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MacLennan SJ, Cox T, Murdoch S, Eatough V. An interpretative phenomenological analysis of the meaning of work to women living with breast cancer. Chronic Illn 2022; 18:503-516. [PMID: 33475434 DOI: 10.1177/1742395320987883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Work is an important aspect of everyday life. This remains true for those living with and beyond cancer. Less is known about how the meaning of work may change over the cancer journey, the needs of the individual in response to changes and how healthcare professionals and employing organisations can meet these needs. The aim of this study was to explore the lived experience of work after treatment for breast cancer in a group of professional working women within the UK. METHODS This article presents an Interpretative Phenomenological Analysis (IPA) of the experiences of 15 professional women diagnosed with breast cancer. RESULTS We discuss these women's journey from (1) rethinking the meaning of work to (2) making decisions about work ability and advice on work to (3) transitioning back in to the workplace and the value of continued engagement with employer. DISCUSSION The findings from this study demonstrate the complex interplay between living with cancer, treatment decisions and work. This study highlights two key areas for inclusion in practice: (1) support from Healthcare Professionals and judgements of functional ability and work ability and (2) the role of line managers in managing cancer and work.
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Affiliation(s)
- Sara J MacLennan
- Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Thomas Cox
- Centre for Sustainable Working Life, Birkbeck University of London, London, UK
| | - Sarah Murdoch
- Academic Urology Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Virginia Eatough
- Department of Psychological Sciences, Birkbeck University of London, London, UK
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Comeaux JG, Culver JO, Lee JE, Dondanville D, McArthur HL, Quinn E, Gorman N, Ricker C, Li M, Lerman C. Risk‐reducing mastectomy decisions among women with mutations in high‐ and moderate‐ penetrance breast cancer susceptibility genes. Mol Genet Genomic Med 2022; 10:e2031. [PMID: 36054727 PMCID: PMC9544212 DOI: 10.1002/mgg3.2031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/08/2022] [Accepted: 07/25/2022] [Indexed: 12/02/2022] Open
Abstract
Background Women harboring mutations in breast cancer susceptibility genes are at increased lifetime risk of developing breast cancer and are faced with decisions about risk management, including whether to undergo high‐risk screening or risk‐reducing mastectomy (RRM). National guidelines recommend BRCA1 or BRCA2 mutation carriers consider RRM, but that carriers of moderate penetrance mutations (e.g., ATM or CHEK2) should be managed based on family history. We aimed to investigate determinants of decision for RRM, and hypothesized that mutation status, age, family history, partner status, and breast cancer would impact RRM decision making. Methods We performed a retrospective study assessing RRM decisions for 279 women. Results Women with BRCA and moderate penetrance gene mutations, a personal history of breast cancer, or a first degree relative with a history of breast cancer were more likely to undergo RRM. Breast cancer status and age showed an interaction effect such that women with breast cancer were less likely to undergo RRM with increasing age. Conclusion Although national guidelines do not recommend RRM for moderate penetrance carriers, the rates of RRM for this population approached those for BRCA mutation carriers. Further insights are needed to better support RRM decision‐making in this population.
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Affiliation(s)
- Jacob G. Comeaux
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Julie O. Culver
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - John E. Lee
- Samuel Oschin Cancer CenterCedars‐Sinai Medical CenterLos AngelesCaliforniaUSA
| | | | - Heather L. McArthur
- Department of Internal MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Emily Quinn
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Nicholas Gorman
- Human Genetics and GenomicsKeck Graduate InstituteClaremontCaliforniaUSA
| | - Charité Ricker
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Ming Li
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Caryn Lerman
- Norris Comprehensive Cancer CenterUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Abstract
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.
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Billig JI, Speth KA, Nasser JS, Wang L, Chung KC. Assessment of Surgeon Variation in Adherence to Evidence-Based Recommendations for Treatment of Trigger Finger. JAMA Netw Open 2019; 2:e1912960. [PMID: 31603484 PMCID: PMC6804023 DOI: 10.1001/jamanetworkopen.2019.12960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Stenosing tenosynovitis (trigger finger) affects approximately 2% of the population. Given the prevalence of trigger finger and rising health care costs, adherence to the cost-effective and evidence-based treatment algorithm will permit better outcomes and allocation of resources. OBJECTIVES To examine treatment patterns for trigger finger and to determine surgeon-level and patient-level factors that influence adherence to evidence-based treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study examined deidentified claims for treatment of trigger finger from a national insurance provider using the Clinformatics Data Mart database. Patients were included if they were 18 years or older and treated from January 1, 2002, through December 31, 2016 (excluding a washout period from July 1, 2008, until June 30, 2010), with a new diagnosis of single-digit trigger finger. Data were analyzed from December 21, 2018, through April 28, 2019. EXPOSURES Cost-effective and evidence-based research published in July 2009 for the treatment of trigger finger. MAIN OUTCOMES AND MEASURES After excluding the 1-year washout period on either side of July 1, 2009, adherence to the recommended treatment algorithm of 2 corticosteroid injections before surgical release of trigger finger was compared with practice before publication of research supporting this cost-effective and evidence-based approach. RESULTS In this analysis of 83 667 patients with trigger finger, 52 698 (63.0%) were women, and 20 045 (24.0%) had type 1 or 2 diabetes. Mean (SD) age was 61 (13) years. From 2002 to 2016, an overall increasing trend in adherence to the cost-effective and evidence-based approach to treatment was noted, with no significant increase in adherence in the postpublication era (67.5% vs 73.3%; P = .27). Substantial variation in adherence was observed at the surgeon level (intraclass correlation, 33%). Plastic surgeons had no change in adherence over time compared with orthopedic surgeons (odds ratio [OR], 1.00; 95% CI, 0.98-1.02; P = .90), whereas general surgeons had increased adherence (OR, 1.04; 95% CI, 1.02-1.06; P < .001). Higher-volume surgeons were also more adherent to these evidence-based recommendations (OR, 1.59; 95% CI, 1.53-1.65; P < .001). CONCLUSIONS AND RELEVANCE This study found substantial surgeon-level variation in adherence to evidence-based treatment of trigger finger. Surgeon specialty and volume were associated with differences in adherence. Efforts to understand surgeon barriers to implementation, regardless of physician specialty, appear to be necessary, and better implementation strategies may permit increased uptake of evidence-based treatment of trigger finger.
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Affiliation(s)
- Jessica I. Billig
- Veterans Affairs (VA)/National Clinician Scholars Program, VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor
| | - Kelly A. Speth
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Jacob S. Nasser
- Comprehensive Hand Center, Section of Plastic Surgery, Michigan Medicine, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Kevin C. Chung
- Comprehensive Hand Center, Section of Plastic Surgery, Michigan Medicine, Ann Arbor
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Gu J, Delisle M, Engler-Stringer R, Groot G. Mastectomy versus breast-conservation therapy: an examination of how individual, clinicopathologic, and physician factors influence decision-making. ACTA ACUST UNITED AC 2019; 26:e522-e534. [PMID: 31548821 DOI: 10.3747/co.26.5079] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The choice of mastectomy compared with breast-conservation therapy (bct) in early-stage breast cancer (esbca) is a complicated decision-making process. Interprovincially, Canada's mastectomy rates vary from 25% to 68%, with Saskatchewan reporting the nation's second-highest mastectomy rate at 63%. The aim of our research was to better understand why women with esbca choose mastectomy rather than bct in Saskatchewan. Methods We created a survey based on a previously developed framework that organizes influencing factors into 3 constructs: clinicopathologic, physician, and individual belief factors. Results Treatment choice was found to be influenced by disease stage and multiple individual belief factors. Compared with their counterparts having stage i disease, women with stage ii disease were significantly more likely to undergo mastectomy [odds ratio (or): 7.48]. Patients rating "worry about cancer recurrence" and "total treatment time" as more influential in their choice were also more likely to undergo mastectomy (or: 3.4 and 1.8 respectively). Conversely, women rating "wanting to keep own breast tissue," "tumour size," and "surgeon's opinion" as influential in their choice were more likely to undergo bct (or: 0.17, 0.66, and 0.69 respectively). Conclusions Our study demonstrates that treatment choices for Saskatchewan women with esbca are influenced primarily by disease stage and individual belief factors. Those findings suggest that women are making their treatment choices predominantly based on individual values and preferences. The use of rates of mastectomy and bct as indicators of quality of care might be misleading. Instead, a shift in attention toward patient-centred care might be more appropriate.
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Affiliation(s)
- J Gu
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
| | - M Delisle
- Department of Surgery, University of Manitoba, Winnipeg, MB
| | - R Engler-Stringer
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
| | - G Groot
- Community Health and Epidemiology, University of Saskatchewan, Saskatoon, SK
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Gu J, Groot G, Boden C, Busch A, Holtslander L, Lim H. Review of Factors Influencing Women's Choice of Mastectomy Versus Breast Conserving Therapy in Early Stage Breast Cancer: A Systematic Review. Clin Breast Cancer 2018; 18:e539-e554. [DOI: 10.1016/j.clbc.2017.12.013] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/22/2017] [Indexed: 01/11/2023]
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Mokhles S, Nuyttens JJME, de Mol M, Aerts JGJV, Maat APWM, Birim Ö, Bogers AJJC, Takkenberg JJM. Treatment selection of early stage non-small cell lung cancer: the role of the patient in clinical decision making. BMC Cancer 2018; 18:79. [PMID: 29334910 PMCID: PMC5769349 DOI: 10.1186/s12885-018-3986-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 01/02/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The objective of this study is to investigate the role and experience of early stage non-small cell lung cancer (NSCLC) patient in decision making process concerning treatment selection in the current clinical practice. METHODS Stage I-II NSCLC patients (surgery 55 patients, SBRT 29 patients, median age 68) were included in this prospective study and completed a questionnaire that explored: (1) perceived patient knowledge of the advantages and disadvantages of the treatment options, (2) experience with current clinical decision making, and (3) the information that the patient reported to have received from their treating physician. This was assessed by multiple-choice, 1-5 Likert Scale, and open questions. The Decisional Conflict Scale was used to assess the decisional conflict. Health related quality of life (HRQoL) was measured with SF-36 questionnaire. RESULTS In 19% of patients, there was self-reported perceived lack of knowledge about the advantages and disadvantages of the treatment options. Seventy-four percent of patients felt that they were sufficiently involved in decision-making by their physician, and 81% found it important to be involved in decision making. Forty percent experienced decisional conflict, and one-in-five patients to such an extent that it made them feel unsure about the decision. Subscores with regard to feeling uninformed and on uncertainty, contributed the most to decisional conflict, as 36% felt uninformed and 17% of patients were not satisfied with their decision. HRQoL was not influenced by patient experience with decision-making or patient preferences for shared decision making. CONCLUSIONS Dutch early-stage NSCLC patients find it important to be involved in treatment decision making. Yet a substantial proportion experiences decisional conflict and feels uninformed. Better patient information and/or involvement in treatment-decision-making is needed in order to improve patient knowledge and hopefully reduce decisional conflict.
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Affiliation(s)
- S Mokhles
- Department of Cardio-thoracic Surgery, Erasmus-MC, Room Bd-577, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - J J M E Nuyttens
- Department of Radiation Oncology, Erasmus-MC-Cancer Institute, Rotterdam, The Netherlands
| | - M de Mol
- Department of Pulmonary Disease, Amphia Hospital, Breda, The Netherlands
| | - J G J V Aerts
- Department of Pulmonary Disease, Erasmus-MC, Rotterdam, The Netherlands.,Department of Pulmonary Disease, Amphia Hospital, Breda, The Netherlands
| | - A P W M Maat
- Department of Cardio-thoracic Surgery, Erasmus-MC, Room Bd-577, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ö Birim
- Department of Cardio-thoracic Surgery, Erasmus-MC, Room Bd-577, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A J J C Bogers
- Department of Cardio-thoracic Surgery, Erasmus-MC, Room Bd-577, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - J J M Takkenberg
- Department of Cardio-thoracic Surgery, Erasmus-MC, Room Bd-577, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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How Well Informed Do Patients Feel about Their Breast Cancer Surgery Options? Findings from a Nationwide Survey of Women after Lumpectomy and/or Mastectomy. J Am Coll Surg 2017; 226:134-146.e3. [PMID: 29246706 DOI: 10.1016/j.jamcollsurg.2017.10.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/05/2017] [Accepted: 10/18/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Women diagnosed with breast cancer often describe the process of treatment decision making as bewildering and worrisome. Patients who do not feel completely informed about their surgical options might make choices that are suboptimal or regretted later. The Institute of Medicine has called for more research on why breast cancer patients are inadequately informed about treatment options. The aims of the study were to explore how women become informed about their breast cancer surgery treatment options and to identify improvement opportunities. STUDY DESIGN A nationwide internet survey was conducted among women who reported being surgically treated by lumpectomy only (n = 215), mastectomy only (n = 140), or by both procedures (n = 132) for breast cancer. To improve generalizability, Census-based enrollment quotas were applied for geographic region, health insurance, and income. RESULTS Only 47% (95% CI 41% to 54%) of lumpectomy-only patients, 67% (95% CI 59% to 75%) of mastectomy-only patients, and 28% (95% CI 21% to 35%) of patients having both procedures said they felt "completely informed" about treatment options before their operations. "Making a quick decision" was more important than "thoroughly researching all options" for 35% of lumpectomy-only patients, 31% of mastectomy-only patients, and 22% of patients having both procedures. Nearly all women used some other source of information to research treatment options. Lumpectomy-only and mastectomy-only patients who relied on their surgeon's recommendation without additional research were significantly less likely to report feeling "completely informed" (odds ratio 0.6; 95% CI 0.4 to 0.9; p < 0.02). CONCLUSIONS Many women who had surgery for breast cancer did not feel completely informed about their surgical options. This appears to be due, in part, to a false sense of urgency and perhaps insufficient or misdirected information gathering by patients. The responsibility for fully informing patients about their treatment options must be better fulfilled by surgeons.
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Abstract
It is known that survival is unaffected by the choice of surgical management for breast cancer (BC) patients. Despite this fact, recent literature reveals that the number of bilateral mastectomies (BMs) in the United States is increasing. In an effort to elucidate potential factors influencing this trend, we investigated socioeconomic and clinicopathologic characteristics of our patient cohort that could have affected a patient's decision between unilateral mastectomy (UM) versus BM. Five-hundred-eight patients with unilateral BC who underwent mastectomy between 2000 and 2009 were analyzed: 397-UM; 111-BM. Influence of patient's age, insurance status, residence (rural versus urban), subsequent reconstruction, marital status, smoking history, family cancer history, cancer stage and grade on the BM versus UM patient's decision were analyzed using independent sample t tests, χ2 and logistic regression analysis. BM was more likely to be chosen by younger (<50 years) patients (P < 0.001); patients with private insurance [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.4–3.5]; residence in urban settings (OR = 5.09, 95% CI = 2.5–10.4); and plans for subsequent reconstruction (OR = 2.31, 95% CI = 1.4–3.8). Marital status, smoking history, family cancer history, BC stage and grade did not significantly impact patient's choice of BM versus UM. We found that patients with unilateral BC who are younger (<50 year) have private insurance, reside in urban settings, or plan for subsequent reconstruction are more likely to undergo BM for unilateral BC. Genetic specific data were not evaluated for this patient cohort, and will be the subject of future analysis.
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Lin PJ, Saret CJ, Neumann PJ, Sandberg EA, Cohen JT. Assessing the Value of Treatment to Address Various Symptoms Associated with Multiple Sclerosis: Results from a Contingent Valuation Study. PHARMACOECONOMICS 2016; 34:1255-1265. [PMID: 27461538 DOI: 10.1007/s40273-016-0435-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Although it is well recognized that people with multiple sclerosis (MS) may experience impairments in addition to limited mobility, there has been little effort to study their relative importance to patients with the condition. The objective of this study was to assess patient preferences for addressing various MS symptoms. METHODS This study was conducted at Tufts Medical Center, Boston, Massachusetts. We developed a national online survey of MS patients and neurologists to estimate the value each group places on treating specific MS symptoms. Each respondent was presented with two randomly selected scenarios with different symptoms and treatments. MS patients were asked about their own preferences, whereas neurologists were asked to consider what a patient of theirs would do or think in each scenario. We used a bidding game approach to elicit respondents' willingness to pay (WTP) for the treatments. RESULTS To treat mobility alone, WTP for MS patients averaged US$410-US$520 per month, depending on the scenario. For paired symptoms, MS patients would pay most to treat mobility and upper limb function (US$525/month) or mobility and cognition (US$514/month), somewhat less to treat mobility and eyesight (US$445/month), and least to treat mobility and fatigue (US$371/month). Patient WTP values increased with income and education. Neurologists believed their patients would be willing to pay US$216-US$249 per month to treat mobility alone, depending on the scenario. For paired symptoms, neurologists believed patients would pay most to treat mobility and fatigue (US$263/month) and least to treat mobility and upper limb function (US$177/month). CONCLUSION Our findings suggest MS patients may value one outcome (e.g., improved arm and hand coordination) over another (e.g., less fatigue). Further, MS patients and neurologists may rank the importance of treating various symptoms differently. Given this potential mismatch, it is crucial for MS patients and their clinicians to discuss treatment priorities that take into account patient preferences.
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Affiliation(s)
- Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA.
| | - Cayla J Saret
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA
| | - Eileen A Sandberg
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Box #63, Boston, MA, 02111, USA
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Boero IJ, Gillespie EF, Hou J, Paravati AJ, Kim E, Einck JP, Yashar C, Mell LK, Murphy JD. The Impact of Radiation Oncologists on the Early Adoption of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:571-580. [PMID: 28126306 DOI: 10.1016/j.ijrobp.2016.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/19/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Isabel J Boero
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Erin F Gillespie
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Jiayi Hou
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Anthony J Paravati
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Ellen Kim
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - John P Einck
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California.
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Lu JJ, Li HA, Xiong Y. Breast Cancer Inpatients Undergoing Mastectomy from a Hospital in Guangzhou, China: A Retrospective Analysis 2004- 2013. Asian Pac J Cancer Prev 2016; 16:4577-81. [PMID: 26107206 DOI: 10.7314/apjcp.2015.16.11.4577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To explore the hospitalizations of breast cancer patients undergoing mastectomy, and to provide a basis for management, clinical prevention and treatment. MATERIALS AND METHODS We conducted an investigation by means of the retrospective survey and the medical records retrieval system, and made out the data of patients suffered from breast cancer in a hospital in Guangzhou from 2004 to 2013, including age, medical payment methods, pathological type, treatment, treatment results, complications, hospitalization days, cost and so on. RESULTS The average age of the inpatients was 50.14 years old. The main histologic types were infiltrating duct carcinoma (88.06%). The main surgery was modified radical mastectomy (80.41%). The cure rate was 90.80% during the 10 years. The main medical payment method was self-paying (57.28%). The average hospital stay was 13.51 days, and average hospitalization cost was RMB 23,083.66 yuan, proportion of drug fees up to 39.70%. Postoperative complication rate was 0.79%. The self-paying group was with the highest proportion of drug fees (P<0.05), while the free medical service group was with the longest hospitalization days (P<0.05). CONCLUSIONS The payment methods significantly affected the proportion of drug fees and hospitalization days. The therapeutic effect was satisfactory with less complications and reasonable proportion of drug fees in our hospital.
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Affiliation(s)
- Jian-Jun Lu
- Department of medical affaires, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China E-mail :
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Abstract
The rate of women choosing to have a bilateral mastectomy as a treatment for unilateral breast cancer has increased since the 1990s, particularly among younger women. This article describes a qualitative study that was conducted to explore this decision-making process.
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Clough KB, Acosta-Marín V, Nos C, Alran S, Rouanet P, Garbay JR, Giard S, Verhaeghe JL, Houvenaeghel G, Flipo B, Dauplat J, Dorangeon PH, Classe JM, Rouzier R, Bonnier P. Rates of Neoadjuvant Chemotherapy and Oncoplastic Surgery for Breast Cancer Surgery: A French National Survey. Ann Surg Oncol 2015; 22:3504-11. [PMID: 25665949 DOI: 10.1245/s10434-015-4378-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The current retrospective study was intended to obtain up-to-date and comprehensive data on surgical practice for breast cancer throughout France, including neoadjuvant chemotherapy (NAC) and the more recent surgical techniques of oncoplastic surgery (OPS). METHODS In June 2011, e-mail surveys were sent to 33 nationally renowned breast cancer surgeons from French public or private hospitals. The questionnaire focused on all the new cases of breast cancer treated in 2010. It included questions regarding surgical practices, with special emphases on NAC and OPS and other surgical characteristics. RESULTS The overall response rate for the survey was 72.7 %. The total number of breast cancer cases from the survey was 13,762, which constitutes 26.2 % of the total incidence in 2010. Breast-conserving surgery (BCS) was performed for 71.0 % of the patients, and the results were similar throughout the types of practices. Of these patients, 13.9 % received OPS, either upfront or after NAC. Mastectomy was performed for 29.0 % of the patients, which is consistent with French official numbers. Among all patients, 16.3 % underwent surgery after NAC. CONCLUSION To the authors' knowledge, there are no publications of national figures on NAC or OPS rates to date. They are convinced that this study offers real-life surgical care information on a large population and covers France's breast cancer surgical landscape. Mastectomy rates in France remain stable and consistent with those in other European countries. However, additional large-scale retrospective studies are required to confirm these figures and further explore NAC and OPS rates as well as surgical practice characteristics.
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Affiliation(s)
| | - Victor Acosta-Marín
- The Paris Breast Center - L'Institut du Sein, Paris, France.,Centro Clínico de Estereotaxia-CECLINES, Caracas, Venezuela
| | - Claude Nos
- The Paris Breast Center - L'Institut du Sein, Paris, France
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Delay of adjuvant chemotherapy after elective mastectomy and immediate reconstruction in breast-conservation candidates: a matched-pair analysis. Am J Clin Oncol 2015; 37:575-9. [PMID: 23466579 DOI: 10.1097/coc.0b013e318280d79f] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To analyze factors that influence the timing of adjuvant chemotherapy in patients who are candidates for breast-conservation therapy (BCT) but elect mastectomy with immediate reconstruction (M-IR). METHODS We identified 35 consecutively treated patients with stage I or II breast cancer between 2004 and 2009 who underwent M-IR and adjuvant chemotherapy from the University of Louisville Cancer Registry. We matched these patients for age and AJCC stage to 35 controls who underwent BCT and adjuvant chemotherapy. We examined the timing and delay of initiation of chemotherapy using univariate logistic regression and McNemar test for matched pairs. RESULTS For the 70 patients evaluated, the median age was 46 years (range, 30 to 65 y), and the distribution for stage I, IIA, and IIB was 22.9%, 65.7%, and 11.4%, respectively. The 2 groups were well balanced in terms of race, rural/urban status, smoking, diabetes, insurance coverage, and histology. For BCT and M-IR, the median time to chemotherapy initiation was 38 days (range, 25 to 103 d) and 55 days (range, 30 to 165 d), respectively. Patients undergoing M-IR were more likely to experience any delay (>45 d; 54.3% vs. 22.9%; P<0.001) and/or significant delay (>90 d; 20.0% vs. 2.9%; P<0.001). On univariate logistic regression analysis, surgery type had a major impact on delay of chemotherapy (odds ratio=8.35; 95% confidence interval, 2.86-24.4; P<0.001). CONCLUSIONS The use of M-IR in breast-conservation candidates independently predicts for delay in initiation of adjuvant chemotherapy. Further study is needed to qualify the causes and clinical significance of these delays.
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Vanderpool RC, Swanberg JE, Chambers MD. A Narrative Review of the Confluence of Breast Cancer and Low-wage Employment and Its Impact on Receipt of Guideline-recommended Treatment. Glob Adv Health Med 2014; 2:75-85. [PMID: 24416698 PMCID: PMC3833560 DOI: 10.7453/gahmj.2013.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Breast cancer is the leading cause of cancer among women in the United States, costing the healthcare system, employers, and society billions of dollars each year. Despite improvements in screening and treatment, significant breast cancer treatment and survivorship disparities exist among various groups of women. One variable that has not been explored extensively as a possible contributor to breast cancer treatment disparities is employment. This is concerning, given the changing economic and employment trends in the United States favoring low-wage employment. Currently, one-quarter to one-third of all US workers are considered to be working poor, and women are disproportionally represented in this group. Characteristics of low-wage work-limited paid time off, minimal health benefits, schedule inflexibility, and economic insecurity-may become even more significant in the event of a breast cancer diagnosis. To date, there has been limited research into how job conditions inherent to low-wage work may influence working poor survivors' receipt of guideline-recommended breast cancer treatment. Therefore, the purpose of this narrative review was to critically examine the current literature to further our understanding of how employment context may impact treatment decisions and adherence-and therefore receipt of guideline-recommended care-among newly diagnosed, working poor breast cancer survivors. After undertaking a comprehensive review, we failed to identify any published literature that explicitly addressed low-wage employment and receipt of guideline-recommended breast cancer treatment. Four articles reported circumstances where women delayed, missed, or quit treatments due to work interference, or alternatively, developed strategies that allowed them to continue to work and obtain their breast cancer treatment concurrent with medical and economic challenges. An additional five articles, while focused on other cancer and employment outcomes, described the need for increased patient-provider communication about the influence of work on treatment decisions and the development of alternative treatment plans. Due to the paucity of research in this area, future policy, practice, and research efforts should focus on the employment context of working poor breast cancer survivors as a potential contributor to cancer disparities. Engagement of women, employers, oncology providers, healthcare systems, and interdisciplinary researchers is warranted to improve cancer outcomes among this disparate population of working women.
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Affiliation(s)
- Robin C Vanderpool
- University of Kentucky College of Public Health, Department of Health Behavior, Lexington, United States
| | | | - Mara D Chambers
- University of Kentucky College of Medicine, Markey Cancer Center, Comprehensive Breast Care Center, Lexington, United States
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Lin PJ, Concannon TW, Greenberg D, Cohen JT, Rossi G, Hille J, Auerbach HR, Fang CH, Nadler ES, Neumann PJ. Does framing of cancer survival affect perceived value of care? A willingness-to-pay survey of US residents. Expert Rev Pharmacoecon Outcomes Res 2014; 13:513-22. [PMID: 23977977 DOI: 10.1586/14737167.2013.814948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS To investigate the relationship between the framing of survival gains and the perceived value of cancer care. METHODS Through a population-based survey of 2040 US adults, respondents were randomized to one of the two sets of hypothetical scenarios, each of which described the survival benefit for a new treatment as either an increase in median survival time (median survival), or an increase in the probability of survival for a given length of time (landmark survival). Each respondent was presented with two randomly selected scenarios with different prognosis and survival improvements, and asked about their willingness to pay (WTP) for the new treatments. RESULTS Predicted WTP increased with survival benefits and respondents' income, regardless of how survival benefits were described. Framing therapeutic benefits as improvements in landmark rather than median time survival increased the proportion of the population willing to pay for that gain by 11-35%, and the mean WTP amount by 42-72% in the scenarios we compared. CONCLUSION How survival benefits are described may influence the value people place on cancer care.
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Affiliation(s)
- Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
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Filson CP, Schwartz K, Colt JS, Ruterbusch J, Linehan WM, Chow WH, Miller DC. Use of nephron-sparing surgery among renal cell carcinoma patients with diabetes and hypertension. Urol Oncol 2014; 32:27.e15-21. [PMID: 23419677 PMCID: PMC3762909 DOI: 10.1016/j.urolonc.2012.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/26/2012] [Accepted: 09/26/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nephron-sparing surgery (NSS) is recommended for patients with renal cell carcinoma (RCC) at risk for chronic kidney disease (CKD). We assessed the prevalence of NSS among RCC patients with pre-existing diabetes or hypertension or both, who participated in a population-based epidemiologic RCC study. MATERIALS AND METHODS Patients with RCC were enrolled in the United States Kidney Cancer Study, a case-control study in the metropolitan areas of Detroit and Chicago from 2002 to 2007. After determining whether patients had diabetes or hypertension or both, we ascertained the proportion of patients from the Detroit site who received NSS. Bivariate and multivariate analyses were performed to evaluate associations between these CKD risk factors and receipt of NSS. RESULTS We identified 835 patients treated with radical nephrectomy (78%) or NSS (22%) from 2002 to 2007. Among this cohort, 60% had pre-existing diabetes or hypertension or both. Patients with both diabetes and hypertension were more than twice as likely to receive NSS (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.47-3.96). Conversely, patients with only hypertension (OR 1.33, 95% CI 0.92-1.93) or diabetes (OR 0.97, 95% CI 0.92-1.93) were no more likely to receive NSS than patients with neither risk factor. CONCLUSIONS The more frequent utilization of NSS among patients with both diabetes and hypertension suggests growing recognition by urologists of the importance of these risk factors for future development of CKD among patients facing surgical therapy for RCC. However, the concurrent observation that patients with only one of these CKD risk factors did not receive increased utilization of NSS highlights an immediate opportunity to improve the surgical treatment of patients with RCC.
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Affiliation(s)
- Christopher P Filson
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Kendra Schwartz
- Karmanos Cancer Institute, Detroit, MI; Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI
| | - Joanne S Colt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | | | | | - Wong-Ho Chow
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - David C Miller
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.
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Katz SJ, Morrow M. Addressing overtreatment in breast cancer: The doctors' dilemma. Cancer 2013; 119:3584-8. [PMID: 23913512 DOI: 10.1002/cncr.28260] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/17/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Steven J Katz
- University of Michigan Health System, Ann Arbor, Michigan
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Momeni A, Ghaly M, Gupta D, Karanas YL, Kahn DM, Gurtner GC, Lee GK. Nipple Reconstruction: Risk Factors and Complications after 189 Procedures. EUROPEAN JOURNAL OF PLASTIC SURGERY 2013; 36:633-638. [PMID: 24072956 DOI: 10.1007/s00238-013-0841-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction. METHODS Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy. RESULTS A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001). CONCLUSION While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center
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Hawley ST, Lillie SE, Morris A, Graff JJ, Hamilton A, Katz SJ. Surgeon-level variation in patients' appraisals of their breast cancer treatment experiences. Ann Surg Oncol 2012; 20:7-14. [PMID: 23054105 DOI: 10.1245/s10434-012-2582-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences. METHODS Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes. RESULTS Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction. CONCLUSIONS Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.
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Affiliation(s)
- Sarah T Hawley
- Division of General Medicine, University of Michigan Health System, Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, MI, USA.
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22
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Decker MR, Greenberg CC. Invited commentary. J Am Coll Surg 2012; 214:276-9. [PMID: 22365505 DOI: 10.1016/j.jamcollsurg.2011.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 12/21/2011] [Indexed: 11/18/2022]
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Politi MC, Studts JL, Hayslip JW. Shared decision making in oncology practice: what do oncologists need to know? Oncologist 2012; 17:91-100. [PMID: 22234632 DOI: 10.1634/theoncologist.2011-0261] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is growing interest by patients, policy makers, and clinicians in shared decision making (SDM) as a means to involve patients in health decisions and translate evidence into clinical practice. However, few clinicians feel optimally trained to implement SDM in practice, and many patients report that they are less involved than they desire to be in their cancer care decisions. SDM might help address the wide practice variation reported for many preference-sensitive decisions by incorporating patient preferences into decision discussions. METHODS This paper provides a perspective on how to incorporate SDM into routine oncology practice to facilitate patient-centered communication and promote effective treatment decisions. Oncology practice is uniquely positioned to lead the adoption of SDM because of the vast number of preference-sensitive decisions in which SDM can enhance the clinical encounter. RESULTS Clinicians can facilitate cancer decision making by: (a) determining the situations in which SDM is critical; (b) acknowledging the decision to a patient; (c) describing the available options, including the risks, benefits, and uncertainty associated with options; (d) eliciting patients' preferences; and (e) agreeing on a plan for the next steps in the decision-making process. CONCLUSION Given recent policy movements toward incorporating SDM and translating evidence into routine clinical practice, oncologists are likely to continue expanding their use of SDM and will have to confront the challenges of incorporating SDM into their clinical workflow. More research is needed to explore ways to overcome these challenges such that both quality evidence and patient preferences are appropriately translated and incorporated into oncology care decisions.
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Affiliation(s)
- Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, CB 8100, St. Louis, Missouri 63110, USA.
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Warren LE, Mendlinger SE, Corso KA, Greenberg CC. A Model of Knowledge Acquisition in Early Stage Breast Cancer Patients. Breast J 2012; 18:69-72. [DOI: 10.1111/j.1524-4741.2011.01183.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Greenberg CC, Lipsitz SR, Hughes ME, Edge SB, Theriault R, Wilson JL, Carter WB, Blayney DW, Niland J, Weeks JC. Institutional variation in the surgical treatment of breast cancer: a study of the NCCN. Ann Surg 2011; 254:339-45. [PMID: 21725233 PMCID: PMC3428030 DOI: 10.1097/sla.0b013e3182263bb0] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer. BACKGROUND Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON. METHODS Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care. RESULTS Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = -0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction. CONCLUSIONS Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.
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MESH Headings
- Academic Medical Centers/supply & distribution
- Adult
- Age Factors
- Aged
- Breast Neoplasms/epidemiology
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/epidemiology
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Combined Modality Therapy
- Female
- Guideline Adherence/statistics & numerical data
- Health Services Accessibility/statistics & numerical data
- Humans
- Mammaplasty/statistics & numerical data
- Mastectomy/statistics & numerical data
- Mastectomy, Segmental/statistics & numerical data
- Middle Aged
- Multivariate Analysis
- Neoplasm Staging
- Patient Care Team/statistics & numerical data
- Practice Patterns, Physicians'
- Radiotherapy, Adjuvant/statistics & numerical data
- Retrospective Studies
- United States
- Utilization Review/statistics & numerical data
- Workforce
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Affiliation(s)
- Caprice C Greenberg
- Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Swainston K, Campbell C, van Wersch A, Durning P. Treatment decision making in breast cancer: a longitudinal exploration of women's experiences. Br J Health Psychol 2011; 17:155-70. [PMID: 22233108 DOI: 10.1111/j.2044-8287.2011.02028.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To explore the lived experience of breast cancer in relation to the treatment decision-making process over time. DESIGN Adopting a hermeneutic phenomenological approach, semi-structured interviews were undertaken at three points in time during the year following diagnosis. METHODS After ethical approval had been obtained, 20 women who were recently diagnosed with breast cancer were recruited from a Symptomatic Breast Cancer Unit in the North East of England. RESULTS Four themes emerged: role in the treatment decision-making process; acceptance of medical opinions; getting rid of it; and cancer schemas. The majority of women reported a passive role in the surgical treatment decision-making process and all women did so in relation to subsequent treatment decisions. However, women adopted this role consciously and consequently were not disengaged from the process but maintained a sense of ownership and control over their health. The women did not describe experiencing decisional regret at any point in the year following diagnosis and rarely revisited the decisions made, only doing so in a positive manner. Trust in the abilities and experience of healthcare professionals and maximizing chances of survival were cited as reasons for not having had greater involvement. Despite being given information about treatment options, many women made the decision not to attend to this information perceiving this to be anxiety provoking. CONCLUSIONS The findings from this study suggest a need for eliciting more specific psycho-social interactions in the treatment decision-making process in order to identify ways in which women can be supported throughout their experience.
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Does it matter where you go for breast surgery?: attending surgeon's influence on variation in receipt of mastectomy for breast cancer. Med Care 2010; 48:892-9. [PMID: 20808256 DOI: 10.1097/mlr.0b013e3181ef97df] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon's influence on the variation in receipt of these procedures. OBJECTIVES To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer. METHODS Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment. RESULTS Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th-95th percentile, 9%-65%) then for mastectomy (median, 18%; 5th-95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%). CONCLUSION Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.
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Hawley ST. Involving patients in the decision-making process regarding breast cancer treatment: implications for surgery utilization. ACTA ACUST UNITED AC 2010; 6:161-4. [PMID: 20187720 DOI: 10.2217/whe.09.87] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer. Med Care 2010; 48:45-51. [PMID: 19956081 DOI: 10.1097/mlr.0b013e3181bd49ca] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions. METHODS We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%). RESULTS Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes. CONCLUSION Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.
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Morrow M, Jagsi R, Alderman AK, Griggs JJ, Hawley ST, Hamilton AS, Graff JJ, Katz SJ. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA 2009; 302:1551-6. [PMID: 19826024 PMCID: PMC4137962 DOI: 10.1001/jama.2009.1450] [Citation(s) in RCA: 254] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Monica Morrow
- Breast Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
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Alderman AK, Hawley ST, Janz NK, Mujahid MS, Morrow M, Hamilton AS, Graff JJ, Katz SJ. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population- based study. J Clin Oncol 2009; 27:5325-30. [PMID: 19805680 DOI: 10.1200/jco.2009.22.2455] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There is concern that minority women have limited access to breast reconstruction. We described patterns of use, experiences with clinicians, and patients' satisfaction with treatment decisions for women of different race/ethnicities. METHODS A total of 3,252 patients with breast cancer from Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries were surveyed near the time of diagnosis (n = 2,260, response rate 72.2%). The primary outcomes were receipt of reconstruction, access to information about reconstruction, and decisional satisfaction. The primary independent variable was race/ethnicity (white, African American [AA], highly acculturated Latina [Latina-high], and less acculturated Latina [Latina-low]). Control variables included other sociodemographic and clinical factors. chi(2) and multivariate logistic regression were used for the analyses. RESULTS Receipt of reconstruction varied significantly by patient race/ethnicity-40.9% of whites, 33.5% of AAs, 41.2% of Latina-high, and only 13.5% of Latina-low (P < .001)-and persisted when we controlled for demographic and clinical factors. Minority women were significantly less likely than whites to see a plastic surgeon before initial surgery and were more likely to desire more information about reconstruction (17.0% of whites v 27.0% of AAs, 30.0% of Latina-high, and 55.9% of Latina-low; P < .001). Decisional satisfaction was lowest among minority women without reconstruction (P < .001). CONCLUSION Minority women, particularly less acculturated Latinas, had low receipt of breast reconstruction, which may be related to limited information about the procedure and less access to plastic surgeons. Greater desire for information and lower satisfaction with surgical decisions among these patients motivate greater attention to treatment support for these patients.
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Affiliation(s)
- Amy K Alderman
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical Center Ann Arbor, MI 48109-0340, USA.
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Hawley ST, Griggs JJ, Hamilton AS, Graff JJ, Janz NK, Morrow M, Jagsi R, Salem B, Katz SJ. Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients. J Natl Cancer Inst 2009; 101:1337-47. [PMID: 19720966 DOI: 10.1093/jnci/djp271] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Few studies have evaluated the association between patient decision involvement and surgery received among racially and ethnically diverse patients or patients' attitudes about surgery and the role of family and friends in surgical treatment choices. METHODS Women diagnosed with nonmetastatic breast cancer from June 2005 through February 2007 and reported to the Los Angeles or Detroit Surveillance, Epidemiology, and End Results registries were mailed a survey after diagnosis (N = 3133). Latina and African American women were oversampled. The response rate was 72.4%. The analytic sample (N = 1651) excluded those with stage IIIA or higher disease, self-reported clinical contraindications to breast-conserving surgery with radiation, and unclear race or ethnicity. The dependent variable was receipt of mastectomy initially. The primary independent variables were patient involvement in decision making, race or ethnicity, attitudes about recurrence, the effects of radiation, the impact of surgery on body image, and the role of others in decision making. Latinas were categorized as low or high acculturated. The association between patient involvement in decision making and the receipt of mastectomy was evaluated using logistic regression while controlling for other independent variables. All statistical tests were two-sided. RESULTS The analytic sample was 23.9% Latina (12.0% low acculturated, 11.9% high acculturated), 27.1% African American, and 48.9% white, and 17.2% received a mastectomy initially. For each racial or ethnic group, more women who reported a patient-based decision received mastectomy than those who reported a shared or surgeon-based decision (P = .022 for low-acculturated Latinas, P < .001 for other groups). Women who reported that concerns about recurrence or radiation effects were very important in their surgery decision were more likely to receive mastectomy than those less concerned (for recurrence concerns, estimated relative risk [RR] = 1.66, 95% confidence interval [CI] = 1.28 to 2.10; for radiation concerns, estimated RR = 2.35, 95% CI = 1.88 to 2.85). Women who reported that body image concerns and their spouse's opinion were very important in their surgery decision less often received mastectomy than those less concerned about body image or who placed less weight on their spouse's opinion (for body image concerns, estimated RR = 0.47, 95% CI = 0.30 to 0.74; for spouse's opinion, estimated RR = 0.53, 95% CI = 0.36 to 0.78). CONCLUSION Greater patient involvement in decision making was associated with receipt of mastectomy for all racial and ethnic groups. Patient attitudes about surgery and the opinions of family and friends contribute to surgical choices made by women with breast cancer.
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Affiliation(s)
- Sarah T Hawley
- Division of General Medicine, Department of Internal Medicine, University of Michigan, 300 N. Ingalls, Ste 7E12, Box 0429, Ann Arbor, MI 48109-0429, USA.
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Lee MC, Rogers K, Griffith K, Diehl KA, Breslin TM, Cimmino VM, Chang AE, Newman LA, Sabel MS. Determinants of breast conservation rates: reasons for mastectomy at a comprehensive cancer center. Breast J 2009; 15:34-40. [PMID: 19141132 DOI: 10.1111/j.1524-4741.2008.00668.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- M Catherine Lee
- Division of Surgical Oncology, The Department of Surgery and the Biostatistics Core of the University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan 48109-0932, USA
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Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res 2008; 43:1366-87. [PMID: 18384361 PMCID: PMC2517271 DOI: 10.1111/j.1475-6773.2008.00843.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah T Hawley
- Division of General Medicine, University of Michigan Health System and Ann Arbor VA Medical Center, 300 N. Ingalls Room 7C27, Ann Arbor, MI, USA.
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McCahill LE, Privette AR, Hart MR, James TA. Are mastectomy rates a reasonable quality measure of breast cancer surgery? Am J Surg 2008; 197:216-21. [PMID: 18614141 DOI: 10.1016/j.amjsurg.2007.12.056] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2007] [Revised: 12/17/2007] [Accepted: 12/19/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Quality measures of breast cancer clinical management adopted by the National Quality Forum do not address the quality of surgical performance. We evaluated mastectomy rate as one potential quality indicator. METHODS We reviewed the surgical management of small (stage T1; < or =2 cm) invasive breast tumors in patients treated from April 2003 through April 2007 at our institution. For patients undergoing mastectomy, factors leading to the selection of mastectomy were analyzed. RESULTS We identified 496 patients with invasive breast cancer: 433 did not undergo neoadjuvant chemotherapy, and 319 of these had pathologic tumors < or =2 cm in size. Of these, 55 (17.2%) underwent initial mastectomy. Medical contraindications to breast conservation were identified in 42 of 319 (13.2%) patients, whereas the selection of mastectomy was attributed to patient choice in 13 of 319 (4.1%) patients. CONCLUSIONS Medical contraindications to breast-conserving therapy were much more common than patient choice as the indication for mastectomy. Institution- or surgeon-specific mastectomy rates are unlikely to reflect the complexity of decision making in the surgical management of patients with breast cancer.
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Waljee JF, Hu ES, Newman LA, Alderman AK. Correlates of patient satisfaction and provider trust after breast-conserving surgery. Cancer 2008; 112:1679-87. [PMID: 18327801 DOI: 10.1002/cncr.23351] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear. METHODS All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n=714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics. RESULTS Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21-0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21-0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14-0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P= .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P= .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers. CONCLUSIONS Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes.
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Affiliation(s)
- Jennifer F Waljee
- Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Miller DC, Saigal CS, Banerjee M, Hanley J, Litwin MS. Diffusion of surgical innovation among patients with kidney cancer. Cancer 2008; 112:1708-17. [PMID: 18330868 DOI: 10.1002/cncr.23372] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite their potential benefits to patients with kidney cancer, the adoption of partial nephrectomy and laparoscopy has been gradual and asymmetric. To clarify whether this trend reflects differences in kidney cancer patients or differences in surgeon practice styles, the authors compared the magnitude of surgeon-attributable variance in the use of partial nephrectomy and laparoscopic radical nephrectomy with that attributable to patient and tumor characteristics. METHODS By using linked Surveillance, Epidemiology, and End Results-Medicare data, the authors identified a cohort of 5483 Medicare beneficiaries who underwent surgery for kidney cancer between 1997 and 2002. Two primary outcomes were defined: 1) the use of partial nephrectomy and (2) the use of laparoscopy among patients undergoing radical nephrectomy. By using multilevel models, surgeon- and patient-level contributions to observed variations in the use of partial nephrectomy and laparoscopic radical nephrectomy were estimated. RESULTS Of the 5483 cases identified, 611 (11.1%) underwent partial nephrectomy (43 performed laparoscopically), and 4872 (88.9%) underwent radical nephrectomy (515 performed laparoscopically). After adjusting for patient demographics, comorbidity, tumor size, and surgeon volume, the surgeon-attributable variance was 18.1% for partial nephrectomy and 37.4% for laparoscopy. For both outcomes, the percentage of total variance attributable to surgeon factors was consistently higher than that attributable to patient characteristics. CONCLUSIONS For many patients with kidney cancer, the surgery provided depends more on their surgeon's practice style than on the characteristics of the patient and his or her disease. Consequently, dismantling barriers to surgeon adoption of partial nephrectomy and laparoscopy is an important step toward improving the quality of care for patients with early-stage kidney cancer.
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Affiliation(s)
- David C Miller
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California 90095-1738, USA
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Iezzoni LI, Ngo LH, Li D, Roetzheim RG, Drews RE, McCarthy EP. Early stage breast cancer treatments for younger Medicare beneficiaries with different disabilities. Health Serv Res 2008; 43:1752-67. [PMID: 18479411 DOI: 10.1111/j.1475-6773.2008.00853.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To explore how underlying disability affects treatments and outcomes of disabled women with breast cancer. DATA SOURCES Surveillance, Epidemiology, and End Results program data, linked with Medicare files and Social Security Administration disability group. STUDY DESIGN Ninety thousand two hundred and forty-three incident cases of early-stage breast cancer under age 65; adjusted relative risks and hazards ratios examined treatments and survival, respectively, for women in four disability groups compared with nondisabled women. PRINCIPAL FINDINGS Demographic characteristics, treatments, and survival varied among four disability groups. Compared with nondisabled women, those with mental disorders and neurological conditions had significantly lower adjusted rates of breast conserving surgery and radiation therapy. Survival outcomes also varied by disability type. CONCLUSIONS Compared with nondisabled women, certain subgroups of women with disabilities are especially likely to experience disparities in care for breast cancer.
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Affiliation(s)
- Lisa I Iezzoni
- Institute for Health Policy, Division of Medicine, Massachusetts General Hospital and Harvard Medical School, 50 Staniford St., Rm 901C, Boston, MA 02114, USA
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Miller DC, Schonlau M, Litwin MS, Lai J, Saigal CS. Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer 2008; 112:511-20. [PMID: 18072263 DOI: 10.1002/cncr.23218] [Citation(s) in RCA: 210] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND To clarify the benefits of nephron-sparing surgery among patients with early-stage kidney cancer, the authors compared the frequency of renal and cardiovascular morbidity after partial or radical nephrectomy. METHODS This retrospective cohort study was based on linked Surveillance, Epidemiology, and End Results-Medicare data. The authors identified 10,886 patients who underwent partial or radical nephrectomy between 1991 and 2002. Medical claims were examined for the occurrence of adverse renal and/or cardiovascular outcomes, and multivariate survival models were fit to estimate the association between type of surgery and each clinical outcome, using propensity scores to balance the treatment cohorts with respect to measured patient and disease characteristics. To control for secular trends in the indications for partial nephrectomy, separate analyses were performed based on treatment era (1991-1999 or 2000-2002). RESULTS During the study interval, 10,123 patients (93%) and 763 patients (7%) underwent radical or partial nephrectomy, respectively. During 2000 to 2002, patients who underwent partial nephrectomy experienced fewer adverse renal outcomes (16.4% vs 21.8%; adjusted hazard ratio, 0.74; 95% confidence interval, 0.58-0.94), including a trend toward less frequent receipt of dialysis services, dialysis access surgery, or renal transplantation. The likelihood of adverse cardiovascular outcomes did not differ by treatment. CONCLUSIONS Among contemporary patients, partial nephrectomy was associated with less clinically apparent renal morbidity than radical nephrectomy. This finding motivates expanded use of partial nephrectomy among patients with early-stage kidney cancer. Given the potential for selection bias and residual confounding in this observational cohort, additional prospective studies will be necessary to validate the current findings.
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Affiliation(s)
- David C Miller
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, California 90095-1738, USA
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Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis. Endoscopy 1979. [PMID: 738222 DOI: 10.1007/s10549-008-0077-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.
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