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Minami CA, Jin G, Freedman RA, Schonberg MA, King TA, Mittendorf EA. Physician-level variation in axillary surgery in older adults with T1N0 hormone receptor-positive breast cancer: A retrospective population-based cohort study. J Geriatr Oncol 2024; 15:101795. [PMID: 38759256 PMCID: PMC11225423 DOI: 10.1016/j.jgo.2024.101795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION We sought to determine how considerations specific to older adults impact between- and within-surgeon variation in axillary surgery use in women ≥70 years with T1N0 HR+ breast cancer. MATERIALS AND METHODS Females ≥70 years with T1N0 HR+/HER2-negative breast cancer diagnosed from 2013 to 2015 in SEER-Medicare were identified and linked to the American Medical Association Masterfile. The outcome of interest was axillary surgery. Key patient-level variables included the Charlson Comorbidity Index (CCI) score, frailty (based on a claims-based frailty index score), and age (≥75 vs <75). Multilevel mixed models with surgeon clusters were used to estimate the intracluster correlation coefficient (ICC) (between-surgeon variance), with 1-ICC representing within-surgeon variance. RESULTS Of the 4410 participants included, 6.1% had a CCI score of ≥3, 20.7% were frail, and 58.3% were ≥ 75 years; 86.1% underwent axillary surgery. No surgeon omitted axillary surgery in all patients, but 42.3% of surgeons performed axillary surgery in all patients. In the null model, 10.5% of the variance in the axillary evaluation was attributable to between-surgeon differences. After adjusting for CCI score, frailty, and age in mixed models, between-surgeon variance increased to 13.0%. DISCUSSION In this population, axillary surgery varies more within surgeons than between surgeons, suggesting that surgeons are not taking an "all-or-nothing" approach. Comorbidities, frailty, and age accounted for a small proportion of the variation, suggesting nuanced decision-making may include additional, unmeasured factors such as differences in surgeon-patient communication.
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Affiliation(s)
- Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Mara A Schonberg
- Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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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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Shao J, Rodrigues M, Corter AL, Baxter NN. Multidisciplinary care of breast cancer patients: a scoping review of multidisciplinary styles, processes, and outcomes. Curr Oncol 2019; 26:e385-e397. [PMID: 31285683 PMCID: PMC6588064 DOI: 10.3747/co.26.4713] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Clinical practice guidelines recommend a multidisciplinary approach to cancer care that brings together all relevant disciplines to discuss optimal disease management. However, the literature is characterized by heterogeneous definitions and few reviews about the processes and outcomes of multidisciplinary care. The objective of this scoping review was to identify and classify the definitions and characteristics of multidisciplinary care, as well as outcomes and interventions for patients with breast cancer. Methods A systematic search for quantitative and qualitative studies about multidisciplinary care for patients with breast cancer was conducted for January 2001 to December 2017 in the following electronic databases: medline, embase, PsycInfo, and cinahl. Two reviewers independently applied our eligibility criteria at level 1 (title/abstract) and level 2 (full-text) screening. Data were extracted and synthesized descriptively. Results The search yielded 9537 unique results, of which 191 were included in the final analysis. Two main types of multidisciplinary care were identified: conferences and clinics. Most studies focused on outcomes of multidisciplinary care that could be variously grouped at the patient, provider, and system levels. Research into processes tended to focus on processes that facilitate implementation: team-working, meeting logistics, infrastructure, quality audit, and barriers and facilitators. Summary Approaches to multidisciplinary care using conferences and clinics are well described. However, studies vary by design, clinical context, patient population, and study outcome. The heterogeneity of the literature, including the patient populations studied, warrants further specification of multidisciplinary care practice and systematic reviews of the processes or contexts that make the implementation and operation of multidisciplinary care effective.
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Affiliation(s)
- J Shao
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - M Rodrigues
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - A L Corter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - N N Baxter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
- Department of Surgery, St. Michael's Hospital, Toronto, ON
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
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The positive impact of surgeon specialization on survival for gastric cancer patients after surgery with curative intent. Gastric Cancer 2015; 18:859-67. [PMID: 25315086 DOI: 10.1007/s10120-014-0436-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 10/05/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many studies have affirmed the survival benefit for cancer patients treated by specialized surgeons. METHODS A total of 967 patients with gastric cancer (GC) who underwent gastrectomy with curative intent in our center were enrolled. Patients were categorized into two groups based on surgeon specialization: the specialized group (SG) and nonspecialized group (NSG). To overcome bias due to the different distribution of covariates for the two groups, a one-to-one match was applied using propensity score analysis. After matching, prognosis and recurrence data were analyzed. RESULTS After one-to-one matching, 261 patients in the SG and 261 patients in the NSG had the same characteristics excluding factors associated with surgery. In multivariate analysis for the whole study series, surgeon specialization was an independent prognostic factor for GC patients after surgery. Patients in the SG demonstrated a significantly higher 5-year overall survival than those in the NSG (50.7 vs. 37.2 %, p = 0.001). With the strata analysis, significant prognostic differences between the two groups were only observed in patients at stage IIIa-b or N1-2. The proportion of locoregional recurrence was greater in the NSG than in the SG. CONCLUSION GC patients treated by specialized surgeons tended to have a better prognosis and lower locoregional recurrence rate. Surgeon specialization was an independent prognostic factor for GC patients after surgery. GC should be treated by specialized surgeons in large-volume centers.
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Improving Quality Metric Adherence to Minimally Invasive Breast Biopsy among Surgeons Within a Multihospital Health Care System. J Am Coll Surg 2015; 221:758-66. [PMID: 26228015 DOI: 10.1016/j.jamcollsurg.2015.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/01/2015] [Accepted: 06/02/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Minimally invasive breast biopsy (MIBB) is the procedure of choice for diagnosing breast lesions indeterminate for malignancy. Multihospital health care systems face challenges achieving systemwide adherence to standardized guidelines among surgeons with varying practice patterns. This study tested whether providing individual feedback about surgeons' use of MIBB to diagnose breast malignancies improved quality metric adherence across a large health care organization. STUDY DESIGN We conducted a prospective matched-pairs study to test differences (or lack of agreement) between periods before and after intervention. All analytical cases of primary breast cancer diagnosed during 2011 (period 1) and from July 2012 to June 2013 (period 2) across a multihospital health care system were reviewed for initial diagnosis by MIBB or open surgical biopsy. Open surgical biopsy was considered appropriate care only if MIBB could not be performed for reasons listed in the American Society of Breast Surgeons' quality measure for preoperative diagnosis of breast cancer. Individual and systemwide results of adherence to the MIBB metric during period 1 were sent to each surgeon in June 2012 and were later compared with period 2 results using McNemar's test of marginal homogeneity for matched binary responses. RESULTS Forty-six surgeons were evaluated on use of MIBB to diagnose breast cancer. In period 1, metric adherence for 100% of cases was achieved by 37 surgeons, for a systemwide 100% compliance rate of 80.4%. After notification of individual performance, 44 of 46 surgeons used MIBB solely or otherwise appropriate care to diagnose breast cancer, which improved systemwide compliance to 95.7%. CONCLUSIONS Providing individual and systemwide performance results to surgeons can increase self-awareness of practice patterns when diagnosing breast cancer, leading to standardized best-practice care across a large health care organization.
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Resection probability maps for quality assessment of glioma surgery without brain location bias. PLoS One 2013; 8:e73353. [PMID: 24039922 PMCID: PMC3765204 DOI: 10.1371/journal.pone.0073353] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 07/18/2013] [Indexed: 11/19/2022] Open
Abstract
Background Intraoperative brain stimulation mapping reduces permanent postoperative deficits and extends tumor removal in resective surgery for glioma patients. Successful functional mapping is assumed to depend on the surgical team's expertise. In this study, glioma resection results are quantified and compared using a novel approach, so-called resection probability maps (RPM), exemplified by a surgical team comparison, here with long and short experience in mapping. Methods Adult patients with glioma were included by two centers with two and fifteen years of mapping experience. Resective surgery was targeted at non-enhanced MRI extension and was limited by functional boundaries. Neurological outcome was compared. To compare resection results, we applied RPMs to quantify and compare the resection probability throughout the brain at 1 mm resolution. Considerations for spatial dependence and multiple comparisons were taken into account. Results The senior surgical team contributed 56, and the junior team 52 patients. The patient cohorts were comparable in age, preoperative tumor volume, lateralization, and lobe localization. Neurological outcome was similar between teams. The resection probability on the RPMs was very similar, with none (0%) of 703,967 voxels in left-sided tumors being differentially resected, and 124 (0.02%) of 644,153 voxels in right-sided tumors. Conclusion RPMs provide a quantitative volumetric method to compare resection results, which we present as standard for quality assessment of resective glioma surgery because brain location bias is avoided. Stimulation mapping is a robust surgical technique, because the neurological outcome and functional-based resection results using stimulation mapping are independent of surgical experience, supporting wider implementation.
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Taban F, Rapiti E, Fioretta G, Wespi Y, Weintraub D, Hugli A, Schubert H, Vlastos G, Castiglione M, Bouchardy C. Breast cancer management and outcome according to surgeon's affiliation: a population-based comparison adjusted for patient's selection bias. Ann Oncol 2012; 24:116-25. [PMID: 22945380 DOI: 10.1093/annonc/mds285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Studies have reported that breast cancer (BC) units could increase the quality of care but none has evaluated the efficacy of alternative options such as private BC networks, which is our study objective. PATIENTS AND METHODS We included all 1404 BC patients operated in the public unit or the private network and recorded at the Geneva Cancer Registry between 2000 and 2005. We compared quality indicators of care between the public BC unit and the private BC network by logistic regression and evaluated the effect of surgeon's affiliation on BC-specific mortality by the Cox model adjusting for the propensity score. RESULTS Both the groups had high care quality scores. For invasive cancer, histological assessment before surgery and axillary lymph node dissection when indicated were less frequent in the public sector (adjusted odds ratio (OR): 0.4, 95% confidence interval (CI) 0.3-0.7, and OR: 0.4, 95% CI 0.2-0.8, respectively), while radiation therapy after breast-conserving surgery was more frequent (OR: 2.5, 95% CI 1.4-4.8). Surgeon affiliation had no substantial effect on BC-specific mortality (adjusted hazard ratio (HR): 0.8, 95% CI 0.5-1.4). CONCLUSIONS This study suggests that private BC networks could be an alternative to public BC units with both structures presenting high quality indicators of BC care and similar BC-specific mortality.
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Affiliation(s)
- F Taban
- SONGe (Séno ONcologie Genevoise), Geneva Private Practitioners Breast Cancer Network, Geneva, Switzerland
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Adkisson CD, Bagaria SP, Parker AS, Bray JM, Gibson T, Thomas CS, Heckman MG, McLaughlin SA. Which eligible breast conservation patients choose mastectomy in the setting of newly diagnosed breast cancer? Ann Surg Oncol 2012; 19:1129-36. [PMID: 21975859 DOI: 10.1245/s10434-011-2080-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Indexed: 12/29/2022]
Abstract
PURPOSE Breast conserving therapy (BCT) and mastectomy offer equivalent survival for women with newly diagnosed breast cancer (BrCa). Despite this, many women eligible for BCT elect mastectomy. Herein, we identify factors associated with choosing ipsilateral mastectomy instead of BCT when mastectomy is not required. METHODS Between July 2007 and June 2010, 520 women with BrCa were treated by a single surgeon who prospectively documented patient eligibility for BCT. For patients who did not require mastectomy (n=392), we evaluated associations between treatment choice and potential predictors using odds ratios (ORs) obtained from multivariable logistic regression models. P values≤0.0029 were significant after correction for multiple testing. RESULTS Of 392 women eligible for BCT, 106 (27%) chose mastectomy and 286 (73%) chose BCT. Multivariate analysis found an increased likelihood of electing mastectomy over BCT for patients with no comorbidities (OR 5.4; P<0.001) and those with previous mastectomy (OR 23.2; P<0.001). MRI and biopsy findings were associated with treatment choice because patients who had a second-site biopsy positive for cancer in the same quadrant as the index tumor were more likely to elect mastectomy compared with patients with no additional MRI abnormalities (OR 4.3; P=0.0027). No association existed on multivariate analysis between choice of mastectomy and patient age, family history, or tumor stage. CONCLUSIONS One in four eligible BCT patients chooses mastectomy. Factors independently associated with choosing mastectomy over BCT include findings of second-site biopsy, previous mastectomy, and absence of comorbidities but not primary tumor characteristics. Further study into a patient’s choice for mastectomy is warranted.
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Affiliation(s)
- Cameron D Adkisson
- Department of General Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA
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Gomez SL, Press DJ, Lichtensztajn D, Keegan THM, Shema SJ, Le GM, Kurian AW. Patient, hospital, and neighborhood factors associated with treatment of early-stage breast cancer among Asian American women in California. Cancer Epidemiol Biomarkers Prev 2012; 21:821-34. [PMID: 22402290 PMCID: PMC3406750 DOI: 10.1158/1055-9965.epi-11-1143] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Clinical guidelines recommend breast-conserving surgery (BCS) with radiation as a viable alternative to mastectomy for treatment of early-stage breast cancer. Yet, Asian Americans are more likely than other groups to have mastectomy or omit radiation after BCS. METHODS We applied polytomous logistic regression and recursive partitioning to analyze factors associated with mastectomy, or BCS without radiation, among 20,987 California Asian Americans diagnosed with stage 0 to II breast cancer from 1990 to 2007. RESULTS The percentage receiving mastectomy ranged from 40% among U.S.-born Chinese to 58% among foreign-born Vietnamese. Factors associated with mastectomy included tumor characteristics such as larger tumor size, patient characteristics such as older age and foreign birthplace among some Asian Americans ethnicities, and additional factors including hospital [smaller hospital size, not National Cancer Institute cancer center, low socioeconomic status (SES) patient composition, and high hospital Asian Americans patient composition] and neighborhood characteristics (ethnic enclaves of low SES). These hospital and neighborhood characteristics were also associated with BCS without radiation. Through recursive partitioning, the highest mastectomy subgroups were defined by tumor characteristics such as size and anatomic location, in combination with diagnosis year and nativity. CONCLUSIONS Tumor characteristics and, secondarily, patient, hospital, and neighborhood factors are predictors of mastectomy and omission of radiation following BCS among Asian Americans. IMPACT By focusing on interactions among patient, hospital, and neighborhood factors in the differential receipt of breast cancer treatment, our study identifies subgroups of interest for further study and translation into public health and patient-focused initiatives to ensure that all women are fully informed about treatment options.
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