Underutilization of breast-conserving therapy in a predominantly rural population: need for improved surgeon and public education

Decision-Making in Breast Cancer Surgery: Where Do Patients Go for Information?

Patient decision-making regarding breast cancer surgery is multifactorial, and patients derive information on surgical treatment options from a variety of sources which may have an impact on choice of surgery. We investigated the role of different information sources in patient decision-making regarding breast cancer surgery. Two hundred and sixty-eight patients with breast cancer, eligible for breast-conserving therapy were surveyed in the immediate preoperative period, and clinical data were also collected. This survey evaluated the scope and features of patient-driven research regarding their ultimate choice of surgical treatment. The two most common sources of information used by patients were written material from surgeons (199/268–74%) and the Internet (184/268–69%). There was a trend for women who chose bilateral mastectomy to use the Internet more frequently than those choosing unilateral mastectomy ( P = 0.056). Number of surgeons consulted, genetic testing, and MRI were significant predictors of patient choice of mastectomy over breast-conserving therapy. Multivariate analysis showed that the number of surgeons consulted ( P < 0.001) and genetic testing ( P < 0.001) were independent predictors of choosing mastectomy, whereas MRI was not. In conclusions, understanding factors driving patient decision-making may promote more effective education for patients requiring breast cancer surgery.

Patterns of care with regard to surgical choice and application of adjuvant radiation therapy for preinvasive and early stage breast cancer in rural Appalachia

BACKGROUND

Many disparities exist in treatment of early stage breast cancer. Our objective was to conduct a cross-sectional registry analysis of women with early stage breast cancer in Appalachian Kentucky to identify factors affecting surgical choice [breast conserving surgery (BCS) vs mastectomy] and appropriate use of adjuvant radiation therapy (RT).

METHODS

Database collection was done through the Kentucky Cancer Registry. Inclusion criteria included female breast cancer patients diagnosed between 1998 and 2007. Patients were diagnosed with ductal carcinoma in situ or American Joint Committee on Cancer stage I or II disease. Database search was limited to Appalachian residents. Statistical analyses were carried out to identify variables affecting surgical choice, receipt of RT, and survival.

RESULTS

Analysis evaluated 5,541 Appalachian patients. The distribution of surgery favored BCS (54.1%) over mastectomy (45.9%). On multivariate analysis, the most significant factors for mastectomy were advanced stage [odds ratio (OR) 2.571, P<0.0001], rural location (OR 2.075, P<0.0001), and insurance status (OR 1.546, P<0.0001). Of patients choosing BCS, 56.2% received adjuvant RT. On multivariate analysis age >70 years (OR 2.506, P<0.0001), rural location (OR 2.416, P<0.0001), and lack of insurance (OR 1.651, P=0.0168) were the strongest predictors for not receiving adjuvant RT.

CONCLUSIONS

Mastectomy rate remains higher and the rate of RT after BCS is lower in Appalachian women compared with other contemporary studies of women with ductal carcinoma in situ and early stage breast cancer.

Effect of community population size on breast cancer screening, stage distribution, treatment use and outcomes

OBJECTIVE

Residents of rural communities have decreased access to cancer screening and treatments compared to urban residents, though use of resources and patient outcomes have not been assessed with a comprehensive population-based analysis. The objectives of this study were to investigate whether breast cancer screening and treatments were utilized less frequently in rural BC and whether this translated into differences in outcomes.

METHODS

All patients diagnosed with breast cancer in British Columbia (BC) during 2002 were identified from the Cancer Registry and linked to the Screening Mammography database. Patient demographics, pathology, stage, treatments, mammography use and death data were abstracted. Patients were categorized as residing in large, small and rural local health authorities (LHAs) using Canadian census information. Use of resources and outcomes were compared across these LHA size categories. We hypothesized that mastectomy rates (instead of breast-conserving surgery) would be higher in rural areas, since breast conservation is standardly accompanied by adjuvant radiotherapy, which has limited availability in rural BC. In contrast we hypothesized that cancer screening and systemic therapy use would be similar, as they are more widely dispersed across BC. Exploratory analyses were performed to assess whether disparities in screening and treatment utilization translated into differences in survival.

RESULTS

2,869 breast cancer patients were included in our study. Patients from rural communities presented with more advanced disease (p=0.01). On multivariable analysis, patients from rural, compared to urban, LHAs were less likely to be screening mammography attendees (OR=0.62; p<0.001). Women from rural communities were less likely to undergo breast-conserving surgery (multivariable OR=0.47; p<0.001). There was no significant difference in use of chemotherapy (p=0.54) or hormonal therapy (p=0.36). The 5-year breast cancer-specific survival for large, small and rural LHAs was 90%, 88% and 86%, respectively (p=0.08), while overall survival was 84%, 81% and 77%, respectively (p=0.01). On multivariable analysis with 7.4 years of median follow-up, neither breast cancer-specific survival (HR=1.16; 0.76-1.76; p=0.49) nor overall survival (HR=1.25; 0.92-1.70; p=0.16) was significantly worse for patients from rural compared to large LHAs.

CONCLUSION

There was a significant difference in screening mammography use, stage distribution and loco-regional treatments use by population size of LHA. After controlling for differences in patient and tumour factors by LHA, survival was not significantly different.

Theory-based design and field-testing of an intervention to support women choosing surgery for breast cancer: BresDex

OBJECTIVE

Design and undertake usability and field-testing evaluation of a theory-guided decision aid (BresDex) in supporting women choosing surgery for early breast cancer.

METHODS

An extended Theory of Planned Behavior (TPB) and the Common Sense Model of Illness Representations (CSM) guided the design of BresDex. BresDex was evaluated and refined across 3 cycles by interviewing 6 women without personal history of breast cancer, 8 women with personal history of breast cancer who had completed treatment and 11 women newly diagnosed with breast cancer. Participants were interviewed for views on content, presentation (usability) and perceived usefulness towards deciding on treatment (utility). Framework analysis was used, guided by the extended TPB and the CSM.

RESULTS

BresDex was positively received in content and presentation (usability). It appeared an effective support to decision-making and useful source for further information, particularly in clarifying attitudes, social norms and perceived behavioral control, and presenting consequences of decisions (utility).

CONCLUSION

This study illustrates the potential benefit of the extended TPB and CSM in designing a decision aid to support women choosing breast cancer surgery.

PRACTICE IMPLICATIONS

BresDex could provide decision-making support and serve as an additional source of information, to complement the care received from the clinical team.

Sequelae of breast cancer and the influence of menopausal status at diagnosis among rural breast cancer survivors

BACKGROUND

Rural women are among the largest medically underserved groups in the nation, yet few studies have evaluated the sequelae of breast cancer in this population. The purpose of this study was to examine the physical and psychosocial effects of breast cancer experienced by rural survivors at the time of treatment and currently and to examine differences in these effects between younger and older rural survivors based on menopausal status at diagnosis.

METHODS

Women treated for breast cancer within the past 6 years at one of three rural cancer centers were mailed a survey with a cover letter from their oncology provider.

RESULTS

Survey respondents (n=918, 83% response rate) were 67±13 years old, on average 3.2 years from treatment, 22% were premenopausal at the time of breast cancer diagnosis, and 95% were postmenopausal at the time of the survey. Women who were premenopausal at diagnosis were significantly more likely to experience numerous symptoms at the time of treatment and currently, including higher rates of hot flashes, vaginal dryness, loss of sexual desire, and weight gain (p≤0.001). The most common psychosocial concerns were fear of recurrence and change in body image, and women premenopausal at diagnosis were significantly more likely than postmenopausal women to report experiencing these concerns (68% vs. 47%, and 43% vs. 27%, respectively, p≤0.001).

CONCLUSIONS

Negative physical and psychosocial sequelae of breast cancer were common in this rural sample and were significantly worse for premenopausal women. Research and resources are needed for delivering targeted survivorship care to rural women, particularly younger rural women.

Preoperative chemotherapy for operable breast cancer is associated with better compliance with adjuvant therapy in matched stage II and IIIA patients

INTRODUCTION

Preoperative chemotherapy (PC) for operable breast cancer has shown significant benefits in prospective trials. Many patients are treated in the community setting and some may question the applicability of PC outside the university setting.

METHODS

Retrospective review was performed of stage II and IIIA breast cancer patients treated from January 2002 to July 2009. Fifty-three of 57 patients who underwent PC were matched based on age, tumor size, and hormone receptor status with 53 patients who did not undergo PC. Differences in patient compliance with physician recommendations for all types of adjuvant therapy were evaluated. Crude odds ratios and adjusted odds ratios derived from conditional logistic regression models were calculated.

RESULTS

There were 106 patients included. Patient compliance with chemotherapy was better in the PC group than in the adjuvant chemotherapy (AC) group (100% versus 70%; p = .0001). Similarly, more patients in the PC group completed radiation therapy (96% versus 65%; p = .0003) and initiated hormonal therapy (100% versus 62%; p = .0001). Conditional logistic regression revealed that higher pathologic stage and current cigarette smoking were associated with poorer compliance with chemotherapy. For radiation therapy, the univariate model revealed that compliance with chemotherapy and being employed were associated with completion of radiation, whereas current cigarette smoking and larger pathologic size were associated with poorer compliance with radiation. For hormonal therapy, current cigarette smokers were more likely to be noncompliant with initiation of hormonal therapy.

CONCLUSIONS

PC for operable breast cancer can improve patient compliance with chemotherapy. Current cigarette smokers were more likely to be noncompliant with all types of adjuvant therapy.

Understanding surgery choices for breast cancer: how might the Theory of Planned Behaviour and the Common Sense Model contribute to decision support interventions?

OBJECTIVE

To describe the evidence about factors influencing breast cancer patients' surgery choices and the implications for designing decision support in reference to an extended Theory of Planned Behaviour (TPB) and the Common Sense Model of Illness Representations (CSM).

BACKGROUND

A wide range of factors are known to influence the surgery choices of women diagnosed with early breast cancer facing the choice of mastectomy or breast conservation surgery with radiotherapy. However, research does not always reflect the complexities of decision making and is often atheoretical. A theoretical approach, as provided by the CSM and the TPB, could help to identify and tailor support by focusing on patients' representations of their breast cancer and predicting surgery choices.

DESIGN

Literature search and narrative synthesis of data.

SYNTHESIS

Twenty-six studies reported women's surgery choices to be influenced by perceived clinical outcomes of surgery, appearance and body image, treatment concerns, involvement in decision making and preferences of clinicians. These factors can be mapped onto the key constructs of both the TPB and CSM and used to inform the design and development of decision support interventions to ensure accurate information is provided in areas most important to patients.

CONCLUSIONS

The TPB and CSM have the potential to inform the design of decision support for breast cancer patients, with accurate and clear information that avoids leading patients to make decisions they may come to regret. Further research is needed examining how the components of the extended TPB and CSM account for patients' surgery choices.

Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States

BACKGROUND

Breast-conserving surgery (BCS) followed by radiotherapy is as effective as mastectomy for treatment of early invasive breast cancer. But earlier studies report low BCS use rates of 12% to 43% nationally, especially in older patients. We sought to determine current patterns and predictors of BCS use.

STUDY DESIGN

In a national Medicare database of all beneficiaries (age greater than 65 years) with incident invasive breast cancer treated with operation in 2003, claims codes identified BCS versus mastectomy and demographic, treatment, and geographic region covariates. The 2003 Area Resource File provided socioeconomic covariates. Logistic regression modeled predictors of BCS.

RESULTS

In 56,725 women, 59% were treated with BCS versus 41% with mastectomy. BCS was more likely in women who were younger than 70 years (odds ratio [OR], 1.37; 95% CI, 1.31 to 1.44; p < 0.001) and had lymph node-negative disease (OR, 1.60; 95% CI, 1.52 to 1.68; p < 0.001). Socioeconomic factors influenced use, with BCS more likely in areas with low poverty (OR, 1.05; 95% CI, 1.00 to 1.09; p = 0.03), high education (OR, 1.13; 95% CI, 1.08 to 1.19), high density of radiation oncologists (OR, 1.30; 95% CI, 1.06 to 1.59), and in metropolitan areas (OR, 1.20; 95% CI, 1.14 to 1.26). Significant geographic variation existed: 70% of women were treated with BCS in northeastern New England compared with only 48% to 50% in the South (p < 0.001).

CONCLUSIONS

Currently, more than half of older women across the US diagnosed with nonmetastatic invasive breast cancer treated surgically receive BCS, representing a substantial increased use compared with historical data. Lack of BCS use appears in part associated with socioeconomic disadvantage, suggesting that persistent barriers to breast conservation exist.

The breast cancer experience of rural women: a literature review

This report is a review of studies that focus on rural breast cancer survivorship. It includes a total of 14 studies using large databases and 27 other studies using qualitative and quantitative methods. In our review of this literature, we identified four broad themes, including access to treatment and treatment type, medical providers and health information, psychosocial adjustment and coping, and social support and psychological support services. We review the findings of the rural breast cancer survivorship studies within each of these broad themes. A few of the findings of the review include that rural and urban women receive different primary treatments for breast cancer, that rural women may have greater difficulty negotiating their traditional gender roles during and after treatment, that rural women desire greater health-related information about their breast cancer, and that rural women have less access to mental health therapy. The review discusses the implications of these findings as well as the weakness in the literature.

An approach to measuring the quality of breast cancer decisions

OBJECTIVE

To explore an approach to measuring the quality of decisions made in the treatment of early stage breast cancer, focusing on patients' decision-specific knowledge and the concordance between patients' stated preferences for treatment outcomes and treatment received.

METHODS

Candidate knowledge and value items were identified after an extensive review of the published literature as well as reports on 27 focus groups and 46 individual interviews with breast cancer survivors. Items were subjected to cognitive interviews with six additional patients. A preliminary decision quality measure consisting of five knowledge items and four value items was pilot tested with 35 breast cancer survivors who also completed the control preferences scale and the decisional conflict scale (DCS).

RESULTS

Preference for control and knowledge did not vary by treatment. The mean of the participants' knowledge scores was 54%. There was no correlation between the knowledge scores and the informed subscale of the DCS (Pearson r = .152, n = 32, p = 0.408). Patients who preferred to keep their breast were over five times as likely to have breast-conserving surgery than those who did not (OR 5.33, 95% CI (1.2, 24.5), p = 0.06). Patients who wanted to avoid radiation were six times as likely to choose mastectomy than those who did not (OR 6.4, 95% CI (1.34, 30.61), p = 0.04).

CONCLUSION

Measuring decision quality by assessing patients' decision-specific knowledge and concordance between their values and treatment received, is feasible and important. Further work is necessary to overcome the methodological challenges identified in this pilot work.

PRACTICE IMPLICATIONS

Guidelines for early stage breast cancer emphasize the importance of including patients' preferences in decisions about treatment. The ability of doctors and patients to make decisions that reflect the considered preferences of well-informed patients can and should be measured.

Versorgungsforschung in der operativen Medizin am Beispiel der Mammakarzinomchirurgie

The epidemiological relevance of breast cancer in Germany has led to a number of initiatives actually changing the processes and structures of care. The ultimate aim of health services research in surgery is to evaluate the impact of these initiatives on the effectiveness and efficiency of the respective health care services. Results of international studies show for instance breast-conserving therapy to be related to the patients' socioeconomic status. In addition, breast specialists tend to operate more in adherence to practice guidelines and to implement new procedures like sentinel lymph node biopsies earlier. Preliminary results from Germany also demonstrate a considerable practice variation in breast cancer surgery. Causes and effects of such variation still have to be explored. For that purpose, newly available data sources on health care services in relation to breast cancer surgery in Germany could be used. The inherent challenge is to combine data from tumour registries, statutory comparative quality assurance activities and inpatient remuneration via DRGs for health services research in surgery.

Patient involvement in surgery treatment decisions for breast cancer

PURPOSE

High rates of mastectomy and marked regional variations have motivated lingering concerns about overtreatment and failure to involve women in treatment decisions. We examined the relationship between patient involvement in decision making and type of surgical treatment for women with breast cancer.

METHODS

All women with ductal carcinoma-in-situ and a 20% random sample of women with invasive breast cancer aged 79 years and younger who were diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries were identified and surveyed shortly after receipt of surgical treatment (response rate, 77.4%; n = 1,844).

RESULTS

Mean age was 60.1 years; 70.2% of the women were white, 18.0% were African American, and 11.8% were from other ethnic groups. Overall, 30.2% of women received mastectomy as initial treatment. Most women reported that they made the surgical decision (41.0%) or that the decision was shared (37.1%); 21.9% of patients reported that their surgeon made the decision with or without their input. Among white women, only 5.3% of patients whose surgeon made the decision received mastectomy compared with 16.8% of women who shared the decision and 27.0% of women who made the decision (P < .001, adjusted for clinical factors, predisposing factors, and number of surgeons visited). However, this association was not observed for African American women (Wald test 10.0, P = .041).

CONCLUSION

Most women reported that they made or shared the decision about surgical treatment. More patient involvement in decision making was associated with greater use of mastectomy. Racial differences in the association of involvement with receipt of treatment suggest that the decision-making process varies by racial groups.

Biologic comparison of partial breast irradiation protocols

PURPOSE

To analyze the dose/fractionation schedules currently used in ongoing clinical trials of partial breast irradiation (PBI) by comparing their biologically effective dose (BED) values to those of three standard whole breast protocols commonly used after segmental mastectomy in the treatment of breast cancer.

METHODS AND MATERIALS

The BED equation derived from the linear-quadratic model for radiation-induced cell killing was used to calculate the BEDs for three commonly used whole breast radiotherapy regimens, in addition to a variety of external beam radiotherapy, as well as high-dose-rate and low-dose-rate brachytherapy, PBI protocols.

RESULTS

The BED values of most PBI protocols resulted in tumor control BEDs roughly equivalent to a 50-Gy standard treatment, but consistently lower than the BEDs for regimens in which the tumor bed receives a total dose of either 60 Gy or 66 Gy. The BED values calculated for the acute radiation responses of erythema and desquamation were nearly all lower for the PBI schedules, and the late-response BEDs for most PBI regimens were in a similar range to the BEDs for the standard treatments.

CONCLUSION

Biologically effective dose modeling raises the concern that inadequate doses might be delivered by PBI to ensure optimal in-field tumor control.

A consultation with Canadian rural women with breast cancer

OBJECTIVE

Relatively little research has been carried out on the health and supportive care needs of rural women living with breast cancer. In this study, results from a Canadian focus group study are used to highlight issues of importance to rural women.

SETTING AND PARTICIPANTS

A total of 276 rural women with breast cancer divided into 17 focus groups participated in the study conducted across Canada. A standardized protocol for discussion was employed. Issues of access to information, support and services were discussed, with women describing their experiences in trying to find appropriate programmes and services.

MAIN RESULTS

The major theme identified through analysis of qualitative data was 'becoming aware of and/or gaining access to health care information, support and services.' Other major themes included: (1) dealing with isolation; (2) having to travel; (3) feeling the financial burden and (4) coping with changing work.

CONCLUSIONS

Rural women with breast cancer have supportive care challenges related to their circumstances. A series of recommendations were generated through the consultation process which are contributing to the development of a national strategy focusing on the development and extension of programmes for rural women with breast cancer. Although the research on the project was not to specified standards, and suffered from less attention than community capacity building and advocacy, it proved to be of worth and revealed potential benefits from collaborations between researchers and community organizations.

Novel approaches to postoperative radiation therapy as part of breast-conserving therapy for early-stage breast cancer

Breast-conserving therapy (BCT) consists of segmental mastectomy followed by postoperative radiation therapy (RT) to the whole breast. At least 6 prospective randomized trials have proven the equivalence of BCT to mastectomy. However, BCT remains underused and, most importantly, a sizable proportion of patients with invasive breast cancer fail to complete the recommended protocol of breast preservation by omitting postoperative RT. The inconvenience of complying with the standard 6-week radiation regimen, which includes approximately 30 daily visits, at least partially explains this lack of adherence. New clinical studies have generated preliminary evidence that more convenient, shorter radiation regimens might reveal equivalence to the current standard. Moreover, the availability of modern technology to deliver and target ionizing radiation by improving homogeneity of radiation dose has made it possible to safely explore the use of greater radiation doses per fraction. Finally, currently ongoing research trials will enable the identification of specific subsets of patients who are likely to be safely treated by partial-breast radiation (instead of radiation to the whole breast) with more accelerated regimens. This article reviews the available data and the current ongoing research on novel RT techniques and fractionation schedules in BCT for early-stage breast cancer.

Advances in Radiation Treatments of Breast Cancer

During the past decade, improvements in treatment-planning tools, computer and imaging technologies, and new therapeutic modalities have allowed radiation to be delivered in a conformal fashion while minimizing treatment toxicity. It is important that physicians involved in breast cancer treatment recognize the numerous advances that have occurred in the delivery of radiation therapy. Changes in 3 specific areas in treatment planning and delivery have revolutionized the way we approach breast cancer treatment: the design of radiation fields using computed tomography (CT) data sets, the development of 3-dimensional dose-calculation algorithms, and the development of new methods to modulate the delivery of radiation dose. With the advent of CT simulators, individual patient anatomy and pathology can be readily visualized and reconstructed in axial, coronal, and sagittal views. With an improved anatomic delineation between the target volumes and critical organ structures, the treatment fields can be designed to be more congruous to the areas at highest risk. In the past few years, new 3-dimensional dose-calculation algorithms have been generated that more accurately calculate dose distributions throughout the treatment-planning volume. Finally, modern linear accelerators allow for modulation of the dose intensity of the radiation beam, which may lead to improved aesthetics and decreased side effects while ensuring that the volumes at high risk receive the prescribed dose. Radiation therapy can be delivered safely and effectively to patients with breast cancer.