Crossing the quality chasm in breast cancer care.

Abstract

Underuse of systemic adjuvant therapies in early-stage breast cancer care is not news. Although diminishing in magnitude, 1 even at the best of centers, some degree of underuse persists. 2 Although variations in breast cancer care have been documented for decades, particularly in relation to age, linking these variations to outcomes has been a methodologic challenge. Breast cancer is a relatively rare disease; its outcomes, especially among those with early-stage disease, are relatively low frequency and occur most commonly up to 5 to 10 years after diagnosis. In the United States, at least, complete information on disease characteristics and treatments is difficult to collect, given lack of integrated clinical care and information systems. 3 Two recent studies from Canada have overcome many of these methodologic challenges by investigating the impact of adjuvant systemic therapies in women with nodenegative disease cared for in community settings. In the first study, investigators from the British Columbia Cancer Agency report findings from their Breast Cancer Outcomes Database. 4 This database includes high-quality demographic, pathologic, staging, treatment, and outcome data for about three fourths of the women diagnosed with breast cancer in British Columbia. More than 1,100 node-negative women not treated with systemic adjuvant therapies who were diagnosed from 1989 through 1991were stratified according to tumor size ( 1, 1.1 to 2, and 2.1 to 5 cm) and observed for a median of 10.4 years. Within these tumor size strata, 10-year survival rates for node-negative women were 82%, 75%, and 66%, and overall survival rates were 79%, 78%, and 66%, respectively. Survival was independently associated with tumor size and grade. 4