Variation In Breast Cancer Care Research Articles

Disparities in the Local Management of Breast Cancer in the US according to Health Insurance Status.

Although standard practice guidelines for breast cancer are clear, the interplay between insurance and practice patterns for the US is poorly defined. This study was performed to test for associations between patient insurance status and presentation of breast cancer as well as local therapy patterns in the US, via a large national dataset. We queried the NCI Surveillance, Epidemiology, and End Results data base for breast cancer cases diagnosed from 2007 to 2011 in women aged 18-64 with nonmetastatic ductal/lobular cancers, treated surgically. We tested for associations between insurance status (insured/Medicaid/uninsured) and choice of surgical procedure (mastectomy/breast conserving surgery [BCS]), omission of radiotherapy (RT) following BCS, and administration of post-mastectomy radiation (PMRT). There were 129,565 patients with localized breast cancer analyzed. The health insurance classification included insured (84.5%), Medicaid (11.5%), uninsured (2.1%) and unknown (1.9%). Medicaid or uninsured status was associated with large, node positive tumors, black race, and low income. The BCS rate varied by insurance status: insured (52.2%), uninsured (47.7%), and Medicaid (45.2%), p < 0.001. In multivariable analysis, Medicaid insurance remained significantly associated with receipt of mastectomy (OR [95% CI] = 1.07 [1.03-1.11]), while RT was more frequently omitted after BCS in both Medicaid (OR [95% CI] = 1.14 [1.07-1.21]) and uninsured (OR [95% CI] = 1.29 [1.14-1.47]) patients. Insurance status was associated with significant variations in breast cancer care in the US. Although patient choice cannot be determined from this dataset, departure from standard of care is associated with specific types of insurance coverage. Further investigation into the reasons for these departures is strongly suggested.

Abstract P4-01-13: Practice patterns of MRI utilization for breast cancer treatment within the University of California system as part of the Athena initiative

Abstract Background: The appropriate utilization of Breast MRI in breast cancer care remains controversial. As part of a quality improvement initiative for breast cancer screening and treatment, we sent out a survey to physicians who treat breast cancer patients. All respondents are participants in the ATHENA initiative, a program which unites physicians, researchers, and patients at the five University of California medical centers. Objective: To use the ATHENA infrastructure to perform a qualitative analysis of variations in breast cancer care. Methods: Surveys were sent to 50 physicians in the ATHENA network whose practices are focused on breast cancer. Respondents were presented with clinical scenarios, and asked whether they would recommend MRI always/usually or sometimes/never. Differences were compared by Chi square. Results: 39 physicians completed the survey (78% response rate). Of these physicians 29% were surgeons, 26% radiation oncologists and 45% medical oncologists. Athena physicians were more likely to order MRI for high risk screening of mutation carriers than not (85% yes vs. 15% no, p &amp;lt; 0.003) but not based on breast density alone or previous history of breast cancer. They were also more likely to order it for monitoring neo-adjuvant chemotherapy (70% yes vs. 30% no, p &amp;lt; 0.03). Although the majority answered that they would order a Breast MRI for new breast cancer the difference between responses was not significantly different (56% yes vs. 44%, p = 0.07). Conclusion: Athena physicians follow established published guidelines which demonstrate a benefit for Breast MRI screening for BRCA mutation carriers but not based on density or previous history of breast cancer. The Athena network allows a forum for new practice guidelines to be implemented as data becomes available to improve patient outcomes and utilize the best evidence for patient care, where both the patterns of MRI use as well as the outcomes of practice patterns will be evaluated prospectively. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-13.

Variation in ‘standard care’ for breast cancer across Europe: A EUROCARE-3 high resolution study

On a population-based sample of 13,500 European breast cancer patients mostly diagnosed in 1996–1998 and archived by 26 cancer registries, we used logistic regression to estimate odds of conservative surgery plus radiotherapy (BCS + RT) versus other surgery, in T1N0M0 cases by country, adjusted for age and tumour size. We also examined: BCS + RT in relation to total national expenditure on health (TNEH); chemotherapy use in N+ patients; tamoxifen use in oestrogen-positive patients; and whether ⩾10 nodes were examined in lymphadenectomies. Stage, diagnostic examinations and treatments were obtained from clinical records. T1N0M0 cases were 33.0% of the total. 55.0% of T1N0M0 received BCS + RT, range 9.0% (Estonia) to 78.0% (France). Compared to France, odds of BCS + RT were lower in all other countries, even after adjusting for covariates. Women of 70–99 years had 67% lower odds of BCS + RT than women of 15–39 years. BCS + RT was 20% in low TNEH, 58% in medium TNEH, and 64% in high TNEH countries. Chemotherapy was given to 63.0% of N+ and 90.7% of premenopausal N+ (15–49 years), with marked variation by country, mainly in post-menopause (50–99 years). Hormonal therapy was given to 55.5% of oestrogen-positive cases, 44.6% at 15–49 years and 58.8% at 50–99 years; with marked variation across countries especially in premenopause. The variation in breast cancer care across Europe prior to the development of European guidelines was striking; older women received BCS + RT much less than younger women; and adherence to ‘standard care’ varied even among countries with medium/high TNEH, suggesting sub-optimal resource allocation.

Geographic variation in breast cancer care in Switzerland

Purpose: Regional disparities in breast cancer outcomes have been reported in Switzerland. The purpose of this study is to investigate geographic variation in early diagnosis and management of breast cancer. Methods: We used data from a representative sample of 4820 women diagnosed with invasive breast cancer between January 1, 2003 and December 31, 2005 identified by seven Swiss population based cancer registries. We collected retrospectively detailed information on mode of detection, tumor characteristics and treatments. Differences across geographic regions were tested for statistical significance using chi-square tests and uni- and multivariate logistic regression. Results: Considerable disparities in early detection and management of early breast cancer were found across regions. In particular, the proportion of early detected cancer varied from 43% in Valais to 27% in St. Gallen-Appenzell. Mastectomy rates varied from 24% in Geneva to 38% in St. Gallen-Appenzell and Grisons-Glarus. Higher reconstruction rates were observed in regions with lower rates of mastectomy. The use of sentinel node procedure in patients with nodal negative disease was high in Geneva and low in Eastern Switzerland. Differences in compliance with recommendations on the use of endocrine therapy and chemotherapy were less pronounced but statistically significant. Conclusions: This analysis shows considerable geographic variation in breast cancer care in a health system characterized by high expenditures, universal access to services and high decentralization. Further study into the causes and effects of this variation on short- and long term patient outcomes is needed.

The care of older women with early-stage breast cancer: what is the role of surgeon gender?

Over the past decade and a half, a substantial literature has documented age-dependent variations in breast cancer care. Accumulating evidence suggests that these variations impact the health outcomes of older women with breast cancer. Surgeon gender may be an important source of age-dependent variations in care. To examine the relationship between surgeon gender and primary tumor therapy and systemic adjuvant therapy among 303 older women with early-stage breast cancer cared for by 20 surgeons in Boston, Massachusetts. The research design was a cross-sectional observational study. The subjects were women at least 55 years of age with newly diagnosed Stage I or II breast cancer. The main outcome measure was definitive primary tumor therapy and systemic adjuvant therapy. After adjustment for patient and tumor characteristics, patients of female surgeons were more likely to receive definitive treatment, with the strongest effect being observed for the receipt of both definitive primary tumor therapy and systemic adjuvant therapy (odds ratio 4.5; 95% confidence interval 2.7, 7.7). Women with early-stage breast cancer cared for by female surgeons are more likely to receive standard therapies. Surgeons provide the initial care, both diagnostic and therapeutic, for all women with breast cancer. Their role in breast cancer care is pivotal and has a substantial impact on the nature of breast cancer care received.

Breast Cancer Care in Old Age: Where Do We Go From Here?

Breast cancer is a disease primarily of older women. The cumulative risk for this disease reaches its maximum well into the ninth decade of life (7). It is also a serious disease in older women. The approximate 10-year risk of disease recurrence for women 70 years of age or older who are lymph node negative with 1- to 5-cm tumors is 20%-30%; the risk for women with one to three positive lymph nodes and tumors of any size is 50%; the risk for women with four or more positive lymph nodes and tumors of any size is 80% (2). These risks are especially clinically relevant because recent gains in life expectancy have occurred at the end of life: The average life expectancy of an 85-year-old woman is nearly 6.5 years (3). During the past decade, several studies (4-9) have documented age-related variations in care among patients with early stage breast cancer. These studies were conducted in a variety of health care settings and geographic regions. They have demonstrated age-related differences in diagnostic and prognostic evaluation as well as in initial treatment patterns. As a result of these studies, there has been heightened interest in understanding, in particular, variations in the use of mastectomy versus breast-conserving surgery with or without radiation therapy among older women and the impact of these variations on patient outcomes. In this issue of the Journal, Ballard-Barbash et al. (70) have added to our understanding of age-related variations in breast cancer care through the use of a unique dataset that links Medicare1 claims records with data from nine tumor registries participating in the Surveillance, Epidemiology, and End Results (SEER) Program.2 Studying older women with newly diagnosed early stage disease, these investigators have documented the independent effects of age and comorbidity on the use of breast-conser ving surgery versus mastectomy and on the use of radiation therapy following breast-conserving surgery. Specifically, they found that women aged 80 years or more, those with two or more comorbid conditions, and those with stage I disease were more likely to receive breast-conserving surgery. In contrast, among those receiving breast-conserving surgery, the oldest old (>80 years of age) were much less likely to receive postoperative radiation therapy. In multivariate modeling, both age and comorbidity were independently associated with the receipt of postoperative radiation therapy. The oldest old and those with two or more comorbid conditions were less likely to receive radiation therapy. Particular strengths of this study include the enrollment of a large cohort of patients (n = 18 704) cared for in nine different geographic settings, the careful attention to statistical control for potentially confounding factors, and the use of a validated measure of comorbidity. Nonetheless, the limitations of the data raise questions about the validity and the interpretation of the findings. First, differential ascertainment of comorbidity may have importantly biased the data. A comorbidity score could not be calculated for 15% of the sample. Moreover, the authors note that only 36% of women who underwent breast-conserving surgery without axillary lymph node dissection had a reference hospitalization identified for the purpose of calculating the comorbidity index. Since it is the oldest old who are least likely to undergo axillary lymph node dissection (8), underascertainment of comorbidity in this group may have magnified the independent effect of age on the receipt of treatment. This possibility is supported by the fact that, for example, although there were 1352 women 80 years old or older who underwent breast-conserving surgery, only 220 of the entire sample undergoing breast-conserving surgery had two or more clinically important comorbid conditions. Not only do 80% of persons 65 years old or older have at least one chronic condition, but also the prevalence of chronic diseases increases dramatically with age, and multiple chronic conditions are especially common among older women (/7).