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Ryan JF, Lesniak DM, Cordeiro E, Campbell SM, Rajaee AN. Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist. Ann Surg Oncol 2023; 30:4695-4713. [PMID: 37036590 DOI: 10.1245/s10434-023-13472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
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.
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Affiliation(s)
- Joanna F Ryan
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - David M Lesniak
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Erin Cordeiro
- Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sandra M Campbell
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
| | - A Nikoo Rajaee
- Department of Surgery, University of Alberta, Edmonton, Canada.
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2
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Arroyo NA, Gessert T, Hitchcock M, Tao M, Smith CD, Greenberg C, Fernandes-Taylor S, Francis DO. What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice. Ann Surg 2021; 273:474-482. [PMID: 33055590 PMCID: PMC10777662 DOI: 10.1097/sla.0000000000004355] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations. BACKGROUND In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework. METHODS A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model. RESULTS Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement). CONCLUSIONS Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.
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Affiliation(s)
- Natalia A. Arroyo
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Thomas Gessert
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mary Hitchcock
- Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael Tao
- Department of Otolaryngology, The State University of New York, Syracuse, New York
| | - Cara Damico Smith
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sara Fernandes-Taylor
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - David O. Francis
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
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3
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Hung P, Wang SY, Killelea BK, Mougalian SS, Evans SB, Sedghi T, Gross CP. Long-Term Outcomes of Sentinel Lymph Node Biopsy for Ductal Carcinoma in Situ. JNCI Cancer Spectr 2019; 3:pkz052. [PMID: 32337481 PMCID: PMC7049982 DOI: 10.1093/jncics/pkz052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 06/21/2019] [Accepted: 07/22/2019] [Indexed: 12/18/2022] Open
Abstract
The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial. Using population-cohort data, we examined whether SLNB improves long-term outcomes among patients with DCIS who underwent breast-conserving surgery. We identified 12 776 women aged 67–94 years diagnosed during 2001–2013 with DCIS who underwent breast-conserving surgery from the US Surveillance, Epidemiology, and End Results-Medicare dataset, 1992 (15.6%) of whom underwent SLNB (median follow-up: 69 months). Tests of statistical significance are two-sided. Patients with and without SLNB did not differ statistically significantly regarding treated recurrence (3.9% vs 3.7%; P = .62), ipsilateral invasive occurrence (1.4% vs 1.7%, P = .33), or breast cancer mortality (1.0% vs 0.9%, P = .86). With Mahalanobis-matching and competing-risks survival analyses, SLNB was not statistically significantly associated with treated recurrence, ipsilateral invasive occurrence, or breast cancer mortality (P ≥ .27). Our findings do not support the routine performance of SLNB for older patients with DCIS amenable to breast conservation.
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Affiliation(s)
- Peiyin Hung
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Brigid K Killelea
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Sarah S Mougalian
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Suzanne B Evans
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Tannaz Sedghi
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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4
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Surgeon-associated variation in breast cancer staging with sentinel node biopsy. Surgery 2018; 164:680-686. [DOI: 10.1016/j.surg.2018.06.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/25/2018] [Accepted: 06/12/2018] [Indexed: 11/23/2022]
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Killelea BK, Long JB, Dang W, Mougalian SS, Evans SB, Gross CP, Wang SY. Associations Between Sentinel Lymph Node Biopsy and Complications for Patients with Ductal Carcinoma In Situ. Ann Surg Oncol 2018. [PMID: 29516364 PMCID: PMC5928184 DOI: 10.1245/s10434-018-6410-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Purpose To examine the associations between sentinel lymph node biopsy (SLNB) and complications among older patients who underwent breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). Methods We identified women from the Surveillance, Epidemiology, and End Results–Medicare dataset aged 67–94 years diagnosed during 1998–2011 with DCIS who underwent BCS as initial treatment. We assessed incidence of complications, including lymphedema, wound infection, seroma, or pain, within 9 months of diagnosis. We used Mahalanobis matching and generalized linear models to estimate the associations between SLNB and complications. Results Our sample consisted of 15,515 beneficiaries, 2409 (15.5%) of whom received SLNB. Overall, 16.8% of women who received SLNB had complications, compared with 11.3% of women who did not receive SLNB (p < 0.001). Use of SLNB was associated with subsequent mastectomy but not radiotherapy. Multivariate analyses of the matched sample showed that, compared with no SLNB, SLNB use was significantly associated with incidence of any complication [adjusted odds ratio (AOR) 1.39; 99% confidence interval (CI) 1.18–1.63], lymphedema (AOR 4.45; 99% CI 2.27–8.75), wound infection (AOR 1.24; 99% CI 1.00–1.54), seroma (AOR 1.40; 99% CI 1.03–1.91), and pain (AOR 1.31; 99% CI 1.04–1.65). Sensitivity analyses excluding patients who underwent mastectomy yielded qualitatively similar results regarding the associations between SLNB and complications. Conclusions Among older women with DCIS who received BCS, SLNB use was associated with higher risks of short-term complications. These findings support consensus guidelines recommending against SLNB for this population and provide empirical information for patients. Electronic supplementary material The online version of this article (10.1245/s10434-018-6410-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Brigid K Killelea
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA.,Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jessica B Long
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA
| | - Weixiong Dang
- Department of Chronic Disease Epidemiology, Yale University School of Public Health, 60 College Street, New Haven, CT, 06520, USA
| | - Sarah S Mougalian
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA.,Section of Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Suzanne B Evans
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA.,Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA.,Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT, USA. .,Department of Chronic Disease Epidemiology, Yale University School of Public Health, 60 College Street, New Haven, CT, 06520, USA.
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6
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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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7
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Reeder-Hayes KE, Anderson BO. Breast Cancer Disparities at Home and Abroad: A Review of the Challenges and Opportunities for System-Level Change. Clin Cancer Res 2017; 23:2655-2664. [PMID: 28572260 PMCID: PMC5499686 DOI: 10.1158/1078-0432.ccr-16-2630] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/03/2017] [Accepted: 04/06/2017] [Indexed: 01/06/2023]
Abstract
Sizeable disparities exist in breast cancer outcomes, both between Black and White patients in the United States, and between patients in the United States and other high-income countries compared with low- and middle-income countries (LMIC). In both settings, health system factors are key drivers of disparities. In the United States, Black women are more likely to die of breast cancer than Whites and have poorer outcomes, even among patients with similar stage and tumor subtype. Over-representation of higher risk "triple-negative" breast cancers contributes to breast cancer mortality in Black women; however, the greatest survival disparities occur within the good-prognosis hormone receptor-positive (HR+) subtypes. Disparities in access to treatment within the complex U.S. health system may be responsible for a substantial portion of these differences in survival. In LMICs, breast cancer mortality rates are substantially higher than in the United States, whereas incidence continues to rise. This mortality burden is largely attributable to health system factors, including late-stage presentation at diagnosis and lack of availability of systemic therapy. This article will review the existing evidence for how health system factors in the United States contribute to breast cancer disparities, discuss methods for studying the relationship of health system factors to racial disparities, and provide examples of health system interventions that show promise for mitigating breast cancer disparities. We will then review evidence of global breast cancer disparities in LMICs, the treatment factors that contribute to these disparities, and actions being taken to combat breast cancer disparities around the world. Clin Cancer Res; 23(11); 2655-64. ©2017 AACRSee all articles in this CCR Focus section, "Breast Cancer Research: From Base Pairs to Populations."
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Affiliation(s)
- Katherine E Reeder-Hayes
- Division of Hematology and Oncology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
- The University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Benjamin O Anderson
- Departments of Surgery and Global Health Medicine, School of Medicine, University of Washington, Seattle, Washington
- Program in Epidemiology, Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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8
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Cobran EK, Chen RC, Overman R, Meyer AM, Kuo TM, O'Brien J, Sturmer T, Sheets NC, Goldin GH, Penn DC, Godley PA, Carpenter WR. Racial Differences in Diffusion of Intensity-Modulated Radiation Therapy for Localized Prostate Cancer. Am J Mens Health 2016; 10:399-407. [PMID: 25657192 PMCID: PMC4570865 DOI: 10.1177/1557988314568184] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intensity-modulated radiation therapy (IMRT), an innovative treatment option for prostate cancer, has rapidly diffused over the past decade. To inform our understanding of racial disparities in prostate cancer treatment and outcomes, this study compared diffusion of IMRT in African American (AA) and Caucasian American (CA) prostate cancer patients during the early years of IMRT diffusion using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database. A retrospective cohort of 947 AA and 10,028 CA patients diagnosed with localized prostate cancer from 2002 through 2006, who were treated with either IMRT or non-IMRT as primary treatment within 1 year of diagnoses was constructed. Logistic regression was used to examine potential differences in diffusion of IMRT in AA and CA patients, while adjusting for socioeconomic and clinical covariates. A significantly smaller proportion of AA compared with CA patients received IMRT for localized prostate cancer (45% vs. 53%, p < .0001). Racial differences were apparent in multivariable analysis though did not achieve statistical significance, as time and factors associated with race (socioeconomic, geographic, and tumor related factors) explained the preponderance of variance in use of IMRT. Further research examining improved access to innovative cancer treatment and technologies is essential to reducing racial disparities in cancer care.
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Affiliation(s)
- Ewan K Cobran
- University of Georgia, College of Pharmacy, Athens, GA, USA
| | - Ronald C Chen
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | | | - Anne-Marie Meyer
- UNC, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Tzy-Mey Kuo
- UNC, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Jonathon O'Brien
- UNC, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Til Sturmer
- UNC, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Nathan C Sheets
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Gregg H Goldin
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Dolly C Penn
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Paul A Godley
- University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
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Yen TW, Li J, Sparapani RA, Laud PW, Nattinger AB. The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer. Medicine (Baltimore) 2016; 95:e4392. [PMID: 27495053 PMCID: PMC4979807 DOI: 10.1097/md.0000000000004392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB. OBJECTIVE To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care. DATA SOURCES/STUDY DESIGN Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB. RESULTS Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12-2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28-2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95-1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82-1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics. CONCLUSIONS Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.
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Affiliation(s)
- Tina W.F. Yen
- Department of Surgery, Division of Surgical Oncology
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
- Correspondence: Tina W.F. Yen, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA (e-mail: )
| | - Jianing Li
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rodney A. Sparapani
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Purushuttom W. Laud
- Division of Biostatistics
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ann B. Nattinger
- Department of Medicine
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
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10
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Zullig LL, Fortune-Britt AG, Rao S, Tyree SD, Godley PA, Carpenter WR. Enrollment and Racial Disparities in Cancer Treatment Clinical Trials in North Carolina. N C Med J 2016; 77:52-8. [PMID: 26763244 PMCID: PMC4714783 DOI: 10.18043/ncm.77.1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Clinical trials provide access to innovative, high-quality cancer treatment. Simultaneously, broad access helps to ensure that trials include heterogeneous patient populations, which improves the generalizability of findings and the development of interventions that are effective for diverse populations. We provide updated data describing enrollment into cancer treatment trials in North Carolina. METHODS For the period 1996-2009, person-level data regarding cancer clinical trial enrollment and cancer incidence were obtained from the North Carolina Central Cancer Registry and the National Cancer Institute (NCI). Enrollment rates were estimated as the ratio of trial enrollment to cancer incidence for race, sex, and year for each county, Area Health Education Center region, and the state overall. Enrollment rates for common cancers are presented. RESULTS From 1996 to 2009, North Carolina NCI treatment trial enrollment rates were 2.4% and 2.2% for white patients and minority patients, respectively. From 2007 to 2009, rates were 3.8% for white women, 3.5% for minority women, 1.3% for white men, and 1.0% for minority men; there was greater enrollment among more urban populations (2.4%) than among the most rural populations (1.5%). LIMITATIONS This study is limited to NCI-sponsored treatment trials in North Carolina. Policies governing collection of original data necessitate a delay in data availability. CONCLUSIONS Effort is needed to ensure trial access and enrollment among all North Carolina populations. Specifically, we identified racial and sex disparities, particularly for certain cancers (eg, breast cancer). Programs in North Carolina and across the nation can use the methods we employed to assess their success in broadening clinical trial enrollment to include diverse populations.
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Affiliation(s)
- Leah L Zullig
- research health science specialist, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; adjunct assistant professor, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; assistant professor, Department of Medicine and Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Alice G Fortune-Britt
- postdoctoral fellow, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Shangbang Rao
- researcher, Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Seth D Tyree
- applications specialist, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul A Godley
- professor, Department of Medicine, University of North Carolina at Chapel Hill; member and principal investigator, UNC-Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - William R Carpenter
- adjunct associate professor, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina; senior research mentor, UNC-Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
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11
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Weight C. Struggles in exporting complex surgical advances. Cancer 2015; 121:828-9. [PMID: 25410597 DOI: 10.1002/cncr.29143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 10/28/2014] [Indexed: 11/08/2022]
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12
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Tan HJ, Meyer AM, Kuo TM, Smith AB, Wheeler SB, Carpenter WR, Nielsen ME. Provider-based research networks and diffusion of surgical technologies among patients with early-stage kidney cancer. Cancer 2015; 121:836-43. [PMID: 25410684 PMCID: PMC4352108 DOI: 10.1002/cncr.29144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/17/2014] [Accepted: 09/18/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Provider-based research networks such as the National Cancer Institute's Community Clinical Oncology Program (CCOP) have been shown to facilitate the translation of evidence-based cancer care into clinical practice. This study compared the utilization of laparoscopy and partial nephrectomy among patients with early-stage kidney cancer according to their exposure to CCOP-affiliated providers. METHODS With linked Surveillance, Epidemiology, and End Results-Medicare data, patients with T1aN0M0 kidney cancer who had been treated with nephrectomy from 2000 to 2007 were identified. For each patient, the receipt of care from a CCOP physician or hospital and treatment with laparoscopy or partial nephrectomy were determined. Adjusted for patient characteristics (eg, age, sex, and marital status) and other organizational features (eg, community hospital and National Cancer Institute-designated cancer center), multivariate logistic regression was used to estimate the association between each surgical innovation and CCOP affiliation. RESULTS During the study interval, 1578 patients (26.8%) were treated by a provider with a CCOP affiliation. Trends in the utilization of laparoscopy and partial nephrectomy remained similar between affiliated and nonaffiliated providers (P ≥ .05). With adjustments for patient characteristics, organizational features, and clustering, no association was noted between CCOP affiliation and the use of laparoscopy (odds ratio [OR], 1.11; 95% confidence interval [CI], 0.81-1.53) or partial nephrectomy (OR, 1.04; 95% CI, 0.82-1.32) despite the more frequent receipt of these treatments in academic settings (P < .05). CONCLUSIONS At a population level, patients treated by providers affiliated with CCOP were no more likely to receive at least 1 of 2 surgical innovations for treatment of their kidney cancer, indicating perhaps a more limited scope to provider-based research networks as they pertain to translational efforts in cancer care.
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Affiliation(s)
- Hung-Jui Tan
- VA/UCLA Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, CA
- Department of Urology, University of California, Los Angeles, CA
| | - Anne-Marie Meyer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Tzy-Mey Kuo
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Angela B. Smith
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Department of Urology, University of North Carolina, Chapel Hill, NC
| | - Stephanie B. Wheeler
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - William R. Carpenter
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Matthew E. Nielsen
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
- Department of Urology, University of North Carolina, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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Diffusion of accelerated partial breast radiotherapy in the United States: physician-level and patient-level analyses. Med Care 2014; 52:969-74. [PMID: 25185635 DOI: 10.1097/mlr.0000000000000215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate diffusion of brachytherapy-based accelerated partial breast radiotherapy (RT) in the United States, a new breast cancer treatment requiring 5 days twice daily, rather than daily treatment for 6-7 weeks. It has limited long-term effectiveness data compared with standard whole breast RT. DATA AND METHODS We used 2005-2008 Medicare claims for female Medicare beneficiaries receiving RT after breast-conserving surgery merged with physician and area-based data (n=74,254 patient-subjects; n=1901 physicians), applying logistic regression to estimate: (1) proportion of patients for whom the radiation oncologist used brachytherapy-based accelerated RT, and (2) probability a patient received brachytherapy-based accelerated RT, clustering on physician. RESULTS Use of accelerated partial breast RT increased over time (8% in 2005 to 17% in 2008). Physician-level analysis indicates rural physicians were less likely to perform accelerated RT [odds ratio (OR): 0.35-0.49; P<0.002)]; as were those licensed 20+years [OR: 0.54; 95% confidence interval (CI), 0.39-0.74]. Overall, 11.7% of patients received accelerated RT. Treatment post 2005 was associated with increasing odds of receiving accelerated RT (P<0.0001). Older age was associated with lower odds of receiving accelerated RT (reference, 66-69 years old, OR: 0.90, P<0.006), as was black (OR: 0.73;95% CI, 0.63-0.85) or other race (OR: 0.80; 95% CI, 0.65-1.00), living in rural areas (OR: 0.8; P<0.0001), or seeing an older physician [20+years postgraduation (OR: 0.7; 95% CI, 0.5-0.9)]. Patients living in counties with more hospitals with advanced RT facilities were more likely to undergo accelerated RT (OR: 1.4; 95% CI, 1.1-1.8). DISCUSSION This new technology appears to be in the early phase of diffusion across the United States and is more rapidly being taken up in younger, white patients living in urban and suburban areas with availability of advanced RT facilities. Rural and older patient populations are not tending to undergo the treatment.
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14
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Abstract
Objective. To understand decision making concerning adoption and nonadoption of accelerated partial breast radiotherapy (RT) prior to long-term randomized trial evidence. Methods. A total of 36 radiation oncologists and surgeons were recruited through purposive and snowball sampling strategies from September 2010 through January 2013. Semistructured phone interviews were conducted and audio-recorded and lasted 20–45 minutes. Qualitative analysis was conducted using a framework approach, iteratively exploring key concepts and emerging issues raised by subjects. Interviews were transcribed and imported into Atlas.ti v6. Transcripts were independently coded by 3 researchers shortly after each interview, followed by consensus development on each coded transcript. Barriers and facilitators of adoption, practice patterns, and informational/educational sources concerning accelerated partial breast RT were all assessed to determine major themes. Results. Nearly half of physicians were surgeons (47%), and half were radiation oncologists (53%), with 61% overall in urban settings. Twenty-nine of the 36 physicians interviewed used brachytherapy-based partial breast RT. Five major factors were involved in physicians’ decisions to adopt accelerated partial breast RT: facilitators encouraging adoption (e.g., enthusiastic colleagues and patient convenience), financial and prestige incentives, pressures to adopt (e.g., potential declines in referrals), judgment concerning acceptable level of scientific evidence, and barriers (e.g., not having appropriate machinery or referral mechanism in place). If technology was adopted, clinical guideline adherence varied. Conclusions. Technology adoption is based on financial and social pressures, along with often-limited scientific evidence and what seems “best” for patients. For technology adoption and diffusion to be rational and evidence-based, we must encourage appropriate financial payment models to curb use outside of research studies and promote development of additional treatment registries until sufficient evidence is gathered.
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Affiliation(s)
- Heather Taffet Gold
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
| | - Kimberly Pitrelli
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
| | - Mary Katherine Hayes
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
| | - Madhuvanti Mahadeo Murphy
- New York University School of Medicine, New York, NY (HTG, KP)
- Weill Cornell Medical College New York, NY (MKH)
- University of the West Indies, Cave Hill, Barbados (MMM)
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