Variation in use of breast surgery and characteristics of hospitals' surgical staff

Variability of breast surgery in women participating in breast cancer screening programs

INTRODUCTION

Currently, variability in surgical practice is a problem to be solved. The aim of this study is to describe the variability in the surgical treatment of breast cancer and to analyze the factors associated with it.

METHODS

The study population included 1057 women diagnosed with breast cancer and surgically treated. Our data were from the CaMISS retrospective cohort.

RESULTS

The mean age at diagnosis was 59.3 ± 5 years. A total of 732 patients were diagnosed through screening mammograms and 325 patients as interval cancers. The mastectomy surgery was more frequent in the tumors detected between intervals (OR=2.5; [95%CI: 1.8-3.4]), although this effect disappeared when we adjusted for the rest of the variables. The most important factor associated with performing a mastectomy was TNM: tumors in stage III-IV had an OR of 7.4 [95%CI: 3.9-13.8], increasing in adjusted OR to 21.7 [95%CI: 11.4-41.8]. Histologically, infiltrating lobular carcinoma maintains significance in adjusted OR (OR=2.5; [95%CI: 1.4-4.7]). According to the screening program, there were significant differences in surgical treatment. Program 3 presented an OR of non-conservative surgery of 4.0 [95%CI: 1.8-8.9]. This program coincided with the highest percentage of reconstruction (58.3%).

CONCLUSIONS

This study shows that, despite taking into account patient and tumor characteristics, there is great variability in the type of surgery depending on the place of diagnosis.

Non Clinical Factors as Determinants of the Use of Breast Conservative Surgery in Italy

The aims of the study were to evaluate the trend of breast conservative surgery (BCS) in Italian breast cancer patients and to identify its nonclinical determinants. Data of 2062 patients surgically treated patients for primary breast cancer were evaluated; 788 (38.0%) had been submitted to breast conservative surgery. A different percentage of breast conservative surgery was found with respect to geographic patient's residence (North, 41.1%; Central, 37.6%; South, 33.0%). Multifactorial analysis showed that time since diagnosis, age at diagnosis and nonclinical factors, such as geographic area of residence and level of education, were significantly associated with breast conservative surgery.

Impact of Preexisting Mental Illnesses on Receipt of Guideline-Consistent Breast Cancer Treatment and Health Care Utilization

This study determined the impact of preexisting mental illnesses on guideline-consistent breast cancer treatment and breast cancer-related health care utilization. This was a retrospective, longitudinal, cohort study conducted using data from the 2006-2008 Medicaid Analytic Extract files. The target population for the study consisted of female Medicaid enrollees who were aged 18-64 years and were newly diagnosed with breast cancer in 2007. Guideline-consistent breast cancer treatment was defined according to established guidelines. Breast cancer-related health care use was reported in the form of inpatient, outpatient, and emergency room visits. Statistical analyses consisted of multivariable hierarchical regression models. A total of 2142 newly diagnosed cases of breast cancer were identified. Approximately 38% of these had a preexisting mental illness. Individuals with any preexisting mental illness were less likely to receive guideline-consistent breast cancer treatment compared to those without any preexisting mental illness (adjusted odds ratio: 0.793, 95% confidence interval [CI]: 0.646-0.973). A negative association was observed between preexisting mental illness and breast cancer-related outpatient (adjusted incident rate ratio (AIRR): 0.917, 95% CI: 0.892-0.942) and emergency room utilization (AIRR: 0.842, 95% CI: 0.709-0.999). The association between preexisting mental illnesses and breast cancer-related inpatient utilization was statistically insignificant (AIRR: 0.993, 95% CI: 0.851-1.159). The findings of this study indicate that breast cancer patients with preexisting mental illnesses experience disparities in terms of receipt of guideline-consistent breast cancer treatment and health care utilization. The results of this study highlight the need for more focused care for patients with preexisting mental illness.

Interactive digital education aid in breast reconstruction

BACKGROUND

An interactive digital education aid for breast reconstruction patients was developed because of a perceived need to provide patients with more education regarding the treatment so that they can make better informed treatment decisions. A prospective randomized study was conducted to assess its effectiveness.

METHODS

Breast cancer patients who were candidates for breast reconstruction were recruited and randomized into a control group and a study group. Both groups received routine assessment and education in the plastic surgery clinic, but the study group also watched the interactive digital education aid. Questionnaires assessing knowledge, anxiety, and satisfaction were administered (1) before the initial plastic surgery consultation, (2) immediately before surgery, and (3) 1 month after surgery.

RESULTS

A total of 133 women participated, 66 in the control group and 67 in the study group. Women in both groups showed decreased anxiety, increased knowledge, and enhanced satisfaction with their decision-making ability associated with preoperative instructions about reconstructive surgery. However, the study group was significantly more satisfied than the control group with the method of receiving information and showed a less steep learning curve regarding the different techniques of breast reconstruction. They also tended to have a reduced mean level of anxiety and increased satisfaction with the treatment choice compared with the control group.

CONCLUSIONS

An interactive digital education aid is a beneficial educational adjunct for patients contemplating breast reconstruction. Patients who use an interactive digital education aid demonstrate greater factual knowledge, reduced anxiety, and increased postoperative satisfaction compared with patients given preoperative instructions using standard methods alone. The benefit of an interactive digital education aid is expected to be higher in a broad-based practice setting outside of a comprehensive cancer center.

The Influence of Gender of the Surgeon on Surgical Procedure Preference for Breast Cancer

There are few data in the literature with regard to the influence of surgeon gender and the treatment of breast cancer. In this retrospective review we propose to test the hypothesis that male surgeons are just as likely as female surgeons to provide breast-conservative treatment. From 1990 through 1997 2271 women with breast cancer in Cincinnati, Ohio were operated on by surgeons within the TriHealth Corporation. We compared the performance rate of breast conservation therapy (BCT) with the rate of mastectomy in early-stage breast cancer patients between male and female surgeons. Male surgeons were significantly more likely to provide their patients with breast-conserving treatment than their female colleagues for stages 0 and IIb ( P < 0.05). Although male surgeons performed more BCT than female surgeons for stages I and IIa the difference was not statistically significant. For the three stages combined there was a 30 per cent greater chance of a patient receiving breast-conserving treatment if she went to a male surgeon ( P < 0.05). We conclude that in our institution male surgeons are no more likely to select mastectomy than their female colleagues and there appears to be an increased use of BCT by male surgeons.

Influences on oncologists' adoption of new agents in adjuvant chemotherapy of breast cancer

PURPOSE

Little is known about how oncologists' adopt new treatments for breast cancer. This study investigated influences on oncologists' adoption of paclitaxel as adjuvant chemotherapy for early-stage breast cancer, 9 months after presentation of phase III data suggesting improved disease-free and overall survival when paclitaxel was added to doxorubicin and cyclophosphamide for such patients.

METHODS

Self-reported data were collected with a mail survey of a random sample of 1,200 oncologists practicing in the United States. Using Rogers' model, we measured four types of influences on adoption of innovation: (1) communication channels, (2) innovation characteristics, (3) a practitioner's social system, and (4) physician characteristics. Multiple regression analysis assessed the associations between oncologist adoption of paclitaxel for early-stage breast cancer patients and variables representing the modeled influences on adoption.

RESULTS

On average, respondents (n = 181) reported having adopted paclitaxel for 37% of their early-stage breast cancer patients. The overall model was significant, with seven variables associated (P < or = .05) with adoption of paclitaxel. Significant influences on adoption included use of symposia as a therapy information source, physician experience with paclitaxel to treat late-stage breast cancer, and perceived advantage in efficacy of paclitaxel.

CONCLUSION

As new modalities become available to treat cancer, it is vital to understand what factors influence oncologists and patients when choosing to use them. Those parties interested in fostering the adoption of new breast cancer treatments should address features of communication channels (eg, use of symposia), characteristics of new treatments (eg, perceived advantage in efficacy), physicians' social systems (eg, patient requests), and characteristics of potential adopters (eg, previous experience with the treatment).

[Variation in medical practice. Apropos of the use of CAT and NMR in INSALUD]

OBJECTIVE

In this study the variability on the utilization of nuclear magnetic resonance (NMR) and computerized tomography (CT) scan among hospitals and provinces in the INSALUD (Spanish National Health System) is evaluated as well as the role of the availability of resources in the variability.

METHOD

Data on availability of resources, its use and the reference population for each hospital were obtained from the Specialized Care Information System (SIAE) for the years 1996-1997. The units of analysis were the hospitals and the provinces in the INSALUD territory. The independent variables were the ratio of technologies and professional per inhabitant. Also the waiting list and the economical level of the province were used. Data analysis included the extremal quotient and multiple linear regression.

RESULTS

The ratio of the highest to lowest rate of CT and NMR use is 15 and 27 among hospitals and 3 and 4 among provinces, respectively. The number of neurosurgeons, number of CT apparatus, waiting list for CT and rate of NMR use, all standardized per population, explains 61% of CT variability among hospitals. Among provinces, the number of CT apparatus explains 31% of all variability. For NMR use among hospitals, the number of neurosurgeons, number of orthopedic surgeons and CT use, all variables standardized per population, explains 42% of variability. The amount of equipment is not associated with NMR rate among provinces.

CONCLUSIONS

The variation found in the INSALUD territory for the two procedures is high and ecologically associated to the availability of resources. It would be convenient to perform an observational study to confirm the findings and evaluate the possible contribution of inappropriate use to the variation.

Lessons learned from the Decision Board: a unique and evolving decision aid

One session of the conference was devoted to the presentation of different types of decision aids. This paper reports the experience and lessons learned through the development and use of the Decision Board. This is a uniquely interactive decision aid administered by the clinician during the medical consultation. The instrument has been developed in a number of clinical contexts, primarily regarding treatment options for cancer patients. Studies have shown the instrument to improve patient understanding and facilitate the shared decision-making process. Randomized trials are ongoing, evaluating the addition of the Decision Board to the traditional medical consultation. The instrument continues to evolve to meet patients' need for information and flexibility in presentation. Computer-based versions of the Decision Board are currently being developed.

Mastectomy or lumpectomy? Helping women make informed choices

PURPOSE

To develop an instrument to help clinicians inform their patients about surgical treatment options for the treatment of breast cancer and to evaluate the impact of the instrument on the clinical encounter.

METHODS

We developed an instrument, called the Decision Board, to present information regarding the benefits and risks of breast-conserving therapy (lumpectomy plus radiation therapy) and mastectomy to women with early-stage breast cancer to enable them to express a preference for the type of surgery. Seven surgeons from different communities in Ontario administered the instrument to women with newly diagnosed clinical stage I or II breast cancer over an 18-month period. Patients and surgeons were interviewed regarding acceptability of the instrument. The rates of breast-conserving surgery performed by surgeons before and after the introduction of the instrument were compared.

RESULTS

The Decision Board was administered to 175 patients; 98% reported that the Decision Board was easy to understand, and 81% indicated that it helped them make a decision. The average score on a true/false test of comprehension was 11.8 of 14 (84%) (range, 6 to 14). Surgeons found the Decision Board to be helpful in presenting information to patients in 91% of consultations. The rate of breast-conserving surgery decreased when the Decision Board was introduced (88% v 73%, P =.001)

CONCLUSION

The Decision Board is a simple method to improve communication and facilitate shared decision making. It was well accepted by patients and surgeons and easily applied in the community.

Italian forum of Europa Donna: a survey of breast cancer associations

Europa Donna is the first European woman's movement against breast cancer. It is a coalition of breast cancer associations and individual women and is active in 20 nations. Europa Donna is not intended to replace existing organizations. Rather, it provides a focus for the exchange of information and experiences between members and serves as a moving force for combined action. It promotes public awareness of breast cancer, advances in research and good clinical practice. In Italy there are more than 200 active breast cancer associations. The Italian forum of Europa Donna was formed in 1996. Between June and September 1996 a postal survey was conducted to research the characteristics and activities of the various breast cancer associations in Italy in order to help, inform and promote future initiatives of the Italian forum of Europa Donna. A total of 213 breast cancer associations were sent a postal questionnaire. Ninety-five of them (44.6%) participated in the survey. The results show that the breast cancer associations in Italy vary markedly in terms of their structure and organization. The associations perceive a variety of deficiencies in the prevention, diagnosis and treatment of breast cancer within the Italian National Health Service and they offer a wide range of services themselves. Their views of the relevance of the 10 goals of Europa Donna vary. In this paper, we discuss the implications of the low rate of participation in the survey and the heterogeneity of the breast cancer associations' structures, activities and views for the future activities of the Italian forum of Europa Donna.

The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research

The analysis of variation in the use of health care services, and particularly of practice variation, has been the subject of renewed interest because of the view that the inappropriate use of procedures could be a major cause of these differences. In this article, recent literature is reviewed and the results of personal research are described on both the variation in care provision and on appropriateness assessment. In the few studies which have focussed on both subjects no evidence has yet been found to suggest that practice variation is to be explained by differences in appropriateness rates. However, there are still many methodological pitfalls in both variation analyses (statistical problems) and appropriateness assessment (reliability of the judgement), implying that this conclusion is far from definitive. More research should therefore be conducted on methodological questions of variation analysis and appropriateness assessment. Furthermore in variation analysis the relative contribution of all potential determinants has to be studied on the various levels of care provision. Finally, to study the relationship between practice variation and appropriateness of care, the clinical problem and not the procedure should be the starting point.