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Zipkin RJ, Schaefer A, Wang C, Loehrer AP, Kapadia NS, Brooks GA, Onega T, Wang F, O'Malley AJ, Moen EL. Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries. Ann Surg Oncol 2022; 29:5759-5769. [PMID: 35608799 PMCID: PMC9128633 DOI: 10.1245/s10434-022-11834-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood. METHODS We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence. RESULTS Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays. CONCLUSIONS Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban status.
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Affiliation(s)
- Ronnie J Zipkin
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andrew Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Changzhen Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, USA
| | - Andrew P Loehrer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Department of Population Sciences, University of Utah, Salt Lake City, UT, USA
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Fahui Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, USA
| | - Alistair J O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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2
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Dsouza R, Gaikwad P, Samuel VM, Thomas C. Breast reconstruction following mastectomy in Indian women: a neglected entity. BMJ Case Rep 2022; 15:e248322. [PMID: 35863860 PMCID: PMC9310151 DOI: 10.1136/bcr-2021-248322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/04/2022] Open
Abstract
Phyllodes tumour is a rapidly growing neoplasm with a propensity to involve the entire breast tissue. In large tumours, the treatment comprises a wide local excision or a mastectomy. A woman in her 20s from rural India presented with complaints of a recurrent left breast lump. The lump progressed to a large size, limiting her social activities and causing depression. On examination, she had a mass occupying almost the entire left breast, with stretched skin, dilated veins and pressure necrosis. There were no palpable axillary nodes. She was offered a wide local excision and reconstruction with a latissimus dorsi pedicled flap. After much discussion and clarification of some misconceptions around breast reconstruction, she underwent the planned surgery. This was followed by adjuvant radiation therapy as the histopathology was consistent with a complex phyllodes tumour with close margins. She was well at 1-year follow-up and led a good family and social life. Breast conservation and reconstruction are seldom offered as part of cancer treatment in India. All women should be offered surgical options that are oncologically safe while preserving body image, and hence healthcare providers must work towards breaking the barriers that prevent breast reconstruction.
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Affiliation(s)
- Royson Dsouza
- General Surgery, ASHWINI Gudalur Adivasi Hospital, Vellore, India
| | - Pranay Gaikwad
- Department of General Surgery Unit 1, Christian Medical College Hospital, Vellore, India
| | - Vasanth Mark Samuel
- Department of General Surgery Unit 1, Christian Medical College Hospital, Vellore, India
| | - Cecil Thomas
- Department of General Surgery Unit 1, Christian Medical College Hospital, Vellore, India
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3
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Frebault J, Bergom C, Cortina CS, Shukla ME, Zhang Y, Huang CC, Kong AL. Invasive Breast Cancer Treatment Patterns in Women Age 80 and Over: A Report from the National Cancer Database. Clin Breast Cancer 2022; 22:49-59. [PMID: 34391660 PMCID: PMC9003119 DOI: 10.1016/j.clbc.2021.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/25/2021] [Accepted: 07/09/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND There are no established treatment guidelines for women with breast cancer aged ≥80 despite increasing representation in the US population. Here we identify national treatment patterns and survival outcomes in women with stage I-III invasive breast cancer. PATIENTS AND METHODS Women age ≥80 diagnosed with stage I-III invasive breast cancer (IBC) were identified from 2005-2014 in the National Cancer Database. χ2, Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Cox proportional hazard models were used to evaluate overall survival (OS). RESULTS A total of 62,575 women with IBC met inclusion criteria, of which the majority received surgery (94%). Receipt of surgery was associated with White race, age <90, lower stage, and fewer comorbidities. OS was higher for those who received surgery compared to those who did not (HR 3.3 [3.18-3.46] P < .001). Molecular subtype analysis demonstrated improved survival with receipt of surgery or radiation for all subtypes, as well as improved survival with chemotherapy for those with triple negative breast cancer. CONCLUSION The vast majority of breast cancer patients aged ≥80 in the National Cancer Database with IBC received primary surgical management, which was associated with a significant OS benefit. Due to this finding, surgical resection should be considered for all patients ≥80 who are suitable operative candidates.
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Affiliation(s)
- Julia Frebault
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Carmen Bergom
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226,Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Chandler S. Cortina
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Monica E. Shukla
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI 53226
| | - Yiwen Zhang
- University of Wisconsin-Milwaukee Zilber School of Public Health, Milwaukee, WI 53201
| | - Chiang-Ching Huang
- University of Wisconsin-Milwaukee Zilber School of Public Health, Milwaukee, WI 53201
| | - Amanda L. Kong
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI 53226
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4
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Killelea BK, Herrin J, Soulos PR, Pollack CE, Forman HP, Yu J, Xu X, Tannenbaum S, Wang SY, Gross CP. Income disparities in needle biopsy patients prior to breast cancer surgery across physician peer groups. Breast Cancer 2020; 27:381-388. [PMID: 31792804 PMCID: PMC7512133 DOI: 10.1007/s12282-019-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Evaluate income disparities in receipt of needle biopsy among Medicare beneficiaries and describe the magnitude of this variation across physician peer groups. METHODS The Surveillance, Epidemiology and End Results (SEER)-Medicare database was queried from 2007-2009. Physician peer groups were constructed. The magnitude of income disparities and the patient-level and physician peer group-level effects were assessed. RESULTS Among 9770 patients, 65.4% received needle biopsy. Patients with low income (median area-level household income < $33K) were less likely to receive needle biopsy (58.5%) compared to patients with high income (≥ $50K) (68.6%; adjusted odds ratio 0.77; 95% confidence interval (CI) 0.65-0.91). Needle biopsy varied substantially across physician peer groups (interquartile range 43.4-81.9%). The magnitude of the disparity ranged from an odds ratio (OR) of 0.50 (95% CI 0.23-1.07) for low vs. high income patients to 1.27 (95% CI 0.60-2.68). The effect of being treated by a physician peer group that treated mostly low-income patients on receipt of needle biopsy was nearly three times the effect of being a low-income patient. CONCLUSIONS Needle biopsy continues to be underused and disparities by income exist. The magnitude of this disparity varies substantially across physician peer groups, suggesting that further work is needed to improve quality and reduce inequities.
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Affiliation(s)
- Brigid K Killelea
- Department of Surgery, Yale School of Medicine, 310 Cedar St., LH 118, New Haven, CT, 06510, USA.
- Yale Cancer Center, New Haven, CT, USA.
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA.
| | - Jeph Herrin
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA
- Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Health Research and Educational Trust, Chicago, IL, USA
- , 2254, Charlottesville, VA, 22902, USA
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 367 Cedar St., Harkness Bldg A, Rm 304, New Haven, CT, 06511, USA
| | - Craig E Pollack
- Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Hampton House 403, 624 N Broadway Street, Baltimore, MD, 21287, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 330 Cedar Street, TE-2, New Haven, CT, 06510, USA
| | - James Yu
- Yale Cancer Center, New Haven, CT, USA
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA
- Department of Therapeutic Radiology, Yale School of Medicine, 333 Cedar St. HRT-138, New Haven, CT, USA
| | - Xiao Xu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar Street, LSOG 205B, New Haven, CT, 06520, USA
| | - Sara Tannenbaum
- Yale University School of Medicine, 367 Cedar St. Harkness Bldg A, Rm 304, New Haven, CT, 06511, USA
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, 208034, New Haven, CT, 06520, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center, Yale School of Medicine, 333 Cedar Street, 208025, New Haven, CT, USA
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 367 Cedar St., Harkness Bldg A, Rm 304, New Haven, CT, 06511, USA
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5
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Park KU, Selby L, Chen XP, Cochran A, Harzman A, Shen C, Gregory ME. Development of Residents' Self-Efficacy in Multidisciplinary Management of Breast Cancer Survey. J Surg Res 2020; 251:275-280. [PMID: 32197183 DOI: 10.1016/j.jss.2020.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/23/2020] [Accepted: 02/16/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Treating patients with breast cancer is multidisciplinary; however, it is unclear whether surgery residency programs provide sufficient training in multidisciplinary care. Self-efficacy is one way of measuring the adequacy of training. Our goal was to develop a method of assessing self-efficacy in multidisciplinary breast cancer care. METHODS Based on a literature review and subject-matter expert input, we developed a 30-item self-efficacy survey to measure six domains of breast cancer care (genetics, surgery, medical oncology, radiation oncology, pathology, and radiology). We constructed and validated the survey using a seven-step survey development framework. The survey was administered to general surgery residents at a single academic surgical residency. RESULTS Response rate was 66% (n = 31). Internal consistency was strong (Cronbach alpha = 0.92). Self-efficacy was moderate (mean = 3.05) and tended to increase with training (postgraduate year [PGY] 1: mean= 2.37 versus PGY 5: mean= 3.54; P < 0.001), providing evidence for construct validity. Self-efficacy was highest in the surgery (3.56) compared with others (genetics 2.67, medical oncology 3, radiation oncology 2.67, pathology 2.67, and radiology 3.33). This trend was similar across all PGY groups, except for interns, whose self-efficacy in surgery was low. CONCLUSIONS We created a survey to assess self-efficacy in multidisciplinary breast cancer care and provided initial evidence of survey validity. Although self-efficacy in surgery improved with years in training, medical and radiation oncology self-efficacy remained low. As modern breast cancer treatment is highly multidisciplinary, an expanded education program is needed to help trainees incorporate multidisciplinary clinical perspectives.
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Affiliation(s)
- Ko Un Park
- Division of Surgical Oncology, Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.
| | - Luke Selby
- Division of Surgical Oncology, Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Xiaodong Phoenix Chen
- Department of Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Amalia Cochran
- Department of Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Alan Harzman
- Department of Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Megan E Gregory
- Department of Biomedical Informatics, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio
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6
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Iverson KR, Svensson E, Sonderman K, Barthélemy EJ, Citron I, Vaughan KA, Powell BL, Meara JG, Shrime MG. Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries. Int J Health Policy Manag 2019; 8:521-537. [PMID: 31657175 PMCID: PMC6815989 DOI: 10.15171/ijhpm.2019.43] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/28/2019] [Indexed: 12/15/2022] Open
Abstract
Background: While recommendations for the optimal distribution of surgical services in high-income countries (HICs) exist, it is unclear how these translate to resource-limited settings. Given the significant shortage and maldistribution of surgical workforce and infrastructure in many low- and middle-income countries (LMICs), the optimal role of decentralization versus regionalization (centralization) of surgical care is unknown. The aim of this study is to review evidence around interventions aimed at redistributing surgical services in LMICs, to guide recommendations for the ideal organization of surgical services. Methods: A narrative-based literature review was conducted to answer this question. Studies published in English between 1997 and 2017 in PubMed, describing interventions to decentralize or regionalize a surgical procedure in a LMIC, were included. Procedures were selected using the Disease Control Priorities’ (DCP3) Essential Surgery Package list. Intervention themes and outcomes were analyzed using a narrative, thematic synthesis approach. Primary outcomes included mortality, complications, and patient satisfaction. Secondary outcomes included input measures: workforce and infrastructure, and process measures: facility-based care, surgical volume, and referral rates. Results: Thirty-five studies were included. Nine (33%) of the 27 studies describing decentralization showed an improvement in primary outcomes. The procedures associated with improved outcomes after decentralization included most obstetric, gynecological, and family planning services as well as some minor general surgery procedures. Out of 8 studies on regionalization (centralization), improved outcomes were shown for trauma care in one study and cataract extraction in one study. Conclusion: Interventions aimed at decentralizing obstetric care to the district hospital and health center levels have resulted in mortality benefits in several countries. However, more evidence is needed to link service distribution to patient outcomes in order to provide recommendations for the optimal organization of other surgical procedures in LMICs. Considerations for the optimal distribution of surgical procedures should include the acuity of the condition for which the procedure is indicated, anticipated case volume, and required level of technical skills, resources, and infrastructure. These attributes should be considered within the context of each country.
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Affiliation(s)
- Katherine R Iverson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,General Surgery Department, University of California Davis Medical Center, Sacramento, CA, USA
| | - Emma Svensson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Lund University, Lund, Sweden
| | - Kristin Sonderman
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Kerry A Vaughan
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,University of Pennsylvania, Philadelphia, PA, USA
| | - Brittany L Powell
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Stanford University School of Medicine, Stanford, CA, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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Abstract
OBJECTIVE The aim of this study was to determine whether hospital volume was associated with mortality in breast cancer, and what thresholds of case volume impacted survival. BACKGROUND Prior literature has demonstrated improved survival with treatment at high volume centers among less common cancers requiring technically complex surgery. METHODS All adults (18 to 90 years) with stages 0-III unilateral breast cancer diagnosed from 2004 to 2012 were identified from the American College of Surgeons National Cancer Data Base (NCDB). A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital volume and overall survival, after adjusting for measured covariates. Intergroup comparisons of patient and treatment characteristics were conducted with X and analysis of variance (ANOVA). The log-rank test was used to test survival differences between groups. A multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) associated with each volume group. RESULTS One million sixty-four thousand two hundred and fifty-one patients met inclusion criteria. The median age of the sample was 60 (interquartile range 50 to 70). Hospitals were categorized into 3 groups using restricted cubic spline analysis: low-volume (<148 cases/year), moderate-volume (148 to 298 cases/year), and high-volume (>298 cases/year). Treatment at high volume centers was associated with an 11% reduction in overall mortality for all patients (HR 0.89); those with stage 0-I, ER+/PR+ or ER+/PR- breast cancers derived the greatest benefit. CONCLUSIONS Treatment at high volume centers is associated with improved survival for breast cancer patients regardless of stage. High case volume could serve as a proxy for the institutional infrastructure required to deliver complex multidisciplinary breast cancer treatment.
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8
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Yen TWF, Laud PW, Pezzin LE, McGinley EL, Wozniak E, Sparapani R, Nattinger AB. Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer. Med Care 2018; 56:78-84. [PMID: 29087982 PMCID: PMC5725235 DOI: 10.1097/mlr.0000000000000832] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity. OBJECTIVE Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND. RESEARCH DESIGN/SUBJECTS Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009. MEASURES Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated. RESULTS Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases. CONCLUSIONS In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.
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Affiliation(s)
- Tina W F Yen
- Department of Surgery
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Purushottam W Laud
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics
| | - Liliana E Pezzin
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine
| | - Emily L McGinley
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Erica Wozniak
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
| | - Rodney Sparapani
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics
| | - Ann B Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI
- Department of Medicine
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9
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Yen TWF, Pezzin LE, Li J, Sparapani R, Laud PW, Nattinger AB. Effect of hospital volume on processes of breast cancer care: A National Cancer Data Base study. Cancer 2017; 123:957-966. [PMID: 27861746 DOI: 10.1002/cncr.30413] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/31/2016] [Accepted: 10/03/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation. METHODS Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy). RESULTS Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24). CONCLUSIONS Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liliana E Pezzin
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jianing Li
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Purushuttom W Laud
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ann B Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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10
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Fung F, Cornacchi SD, Vanniyasingam T, Dao D, Thabane L, Simunovic M, Hodgson N, O'Brien MA, Reid S, Heller B, Lovrics PJ. Predictors of 5-year local, regional, and distant recurrent events in a population-based cohort of breast cancer patients. Am J Surg 2017; 213:418-425. [DOI: 10.1016/j.amjsurg.2016.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/02/2016] [Accepted: 03/09/2016] [Indexed: 10/21/2022]
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11
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Simpson JS, Scheer AS. A Review of the Effectiveness of Breast Surgical Oncology Fellowship Programs Utilizing Kirkpatrick's Evaluation Model. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2016; 31:466-471. [PMID: 26058681 DOI: 10.1007/s13187-015-0866-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
It has been 10 years since the first class of Society of Surgical Oncology (SSO) fellowship trained Breast Surgical Oncologist entered practice. To date, there has been no publications examining the effectiveness of these training programs that are today throughout North America and Europe. This evaluative review examines the effectiveness of these fellowship training programs through the lens of the Kirkpatrick Evaluation Model. An extensive review of the literature was performed, and articles were categorized to capture how fellows are reacting to the program, what they are learning, and how the program is effecting their career path and impacting their patients. We can conclude that there is both direct and indirect evidence to support the effectiveness of this training program, but there is a paucity of direct evidence as one progresses from a level 1 Kirkpatrick analysis to a level 4. This review sets the framework for program evaluation in surgical fellowships and should encourage stakeholders to constantly evaluate the impact their program is having on trainees and oncology patients.
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Affiliation(s)
- Jory S Simpson
- St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | - A S Scheer
- St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
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Kong AL, Pezzin LE, Nattinger AB. Identifying patterns of breast cancer care provided at high-volume hospitals: a classification and regression tree analysis. Breast Cancer Res Treat 2015; 153:689-98. [DOI: 10.1007/s10549-015-3561-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/20/2015] [Indexed: 11/30/2022]
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13
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Yen TWF, Laud PW, Sparapani RA, Nattinger AB. Surgeon specialization and use of sentinel lymph node biopsy for breast cancer. JAMA Surg 2014; 149:185-92. [PMID: 24369337 DOI: 10.1001/jamasurg.2013.4350] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema. OBJECTIVE To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer. DESIGN, SETTING, AND POPULATION A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined. MAIN OUTCOME AND MEASURE Type of axillary surgery performed. RESULTS Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB. CONCLUSIONS AND RELEVANCE Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Purushuttom W Laud
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Rodney A Sparapani
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Ann B Nattinger
- Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
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Luther SL, Neumayer L, Henderson WG, Foulis P, Richardson M, Haun J, Mikelonis M, Rosen A. The use of breast-conserving surgery for women treated for breast cancer in the Department of Veterans Affairs. Am J Surg 2013; 206:72-9. [PMID: 23611837 DOI: 10.1016/j.amjsurg.2012.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/26/2012] [Accepted: 08/28/2012] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous non-stage-adjusted research described a lower use of breast-conserving surgery (BCS) for the treatment of breast cancer in the Veterans Health Administration (VHA) facilities than in the private sector. METHODS We combined data from the VHA Centralized Cancer Registry with administrative datasets to describe surgical treatment for locoregional breast cancer in VHA facilities from 2000 to 2006. RESULTS When considering only procedures performed in VHA facilities, BCS rates decreased from 50.5% (53/105) in 2000 to 42.3% (n = 58/137) in 2006; however, after accounting for procedures conducted in the private sector and paid for by the VHA, BCS rates approached those experienced in breast cancer patients cared for outside the VHA. CONCLUSIONS Based solely on procedures performed in the VHA, rates of BCS use are much lower in the VHA than in the private sector. We were able to show similar rates of BCS use when we accounted for procedures paid for by the VHA but performed at an outside facility. Further exploration and prospective analyses to examine these findings are needed.
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Affiliation(s)
- Stephen L Luther
- HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes, James A. Haley Veterans Hospital, 8900 Grand Oak Circle, Tampa, FL 33637-1022, USA.
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Peltoniemi P, Huhtala H, Holli K, Pylkkänen L. Effect of surgeon's caseload on the quality of surgery and breast cancer recurrence. Breast 2012; 21:539-43. [DOI: 10.1016/j.breast.2012.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022] Open
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Veiga DF, Veiga-Filho J, Ribeiro LM, Archangelo-Junior I, Mendes DA, Andrade VO, Caetano LV, Campos FS, Juliano Y, Ferreira LM. Evaluations of aesthetic outcomes of oncoplastic surgery by surgeons of different gender and specialty: A prospective controlled study. Breast 2011; 20:407-12. [DOI: 10.1016/j.breast.2011.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 08/25/2010] [Accepted: 04/06/2011] [Indexed: 01/11/2023] Open
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Kong AL, Yen TWF, Pezzin LE, Miao H, Sparapani RA, Laud PW, Nattinger AB. Socioeconomic and racial differences in treatment for breast cancer at a low-volume hospital. Ann Surg Oncol 2011; 18:3220-7. [PMID: 21861226 DOI: 10.1245/s10434-011-2001-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE Population-based studies have revealed higher mortality among breast cancer patients treated in low-volume hospitals. Other studies have demonstrated disparities in race and socioeconomic status (SES) in breast cancer survival. The purpose of our study was to determine whether nonwhite or low-SES patients are disproportionately treated in low-volume hospitals. METHODS A population-based cohort of 2,777 Medicare breast cancer patients who underwent breast cancer surgery in 2003 participated in a survey study examining breast cancer outcomes. Information was obtained from survey responses, Medicare claims, and state tumor registry data. RESULTS On univariate analysis, patients treated at low-volume hospitals were less likely to be white, less likely to live in an urban location, and more likely to have a low SES with less social support and live a greater distance from a high-volume hospital. Education, marital status, total household income, having additional insurance besides Medicare, population density of primary residence, and tangible support were associated with distance to the nearest high-volume hospital. On multivariate analysis, the independent predictors of treatment at a low-volume hospital were being nonwhite (P = 0.003), having a lower household income (P < 0.0001), residence in a rural location (P = 0.01), and living a greater distance from a high-volume hospital (P < 0.0001). CONCLUSIONS In this large population-based cohort, women who were poorer, nonwhite, and who lived in a rural location or at a greater distance from a high-volume hospital were more likely to be treated at low-volume hospitals. These differences may partially explain racial and SES disparities in breast cancer outcomes.
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Affiliation(s)
- Amanda L Kong
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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Dickson-Witmer D, Bleznak AD, Kennedy JS, Stewart AK, Palis BE, Bailey L, Laidley AL, Penman EJ. Breast Cancer Care in the Community: Challenges, Opportunities, and Outcomes. Surg Oncol Clin N Am 2011; 20:555-80, ix. [DOI: 10.1016/j.soc.2011.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Peltoniemi P, Peltola M, Hakulinen T, Häkkinen U, Pylkkänen L, Holli K. The Effect of Hospital Volume on the Outcome of Breast Cancer Surgery. Ann Surg Oncol 2011; 18:1684-90. [DOI: 10.1245/s10434-010-1514-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Indexed: 11/18/2022]
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Abstract
The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.
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Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States. J Am Coll Surg 2009; 209:425-433.e2. [PMID: 19801315 DOI: 10.1016/j.jamcollsurg.2009.06.363] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 06/15/2009] [Accepted: 06/16/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND Breast-conserving surgery (BCS) followed by radiotherapy is as effective as mastectomy for treatment of early invasive breast cancer. But earlier studies report low BCS use rates of 12% to 43% nationally, especially in older patients. We sought to determine current patterns and predictors of BCS use. STUDY DESIGN In a national Medicare database of all beneficiaries (age greater than 65 years) with incident invasive breast cancer treated with operation in 2003, claims codes identified BCS versus mastectomy and demographic, treatment, and geographic region covariates. The 2003 Area Resource File provided socioeconomic covariates. Logistic regression modeled predictors of BCS. RESULTS In 56,725 women, 59% were treated with BCS versus 41% with mastectomy. BCS was more likely in women who were younger than 70 years (odds ratio [OR], 1.37; 95% CI, 1.31 to 1.44; p < 0.001) and had lymph node-negative disease (OR, 1.60; 95% CI, 1.52 to 1.68; p < 0.001). Socioeconomic factors influenced use, with BCS more likely in areas with low poverty (OR, 1.05; 95% CI, 1.00 to 1.09; p = 0.03), high education (OR, 1.13; 95% CI, 1.08 to 1.19), high density of radiation oncologists (OR, 1.30; 95% CI, 1.06 to 1.59), and in metropolitan areas (OR, 1.20; 95% CI, 1.14 to 1.26). Significant geographic variation existed: 70% of women were treated with BCS in northeastern New England compared with only 48% to 50% in the South (p < 0.001). CONCLUSIONS Currently, more than half of older women across the US diagnosed with nonmetastatic invasive breast cancer treated surgically receive BCS, representing a substantial increased use compared with historical data. Lack of BCS use appears in part associated with socioeconomic disadvantage, suggesting that persistent barriers to breast conservation exist.
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Beckmann MW, Bani MR, Loehberg CR, Hildebrandt T, Schrauder MG, Wagner S, Fasching PA, Lux MP. Are Certified Breast Centers Cost-Effective? ACTA ACUST UNITED AC 2009; 4:245-250. [PMID: 20877662 DOI: 10.1159/000229190] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The German health care system has entered an era of specialist centers and certification. Hospitals are required to introduce quality management with external monitoring, refining and improving their quality of treatment. These statutory requirements can only be met through specialization, centralization, and establishing centers and networks with internal and external interdisciplinary collaboration. The breast centers certified according to the criteria of the German Cancer Society (DKG) and German Society for Mastology (DGS) are pioneers here. Simultaneously, there are increasing demands for more cost-effective medical services despite limited resources - making economic analysis of health care provision necessary. Few economic studies of the centers and certification system have been conducted, however. General long-term quality data, particularly for results, are not yet available from certified breast centers. At present, a certified breast center is not itself a proven independent prognostic parameter for treatment results. However, the individual criteria required for breast center certification show a significant positive influence on clinical efficacy. Certified breast centers involve substantial extra costs that are not reimbursed by funding bodies, so the slightest potential benefit for patients from certified centers already appears cost-effective. When the actual costs, currently usually subsidized by other departments, are considered, it is unclear whether certified breast centers remain cost-effective.
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Yen TWF, Fan X, Sparapani R, Laud PW, Walker AP, Nattinger AB. A contemporary, population-based study of lymphedema risk factors in older women with breast cancer. Ann Surg Oncol 2009; 16:979-88. [PMID: 19194754 DOI: 10.1245/s10434-009-0347-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 01/09/2009] [Accepted: 01/09/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND We studied potential risk factors for lymphedema in a contemporary population of older breast cancer patients. METHODS Telephone surveys were conducted among women (65-89 years) identified from Medicare claims as having initial breast cancer surgery in 2003. Lymphedema was classified by self-report. Surgery and pathology information was obtained from Medicare claims and the state cancer registries. RESULTS Of 1,338 patients treated by 707 surgeons, 24% underwent sentinel lymph node biopsy (SLNB) and 57% axillary lymph node dissection (ALND). At a median of 48 months postoperatively, 193 (14.4%) had lymphedema. Lymphedema developed in 7% of the 319 patients who underwent SLNB and in 21% of the 759 patients who underwent ALND. When controlling for patient age, tumor size, type of breast cancer, type of breast and axillary surgery, receipt of radiation, chemotherapy, and hormonal therapy, and surgeon case volume, the independent predictors of lymphedema were removal of more than five lymph nodes [odds ratio (OR) 4.68-5.61, 95% confidence interval (CI) 1.36-19.74 for 6-15 nodes; OR 10.50, 95% CI 2.88-38.32 for >15 nodes] and presence of lymph node metastases (OR 1.98, 95% CI 1.21-3.24). CONCLUSIONS Four years postoperatively, 14% of a contemporary, population-based cohort of elderly breast cancer survivors had self-reported lymphedema. In this group of predominantly community-based surgeons, the number of lymph nodes removed is more predictive of lymphedema rather than whether SLNB or ALND was performed. As more women with breast cancer undergo only SLNB, it is essential that they still be counseled on their risk for lymphedema.
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Affiliation(s)
- Tina W F Yen
- Division of General Surgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
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24
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Tisnado DM, Malin JL, Tao ML, Ganz P, Rose-Ash D, Hu AF, Adams J, Kahn KL. The structural landscape of the health care system for breast cancer care: results from the Los Angeles Women's Health Study. Breast J 2008; 15:17-25. [PMID: 19120382 DOI: 10.1111/j.1524-4741.2008.00666.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The structure of health care has been rapidly evolving in response to financial pressures and demands to improve quality. Little work has documented the structure of care and its impact in the context of breast cancer care. We conducted a survey to characterize Los Angeles physicians caring for breast cancer patients and the structural landscape of the healthcare system in which they practice. Cross-sectional survey of physicians who treated a population-based cohort of breast cancer patients. We surveyed 477 physicians, targeting all Los Angeles County medical oncologists, radiation oncologists, and surgeons reported by patients participating in the Los Angeles Women's Health Study (77% response rate). Specialty-specific questionnaires were developed. Items were based on the structure and quality of care literature, cognitive interviews with cancer care specialists, and existing physician survey instruments. Breast cancer care providers in Los Angeles are diverse, with one-third non-white and 46% speaking a non-English language. Group practice is most common, (37% single specialty, 16% group-model HMO, 8% multi-specialty group). Minimal teaching involvement predominates. Mean new breast cancer patient volumes are relatively high (8 per month overall; six for surgeons), representing 46% of new cancer patients. Physicians reported high career satisfaction levels (83-92%). Physicians were least satisfied with the amount of time spent with patients (82%). Data from this study represent important building blocks for further analyses to determine the impact of structural characteristics on the quality of care that breast cancer patient's experience.
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Affiliation(s)
- Diana M Tisnado
- Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles, California 90095-1736, USA.
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Halpern MT, Chen AY, Marlow NS, Ward E. Disparities in Receipt of Lymph Node Biopsy Among Early-Stage Female Breast Cancer Patients. Ann Surg Oncol 2008; 16:562-70. [DOI: 10.1245/s10434-008-0205-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 09/25/2008] [Accepted: 09/26/2008] [Indexed: 11/18/2022]
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Orr RK, Wheeler KL, Barrineau DD, Hird RB. Improvement in sentinel node biopsy results in a teaching community hospital: results of a multidisciplinary quality improvement program. Am J Surg 2008; 196:569-71. [DOI: 10.1016/j.amjsurg.2008.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 06/04/2008] [Accepted: 06/04/2008] [Indexed: 11/25/2022]
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Pass HA, Klimberg SV, Copeland EM. Are "breast-focused" surgeons more competent? Ann Surg Oncol 2008; 15:953-5. [PMID: 18247092 PMCID: PMC2266785 DOI: 10.1245/s10434-008-9835-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 01/09/2008] [Indexed: 11/18/2022]
Affiliation(s)
- Helen A Pass
- Columbia University College of Physicians and Surgeons, 55 Palmer Avenue, Bronxville, NY 10708, USA.
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Waljee JF, Hawley S, Alderman AK, Morrow M, Katz SJ. Patient Satisfaction With Treatment of Breast Cancer: Does Surgeon Specialization Matter? J Clin Oncol 2007; 25:3694-8. [PMID: 17635952 DOI: 10.1200/jco.2007.10.9272] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Experience and practice setting vary greatly among surgeons who treat breast cancer patients. However, less is known about how these factors influence patient satisfaction with their care. Patients and Methods We surveyed all ductal carcinoma in situ patients and a 20% random sample of invasive breast cancer patients diagnosed in 2002 reported to the Detroit, MI, and Los Angeles, CA, Surveillance, Epidemiology, and End Results registries. Attending surgeons were surveyed, yielding dyad information for 64.6% of patients (n = 1,539) and 69.7% of surgeons (n = 318). Logistic regression was used to examine the associations between surgeon specialization (percentage of practice devoted to breast disease) and hospital cancer program status, with four domains of patient satisfaction: (1) the surgical decision, (2) decision-making process, (3) surgeon-patient relationship, and (4) surgeon-patient communication, adjusting for patient and surgeon demographics and disease stage. Results In this sample, 34.5% of patients were treated by surgeons who devoted less than 30% (low volume) of their practice to breast disease, 32.5% by surgeons who devoted 30% to 60% (medium volume) of their practice to breast disease, and 33.0% by surgeons who devoted more than 60% (high volume) of their practice to breast disease. Compared to patients treated by low-volume surgeons, patients treated by higher volume surgeons were more satisfied with the decision-making process (medium volume, odds ratio [OR], 1.16; 95% CI, 0.80 to 1.67; high volume: OR, 1.79; 95% CI, 1.14 to 2.80) and with the surgeon-patient relationship (medium volume: OR, 1.13; 95% CI, 0.72 to 1.76; high volume: OR, 1.98; 95% CI, 1.08 to 3.61). Treatment setting was not associated with patient satisfaction after controlling for other factors. Conclusion Surgeon specialization is correlated with patient satisfaction. Examining the processes underlying these associations can inform strategies to improve breast cancer care.
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Affiliation(s)
- Jennifer F Waljee
- Section of General Surgery, Department of Surgery; Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor, MI, USA.
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Hébert-Croteau N, Roberge D, Brisson J. Provider’s volume and quality of breast cancer detection and treatment. Breast Cancer Res Treat 2006; 105:117-32. [PMID: 17186361 DOI: 10.1007/s10549-006-9439-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 10/24/2006] [Indexed: 11/26/2022]
Abstract
For many health conditions, the process or result of medical procedures improves with increasing caseload. The evidence about breast cancer has not been thoroughly assessed. This review synthesizes the literature about provider's volume and performance in either breast cancer screening with mammography or treatment. Articles published in English between 1990 and 2006 were identified by a computerized search and by review of reference lists. In screening with mammography, the reading volume of the radiologist and the screening volume of the facility influence different components of performance. The most conclusive evidence for breast cancer treatment concerns the association between the surgeon's caseload and the process or end-results of therapeutic interventions. Although the mechanisms of these associations still need to be clarified, large provider's volume in screening mammography or breast cancer treatment is often related to the quality of medical interventions.
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Affiliation(s)
- Nicole Hébert-Croteau
- Direction des Systèmes de Soins et Services, Institut National de Santé Publique du Québec, 190 Boul. Crémazie Est, Bureau 2.24, Montréal, Quebec, Canada.
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Silliman RA. Whither quality of breast cancer care? Med Care 2006; 44:607-8. [PMID: 16799354 DOI: 10.1097/01.mlr.0000225363.93560.8e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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