that a provider had explained radiation was high (77% of those in whom PMRT was indicated, 76% of those in whom medical opinion was divided, and 73% of those in whom PMRT was not indicated; P=.10). The adjusted proportions reporting recommendations for radiation (86%, 35%, and 17%, respectively) and receipt (81%, 34%, and 10%, respectively) varied significantly by indication grouping (P<.001). On multivariate analysis, tumor size (P<.001), lymph node status (P<.001), comorbidity (P=.02), and chemotherapy receipt (P=.003) were found to be independent significant correlates of PMRT receipt. The most common reasons cited for not pursuing PMRT were lack of physician recommendation and perceived lack of need.

CONCLUSIONS

PMRT receipt is strongly correlated with clinical indication. The authors found no sociodemographic disparities in utilization. However, approximately one-fifth of patients with strong indications did not receive treatment.