Low rate of breast conservation surgery in large urban hospital serving the medically indigent

Correct information to patients undergoing breast-conserving surgery: the medicolegal significance

Many of the women newly diagnosed with breast cancer not have access to all the information they need to make the surgical and treatment choices that are most appropriate for them. Research clearly shows that lumpectomy and other breast-conserving surgeries are just as safe as mastectomy for most women with early stage disease, and yet approximately half will undergo the more disfiguring procedures, but many healthy women who have strong family histories of breast cancer consider prophylactic mastectomies, and their decisions are also based on very limited information, because there are few studies showing the effectiveness of that procedure. This paper delineates how to avoid limited information and biased recommendations is important for a conscious and informed choice by the patients.

Inflammatory and non-inflammatory breast cancer survival by socioeconomic position in the Surveillance, Epidemiology, and End Results database, 1990-2008

Although it has been previously reported that patients with inflammatory breast cancer (IBC) experience worse survival than patients with other breast cancer (BC) types, the socioeconomic and ethnic factors leading to this survival difference are not fully understood. The association between county-level percent of persons below the poverty level and BC-specific (BCS) survival for cases diagnosed from 1990 to 2008 in the Surveillance, Epidemiology, and End Results (SEER) database linked to census derived county attributes was examined. A sub-analysis of cases from 2000 to 2008 also examined BCS survival by an index combining percent below poverty and less than high school graduates as well as metropolitan versus non-metropolitan county of residence. The Kaplan-Meier estimator was used to construct survival curves by stage, inflammatory status, and county-level socioeconomic position (SEP). Stage and inflammatory status stratified proportional hazards models, adjusted for age, race/ethnicity, tumor and treatment characteristics were used to determine the hazard of BCS death by county-level SEP. Kaplan-Meier survival curves indicated IBC has worse survival than stage matched non-IBC, (stage III IBC median survival = 4.75 years vs. non-IBC = 13.4 years, p < 0.0001). Residing in a lower SEP, non-metro county significantly worsens BCS survival for non-IBC in multivariate proportional hazards models. African American cases appear to have worse survival than non-Hispanic Whites regardless of inflammatory status, stage, county-level SEP, tumor, or treatment characteristics. This is the first study to examine IBC survival by SEP in a nation-wide population-based tumor registry. As this analysis found generally poorer survival for IBC, regardless of SEP or race/ethnicity, it is important that interventions that help educate women on IBC symptoms target women in various SEP and race/ethnicity groups.

Adjuvant therapy for resected gastric cancer--rapid, yet incomplete adoption following results of intergroup 0116 trial

PURPOSE

The Southwest Oncology Group/Intergroup 0116 (INT-0116) trial showed that adjuvant chemoradiotherapy improves survival in high-risk gastric adenocarcinoma patients. This study examined the adoption of adjuvant treatment following the trial results and the factors associated with its use.

METHODS AND MATERIALS

Between 1996 and 2003, patients aged 18-85 years with resected gastric adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results (SEER) database and classified as diagnosed before (January 1996 to April 2000) or after (May 2000 to December 2003) presentation of the INT-0116 trial findings. Univariate and multivariable models were used to determine the factors associated with use of adjuvant radiotherapy (RT).

RESULTS

Of 10,230 patients studied, 14.6% were given adjuvant RT before the INT-0116 trial, increasing to 30.4% afterward (p<0.001). Significant increases in adjuvant RT from before to after INT-0116 were seen in all demographic categories. Younger patients were significantly more likely to receive adjuvant RT (44.5%, 18-59 years; 31.0%, 60-74 years; and 12.6%, 75-85 years, p<0.0001). Married patients were significantly more likely to receive adjuvant RT (30.9%) than were unmarried patients (23.6%, p<0.001). A greater depth of tumor invasion, worse nodal status, and more lymph nodes assessed were associated with adjuvant RT (p<0.0001). The rate of adjuvant RT varied from 22.9-44.2% across SEER regions. On multiple logistic regression analysis, age, SEER region, marital status, assessed lymph nodes, tumor depth, and nodal status were all significant independent predictors of the use of adjuvant RT.

CONCLUSION

Use of adjuvant RT doubled after the INT-0116 trial results became public; however, the fraction of patients receiving adjuvant RT is still low. Additional examination of the statistically significant and clinically relevant variability between different SEER regions, tumor characteristics, and patient demographics is warranted.

The importance of location in determining breast conservation rates

BACKGROUND

This study evaluates differences in the utilization of breast conservation surgery (BCS) between major metropolitan areas in the United States (US) and the United Kingdom (UK).

METHODS

Surgical and staging information were obtained from the Cancer Surveillance Program for Los Angeles County (LAC), the New York State (NYS) Department of Health Cancer Registry, and the UK National Health Service (NHS) Breast Screening Program. Demographic data were obtained from the census databases from the US, UK, Northern Ireland, and Scotland. Descriptive statistics, correlation analysis, and chi-square tests were used to compare rates of BCS across the locations under study.

RESULTS

Breast conservation rates were highest in London (79.3%) compared to New York City (NYC) (69.7%) and LAC (66.5%) (P < .0001). Both in NYS and the UK, the cities differ from the surrounding regions in population density, education levels, agricultural activities, and unemployment. BCS rates tended to increase with population density and education levels, and decrease with increased unemployment and agricultural activity, but there was no impact on BCS rates when adjustments for these variables were included in regression models. BCS rates increase with increasing hospital case volume in LAC and NYC (P < .0001).

CONCLUSION

When comparing large metropolitan areas in the US and UK there are significantly different rates of BCS in different locations. These differences reflect differences in population density, socioeconomic status (SES), education levels, hospital volume, and the effects of a nationally funded screening program.

Unequal access to breast-conserving surgery in Western Australia 1982-2000

BACKGROUND

The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy.

METHODS

The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression.

RESULTS

Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79).

CONCLUSION

Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups.

Predictors of breast conservation therapy

BACKGROUND

Despite the National Institutes of Health consensus statement in 1991 that breast-conserving surgery (BCS) followed by radiotherapy is an appropriate approach to the treatment of early-stage breast carcinoma, studies have shown a relatively low rate of BCS in the United States. The current study investigated predictors of breast conservation therapy in a large, diverse patient population.

METHODS

Between 1990 and 1998, 43,111 patients underwent surgery for breast carcinoma and were entered into the Cancer Surveillance Program database for Los Angeles County. Of these, 29,666 (68.3%) had complete data on patient demographics, staging, surgeon, type of surgery, and hospital. Data were collected regarding extent of disease, lymph node status, tumor size, age, race, socioeconomic status (SES), surgeon specialization, surgeon volume, hospital specialization, and hospital volume. Univariate and multivariate analyses were performed.

RESULTS

Univariate analysis showed that extent of disease, lymph node status, tumor size, age, race, SES, surgeon and hospital specialization, and surgeon and hospital volume all were significantly associated with surgery type (P <0.0001). Multivariate analysis showed that not only did extent of disease impact choice of surgery, but so did race, SES, hospital volume, surgeon volume, and surgeon specialization (P <0.0001).

CONCLUSIONS

These results suggest that not only does the extent of locoregional disease play a role in the likelihood of a woman undergoing breast conservation therapy, but patient age, socioeconomic status, racial/ethnic factors, and the experience of both the surgeon and hospital have an effect.

Diffusion of breast conserving surgery in medical communities

Excluding skin cancers, breast cancer is the most common form of cancer in women. Due to an increased focus on early detection, many more cases of breast cancer are now diagnosed at an early stage, which makes the use of breast conserving surgery (BCS) an efficacious and often more desirable treatment choice than mastectomy. An analysis of the variation in the use of BCS in the United States was performed using data from the years 1988 and 1994, and stratifying hospitals on the basis of teaching status. In both 1988 and 1994, BCS was highest in academic teaching hospitals and lowest in community hospitals. This finding is interpreted within the framework of classical diffusion theory. Social and cultural norms in local medical communities have a strong effect on the degree to which innovations diffuse rapidly or not. This analysis is useful in the understanding of geographic and hospital-based variations in treatment for early stage breast cancer and other illnesses that have long and strongly held traditions of treatment.

Breast-conserving therapy in low-literacy patients in a developing country

The purpose of this study was to determine the frequency with which low-literacy patients in a developing country chose their treatment plan. In this study, data for 312 patients admitted to different hospitals in Egypt were reviewed regarding their disease stage, optimal management plan, and treatment. It was found that the majority of patients were primarily concerned with keeping their breasts, regardless of the disease stage.

Socioeconomic factors and breast carcinoma in multicultural women

Breast carcinoma is the most common cancer in women in the U.S. and the second leading cause of cancer death in women. Furthermore, there are racial differences in breast carcinoma incidence, mortality, and survival rates. Social and economic factors within racial/ethnic groups are being examined as risk factors not only for breast carcinoma mortality and survival but also as determinants of the rate of incidence. Social and economic factors have been associated in the literature predominantly with cancer mortality and survival. When socioeconomic status (SES) is considered, certain studies suggest that racial disparities in breast carcinoma are smaller than when social and economic factors are examined alone, but these disparities still persist. Sources of data for this discussion include the National Cancer Institute (NCI) (the Surveillance, Epidemiology, and End Results [SEER] program, a group of population-based cancer registries that cover up to 14% of the U.S. population. SEER reports cancer incidence, mortality, and survival rates), the U.S. Bureau of the Census, the National Center for Health Statistics (NCHS), and numerous articles from the scientific literature. Socioeconomic factors or SES can be considered "cross-cutting risk factors" (i.e., they can be related to the risk of developing breast carcinoma [rate of incidence] as well as to the risk of dying [mortality] from this disease). They also are the risk factors that "cut across" racial and ethnic populations. Socioeconomic factors are related to breast carcinoma mortality and survival rates in multicultural women. Racial disparities in breast carcinoma mortality and survival rates can be explained partially by stage distribution at the time of diagnosis, which may be related to SES. For example, African-American women present with more advanced stage distributions for breast carcinoma than white women. Similarly, women of lower SES present with higher stage disease than women of upper SES who present with more localized breast carcinoma. The lack of data regarding the SES of cancer patients limits our understanding of the contributions of SES to cancer incidence and mortality rates. SES appears to be related to breast carcinoma incidence, mortality, and survival rates. Breast carcinoma mortality is higher in women of lower SES. Additional research on SES, race, culture, and the relation of these factors to cancer incidence rate is needed.

Breast conservation therapy in affiliated county, university, and private hospitals

BACKGROUND

Breast conservation therapy (BCT) offers equivalent survival to modified radical mastectomy in patients with early-stage (I and IIa) breast cancer, but is utilized in less than 50% of eligible patients. While patient demographics have been linked to BCT rates, we suspected that physician influence was a major factor. The purpose of this study was to compare BCT at three affiliated centers staffed by similarly trained surgeons yet serving widely disparate populations, in order to assess the importance of physician influence on the utilization of BCT.

METHODS

Tumor registry data were reviewed from 1993 through 1997 at affiliated city/county (CH), university (UH), and private hospitals (PH). Data were analyzed for clinical stage, treatment, and age of patient.

RESULTS

The utilization of BCT for stage I and IIa breast cancer is similar at the three hospitals: 45% of patients at CH, 55% of patient at UH, and 57% of patients at PH (P>0.05). Rates of BCT were similar across all patient age groups at all sites.

CONCLUSIONS

Similar BCT utilization rates can be achieved despite widely disparate patient populations. The three affiliated hospitals are staffed by surgeons with similar training, and all offer a multidisciplinary approach to breast cancer care. This suggests that physician influence may override patients' socioeconomic issues in providing optimal breast cancer therapy.

Low use of breast conservation surgery in medically indigent populations

BACKGROUND

Breast conservation surgery (BCS) with radiation is an acceptable treatment for early-stage breast cancer.

METHODS

Data were obtained from hospital cancer registries on women surgically treated for Stage 0 to II breast cancer from 1993 to 1997. Data on 1,747 patients were analyzed for surgical treatment, hospital type (private versus public), disease stage, and ethnic origin.

RESULTS

In this study, 34% of women received BCS. Women treated in private hospitals received BCS more often than women treated in public hospitals. Women with stage II disease received BCS less often than women with earlier stage disease. Hospital type (public versus private) and disease stage were strong, independent predictors for use of BCS. When hospital type and disease stage were statistically controlled, no treatment differences across ethnic groups were identified.

CONCLUSIONS

Use of BCS in this study was low compared with National Cancer Database statistics. Women treated in publicly funded hospitals and those with stage II disease were significantly less likely to receive BCS.