Surgeon perspectives about local therapy for breast carcinoma

Higher 10-Year Survival with Breast-Conserving Therapy over Mastectomy for Women with Early-Stage (I-II) Breast Cancer: Analysis of the CDC Patterns of Care Data Base

Background

Studies in the United States are scarce that assess the survival differences between breast-conserving surgery plus radiation (Breast-Conserving Therapy; BCT) and mastectomy groups using population-based data while accounting for sociodemographic and clinical factors that affect the survival of women with early-stage breast cancer (ESBC).

Objective

To assess whether BCT provides superior long-term overall survival (OS) and breast cancer-specific survival (BCSS) compared with mastectomy in women with ESBC, while considering key factors that impact survival.

Design

Cohort study.

Methods

We analyzed data on women aged 20 years and older diagnosed with stage I-II breast cancer (BC) in 2004 who received either BCT or mastectomy. The data were collected by 5 state cancer registries through the Centers for Disease Control and Prevention-funded Patterns of Care study. Multivariable Cox proportional hazard models, accounting for sociodemographic and clinical factors, were used to calculate hazard ratios (HRs) with 95% confidence intervals (CI). Sensitivity analysis involved optimal caliper propensity score (PS) matching to address residual confounding.

Results

Of the 3495 women, 41.5% underwent mastectomy. The 10-year OS and BCSS were 82.7% and 91.1% for BCT and 72.3% and 85.7% for mastectomy, respectively. Adjusted models showed that mastectomy recipients had a 22% higher risk of all-cause deaths (ACD) (HR = 1.22, 95% CI = [1.06, 1.41]) and a 26% higher risk of breast cancer-specific deaths (BCD) (HR = 1.26, 95% CI = [1.02, 1.55]) than BCT recipients. Sensitivity analysis demonstrated that mastectomy was associated with a higher risk of ACD (P < .05) but did not exhibit a statistically significant risk for BCD. Women with HR+/HER2+ (luminal B) or invasive ductal carcinoma BC who underwent mastectomy had higher risks of ACD and BCD compared with BCT recipients, while the hazards for ACD in triple-negative BC did not remain significant after adjusting for covariates.

Conclusion

ESBC BCT recipients demonstrate superior OS and BCSS compared with mastectomy recipients.

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

The Impact of Surgeons on the Likelihood of Mastectomy in Breast Cancer

OBJECTIVE

This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer.

SUMMARY OF BACKGROUND DATA

Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process.

METHODS

A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution.

RESULTS

Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quintile of surgeons to 58.0% in the top quintile. On multivariable analysis, the individual surgeon (MOR 1.97) had a greater impact on mastectomy than did the institution (MOR 1.71) or all other clinical and demographic variables except tumor size (OR 3.06) and nodal status (OR 2.95). Surgeons with more years in practice, or those with a lower case volume were more likely to perform mastectomy (P < 0.05).

CONCLUSION

The individual surgeon influences the likelihood of mastectomy for the treatment of localized breast cancer. Further research should focus on physician-related biases that influence this decision to ensure patient autonomy.

Mastectomy or Breast-Conserving Therapy: Which Factors Influence A Patient's Decision?

BACKGROUND

The choice between mastectomy and breast-conserving therapy (BCT) is a first step for patients with breast cancer who are confronting decisions about treatment.

OBJECTIVE

To identify the most important determinants in treatment decision making by patients with breast cancer.

METHODS

Between 2003 and 2013, a total of 5258 patients with breast cancer were recorded in Kaiser Permanente Northwest's cancer registry. Patients had similar clinical-pathologic profiles, education, and insurance coverage, and were managed by 1 surgical group. A total of 2604 patients with invasive breast cancer chose mastectomy or BCT as they met unambiguous criteria for equivalent outcomes with either option. We examined the influence of the patient's surgeon on patient preferences.

RESULTS

Our retrospective analyses examined a study population that had similar risk profiles (age, family history of breast cancer, T category on tumor-node-metastasis staging system, tumor size, physical examination findings), surgeons consulting on similar patient types, and managed by surgeons with similar surgical performance patterns (case volumes, reexcision rates, number of reoperations, and ability to meet patient's expectations). Patients who preferred mastectomy were strongly influenced by tumor size (p < 0.001) and abnormal physical examination findings (palpable mass; p = 0.004), rather than age, family history of breast cancer, T category, or surgeon.

CONCLUSION

Physical examination findings and tumor size were statistically significant determinants influencing patients to choose mastectomy. Because geographic and practice style explanations fail to explain these variations, surgeons can identify, anticipate, and consider these factors when counseling patients about mastectomy and BCT therapeutic equivalency.

Doxorubicin-loaded nanoscale metal–organic framework for tumor-targeting combined chemotherapy and chemodynamic therapy

DMH NPs were prepared and could effectively induce MCF-7 cell death through the combination of chemotherapy and chemodynamic therapy.

The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer

PURPOSE

Despite multiple randomized trials showing the efficacy of hypofractionated radiation therapy in early-stage breast cancer, the United States has been slow to adopt this treatment. The goal of this study was to evaluate the impact of individual radiation oncologists on the early adoption of hypofractionated radiation therapy for early-stage breast cancer.

METHODS

We identified 22,233 Medicare beneficiaries with localized breast cancer that was diagnosed from 2004 to 2011 who underwent breast-conserving surgery with adjuvant radiation. Multilevel, multivariable logistic models clustered by radiation oncologist and geographic practice area were used to determine the impact of the provider and geographic region on the likelihood of receiving hypofractionated compared with standard fractionated radiation therapy while controlling for a patient's clinical and demographic covariates. Odds ratios (OR) describe the impact of demographic or clinical covariates, and the median OR (MOR) describes the relative impact of the individual radiation oncologist and geographic region on the likelihood of undergoing hypofractionated radiation therapy.

RESULTS

Among the entire cohort, 2333 women (10.4%) were treated with hypofractionated radiation therapy, with unadjusted rates ranging from 0.0% in the bottom quintile of radiation oncologists to 30.4% in the top quintile. Multivariable analysis found that the individual radiation oncologist (MOR 3.08) had a greater impact on the use of hypofractionation than did geographic region (MOR 2.10) or clinical and demographic variables. The impact of the provider increased from the year 2004 to 2005 (MOR 2.82) to the year 2010 to 2011 (MOR 3.16) despite the publication of long-term randomized trial results in early 2010. Male physician and radiation oncologists treating the highest volume of breast cancer patients were less likely to perform hypofractionation (P<.05).

CONCLUSIONS

The individual radiation oncologist strongly influenced the likelihood of a patient's receiving hypofractionated radiation therapy, and this trend increased despite the publication of long-term data showing equivalence to standard fractionation. Future research should focus on physician-related factors that influence this decision.

A Review of the Effectiveness of Breast Surgical Oncology Fellowship Programs Utilizing Kirkpatrick's Evaluation Model

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.

Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer

PURPOSE

To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada.

METHODS

All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals.

RESULTS

Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated.

CONCLUSIONS

Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.

Surgeons' Approaches and Professional Perspectives on Breast Masses: A National Survey in Turkey

OBJECTIVE

General surgeons' approaches to breast masses in their daily practices and their perspectives for issues on breast diseases and breast surgery are investigated through a survey.

MATERIALS AND METHODS

Answers of 524 general surgeons for the survey "Approach to breast diseases and breast surgery" between November 2012 and February 2013 were assessed. Demographic features, approaches to the breast masses, and answers for the clinical scenerios of surgeons were questioned. Surgeons were asked about management of breast cancer and the future role of surgeons for oncoplastic breast surgery and breast diseases.

RESULTS

Participants were representing 14.6% of all general surgeons in Turkey. The survey revealed that breast diseases are the most common cause for admission in general surgery outpatient clinics. Needle biopsies were employed by 241 (60%) respondents. Three hundred and seventy-one (71%) participants indicated that breast cancer management could be accurately conducted by the general surgeons. Two hundred and seventy-three (52%) respondents think that oncoplastic breast surgery should be performed by a general surgeon and 241 (41%) respondents predict that the role of general surgeons for breast diseases and breast surgery will decrease in the future.

CONCLUSION

Basic approaches towards breast masses need to be improved in our country despite the highest frequency of breast diseases in outpatient admissions. The views and opinions of surgeons on breast diseases and the course of breast surgery in different regions and different communities need to be defined and clarified.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Postmastectomy radiation therapy: an overview for the practicing surgeon

Locoregional control of breast cancer is the shared domain and responsibility of surgeons and radiation oncologists. Because surgeons are often the first providers to discuss locoregional control and recurrence risks with patients and because they serve in a key gatekeeping role as referring providers for radiation therapy, a sophisticated understanding of the evidence regarding radiotherapy in breast cancer management is essential for the practicing surgeon. This paper synthesizes the complex and evolving evidence regarding the role of radiation therapy after mastectomy. Although substantial evidence indicates that radiation therapy can reduce the risk of locoregional failure after mastectomy (with a relative reduction of risk of approximately two-thirds), debate persists regarding the specific subgroups who have sufficient risks of residual microscopic locoregional disease after mastectomy to warrant treatment with radiation. This paper reviews the evidence available to guide appropriate referral and patient decision making, with special attention to areas of controversy, including patients with limited nodal disease, those with large tumors but negative nodes, node-negative patients with high risk features, patients who have received systemic chemotherapy in the neoadjuvant setting, and patients who may wish to integrate radiation therapy with breast reconstruction surgery.

Decision making about surgery for early-stage breast cancer

BACKGROUND

Practice variation in breast cancer surgery has raised concerns about the quality of treatment decisions. We sought to evaluate the quality of decisions about surgery for early-stage breast cancer by measuring patient knowledge, concordance between goals and treatments, and involvement in decisions.

STUDY DESIGN

A mailed survey of stage I/II breast cancer survivors was conducted at 4 sites. The Decision Quality Instrument measured knowledge, goals, and involvement in decisions. A multivariable logistic regression model of treatment was developed. The model-predicted probability of mastectomy was compared with treatment received for each patient. Concordance was defined as having mastectomy and predicted probability >0.5 or partial mastectomy and predicted probability <0.5. Frequency of discussion about partial mastectomy was compared with discussion about mastectomy using chi-square tests.

RESULTS

Four hundred and forty patients participated (59% response rate). Mean overall knowledge was 52.7%; 45.9% knew that local recurrence risk is higher after breast conservation and 55.7% knew that survival is equivalent for the 2 options. Most participants (89.0%) had treatment concordant with their goals. Participants preferring mastectomy had lower concordance (80.5%) than those preferring partial mastectomy (92.6%; p = 0.001). Participants reported more frequent discussion of partial mastectomy and its advantages than of mastectomy, and 48.6% reported being asked their preference.

CONCLUSIONS

Breast cancer survivors had major knowledge deficits, and those preferring mastectomy were less likely to have treatment concordant with goals. Patients perceived that discussions focused on partial mastectomy, and many were not asked their preference. Improvements in the quality of decisions about breast cancer surgery are needed.

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.

Review of breast conservation therapy: then and now

Breast conservation therapy (BCT), which is the marriage of breast conserving surgery and radiation therapy to the breast, has revolutionized the treatment of breast cancer over the last few decades. Surgical direction had seen a heightened interest in the performance of cosmetically superior partial and segmental resections in breast conservation as well as increased demand by patients for breast preservation. The broadening of approaches to delivery of breast irradiation from whole breast to accelerated partial breast has allowed more patients to opt for breast conservation and allowed for what appears to be comparable measurable outcomes in emerging data. As well, the addition of state-of-the-art chemotherapeutic and hormonal therapies has allowed improved outcomes of patients from both local regional recurrence and overall survival standpoints. This paper will provide an overview of BCT and review some of the newest developments in optimizing this therapy for patients with breast cancer from a surgical-, medical-, and radiation-oncology standpoint.

Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain

Background

Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. In these cases, when variation is larger than expected by need, socioeconomic factors have been argued as an explanation. Objectives: Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. Additionally, it seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique.

Methods

81,868 mastectomies performed between 2002 and 2006 in 180 healthcare areas were studied. Standardized utilization rates of breast cancer conservative (CS) and non-conservative (NCS) procedures were estimated as well as the variation among areas, using small area statistics. Concentration curves and dominance tests were estimated to determine the impact of income and instruction levels in the healthcare area on surgery rates. Multilevel analyses were performed to determine the influence of regional policies.

Results

Variation in the use of CS was massive (4-fold factor between the highest and the lowest rate) and larger than in the case of NCS (2-fold), whichever the age group. Healthcare areas with higher economic and instruction levels showed highest rates of CS, regardless of the age group, while areas with lower economic and educational levels yielded higher rates of NCS interventions. Living in a particular Autonomous Community (AC), explained a substantial part of the CS residual variance (up to a 60.5% in women 50 to 70).

Conclusion

The place where a woman lives -income level and regional policies- explain the unexpectedly high variation found in utilization rates of conservative breast cancer surgery.

The choice for breast cancer surgery: can women accurately predict postoperative quality of life and disease-related stigma?

BACKGROUND

To make an informed choice, breast cancer patients facing surgery must imagine the effect of surgery on their future life experiences. However, the accuracy of patient predictions of postoperative quality of life (QoL) and disease-related stigma is not well understood.

MATERIALS AND METHODS

Four groups of breast cancer patients at the University of Michigan Medical Center were surveyed by mail and interview (response rate 76.3%): (1) preoperative (N = 59), (2) mastectomy (N = 146), (3) mastectomy with reconstruction (N = 250), and (4) breast conservation (N = 705). Subjects rated their QoL (1 = lowest, 100 = highest) and stigma (1 = lowest, 5 = highest) and estimated QoL and stigma associated with mastectomy alone, mastectomy with reconstruction, and breast conserving surgery (BCS). Mean scores were compared using linear regression controlling for age, race, partnered status, and income.

RESULTS

Preoperatively, women inaccurately predicted postoperative QoL and stigma for all surgical options, particularly for mastectomy. Preoperative patients underestimated the postoperative QoL for mastectomy alone (predicted: 56.8 vs actual: 83.7; P < .001). Preoperative patients underestimated QoL following mastectomy following reconstruction (predicted: 73.4 vs actual: 83.9; P < .001) and BCS (predicted: 72.2 vs actual: 88.6; P < .001). Additionally, preoperative patients overestimated stigma related to mastectomy (predicted: 3.25 vs actual: 2.43; P < .001). Finally, preoperative women overestimated stigma related to mastectomy with reconstruction (predicted: 2.54 vs actual: 2.03; P < .001) and BCS (predicted: 1.90 vs actual: 1.76; P < .001).

CONCLUSION

Predicting QoL and stigma following breast cancer surgery is challenging for patients facing a diagnosis for surgery. Identifying strategies to better inform patients of surgical outcomes can improve the decision-making process.

The Impact of Facility Volume/Size on Breast Cancer Treatment and Outcome

Recent studies have suggested that outcomes and survival from breast cancer are improved when definitive treatment is rendered at high-volume and/or teaching centers. Consolidation of such cases in tertiary centers, however, is often impractical and impossible. Patients often desire primary treatment of their breast cancer in their own communities. The current study was undertaken to examine the impact of treatment facility type on the treatment performed as well as on overall survival. Breast cancer treatment and survival data were available from the American College of Surgeons National Cancer Data Base. Only patients in whom no previous treatment had been rendered were included in the analysis. Data were stratified with regard to type and size of treatment facility/hospital; stage distribution; initial treatment performed; and 1-, 2-, and 5-year survival. A total of 665,409 patients were included in the current analysis. There were no significant differences in stage distribution between facility types nor was there a significant difference in the treatment performed (although there was a slight trend toward breast conservation at the larger centers). This was true overall and for each stage of cohort. There were also no significant differences in 1-, 2-, and 5-year survival rates overall and at any stage (although again, there was a slight trend toward a minimal survival advantage at the larger centers). There was no significant impact of facility size or type on either breast cancer treatment performed or overall survival. There was no evidence that more “advanced” treatments were offered at larger centers nor was there evidence of improved outcome/survival at larger centers. Care can be rendered safely, efficiently, and effectively in the community setting.

Body Image Perception and Quality of Life in Patients who Underwent Breast Surgery

Quality of Life (QoL) has become a standard measure in assessing the effectiveness of medical interventions. We compared the differences between QoL and body image scale (BIS) in a group of patients who underwent breast surgery, including lumpectomy or conservative surgery, modified radical mastectomy and radical mastectomy with breast reconstruction. We included patients who underwent breast surgery between August of 2005 and June of 2006 in two tertiary referral centers in Mexico City. Two self-administered questionnaires assessing body image perception, BIS and quality of life (SF-36), were assigned and a physician-conducted interview was done. We stratified patients by age, marital status, and scholar grade. The sample comprised 202 patients. The BIS results yielded: the group with a benign lesion demonstrated favorable body image perception when compared with the malignant lesion group. A confirmed diagnosis of malignancy hinders QoL in older and younger age groups. Conservative surgery and breast reconstruction improves QoL in younger patients without significance in the older group. The most significant variable that hinders the BIS and QoL is the cancer diagnosis. Impact of conservative surgery and breast reconstruction in body image perception and quality of life is influenced by patient age and educational level.

Development of instruments to measure the quality of breast cancer treatment decisions

BACKGROUND

Women with early-stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients' knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality.

OBJECTIVE

To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them.

METHODS

Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined.

RESULTS

Thirty-eight facts (11-14 per decision) and 27 goals (8-10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals.

CONCLUSIONS

Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients' and providers' perspectives are different, it is vital that instrument development should include items reflecting both views.

Breast cancer treatment beliefs and influences among surgeons in areas of scientific uncertainty

BACKGROUND

Breast cancer treatment beliefs in areas of scientific uncertainty may contribute to widely variable practices. We sought to better describe surgeons' beliefs and to identify the relative importance of different information sources on surgeons' decision-making.

METHODS

A total of 2,188 American College of Surgeons (ACoS) members were surveyed on their treatment beliefs in 4 controversial areas and on the perceived influence of various information sources on their decision-making. Responses were analyzed by sex, practice type, oncology training, professional society membership, and breast cancer patient volume.

RESULTS

Nine hundred twenty-three responses were received, with 459 eligible for analysis. Responses diverged most regarding significance of positive sentinel lymph node biopsy (SNLB) and role of post-lumpectomy radiation for low-risk ductal carcinoma-in-situ (DCIS). Overall, expert opinion ranked as the most influential information source.

CONCLUSIONS

Axillary dissection after positive SLNB and post-lumpectomy radiation in low-risk DCIS denoted areas of greater uncertainty. Breast cancer opinion leaders have substantial influence when standard practice is uncertain.

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.

Change in clinical practice after publication of guidelines on breast cancer treatment

OBJECTIVE

Several studies raise questions about whether clinical practice guidelines actually guide practice. We evaluated patterns of use of breast-conserving surgery (BCS) over time to examine the effect of guideline publication.

DESIGN

Retrospective analysis of time-series data on breast cancer treatment. Multiple logistic regression analysis was performed, adjusting for covariates including the patient's age, comorbidity status and admission year, to assess whether the use of BCS was higher after publication of treatment guidelines.

SETTING

Five teaching hospitals participating in the Quality Improvement/Indicator Project (QIP) in Japan.

PARTICIPANTS

Female breast cancer patients who received surgical treatment at five teaching hospitals from January 1996 through December 2007 (n = 2199).

MAIN OUTCOME MEASURE

Rates of use of BCS.

RESULTS

The proportion of BCS use increased from 26.4% before guideline publication to 59.9% after guideline publication in Japan. After controlling for other characteristics, the use of BCS has increased significantly over time, especially since 2001. Women aged 70 years and older (P=0.004) and those with any comorbidity (P < 0.001) were significantly less likely to receive BCS.

CONCLUSIONS

This study demonstrated that the adjusted proportion of BCS has increased dramatically since 2001, 2 years after guideline publication in Japan and this is consistent with a relationship between guideline publication and a change in this clinical practice.

Current surgery for breast cancer

Surgeons retain the central role in the multidisciplinary care of the breast cancer patient. While technical details of the operations for these patients remain important, effective evidence-based decision making may be even more so. Advances in the methods of breast cancer diagnosis, localization techniques and surgical therapies, as well as the expanded role of the surgeon in breast cancer prevention, radiation therapy and the treatment of distant disease, requires surgeons to stay up to date with the available evidence. Herein, we present a review of the current surgical therapy of invasive breast cancer.

Quality of life after breast cancer surgery: What have we learned and where should we go next?

Treatment options for women with newly diagnosed breast cancer include breast conservation therapy and mastectomy with or without reconstruction, which provide equivalent cancer outcomes in properly selected patients. Although multiple studies have evaluated breast surgery quality-of-life outcomes, the data are inconsistent. This factor is important to consider when counseling patients and defining surgical quality measures.

Surgeon characteristics and use of breast conservation surgery in women with early stage breast cancer

BACKGROUND

Most women with localized breast cancer have a choice between mastectomy and breast conserving surgery (BCS). Aside from clinical factors, this decision may be associated with surgeon and patient characteristics. We investigated the effect of surgeon characteristics on the BCS rate.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women >65 years, diagnosed with stages I-II BC, between 1991 and 2002, and used the Physician Unique Identification Number linked to the American Medical Association Masterfile to obtain information on surgeons. We investigated the association of patient demographic, tumor, and surgeon-related factors with receipt of BCS, using Generalized Estimating Equations to control for clustering.

RESULTS

Of 56,768 women with breast cancer, 30,006 (53%) underwent BCS, whereas 26,762 (47%) underwent mastectomy. Between 1991 and 2002, the proportion of patients undergoing BCS increased from 35% to 60%. In a multivariate analysis, patients who received BCS were younger, of higher SES, and had more favorable tumor characteristics. They were also more likely to be black and live in metropolitan areas. Women who underwent BCS were more likely to have surgeons who were female (OR = 1.40; 95% CI: 1.25-1.55), US-trained (OR = 1.12; 95% CI: 1.02-1.22), with a larger patient panel (OR = 1.29; 95% CI: 1.21-1.39), and completed training after 1975 (OR = 1.16; 95% CI: 1.08-1.25), than surgeons of patients who underwent mastectomy.

CONCLUSIONS

Surgeon characteristics, such as gender, training, year of graduation, and volume, are small but significant independent predictor of BCS. Efforts to differentiate whether these associations reflect patients' preferences, quality of physician training, surgeon attitudes, physician-patient communication, or other effects on decision-making are warranted.

Determinants of breast conservation rates: reasons for mastectomy at a comprehensive cancer center

Bias in referral patterns and variations in multi-disciplinary management may impact breast conservation therapy (BCT) rates between hospitals. Retrospective studies of BCT rates are limited by their inability to differentiate indicated mastectomies versus those chosen by the patient. Our prospective breast cancer data base was queried for patients with invasive breast cancer who underwent surgical therapy at the University of Michigan over a 3-year period. Demographics, stage and histology were recorded along with the reason mastectomy was performed, categorized as "by need" (contraindication to BCT) or "by choice." Multivariate analysis was used to identify factors significantly associated with mastectomy by choice. BCT was associated with tumor size, histology and nodal status, but not older age, either by choice or by need. Of the 34% of patients initially felt to be poor candidates for BCT, it was absolutely contraindicated in 44%, while 56% were thought to have a tumor-to-breast size ratio too large for successful BCT. Of this latter group, 80% underwent neo-adjuvant chemotherapy in an attempt to downstage the primary tumor and perform BCT, which was successful in over half the patients. For the patients initially thought to be good candidates for BCT, only 15% chose to undergo mastectomy, while 5% eventually required mastectomy due to failed attempts to achieve negative margins. Overall, the BCT rate was 63%, however without the use of neo-adjuvant chemotherapy, the BCT rate would have been only 53%. At a tertiary referral center, BCT rates are driven more by contraindications than patient choice, and may be heavily skewed towards mastectomy due to referral patterns. In addition to tumor factors such as stage and histology, BCT rate can be dramatically impacted by neo-adjuvant chemotherapy or genetic counseling. Examining BCT rates alone as a measure of quality, therefore, is not an appropriate standard across institutions serving diverse populations.

The structural landscape of the health care system for breast cancer care: results from the Los Angeles Women's Health Study

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.

Patterns of drug prescription for Japanese cedar pollinosis using a clinical vignette questionnaire

BACKGROUND

Although prescribed drugs directly affect patient outcome, the variation in physicians' attitudes towards drug therapy for cedar pollinosis has not been quantitatively assessed. This research investigated the prescription patterns of drugs for cedar pollinosis by ear, nose, and throat specialists (ENTs), general physicians (GPs) and internal medicine doctors (IMs) in Yamanashi Prefecture, Japan.

METHODS

A cross-sectional study was conducted by mailing questionnaires to 532 physicians in autumn 2006. The main part of the questionnaire constituted clinical vignettes of pollinosis cases with nasal and ocular symptoms ranging from mild to severe. We requested that the physicians fill out prescription medications they considered appropriate for each vignette.

RESULTS

Responses from 172 physicians (32%) for six clinical vignettes were analyzed. The number of drugs prescribed by ENTs was significantly higher than that by GPs and IMs for vignettes representing moderate to severe cases (p < 0.004). The percentage of physicians who said they would prescribe nasal corticosteroid and eye drops was higher in the ENT group compared to the other two groups in these vignettes. In terms of second-generation antihistamines, no differences were observed between the three groups for all vignettes.

CONCLUSIONS

Our investigation suggested that, compared to ENTs, GPs and IMs have a lower tendency to concomitantly prescribe drugs for localized treatment such as nasal corticosteroids and eye drops with oral medication. There may be differences in prescription patterns of drugs for pollinosis between ENTs and non-specialist physicians.

Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go?

OBJECTIVE

To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits.

DATA SOURCES/DATA COLLECTION

Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses (N=1,132 patients, 277 surgeons).

STUDY DESIGN

Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation.

PRINCIPAL FINDINGS

Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts (p<.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient-physician communication was significantly (p<.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge.

CONCLUSIONS

Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.

Clinical trial priorities among surgeons caring for breast cancer patients

BACKGROUND

Designing and prioritizing successful clinical trials benefits from increased community physician input. We surveyed practicing surgeons about current controversies in breast cancer surgery, reported practices of discussing trial participation, and perceived obstacles to trial participation.

METHODS

A 44-question survey was mailed in 2005-2006 to 2,187 randomly selected American College of Surgeons members actively seeing breast cancer patients. Responses were analyzed by surgeon sex, practice type, oncology training, professional society membership, and breast cancer patient volume.

RESULTS

A total of 923 responses were received, with 460 eligible responses remaining for analysis. Most surgeons infrequently or never discuss trial participation with breast cancer patients. Inadequate infrastructure presents the greatest physician obstacle to trial participation. Identifying proven indications for completion axillary dissection after positive sentinel node biopsy marks the highest-ranked research priority for surgeons providing breast care.

CONCLUSIONS

Understanding topics of interest among practicing surgeons and addressing common obstacles to trial participation may result in improved breast cancer patient accrual through surgeons.

Individual physician practice variation in hematopoietic cell transplantation

PURPOSE

Previous studies have evaluated practice variation in hematopoietic cell transplantation (HCT) among transplant centers and countries. There are no studies investigating individual physician practice variation in HCT.

METHODS

An international Internet-based survey of transplant physicians collected data on medical decisions made by adult and pediatric HCT physicians. Multivariable analyses identified practitioner and transplant center characteristics predictive of medical decision making.

RESULTS

Analysis of 526 assessable respondents showed a wide variation in management approaches to specific clinical scenarios. Pediatric and adult transplant physicians differed significantly in their management strategies for chronic myeloid leukemia, acute and chronic graft-versus-host disease, and choice of graft source for patients with aplastic anemia. Among adult transplant physicians, there was little agreement on the patient factors favoring reduced intensity conditioning or myeloablative conditioning.

CONCLUSION

These results emphasize the heterogeneity of worldwide transplant practices. Local preferences or biases likely result in similar patients being offered different transplant and treatment procedures. The degree of practice variation also highlights the need for clinical trials to clarify areas of controversy. Where clinical trials are not feasible, data from observational studies may be the best available evidence to guide practice.

Conflicts in decision-making for breast cancer surgery

BACKGROUND

Little is known about the interaction among surgeons, patients, and other physicians in selecting breast cancer surgery.

METHODS

We contacted attending surgeons (n = 456) of a population-based sample of 2645 breast cancer patients diagnosed in Detroit and Los Angeles from December 2001 to January 2003. Eighty percent completed a written survey with clinical scenarios.

RESULTS

The mean surgeon age was 50 years, 50% practiced in a community hospital, and breast cancer averaged 31% of practice volume. The mean number of years in practice was 17.2. Female surgeons made up 14.4% of the sample and 35% of the high-volume surgeons. Conflict with patients and other providers was reported by 58% and 32% of surgeons, respectively. When the patient preferred mastectomy and the surgeon favored BCS, conflict was reported by 49.9% of surgeons. Compared with low-volume surgeons, high-volume surgeons were significantly more likely to report conflict in this scenario (44% vs 62%; P = .047). When another provider preferred mastectomy and the respondent surgeon favored BCS, conflict was reported by 34% of surgeons and was more common for high-volume surgeons (P < .001). In a logistic regression model, surgeon volume and practice setting were strongly associated with conflict in this scenario.

CONCLUSION

High-volume surgeons and those in cancer centers more frequently endorse current clinical guidelines that favor BCS over mastectomy, resulting in greater conflict with patients. These findings support patient reports that patient choice is a key factor in continued mastectomy use.

Patient Satisfaction With Treatment of Breast Cancer: Does Surgeon Specialization Matter?

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.

Factors associated with patient involvement in surgical treatment decision making for breast cancer

OBJECTIVE

To evaluate factors associated with women's reported level of involvement in breast cancer surgical treatment decision making, and the factors associated with the match between actual and preferred involvement in this decision.

METHODS

Survey data from breast cancer patients in Detroit and Los Angeles was merged with surgeon data for an analytic dataset of 1101 patients and 277 surgeons. Decisional involvement and the match between actual and preferred amount of involvement were analyzed as three-level dependent variables using multinomial logistic regression controlling for clustering within surgeons. Independent variables included patient demographic and clinical factors, surgeon demographic and practice factors, cancer program designation, and two measures of patient-surgeon communication.

RESULTS

We found variation in women's actual decisional involvement and match between actual and preferred involvement. Women with a surgeon-based or patient-based (versus shared) decision were significantly (p < or = 0.05) younger. Women who had too little decisional involvement (versus the right amount) were younger, while women with too much involvement had less education. Patient-surgeon communication variables were significantly associated with both involvement and match, and higher surgeon volume as associated with too little involvement.

CONCLUSION

Patient factors and patient-surgeon communication influence women's perception of their involvement in breast cancer surgical treatment decision making.

PRACTICE IMPLICATIONS

Decision tools are needed across surgeons and practice settings to elicit patients' preferences for involvement in treatment decisions for breast cancer.

Diffusion of surgical techniques in early stage breast cancer: variables related to adoption and implementation of sentinel lymph node biopsy

BACKGROUND

Understanding how physicians acquire and adopt new technologies for cancer diagnosis and treatment is poorly understood, yet is critical to the dissemination of evidence-based practices. Sentinel lymph node biopsy (SLNB) has recently become a standard technique for axillary staging in early breast cancer and is an ideal platform for studying medical technology diffusion. We sought to describe the timing of SLNB adoption and patterns of surgeon interactions with the following educational sources: local university training program, surgical literature, national meetings/courses, national specialty centers, and other local surgeons.

METHODS

A cross-sectional survey that used semistructured interviews was used to assess timing of adoption, practice patterns, and learning sources for SLNB among surgical oncologists and general surgeons in a single metropolitan area.

RESULTS

A total of 44 eligible surgeons were identified; 38 (86%) participated. All surgical oncologists (11 of 11) and most general surgeons (26 of 27) had implemented SLNB. Surgical oncologists were older (mean 51 vs. 48 years, P = .02) and had used SLNB longer (6.1 vs. 3.3 years, P = .01) than general surgeons. By use of social network diagrams, surgical oncologists and the university training program were shown to be key intermediaries between general surgeons and national specialty centers. Surgeons in group practice tended to use more learning sources than solo practitioners.

CONCLUSIONS

Surgical oncologists and university-based surgeons play key educational roles in disseminating new cancer treatments and therefore have a professional responsibility to educate other community physicians to increase the use of the most current, evidence-based practices.

Patterns and Correlates of Patient Referral to Surgeons for Treatment of Breast Cancer

Purpose

Characteristics of surgeons and their hospitals have been associated with cancer treatments and outcomes. However, little is known about factors that are associated with referral pathways.

Methods

We analyzed tumor registry and survey data from women with breast cancer diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries (n = 1,844; response rate, 77.4%) and their attending surgeons (n = 365; response rate 80.0%).

Results

About half of the patients (54.3%) reported that they were referred to the surgeon by another provider or health plan; 20.3% reported that they selected the surgeon; and 21.9% reported that they both were referred and were involved in selecting the surgeon. Patients who selected the surgeon based on reputation were more likely to have received treatment from a high-volume surgeon (adjusted odds ratio [OR], 2.2; 95% CI, 1.5 to 3.4) and more likely to have been treated in an American College of Surgeons–approved cancer program or a National Cancer Institute (NCI) –designated cancer center (adjusted OR, 2.0; 95% CI, 1.3 to 3.1; adjusted OR, 3.4; 95% CI, 1.9 to 6.2, respectively). Patients who were referred to the surgeon were less likely to be treated in an NCI-designated cancer center (adjusted OR, 0.5; 95% CI, 0.3 to 0.9).

Conclusion

Women with breast cancer who actively participate in the surgeon selection process are more likely to be treated by more experienced surgeons and in hospitals with cancer programs. Patients should be aware that provider or health plan–based referral may not connect them with the most experienced surgeon or comprehensive practice setting in their community.

Locoregional therapy of breast cancer: maximizing control, minimizing morbidity

The goal of locoregional therapy in breast cancer has remained unchanged for a century: the eradication of all malignant cells from the breast and draining lymph nodes, hopefully prior to them having spread to distant organs. However, how we accomplish this goal has changed dramatically over this time period and our success in achieving this goal has been greatly enhanced by improvements in breast imaging and systemic therapies. The therapeutic importance of surgery and radiation has been underestimated in recent years and is thought to have minimal impact on long-term outcome. More recent data have reputed this contention and the relationship between local control and survival in breast cancer is becoming increasingly apparent. This article will review the importance of attaining optimum local control with minimum morbidity and examine where the future of locoregional therapy of breast cancer may lie.

Correlates of Between-Surgeon Variation in Breast Cancer Treatments

BACKGROUND

Determinants of between-surgeon variation in breast cancer treatment utilization are not well understood.

OBJECTIVES

The objectives of this study were to evaluate variation in receipt of surgical treatment (ie, mastectomy or breast-conserving surgery with or without radiation) for women with stage I, II, or III breast cancer and receipt of breast reconstruction attributable to surgeons, and to assess factors associated with this between-surgeon variation.

METHODS

We surveyed all attending surgeons (n = 456) of a population-based sample of patients with breast cancer diagnosed in Detroit and Los Angeles during 2002 (n = 1844). Our analytic dataset linked data from 1477 patients with that of 311 surgeons. We used random-effects modeling to account for the multilevel dataset and evaluated 2 outcomes: 1) primary surgical treatment (mastectomy vs. BCS); and 2) receipt of reconstruction before being surveyed (yes vs. no). Independent variables included patient-related factors (clinical and demographic), surgeon-related factors (breast procedure volume, practice setting, and demographics), surgeon treatment recommendation, and referral propensity.

RESULTS

Surgeons explain some variation in use of both mastectomy and reconstruction (9.9% and 26%, respectively). Patient clinical factors and surgeon volume together explain approximately one-third of the between-surgeon variation in mastectomy. Patient factors and surgeon demographics explain approximately 60% of between-surgeon variation in reconstruction, and surgeon referral propensity explains an additional 15%.

CONCLUSION

Our findings suggest that similar patients may get different treatment depending on their surgeon. Broader dissemination of guidelines coupled with increasing patient access to consultations before definitive surgery may reduce between-surgeon variation. Contributing factors such as patient-physician communication should be explored.