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Abstract
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.
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Mrózek E, Povoski SP, Shapiro CL. The challenges of individualized care for older patients with localized breast cancer. Expert Rev Anticancer Ther 2013; 13:963-73. [PMID: 23984898 DOI: 10.1586/14737140.2013.820568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Individualized care is achieved when the appropriate screening and/or evaluative tests are used, the treatment plan is driven by evidence-based data and the patient's functional ability, physical and mental health, preference and social situation are incorporated into treatment decisions. Breast cancer is a disease of aging; yet, the management of breast cancer in older women in most cases lacks evidence from prospective randomized clinical trials (i.e., level 1 evidence) to support treatment recommendations. Older women are underrepresented in therapeutic clinical studies, even though studies show that selected fit older women enrolled on clinical trials derive similar benefits as younger women. Very few studies have focused on the distribution and biological behavior of different molecular subtypes of breast cancer in older women making it difficult to conclude whether old age adds extra biological complexity. A comprehensive geriatric assessment that includes a multidimensional process designed to assess functional ability, physical health, cognitive and mental health, social issues and environmental situation of elderly person should be an integral part of individualized care for older patients with breast cancer. However, incorporation of this tool into standard oncology practice is very slow despite the expected steep increase in older individuals with cancer projected over the next 25 years. All of the factors mentioned above hinder progress in delivering individualized care to older patients with breast cancer. This article provides an overview on progress and challenges of individualized and personalized health care in older women with breast cancer.
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Affiliation(s)
- Ewa Mrózek
- Division of Medical Oncology, The Wexner Medical Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH, USA.
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Dehal A, Abbas A, Johna S. Racial disparities in clinical presentation, surgical treatment and in-hospital outcomes of women with breast cancer: analysis of nationwide inpatient sample database. Breast Cancer Res Treat 2013; 139:561-9. [PMID: 23690143 DOI: 10.1007/s10549-013-2567-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 05/10/2013] [Indexed: 02/06/2023]
Abstract
To examine racial/ethnic disparities in stage of disease and comorbidity (pre-treatment), surgical treatment allocation (breast-conserving surgery versus mastectomy), and in-hospital outcomes after surgery (post-treatment) among women with breast cancer. Nationwide inpatient sample is a nationwide clinical and administrative database compiled from 44 states representing 95 % of all hospital discharges in the Unites States. Discharges of adult women who underwent surgery for breast cancer from 2005 to 2009 were identified. Information about patients and hospitals characteristics was obtained. Multivariate logistic regression analyses were used to examine the risk adjusted association between race/ethnicity and the aforementioned outcomes (pre-treatment, treatment, and post-treatment). We identified 75,100 patient discharges. Compared to Whites, African-Americans (1.17, p < 0.001), and Hispanics (1.20, p < 0.001) were more likely to present with regional or metastatic disease. Similarly, African-American (1.58, p < 0.001) and Hispanics (1.11, p 0.003) were more likely to have comorbidity. Compared to Whites, African-Americans (0.71, p < 0.001), and Hispanics (0.77, p < 0.001) were less likely to receive mastectomy. Compared to Whites, African-Americans were more likely to develop post-operative complications (1.35, p < 0.001) and in-hospital mortality (1.87, p 0.13). Other racial groups showed no statistically significant difference compared to Whites. After controlling for potential confounders, we found racial/ethnic disparities in stage, comorbidity, surgical treatment allocation, and in-hospital outcomes among women with breast cancer. Future researches should examine the underlying factors of these disparities.
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Affiliation(s)
- Ahmed Dehal
- Arrowhead Regional Medical Center, Colton, CA 92324, USA.
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Fajdic J, Djurovic D, Gotovac N, Hrgovic Z. Criteria and procedures for breast conserving surgery. Acta Inform Med 2013; 21:16-9. [PMID: 23572855 PMCID: PMC3610577 DOI: 10.5455/aim.2013.21.16-19] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 02/10/2013] [Indexed: 11/03/2022] Open
Abstract
AIM Emphasizing circumstances that determine increasingly popular surgical approach of breast conserving surgery (BCS), used in lower grade breast tumors, while maintaining survival that is found when more radical procedures are used. PATIENTS AND METHODS Several leading oncological protocols in the world are compared, using PubMed database, and our own experience. Data gathered are compared to conclusions of Consensus Conference on Breast Conservation (Milan, 2005). Furthermore, surgical contraindications found in our everyday work are considered, having in mind satisfactory cosmetic outcome, as well as keeping the 1 cm border of "clear" edges. Such more practical problems of edge detection can compromise BCS results. RESULTS After observing several relevant protocols, we found very high frequency of mastectomy vs. BCS, despite the fact that stage of disease was low. We also found only 20% of absolute contraindications for BCS. Most frequent contraindication for BCS was multicentricity of the tumor (with micro calcifications), especially in ductal in situ carcinoma. CONCLUSION BCS followed by radiation therapy with tumor-free edges is standard procedure in treatment of T1 and small T2 breast cancers. This approach implies higher risk of local recurrence (LR), although local recurrence is low (1% per year), with rates of survival similar to radical procedures.
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Affiliation(s)
- Josip Fajdic
- Department of surgery, County hospital , Pozega , Croatia
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Joerger M, Thürlimann B, Savidan A, Frick H, Rageth C, Lütolf U, Vlastos G, Bouchardy C, Konzelmann I, Bordoni A, Probst-Hensch N, Jundt G, Ess S. Treatment of breast cancer in the elderly: a prospective, population-based Swiss study. J Geriatr Oncol 2012; 4:39-47. [PMID: 24071491 DOI: 10.1016/j.jgo.2012.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 06/16/2012] [Accepted: 08/03/2012] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The primary objective of this population-based study is to describe the patterns of care of elderly patients with breast cancer (BC), and evaluate potential causative factors for the decrease in BC-specific survival (BCSS) in the elderly. PATIENTS AND METHODS We included all or representative samples of patients with newly diagnosed BC from seven Swiss cancer registries between 2003 and 2005 (n=4820). Surgical and non-surgical BC treatment was analyzed over 5 age groups (<65, 65 to <70, 70 to <75, 75 to <80 and ≥80years), and the predictive impact of patient age on specific treatments was calculated using multivariate logistic regression analysis. RESULTS The proportion of locally advanced, metastatic and incompletely staged BC increased with age. The odds ratio for performing breast-conserving surgery (BCS) in stages I-II BC (0.37), sentinel lymph node dissection (SLND) in patients with no palpable adenopathy (0.58), post-BCS radiotherapy (0.04) and adjuvant endocrine treatment (0.23) were all in disfavor of patients ≥80years of age compared to their younger peers. Only 36% of patients ≥80years of age with no palpable adenopathy underwent SLND. In the adjusted model, higher age was a significant risk factor for omitting post-BCS radiotherapy, SLND and adjuvant endocrine treatment. CONCLUSIONS This study found an increase in incomplete diagnostic assessment, and a substantial underuse of BCS, post-BCS radiotherapy, SLND and adjuvant endocrine treatment in elderly patients with BC. There is a need for improved management of early BC in the elderly even in a system with universal access to health care services.
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Affiliation(s)
- M Joerger
- Cancer Registry St. Gallen-Appenzell, St.Gallen, Switzerland; Department of Medical Oncology, Cantonal Hospital, St. Gallen, Switzerland.
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Nelson MC, Norton HJ, Greene FL. Breast conservation therapy versus mastectomy in the community-based setting: can this rate be used as a benchmark for cancer care? Surg Oncol Clin N Am 2011; 20:427-37, vii. [PMID: 21640912 DOI: 10.1016/j.soc.2011.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite strong evidence supporting the use of breast conservation therapy (BCT) in the treatment of breast carcinoma, the actual rates of use remain low. This article is a retrospective review of a sample of patients from the cancer registry of the Carolinas Medical Center (CMC), comparing breast conservation and mastectomy rates during an 11-year period. BCT rates have increased in CMC during this time frame and have reached national levels. Further research is needed to determine whether BCT rates can be used as a benchmark for the care of patients with cancer.
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Affiliation(s)
- Marsha Criscio Nelson
- Department of Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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Alderman AK, Bynum J, Sutherland J, Birkmeyer N, Collins ED, Birkmeyer J. Surgical treatment of breast cancer among the elderly in the United States. Cancer 2010; 117:698-704. [DOI: 10.1002/cncr.25617] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 07/06/2010] [Accepted: 07/28/2010] [Indexed: 11/05/2022]
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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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Trends in surgical treatment of breast cancer at Mayo Clinic 1980–2004. Breast 2008; 17:555-62. [DOI: 10.1016/j.breast.2008.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Revised: 08/15/2008] [Accepted: 08/18/2008] [Indexed: 11/20/2022] Open
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Fedeli U, Alba N, Schievano E, Visentin C, Rosato R, Zorzi M, Ruscitti G, Spolaore P. Diffusion of good practices of care and decline of the association with case volume: the example of breast conserving surgery. BMC Health Serv Res 2007; 7:167. [PMID: 17945000 PMCID: PMC2121646 DOI: 10.1186/1472-6963-7-167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 10/18/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several previous studies conducted on cancer registry data and hospital discharge records (HDR) have found an association between hospital volume and the recourse to breast conserving surgery (BCS) for breast cancer. The aim of the current study is to depict concurrent time trends in the recourse to BCS and its association with hospital volume. METHODS Admissions of breast cancer patients for BCS or mastectomy in the period 2000-2004 were identified from the discharge database of the Veneto Region (Italy). The role of procedural volume (low < 50, medium 50-100, high > 100 breast cancer surgeries/year), and of individual risk factors obtainable from HDR was assessed through a hierarchical log-binomial regression. RESULTS Overall, the recourse to BCS was higher in medium (risk ratio = 1.12, 95% confidence interval 1.07-1.18) and high-volume (1.09, 1.03-1.14) compared to low-volume hospitals. The proportion of patients treated in low-volume hospitals dropped from 22% to 12%, with a concurrent increase in the activity of medium-volume providers. The increase over time in breast conservation (globally from 56% to 67%) was steeper in the categories of low- and medium-volume hospitals with respect to high caseload. CONCLUSION The growth in the recourse to BCS was accompanied by a decline of the association with hospital volume; larger centers probably acted as early adopters of breast conservation strategies that subsequently spread to smaller providers.
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Affiliation(s)
- Ugo Fedeli
- SER-Epidemiological Department, Veneto Region, Via Ospedale 18-31033 Castelfranco Veneto (TV), Italy.
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Luo R, Giordano SH, Zhang DD, Freeman J, Goodwin JS. The role of the surgeon in whether patients with lymph node-positive colon cancer see a medical oncologist. Cancer 2007; 109:975-82. [PMID: 17265530 PMCID: PMC1851914 DOI: 10.1002/cncr.22462] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chemotherapy improves survival for patients with stage III colon cancer, but some older patients with lymph node-positive colon cancer do not see a medical oncologist and, thus, do not receive adjuvant chemotherapy. METHODS To evaluate the role of the surgeon in determining referrals to medical oncology among patients with stage III colon cancer, the authors conducted a retrospective cohort study of 6158 patients aged >or=66 years who were diagnosed with stage III colon cancer from 1992 through 1999 by using the Surveillance, Epidemiology, and End Results-Medicare linked database. Multilevel analysis was used to simultaneously model variations in patients' seeing a medical oncologist at the patient and surgeon levels. RESULTS Twenty-one percent of the total variance in seeing a medical oncologist was attributable to the surgeon after adjusting for available patient, tumor, and surgeon characteristics. The individual surgeon characteristics that significantly predicted whether the patient saw a medical oncologist were year since graduation (<or=10 years vs >20 years; hazard ratio [HR], 1.60; 95% confidence interval [95% CI], 1.19-2.16), practicing in a teaching hospital (yes vs. no: HR; 1.30; 95% CI, 1.07-1.58), and volume of patients with colon cancer (<30 patients vs >or=121 patients; HR, 0.66; 95% CI, 0.46-0.94). Surgeon sex, race, board certification, and type of practice were not independent predictors of medical oncology referral. CONCLUSIONS Surgeons accounted for approximately 20% of the variation in patients seeing a medical oncologist. Interventions at the level of the surgeon may be appropriate to improve the care of patients with colon cancer.
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Affiliation(s)
- Ruili Luo
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Sharon H. Giordano
- Department of Breast Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Dong D. Zhang
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Jean Freeman
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - James S. Goodwin
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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Reports · Mitteilungen. Breast Care (Basel) 2007. [DOI: 10.1159/000108362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hébert-Croteau N, Roberge D, Brisson J. Provider’s volume and quality of breast cancer detection and treatment. Breast Cancer Res Treat 2006; 105:117-32. [PMID: 17186361 DOI: 10.1007/s10549-006-9439-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 10/24/2006] [Indexed: 11/26/2022]
Abstract
For many health conditions, the process or result of medical procedures improves with increasing caseload. The evidence about breast cancer has not been thoroughly assessed. This review synthesizes the literature about provider's volume and performance in either breast cancer screening with mammography or treatment. Articles published in English between 1990 and 2006 were identified by a computerized search and by review of reference lists. In screening with mammography, the reading volume of the radiologist and the screening volume of the facility influence different components of performance. The most conclusive evidence for breast cancer treatment concerns the association between the surgeon's caseload and the process or end-results of therapeutic interventions. Although the mechanisms of these associations still need to be clarified, large provider's volume in screening mammography or breast cancer treatment is often related to the quality of medical interventions.
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Affiliation(s)
- Nicole Hébert-Croteau
- Direction des Systèmes de Soins et Services, Institut National de Santé Publique du Québec, 190 Boul. Crémazie Est, Bureau 2.24, Montréal, Quebec, Canada.
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Luo R, Giordano SH, Freeman JL, Zhang D, Goodwin JS. Referral to medical oncology: a crucial step in the treatment of older patients with stage III colon cancer. Oncologist 2006; 11:1025-33. [PMID: 17030645 PMCID: PMC1913211 DOI: 10.1634/theoncologist.11-9-1025] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Adjuvant chemotherapy for stage III colon cancer produces a substantial survival benefit, but many older patients do not receive chemotherapy. This study examines factors associated with medical oncology consultation and evaluates the impact of such consultation on chemotherapy use. PATIENTS AND METHODS We used the Surveillance Epidemiology and End Results-Medicare linked database and identified 7,569 patients, aged 66-99, with stage III colon cancer diagnosed from 1992-1999. Modified Poisson regression was used to assess the relative risk for seeing a medical oncologist and for receiving chemotherapy as a function of individual characteristics. RESULTS 78.08% of patients saw a medical oncologist within 6 months of diagnosis. Patients who were female, white, married, had low comorbidity scores, were diagnosed in more recent years, or had four or more positive lymph nodes were more likely to see a medical oncologist. Patients seeing a medical oncologist were 10 times more likely to receive chemotherapy (odds ratio, 9.98; 95% confidence interval, 8.21-12.14), after controlling for demographic and tumor characteristics. Chemotherapy use increased over time, but was substantially lower among older, black, and unmarried patients. CONCLUSIONS Referral to medical oncology is one of the most important factors associated with receipt of chemotherapy among older patients with stage III colon cancer. Comorbidity decreases the likelihood of receiving chemotherapy, but its effect is the same for those who see a medical oncologist and all patients combined. Ensuring that high-risk patients are referred to medical oncology is a crucial step in quality care for patients with colon cancer.
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Affiliation(s)
- RuiLi Luo
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Sharon H. Giordano
- Department of Breast Medical Oncology, University of Texas M. D. Anderson Cancer Center, Galveston, Texas, USA
| | - Jean L. Freeman
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Dong Zhang
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - James S. Goodwin
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
- Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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Doubeni CA, Field TS, Ulcickas Yood M, Rolnick SJ, Quessenberry CP, Fouayzi H, Gurwitz JH, Wei F. Patterns and predictors of mammography utilization among breast cancer survivors. Cancer 2006; 106:2482-8. [PMID: 16634097 DOI: 10.1002/cncr.21893] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Improvements in cancer detection and treatment have resulted in increasing numbers of breast cancer survivors. Information regarding the use of mammography by breast cancer survivors is limited. METHODS The use of surveillance mammography was examined over a 5-year period in a retrospective cohort of women age>or=55 years who were diagnosed with incident primary breast cancer (1996-1997) while enrolled in 1 of 4 geographically diverse integrated health systems. RESULTS Of the 797 women included in the study, 80% (n=636) underwent mammograms during the first year after treatment for breast cancer. The percentage of women having mammograms during each yearly period decreased significantly over time. In multivariable analyses, older women with comorbid illnesses or those with late-stage disease were less likely to undergo mammograms, whereas those who underwent breast-conserving therapy (adjusted odds ratio [OR] of 1.38 [95% confidence interval (95% CI), 1.09-1.75]) were more likely to have mammograms. Women who had outpatient visits with a gynecologist (adjusted OR of 3.49 [95% CI, 2.55-4.79]), or a primary care physician (adjusted OR of 2.21 [95% CI, 1.73-2.82]) during the year were more likely to undergo mammograms in that year. CONCLUSIONS The use of mammography among breast cancer survivors declines over time. Efforts are needed to increase awareness among healthcare providers and breast cancer survivors of the value of follow-up mammography. The current findings highlight the importance of maintaining ongoing contact with primary care physicians and gynecologists.
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Affiliation(s)
- Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Massachusetts, Worcester, Massachusetts 01655, USA.
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Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, Deapen D, Salem B, Lakhani I, Morrow M. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol 2005; 23:5526-33. [PMID: 16110013 DOI: 10.1200/jco.2005.06.217] [Citation(s) in RCA: 249] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Steven J Katz
- 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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Laliberte L, Fennell ML, Papandonatos G. The Relationship of Membership in Research Networks to Compliance With Treatment Guidelines for Early-Stage Breast Cancer. Med Care 2005; 43:471-9. [PMID: 15838412 DOI: 10.1097/01.mlr.0000160416.66188.f5] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Research has shown that older women with breast cancer are less likely than younger women to receive treatment in accordance with accepted guidelines. Cancer-related research networks (eg, Comprehensive Cancer Centers) have been funded by the National Cancer Institute to increase the dissemination of new treatment strategies, but little is known about their relationship to cancer treatment patterns. OBJECTIVES We used a 3-level hierarchical regression model to examine the relationship of treating facilities' memberships in cancer research networks to compliance with guidelines for primary treatment of early stage breast cancer, controlling for patient and facility factors. RESEARCH DESIGN We analyzed data from a database linking SEER registry data and Medicare claims in patients aged 65 years of age or older with early-stage breast cancer to data on the treating facility, including variables that indicate membership(s) in cancer research networks. SUBJECTS A total of 16,600 women with stage I or stage II breast cancer, diagnosed between 1990 and 1994, and who received treatment in one of 423 facilities were studied. MEASURES The key independent variable in this analysis was membership in NCI-funded cancer research networks. The outcome measure is a 3-category variable defined as (1) mastectomy (MAST), (2) breast-conserving surgery plus radiation therapy (BCS+RT), or (3) BCS alone. RESULTS Patients treated at facilities that were members of 2 or more cancer research networks were more likely to receive guideline-concordant treatment (ie, MAST or BCS+RT) than similar patients treated at non-member facilities. CONCLUSIONS Organizational factors may influence compliance with treatment guidelines and be useful in improving the quality of care.
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Affiliation(s)
- Linda Laliberte
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island 02912, USA.
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Declining use of mastectomy for invasive breast cancer in Canada, 1981-2000. Canadian Journal of Public Health 2004. [PMID: 15490921 DOI: 10.1007/bf03405141] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the rate and magnitude of change in surgical practice for breast cancer in Canada in relation to publication dates of clinical trials and consensus conferences. METHODS Hospital separations with a diagnosis of invasive breast cancer were extracted from the Hospital Morbidity File from 1981 to 2000. Age-standardized rates of in-patient procedures for breast-conserving surgery and mastectomy were analyzed by province and age group and by geographic region. RESULTS In Canada, mastectomy rates decreased from 62.2 to 37.9 per 100,000 between 1981 and 2000; declines were largest between 1984 and 1985, following publication of the NSABP B-06 clinical trial in March 1985, and between 1991 and 1993, after the US NIH Consensus Conference in February 1991. Mastectomy rates plateaued between 1985 and 1991, and from 1993 to 2000; the transitory peak in 1988 corresponded to publicity surrounding Nancy Reagan's choice of mastectomy in 1987. Regional variations from the main pattern led to increasingly divergent mastectomy rates over time. Women aged 80+ were less likely to be treated by any surgery. INTERPRETATION Publication of clinical trial results and consensus conferences were associated with changes in surgical treatment for breast cancer in Canada. However, divergent mastectomy rates among Canadian regions point to inconsistent adoption of less invasive therapy despite a publicly-funded health care system and national consensus guidelines.
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Goodwin JS, Satish S, Anderson ET, Nattinger AB, Freeman JL. Effect of nurse case management on the treatment of older women with breast cancer. J Am Geriatr Soc 2003; 51:1252-9. [PMID: 12919237 DOI: 10.1046/j.1532-5415.2003.51409.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the effect of nurse case management on the treatment of older women with breast cancer. DESIGN Randomized prospective trial. SETTING Sixty surgeons practicing at 13 community and two public hospitals in southeast Texas. PARTICIPANTS Three hundred thirty-five women (166 control and 169 intervention) aged 65 and older newly diagnosed with breast cancer. INTERVENTION Women seeing surgeons randomized to the intervention group received the services of a nurse case manager for 12 months after the diagnosis of breast cancer. MEASUREMENTS The primary outcome was the type and use of cancer-specific therapies received in the first 6 months after diagnosis. Secondary outcomes were patient satisfaction and arm function on the affected side 2 months after diagnosis. RESULTS More women in the intervention group received breast-conserving surgery (28.6% vs 18.7%; P=.031) and radiation therapy (36.0% vs 19.0%; P=.003). Of women undergoing breast-conserving surgery, greater percentages in the case management group received adjuvant radiation (78.3% vs 44.8%; P=.001) and axillary dissection (71.4% vs 44.8%; P=.057). Women in the case management group were also more likely to receive more breast reconstruction surgery (9.3% vs 2.6%, P=.054), and women in the case management group with advanced cancer were more likely to receive chemotherapy (72.7% vs 30.0%, P=.057). Two months after surgery, higher percentages of women in the case manager group had normal arm function (93% vs 84%; P=.037) and were more likely to state that they had a real choice in their treatment (82.2% vs 69.9%, P=.020). Women with indicators of poor social support were more likely to benefit from nurse case management. CONCLUSION Nurse case management results in more appropriate management of older women with breast cancer.
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Affiliation(s)
- James S Goodwin
- Department of Internal Medicine, School of Medicine, The University of Texas Medical Branch, Galveston, Texas 77555, USA.
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Hislop TG, Coldman AJ, Olivotto IA, D'yachkova Y, Speers C. Local and regional therapy for women with breast cancer in British Columbia. Breast J 2003; 9:192-9. [PMID: 12752627 DOI: 10.1046/j.1524-4741.2003.09310.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
British Columbian provincial practice guidelines (PPGs) have recommended breast-conserving surgery (BCS), axillary node dissection, and radiation therapy following BCS for specific subgroups of breast cancer patients. Patient-, disease-, and physician-specific factors associated with these therapies were investigated in nonmetastatic invasive breast cancer patients. Temporal trends in BCS and physicians' experiences with PPGs were also examined. Sources of data for patient, disease, treatment, and treating physician factors included medical records, source documents, and the British Columbia Medical Directory for 967 nonmetastatic invasive breast cancer patients diagnosed in British Columbia in 1995. BCS utilization among 496 patients with pathologically node-negative breast cancer (NNBC) was compared to earlier British Columbian data. Family physicians and surgeons were surveyed in 1997 regarding their experience with PPGs. 57% of "ideal" candidates received BCS; 87% of patients received axillary node dissection; and 95% of women treated with BCS also received radiation therapy. Tumor size, tumor location, and extent of ductal carcinoma in situ (DCIS) were associated with BCS use; age, tumor size, and tumor location were associated with axillary node dissection; and age alone was associated with radiation therapy following BCS. Fifty-four percent of NNBC patients received BCS in 1995, compared to 44% in 1991, with increases seen in most patient-, disease-, and physician-specific comparisons. The increase in BCS, and high proportion completing radiation therapy, are encouraging and may be due in part to greater exposure to PPGs.
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Affiliation(s)
- T Gregory Hislop
- Population and Preventative Oncology Program, BC Cancer Agency, Vancouver, British Columbia, Canada.
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Jakesz R, Samonigg H, Gnant M, Kubista E, Depisch D, Kolb R, Mlineritsch B, Mischinger HJ, Menzel RC, Steindorfer P, Kwasny W, Tausch C, Stierer M, Taucher S, Seifert M, Hausmaninger H. Significant increase in breast conservation in 16 years of trials conducted by the Austrian Breast & Colorectal Cancer Study Group. Ann Surg 2003; 237:556-64. [PMID: 12677153 PMCID: PMC1514470 DOI: 10.1097/01.sla.0000059990.43981.4e] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To confirm evidence that breast-conserving treatment (BCT) does not impair the prognosis in breast cancer patients as compared to mastectomy and to argue that it be regarded as the treatment of choice in stage I and II disease. SUMMARY BACKGROUND DATA Scientifically, survival rates in breast cancer have been shown to be stage-dependent, but independent of the extent of surgical breast tissue removal, as long as the resection margins are free of tumor infiltration. METHODS Between 1984 and 1997, six different trials conducted by the Austrian Breast & Colorectal Cancer Study Group accrued a total of 4,259 women with hormone-responsive disease. The authors selected and compared three patient groups (n = 3,316) according to pathologic stage, age, and the surgical procedure applied. RESULTS Over this interval, the BCT rate in the premenopausal node-positive subgroup experienced a highly significant increase from 27.2% to 73.2% overall. In the group of postmenopausal node-negative patients, the BCT rate grew significantly by 37.3% to 77.3% in total. With an overall BCT rate growing from 22.5% to 56.8% in postmenopausal node-positive women, those presenting with T1 tumors saw a significant increase from 35.1% to 65.9%. Mortality and local recurrence rates proved stable or even decreased considerably over time and in all subgroups. CONCLUSIONS The presented outcome of BCT rates, significantly improved over this 16-year period and in no way counterbalanced by higher local recurrence or death rates, reflects an excellent example of surgical quality control. BCT can safely be regarded as the standard of therapy for T1 and increasingly for T2 disease. Especially in multi-institutional adjuvant breast cancer trials, the highest priority should be given to breast-conserving procedures.
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Affiliation(s)
- Raimund Jakesz
- Department of Surgery, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Hadley J, Mandelblatt JS, Mitchell JM, Weeks JC, Guadagnoli E, Hwang YT. Medicare breast surgery fees and treatment received by older women with localized breast cancer. Health Serv Res 2003; 38:553-73. [PMID: 12785561 PMCID: PMC1360902 DOI: 10.1111/1475-6773.00133] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [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 determine whether area-level Medicare physician fees for mastectomy and breast conserving surgery were associated with treatment received by Medicare beneficiaries with localized breast cancer and to compare these results with an earlier analysis conducted using small areas (three-digit zip codes) as the unit of observation. DATA SOURCE Medicare claims and physician survey data for a national sample of elderly (aged 67 or older) Medicare beneficiaries with localized breast cancer treated in 1994 (unweighted n = 1,787). STUDY DESIGN Multinomial logistic regression analysis was used to estimate a model of treatment received as a function of Medicare fees, controlling for other area economic factors, patient demographic and clinical characteristics, physician experience, and region. PRINCIPAL FINDINGS In 1994, average Medicare fees (adjusted for the effects of modifiers and procedure mix) for mastectomy (MST) and breast conserving surgery (BCS) were 904 dollars and 305 dollars, respectively. Holding other fees and factors fixed, a 10 percent increase in the BCS fee increased the odds of breast conserving surgery with radiation therapy relative to mastectomy to 1.34 (p = 0.02), while a 10 percent decrease in the MST fee increased the odds of breast conserving surgery with radiation therapy to 1.86 (p < 0.01). CONCLUSIONS Among older women with localized breast cancer, financial incentives appear to influence the use of mastectomy and breast conserving surgery with radiation therapy. This finding is consistent with the hypothesis that physicians are responsive to financial incentives when the alternative procedures have clinically equivalent outcomes and the patient's clinical condition does not dominate the treatment choice. We also find that the fee effects derived from this analysis of individual data with more precise measurement of both diagnosis and treatment are qualitatively similar to the results of the small-area analysis. This suggests that the earlier study was not severely affected by ecological bias or other data limitations inherent in Medicare claims data.
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Affiliation(s)
- Jack Hadley
- The Urban Institute, Washington, DC 20037, USA
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Polsky D, Mandelblatt JS, Weeks JC, Venditti L, Hwang YT, Glick HA, Hadley J, Schulman KA. Economic evaluation of breast cancer treatment: considering the value of patient choice. J Clin Oncol 2003; 21:1139-46. [PMID: 12637482 DOI: 10.1200/jco.2003.03.126] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To use 5 years of primary data to compare the incremental cost-effectiveness of breast conservation and radiation versus mastectomy with the restriction of choice to a single therapy versus providing a choice of either therapy. PATIENTS AND METHODS We evaluated a random retrospective cohort of 2,517 Medicare beneficiaries treated for newly diagnosed stage I or II breast cancer from 1992 through 1994. The outcome measures were quality-adjusted life-years (QALYs) and 5-year medical costs. Risk and propensity score adjustments were used in the analysis. RESULTS A breast conservation and radiation regimen has significantly higher costs than mastectomy in the first year after surgery; the adjusted 5-year costs are $14,054 (95% confidence interval, $9,791 to $18,312) greater than those of mastectomy. The adjusted incremental cost-effectiveness ratio comparing breast conservation and radiation to mastectomy was $219,594 per QALY for the comparison of the two strategies. If the possibility of patient choice from maintaining the availability of multiple treatments versus restricting choice to mastectomy alone provides a quality-of-life gain of 0.031 QALYs, then the cost-effectiveness ratio of this choice option is $80,440 per QALY. CONCLUSION The current system of providing a choice between mastectomy and breast conservation surgery is economically attractive when the economic analysis includes the benefit of patient choice of treatment.
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Affiliation(s)
- Daniel Polsky
- University of Pennsylvania, Philadelphia, PA 19104-6021, USA.
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Hadley J, Polsky D, Mandelblatt JS, Mitchell JM, Weeks JC, Wang Q, Hwang YT. An exploratory instrumental variable analysis of the outcomes of localized breast cancer treatments in a medicare population. HEALTH ECONOMICS 2003; 12:171-186. [PMID: 12605463 DOI: 10.1002/hec.710] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This study is motivated by the potential problem of using observational data to draw inferences about treatment outcomes when experimental data are not available. We compare two statistical approaches, ordinary least-squares (OLS) and instrumental variables (IV) regression analysis, to estimate the outcomes (three-year post-treatment survival) of three treatments for early stage breast cancer in elderly women: mastectomy (MST), breast conserving surgery with radiation therapy (BCSRT), and breast conserving surgery only (BCSO). The primary data source was Medicare claims for a national random sample of 2907 women (age 67 or older) with localized breast cancer who were treated between 1992 and 1994. Contrary to randomized clinical trial (RCT) results, analysis with the observational data found highly significant differences in survival among the three treatment alternatives: 79.2% survival for BCSO, 85.3% for MST, and 93.0% for BCSRT. Using OLS to control for the effects of observable characteristics narrowed the estimated survival rate differences, which remained statistically significant. In contrast, the IV analysis estimated survival rate differences that were not significantly different from 0. However, the IV-point estimates of the treatment effects were quantitatively larger than the OLS estimates, unstable, and not significantly different from the OLS results. In addition, both sets of estimates were in the same quantitative range as the RCT results.We conclude that unadjusted observational data on health outcomes of alternative treatments for localized breast cancer should not be used for cost-effectiveness studies. Our comparisons suggest that whether one places greater confidence in the OLS or the IV results depends on at least three factors: (1) the extent of observable health information that can be used as controls in OLS estimation, (2) the outcomes of statistical tests of the validity of the instrumental variable method, and (3) the similarity of the OLS and IV estimates. In this particular analysis, the OLS estimates appear to be preferable because of the instability of the IV estimates.
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Affiliation(s)
- Jack Hadley
- The Urban Institute, Washington, DC 20037, USA.
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Malin JL, Kahn KL, Adams J, Kwan L, Laouri M, Ganz PA. Validity of cancer registry data for measuring the quality of breast cancer care. J Natl Cancer Inst 2002; 94:835-44. [PMID: 12048271 DOI: 10.1093/jnci/94.11.835] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Various groups have called for a national system to monitor the quality of cancer care. The validity of cancer registry data for quality of cancer care has not been well studied. We investigated the validity of such information in the California Cancer Registry. METHODS We compared registry data associated with care with data abstracted from the medical records of patients diagnosed with breast cancer. We also calculated a quality score for each subject by determining the proportion of four evidence-based quality indicators that were met and then compared overall quality scores obtained from registry and medical record data. All statistical tests were two-sided. RESULTS Records of 304 patients were studied. Compared with the medical record data gold standard, the accuracy of registry data was higher for hospital-based services (sensitivity = 95.0% for mastectomy, 94.9% for lumpectomy, and 95.9% for lymph node dissection) than for ambulatory services (sensitivity = 9.8% for biopsy, 72.2% for radiation therapy, 55.6% for chemotherapy, and 36.2% for hormone therapy). On average, quality scores calculated from registry data were 11 percentage points (95% confidence interval [CI] = 9 to 13 percentage points, P<.001) lower than those calculated from medical record data. Quality scores calculated from registry data were 5 percentage points (95% CI = 3 to 7 percentage points) lower for patients with stage I breast cancer, 16 percentage points (95% CI = 12 to 20 percentage points) lower for patients with stage II breast cancer, and 20 percentage points (95% CI = 8 to 32 percentage points) lower for patients with stage III breast cancer than were corresponding scores calculated from medical record data (all P<.001). The greater difference in quality scores for stage II and III patients revealed that disease severity and setting of care affected the validity of registry data. CONCLUSIONS Cancer registry data for quality measurement may not be valid for all care settings, but registries could provide the infrastructure for collecting data on the quality of cancer care. We urge that funding be increased to augment data collection by cancer registries.
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Affiliation(s)
- Jennifer L Malin
- Divisions of General Internal Medicine-Health Services Research, and Hematology-Oncology, Department of Medicine and Jonsson Comprehensive Cancer Center, University of California, Los Angeles 90095-1736, USA.
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Kahn KL, Malin JL, Adams J, Ganz PA. Developing a reliable, valid, and feasible plan for quality-of-care measurement for cancer: how should we measure? Med Care 2002; 40:III73-85. [PMID: 12064761 DOI: 10.1097/00005650-200206001-00011] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent changes in the US health care delivery system have raised expectations that the medical marketplace will compete on quality and cost of care. This effort will require a systematic evaluation of the measurement of quality of care as it applies to cancer and other critical conditions. OBJECTIVES To articulate the components of the design of quality-of-care measurement systems that must be considered and optimally manipulated to generate feasible, reliable, and valid data pertinent to patients with cancer. RESEARCH DESIGN A synthesis of information obtained from literature reviews and experience. MEASURES Four key areas of design that influence quality-of-care measurement scores are discussed: case identification, data source, data-collection strategies, and the quality of the care-measurement model. RESULTS Challenges associated with these design and measurement strategies are defined and discussed. CONCLUSIONS Policy analyses vary as a function of measurement domains. The design of a quality-of-care measurement system should consider trade-offs between validity and burden by considering the intricate relations between domains of measurement.
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Lantz PV, Zemencuk JK, Katz SJ. Is mastectomy overused? A call for an expanded research agenda. Health Serv Res 2002; 37:417-31. [PMID: 12036001 PMCID: PMC1430371 DOI: 10.1111/1475-6773.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Paula V Lantz
- Department of Health Management and Policy, School of Public Health, University of Michigan SPH, Ann Arbor 48109, USA
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Maskarinec G, Dhakal S, Yamashiro G, Issell BF. The use of breast conserving surgery: linking insurance claims with tumor registry data. BMC Cancer 2002; 2:3. [PMID: 11879527 PMCID: PMC100324 DOI: 10.1186/1471-2407-2-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2001] [Accepted: 03/05/2002] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The purpose of this study was to use insurance claims and tumor registry data to examine determinants of breast conserving surgery (BCS) in women with early stage breast cancer. METHODS Breast cancer cases registered in the Hawaii Tumor Registry (HTR) from 1995 to 1998 were linked with insurance claims from a local health plan. We identified 722 breast cancer cases with stage I and II disease. Surgical treatment patterns and comorbidities were identified using diagnostic and procedural codes in the claims data. The HTR database provided information on demographics and disease characteristics. We used logistic regression to assess determinants of BCS vs. mastectomy. RESULTS The linked data set represented 32.8% of all early stage breast cancer cases recorded in the HTR during the study period. Due to the nature of the health plan, 79% of the cases were younger than 65 years. Women with early stage breast cancer living on Oahu were 70% more likely to receive BCS than women living on the outer islands. In the univariate analysis, older age at diagnosis, lower tumor stage, smaller tumor size, and well-differentiated tumor grade were related to receiving BCS. Ethnicity, comorbidity count, menopausal and marital status were not associated with treatment type. CONCLUSIONS In addition to developing solutions that facilitate access to radiation facilities for breast cancer patients residing in remote locations, future qualitative research may help to elucidate how women and oncologists choose between BCS and mastectomy.
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Affiliation(s)
- Gertraud Maskarinec
- Cancer Research Center of Hawaii, University of Hawaii at Manoa, 1236 Lauhala Street, Honolulu, Hawaii 96813, USA
| | - Sanjaya Dhakal
- Cancer Research Center of Hawaii, University of Hawaii at Manoa, 1236 Lauhala Street, Honolulu, Hawaii 96813, USA
| | - Gladys Yamashiro
- Cancer Research Center of Hawaii, University of Hawaii at Manoa, 1236 Lauhala Street, Honolulu, Hawaii 96813, USA
| | - Brian F Issell
- Cancer Research Center of Hawaii, University of Hawaii at Manoa, 1236 Lauhala Street, Honolulu, Hawaii 96813, USA
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Gilligan MA, Kneusel RT, Hoffmann RG, Greer AL, Nattinger AB. Persistent differences in sociodemographic determinants of breast conserving treatment despite overall increased adoption. Med Care 2002; 40:181-9. [PMID: 11880791 DOI: 10.1097/00005650-200203000-00002] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of breast-conserving treatment (BCT) has previously demonstrated variability by sociodemographic factors. OBJECTIVE To determine whether variation in use of BCT by age, race, county income, county education, and population density declined between 1983 and 1996. DESIGN Trends in use of BCT over time were modeled with logistic regression. SETTING Surveillance, Epidemiology, and End Results national tumor registry data. PATIENTS Population-based cohort of 158,496 women with local or regional stage breast cancer. MAIN OUTCOME MEASURE Receipt of BCT. RESULTS Use of BCT increased overall, and among all subgroups of age, county income, county education, population density, and race. There was no decline in age-related variation in use of BCT over time. However, older women were less likely to undergo BCT including radiotherapy (RT) and lymph node dissection (LND), and were more likely to undergo BCT omitting RT and/or LND. Variation in use of BCT by county income persisted, with women residing in poorer counties less likely to undergo BCT, whether accompanied by RT and LND. Variation in overall use of BCT by county education also persisted. Although women residing in better-educated counties were more likely to undergo BCT accompanied by RT and LND, they were not more likely to undergo BCT omitting RT, LND, or both. No decline in variation by population density occurred, with women residing in urban areas more likely to use BCT whether accompanied by RT and LND. CONCLUSIONS Sociodemographic differences in BCT use have persisted over time. The increased overall adoption of BCT has not led to consistency in use of this treatment.
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Affiliation(s)
- Mary Ann Gilligan
- Department of Medicine, Medical College of Wisconsin, Milwaukee 53226, USA.
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Liang W, Burnett CB, Rowland JH, Meropol NJ, Eggert L, Hwang YT, Silliman RA, Weeks JC, Mandelblatt JS. Communication between physicians and older women with localized breast cancer: implications for treatment and patient satisfaction. J Clin Oncol 2002; 20:1008-16. [PMID: 11844824 DOI: 10.1200/jco.2002.20.4.1008] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To identify factors associated with patient-physician communication and to examine the impact of communication on patients' perception of having a treatment choice, actual treatment received, and satisfaction with care among older breast cancer patients. MATERIALS AND METHODS Data were collected from 613 pairs of surgeons and their older (greater-than-or-equal 67 years) patients diagnosed with localized breast cancer. Measures of patients' self-reported communication included physician- and patient-initiated communication and the number of treatment options discussed. Logistic regression analyses were conducted to examine the relationships between communication and outcomes. RESULTS Patients who reported that their surgeons mentioned more treatment options were 2.21 times (95% confidence interval [CI], 1.62 to 3.01) more likely to report being given a treatment choice, and 1.33 times (95% CI, 1.02 to 1.73) more likely to get breast-conserving surgery with radiation than other types of treatment. Surgeons who were trained in surgical oncology, or who treated a high volume of breast cancer patients (greater-than-or-equal 75% of practice), were more likely to initiate communication with patients (odds ratio [OR] = 1.62; 95% CI, 1.02 to 2.56; and OR = 1.68; 95% CI, 1.01 to 2.76, respectively). A high degree of physician-initiated communication, in turn, was associated with patients' perception of having a treatment choice (OR = 2.46; 95% CI, 1.29 to 4.70), and satisfaction with breast cancer care (OR = 2.13; 95% CI, 1.17 to 3.85) in the 3 to 6 months after surgery. CONCLUSION Greater patient-physician communication was associated with a sense of choice, actual treatment, and satisfaction with care. Technical information and caring components of communication impacted outcomes differently. Thus, the quality of cancer care for older breast cancer patients may be improved through interventions that improve communication within the physician-patient dyad.
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Affiliation(s)
- Wenchi Liang
- Department of Oncology, Georgetown University Medical Center, Washington, DC 20007, USA.
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Jonkman JN, Normand SL, Wolf R, Borbas C, Guadagnoli E. Identifying a cohort of patients with early-stage breast cancer: a comparison of hospital discharge and primary data. Med Care 2001; 39:1105-17. [PMID: 11567173 DOI: 10.1097/00005650-200110000-00008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospital discharge data are a potential source of information for quality of care; however, they lack detailed clinical data. OBJECTIVES To assess the usefulness of hospital discharge data for describing patterns of care. RESEARCH DESIGN Cohort study comparing hospital discharge data with data collected from medical records and patients. PATIENTS Women diagnosed with early-stage breast cancer in Massachusetts and Minnesota (1993-1995). MEASURES The percentage of patients in the primary data set who did not match a record in the discharge data set, and the percentage of patients in the discharge data set who did not match a record in the primary data set. Odds ratios for appearing in one data set, but not the other according to patient and hospital characteristics. RESULTS For patients in the primary data set, 26.9% from Massachusetts and 13.2% from Minnesota did not match a record in the discharge data set. In both states, factors associated with failure to match to the discharge data included receipt of breast conserving surgery, shorter length of stay, and treatment hospital. For patients in the discharge data set, 43.4% in Massachusetts and 30.3% in Minnesota did not match a patient in the primary data set. In both states, factors associated with failure to match to the primary data included treatment hospital and the presence of positive lymph nodes. CONCLUSIONS Hospital discharge data were fairly sensitive when linked to patients with early-stage breast cancer who were identified through hospital records. The discharge data lacked specificity, however. If discharge data are used to characterize patterns care for inpatients with early stage disease, estimates are likely to be inaccurate due to the inclusion of unsuitable patients in the denominator used to calculate procedure rates.
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Affiliation(s)
- J N Jonkman
- Department of Mathematics and Statistics, Mississippi State University, Mississippi State, MS, USA
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Nattinger AB, Kneusel RT, Hoffmann RG, Gilligan MA. Relationship of distance from a radiotherapy facility and initial breast cancer treatment. J Natl Cancer Inst 2001; 93:1344-6. [PMID: 11535710 DOI: 10.1093/jnci/93.17.1344] [Citation(s) in RCA: 198] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A B Nattinger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, USA.
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Hadley J, Mitchell JM, Mandelblatt J. Medicare fees and small area variations in breast-conserving surgery among elderly women. Med Care Res Rev 2001; 58:334-60. [PMID: 11523293 DOI: 10.1177/107755870105800303] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study used data from Medicare files, the American Hospital Association's Annual Survey of Hospitals, and the 1990 census to investigate whether Medicare fees for breast-conserving surgery (BCS) and mastectomy (MST) affected the rate of BCS across 799 3-digit ZIP code areas in 1994. The full model, which was based on the conceptual framework of the supply of and demand for different treatments, explained 51 percent of the variation in BCS rates. Medicare fees were statistically significant and had the hypothesized effects: a 10 percent higher BCS fee was associated with a 7 to 10 percent higher BCS rate, while a 10 percent higher MST fee was associated with a 2 to 3 percent lower proportion receiving BCS. Other significant economic variables were proximity to a radiation therapy hospital, a teaching hospital or a cancer center, and the percentage of elderly women with incomes below the poverty rate, which were negatively related to the BCS rate. Variations in age, race, and metropolitan populations had small or insignificant effects. The single most important was the percentage of cases with one or more comorbidities.
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Vlastos G, Mirza NQ, Meric F, Hunt KK, Kuerer HM, Ames FC, Ross MI, Buchholz TA, Hortobagyi GN, Singletary SE. Breast conservation therapy as a treatment option for the elderly. The M. D. Anderson experience. Cancer 2001; 92:1092-100. [PMID: 11571720 DOI: 10.1002/1097-0142(20010901)92:5<1092::aid-cncr1425>3.0.co;2-p] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although almost half of all incidents of breast carcinoma occur in women age > or = 65 years, not enough is known about appropriate care for patients in this age group. The objective of the current study was to evaluate the role of breast conservation therapy in the management of breast carcinoma in women age > or = 65 years. METHODS From 1970 to 1994, 1325 patients with carcinoma of the breast were treated with breast conservation therapy (segmental mastectomy and radiation therapy with or without axillary lymph node dissection) at The University of Texas M. D. Anderson Cancer Center. From this patient group, the authors identified 184 elderly women (> or = 65 years) with Stage 0-III disease at the time of diagnosis. RESULTS The median patient age was 70 years (range, 65-88 years). The distribution of disease by stage among the women was Stage 0 disease in 12 patients (7%), Stage I disease in 107 patients (58%), Stage II disease in 63 patients (34%), and Stage III disease in 2 patients (1%). Comorbid conditions that may have influenced treatment planning were reported in 91 patients (50%). An axillary lymph node dissection was performed in 135 patients (73%), with positive axillary lymph nodes found in 30 patients (22%). Adjuvant chemotherapy was given to 10 patients (5%), and tamoxifen therapy was given to 63 patients (34%). Complications from treatment were reported in 24 patients (13%). With a median follow-up of 7.3 years (range, 0.25-23.5 years), 9 patients developed locoregional disease recurrence (5%), 10 patients developed contralateral breast carcinoma (5%), and 21 patients developed distant metastasis (11%). At last follow-up, 113 patients (61%) were alive, 15 patients (8%) were dead of disease, and 56 patients (30%) were dead of other causes. The 5-year and 10-year disease specific survival rates were 96% and 91%, respectively. CONCLUSIONS Breast conservation therapy with segmental mastectomy and postoperative radiation therapy with or without axillary lymph node dissection provides excellent local control and disease free survival in elderly women with breast carcinoma. This treatment should be considered as the standard of care for elderly patients without severe comorbid disease.
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Affiliation(s)
- G Vlastos
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Keating NL, Weeks JC, Landrum MB, Borbas C, Guadagnoli E. Discussion of treatment options for early-stage breast cancer: effect of provider specialty on type of surgery and satisfaction. Med Care 2001; 39:681-91. [PMID: 11458133 DOI: 10.1097/00005650-200107000-00005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the physicians with whom breast cancer patients discuss treatment options and assess whether discussing surgical options with a medical oncologist is associated with type of surgery and satisfaction. RESEARCH DESIGN Medical record abstraction and survey. SUBJECTS Women with early-stage breast cancer numbering 2,426 in two states-Massachusetts, where the rate of breast-conserving surgery is high, and Minnesota, where it is lower. MEASURES Receipt of breast-conserving surgery and satisfaction. RESULTS Women in Massachusetts discussed breast cancer treatments with more physicians than women in Minnesota (mean 3.5 vs. 2.8; P <0.001) and more often discussed surgical options with a medical oncologist (52% vs. 28%; P <0.001). Using propensity score analyses, in Massachusetts, discussing surgical options with a medical oncologist was not related to type of surgery (adjusted difference in rate of breast-conserving surgery: 3.9%, 95% CI -3.6% to 11.5%) but was associated with greater satisfaction (adjusted difference: 8.1, 95% CI 2.0% to 14.2%). In Minnesota, discussing surgical options with a medical oncologist was associated with breast-conserving surgery (adjusted difference: 12.6%, 95% CI 5.6% to 19.7%) with no difference in satisfaction (adjusted difference: -1.5%, 95% CI -6.8% to 3.8%). CONCLUSIONS Outcomes associated with discussing surgical treatments with a medical oncologist vary with local care patterns. Where breast-conserving surgery is standard care, seeing a medical oncologist is not related to type of surgery, but is associated with greater satisfaction. Where it is not the standard, seeing a medical oncologist is associated with more breast-conserving surgery and equivalent satisfaction. These findings suggest that collaborative care may benefit women with respect to treatment selection or satisfaction.
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Affiliation(s)
- N L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
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Morrow M, White J, Moughan J, Owen J, Pajack T, Sylvester J, Wilson JF, Winchester D. Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma. J Clin Oncol 2001; 19:2254-62. [PMID: 11304779 DOI: 10.1200/jco.2001.19.8.2254] [Citation(s) in RCA: 295] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To define patterns of care for the local therapy of stage I and II breast cancer and to identify factors used to select patients for breast-conserving therapy (BCT). PATIENTS AND METHODS A convenience sample of 16,643 patients with stage I and II breast cancer treated in 1994 was obtained from hospital-based tumor registries. Histologic variables were determined from original pathology reports. RESULTS BCT was performed in 42.6% of patients. Multivariate analysis demonstrated that living in the Northeast United States (odds ratio [OR], 2.48; 95% confidence interval [CI], 2.16 to 2.84), having a clinical T1 tumor (OR, 2.51; 95% CI, 2.27 to 2.78), and having a tumor without an extensive intraductal component (OR, 2.07; 95% CI, 1.81 to 2.37) were the strongest predictors of breast-conserving surgery. Radiation therapy was given to 86% of patients who had breast-conserving surgery. Age less than 70 years was the most significant predictor of receiving radiation (OR, 2.11; 95% CI, 1.77 to 2.25). Tumor variables did not correlate with the use of radiation, but favorable tumor characteristics were associated with the use of breast-conserving surgery. CONCLUSION Despite strong evidence supporting the use of BCT, the majority of women continue to be treated with mastectomy. Predictors of the use of BCT do not correspond to those suggested in guidelines.
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Affiliation(s)
- M Morrow
- American College of Surgeons Commission on Cancer, Chicago, IL, USA
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Lee-Feldstein A, Feldstein PJ, Buchmueller T, Katterhagen G. Breast cancer outcomes among older women: HMO, fee-for-service, and delivery system comparisons. J Gen Intern Med 2001; 16:189-99. [PMID: 11318915 PMCID: PMC1495182 DOI: 10.1111/j.1525-1497.2001.91112.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To analyze the relationship of health insurance status and delivery systems to breast cancer outcomes--stage at diagnosis, treatment selected, survival--focusing on comparisons among women aged 65 or more having Medicare alone, Medicare/Medicaid, or Medicare with group model HMO, non-group model HMO, or private fee-for-service (FFS) supplement. DESIGN Retrospectively defined cohort from Sacramento, Calif, regional cancer registry. SETTING Thirteen-county region in northern California with mature managed care market. PATIENTS Female invasive breast cancer patients aged 65 or more (N = 1,146), diagnosed 1987-1993. MEASUREMENTS AND MAIN RESULTS Health insurance was determined from hospital records. Outcomes were analyzed with multivariate regression models, controlling for age, ethnicity, time, and SES measures. Stage I diagnosis was more likely among group model HMO patients than among private FFS insured (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.84 to 2.40). Stage I tumors were significantly less likely for Medicaid patients (OR, 0.50; 95% CI, 0.31 to 0.82). Use of breast-conserving surgery plus radiation (BCS+) varied significantly by hospital type (including HMO-owned and various-sized community hospitals) and time. Survival of patients with private FFS, group-, and non-group model HMO insurance was not significantly different, but was for those with Medicaid or Medicare alone. CONCLUSIONS This study sheds new light on the relationship of insurance to stage and survival among older breast cancer patients, highlighting the importance of distinguishing types of HMOs and types of FFS plans. These outcomes do not differ significantly between women with Medicare who are in HMOs and those with private FFS supplemental insurance. However, patients with Medicare/Medicaid or Medicare alone are at risk for poorer outcomes.
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Affiliation(s)
- A Lee-Feldstein
- Center for Health Policy and Research, Department of Medicine, College of Medicine, University of California, Irvine, Calif 92697-5800, USA
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Buban GM, Link BK, Doucette WR. Influences on oncologists' adoption of new agents in adjuvant chemotherapy of breast cancer. J Clin Oncol 2001; 19:954-9. [PMID: 11181657 DOI: 10.1200/jco.2001.19.4.954] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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).
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Affiliation(s)
- G M Buban
- Wellmark Foundation, Des Moines, Iowa, USA
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Roetzheim RG, Gonzalez EC, Ferrante JM, Pal N, Van Durme DJ, Krischer JP. Effects of health insurance and race on breast carcinoma treatments and outcomes. Cancer 2000; 89:2202-13. [PMID: 11147590 DOI: 10.1002/1097-0142(20001201)89:11<2202::aid-cncr8>3.0.co;2-l] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma. METHODS The authors examined treatments and adjusted risk of death (through 1997) for all incident cases of breast carcinoma occurring in Florida in 1994 (n = 11,113) by using state tumor registry data. RESULTS Patients lacking health insurance were less likely to receive breast-conserving surgery (BCS) compared with patients who had private health insurance. Among patients insured by Medicare, those belonging to a health maintenance organization (HMO) were more likely to receive BCS but less likely to receive radiation therapy after BCS. Non-Hispanic African Americans had higher mortality rates even when stage at diagnosis, insurance payer, and treatment modalities used were adjusted in multivariate models (adjusted risk ratio [RR], 1.35; 95% confidence interval [CI], 1.12-1.61; P = 0.001). Patients who had HMO insurance had similar survival rates compared with those with fee-for-service (FFS) insurance. Among non-Medicare patients, mortality rates were higher for patients who had Medicaid insurance (RR, 1.58, 95% CI, 1.18-2.11; P = 0.002) and those who lacked health insurance (RR, 1.31; 95% CI, 1.03-1.68; P = 0.03) compared with patients who had commercial FFS insurance. There were no insurance-related differences in survival rates, however, once stage at diagnosis was controlled. CONCLUSIONS As a result of later stage at diagnosis, patients with breast carcinoma who were uninsured, or insured by Medicaid, had higher mortality rates. Mortality rates were also higher among non-Hispanic African Americans, a finding that was not fully explained by differences in stage at diagnosis, treatment modalities used, or insurance payer.
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Affiliation(s)
- R G Roetzheim
- University of South Florida, Department of Family Medicine, Tampa 33612, USA.
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Nold RJ, Beamer RL, Helmer SD, McBoyle MF. Factors influencing a woman's choice to undergo breast-conserving surgery versus modified radical mastectomy. Am J Surg 2000; 180:413-8. [PMID: 11182389 DOI: 10.1016/s0002-9610(00)00501-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The use of breast-conserving surgery (BCS) rather than modified radical mastectomy (MRM) for the treatment of breast carcinoma is an option for the majority of women (75%) with early stage breast cancer, but only 20% to 50% choose to undergo this procedure nationwide. The objective of this study was to identify factors influencing a woman's choice between BCS and MRM, and specifically, the surgeon's influence on this choice. METHODS A total of 134 women eligible for BCS were sent a survey. Data obtained included demographics, influential factors in treatment choice, and satisfaction with preoperative discussion and postoperative results. RESULTS Ninety-six women completed the questionnaire. Mean patient age was 62 years. Most women surveyed felt their treatment options were satisfactorily explained to them. BCS, MRM with reconstruction (MRM-R), and MRM without reconstruction (MRM-NR) were performed in 45%, 15%, and 40% of patients, respectively. Overall, the most influential factor was the fear of cancer. Women choosing BCS indicated that the surgeon, cosmetic result, and psychological aspects were more influential in their decision than in women undergoing MRM-NR (P <0.02). Fear of cancer was the most important factor affecting the choice to undergo MRM-NR. In comparing MRM-R with MRM-NR, there was a similar fear of cancer; however, MRM-R had much greater concern with cosmesis (P = 0.0002). CONCLUSION The surgeon's input is important in a woman's choice to undergo BCS or MRM-R. However, it appears that if a woman wants to have MRM-NR, even when she is a candidate for BCS, the surgeon's input is overshadowed by the patient's fear of cancer.
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Affiliation(s)
- R J Nold
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, Kansas 67214, USA
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Brooks JM, Chrischilles E, Scott S, Ritho J, Chen-Hardee S. Information gained from linking SEER Cancer Registry Data to state-level hospital discharge abstracts. Surveillance, Epidemiology, and End Results. Med Care 2000; 38:1131-40. [PMID: 11078053 DOI: 10.1097/00005650-200011000-00007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Our goal was to link patients from the Iowa Surveillance, Epidemiology, and End Results (SEER) Registry to their respective inpatient discharge abstracts from an Iowa Health Care Cost and Utilization Project (HCUP)-formatted database and evaluate whether this linkage provides information related to cancer treatment variation. METHODS Computer algorithms linked patients from the Iowa SEER Registry to discharge abstracts using 5 variables consistently defined between the databases (hospital identification, date of birth, admission date, discharge date, and zip code). Abstracts were reviewed for validity, and links not passing face validity were excluded. SUBJECTS Our sample contained 7,296 patients with early-stage breast cancer (I, IIa, IIb) with surgery from the Iowa SEER Registry from 1989 through 1994 with contacts only with Iowa hospitals. RESULTS Inpatient discharges abstracts were linked to 86.4% of the patients in our sample. More than 96% of the linked discharges for Medicare patients had a corresponding Medicare claim. Over 45% of the linked patients were not covered by Medicare. Comorbidity indexes were comparable to other published sources. Significant differences in diagnosis, comorbidities, and treatment were found across third-party payers. CONCLUSIONS This linkage provides a valuable source of comorbidity and insurance data and perhaps the only source of secondary clinical information for the uninsured. This linkage is best suited for cancers requiring inpatient stays for treatment and for those states where border crossing for treatment is low.
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Affiliation(s)
- J M Brooks
- College of Pharmacy, University of Iowa, Iowa City 52242, USA.
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Nattinger AB, Hoffmann RG, Kneusel RT, Schapira MM. Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery. Lancet 2000; 356:1148-53. [PMID: 11030294 DOI: 10.1016/s0140-6736(00)02757-4] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Breast-conserving surgery is a more complex treatment than mastectomy, because a separate incision is needed for axillary lymph-node dissection, and postoperative radiotherapy is necessary. We postulated that adoption of this therapy into clinical practice might have led to discrepancies between the care recommended and that received. METHODS We used records of the US national Surveillance, Epidemiology, and End Results tumour registry to study 144,759 women aged 30 years and older who underwent surgery for early-stage breast cancer between 1983 and 1995. We calculated the proportion undergoing at least the minimum appropriate primary treatment (defined, in accordance with the recommendations of a National Institutes of Health Consensus Conference in 1990, as total mastectomy with axillary node dissection or breast-conserving surgery with axillary node dissection and radiotherapy) during each 3-month period. FINDINGS The proportion of women receiving appropriate primary therapy fell from 88% in 1983-89 to 78% by the end of 1995. This decline was observed in all subgroups of age, race, stage, and population density. Of all women in the cohort, the proportion undergoing an inappropriate form of mastectomy remained stable at about 2.7% throughout the study period. The proportion undergoing an inappropriate form of breast-conserving surgery (omission of radiotherapy, axillary node dissection, or both) increased from 10% in 1989 to 19% at the end of 1995. INTERPRETATION Although most women undergo appropriate care, the appropriateness of care for early-stage breast cancer in the USA declined from 1990 to 1995. Because the proportion of all women who were treated by breast-conserving surgery increased, and because this approach was more likely than was mastectomy to be applied inappropriately, the proportion of all women having inappropriate care increased.
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Affiliation(s)
- A B Nattinger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, USA
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Mandelblatt JS, Hadley J, Kerner JF, Schulman KA, Gold K, Dunmore-Griffith J, Edge S, Guadagnoli E, Lynch JJ, Meropol NJ, Weeks JC, Winn R. Patterns of breast carcinoma treatment in older women. Cancer 2000. [DOI: 10.1002/1097-0142(20000801)89:3<561::aid-cncr11>3.0.co;2-a] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Du X, Freeman JL, Warren JL, Nattinger AB, Zhang D, Goodwin JS. Accuracy and completeness of Medicare claims data for surgical treatment of breast cancer. Med Care 2000; 38:719-27. [PMID: 10901355 DOI: 10.1097/00005650-200007000-00004] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although a number of studies have used Medicare claims data to study trends and variations in breast cancer treatment, the accuracy and completeness of information on surgical treatment for breast cancer in the Medicare data have not been validated. OBJECTIVES This study assessed the accuracy and completeness of Medicare claims data for breast cancer surgery to determine whether Medicare claims can serve as a source of data to augment information collected by cancer registries. METHODS We used the Surveillance, Epidemiology and End Results (SEER) Cancer Registry-Medicare data and compared Medicare claims on surgery with the surgery recorded by the SEER registries for 23,709 women diagnosed with breast cancer at > or =65 years of age from 1991 through 1993. RESULTS More than 95% of women having mastectomies according to the Medicare data were confirmed by SEER. For breast-conserving surgery, 91% of cases were confirmed by SEER. The Medicare physician services claims and inpatient claims were approximately equal in accuracy on type of surgery. The Medicare outpatient claims were less accurate for breast-conserving surgery. In terms of completeness, when the 3 claims sources were combined, 94% of patients receiving breast cancer surgery according to SEER were identified by Medicare. CONCLUSIONS The combined Medicare claims database, which includes the inpatient, outpatient, and physician service claims, provides valid information on surgical treatment among women known to have breast cancer. The claims are a rich source of data to augment the information collected by tumor registries and provide information that can be used to follow long-term outcomes of Medicare beneficiaries.
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Affiliation(s)
- X Du
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston 77555-0460, USA.
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Du X, Freeman DH, Syblik DA. What drove changes in the use of breast conserving surgery since the early 1980s? The role of the clinical trial, celebrity action and an NIH consensus statement. Breast Cancer Res Treat 2000; 62:71-9. [PMID: 10989987 DOI: 10.1023/a:1006414122201] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Three important events in the history of breast cancer treatment occurred between 1983 and 1995: a large clinical trial, first lady Nancy Reagan's choice of mastectomy and the publishing of an NIH consensus statement. OBJECTIVE To assess the effects of these events on use of breast conserving surgery (BCS). RESEARCH DESIGN Data from the cohort study of the surveillance, epidemiology and end results (SEER) Program from 1983 to 1995 were divided into four periods: Baseline, Trial, Celebrity, and Consensus. SUBJECTS Of the women, 169,466 diagnosed with early stage breast cancer in nine SEER areas. MEASURES Monthly percentages of BCS. RESULTS A linear regression model generated a separate intercept and slope term for four time periods, adjusting for demographic characteristics of breast cancer patients. For the Baseline, Celebrity and Consensus Periods, slopes indicated an increasing use of BCS which varied between 0.24% and 0.28% per month. Slopes for these three periods were not statistically different (p = 0.120). In contrast, there was no change in use of BCS during the trial period (p = 0.247). We tested the magnitude of discontinuity between periods. At the beginning of the trial, celebrity and consensus periods, there were increases in BCS of 5.54% (p < 0.001), -3.55% (p < 0.001), and 2.37% (p < 0.001), respectively. CONCLUSIONS The use of BCS was substantially affected by the reports of a clinical trial of BCS and by celebrity action. These effects were abrupt but transient. The NIH consensus statement stimulated a small change in use of BCS and may be an important intervention for maintaining the increasing trend in use of BCS since the 1990s.
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Affiliation(s)
- X Du
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston 77555-0460, USA.
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Nattinger AB. Care for breast cancer: the adoption of newer clinical paradigms. Med Care 2000; 38:693-5. [PMID: 10901352 DOI: 10.1097/00005650-200007000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lazovich D, Raab KK, Gurney JG, Chen H. Knowledge and preference for breast conservation therapy among women without breast cancer. Womens Health Issues 2000; 10:210-6. [PMID: 10899668 DOI: 10.1016/s1049-3867(00)00045-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We interviewed 419 adult women in Minnesota, who were selected at random and without a history of breast cancer, to ascertain what percentage could correctly report that cure was the same for breast conservation therapy and mastectomy, what percentage would state a preference for breast conservation therapy rather than mastectomy, and characteristics associated with these outcomes. Nearly all women (n = 360; 86%) had heard of both mastectomy and breast conservation therapy; among these women, 37% correctly reported that the two treatments were equally efficacious. Given a scenario where they were diagnosed with breast cancer amenable to either treatment, 58% of participants stated a preference for breast conservation therapy. Older women were less likely than younger women to know that cure was the same for breast conservation therapy and mastectomy (adjusted OR = 0.5, 95% CI 0.2, 1.0), and women residing in urban areas were more likely to prefer breast conservation therapy over mastectomy compared to rural residents (adjusted OR = 2.2, 95% CI 1. 3, 3.8). Comparing these findings to women diagnosed with breast cancer in Minnesota, breast conservation therapy was found to be performed less frequently than preference for such therapy among women in our study would suggest. Educating women prior to diagnosis about breast cancer treatment options, and exploring reasons for the gap between actual utilization of breast conservation therapy and prediagnosis preference, may be indicated.
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Affiliation(s)
- D Lazovich
- Division of Epidemiology School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Freeman JL, Zhang D, Freeman DH, Goodwin JS. An approach to identifying incident breast cancer cases using Medicare claims data. J Clin Epidemiol 2000; 53:605-14. [PMID: 10880779 DOI: 10.1016/s0895-4356(99)00173-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study developed and evaluated a method for ascertaining a newly diagnosed breast cancer case using multiple sources of data from the Medicare claims system. Predictors of an incident case were operationally defined as codes for breast cancer-related diagnoses and procedures from hospital inpatient, hospital outpatient, and physician claims. The optimal combination of predictors was then determined from a logistic regression model using 1992 data from the linked SEER registries-Medicare claims data base and a sample of noncancer controls drawn from the SEER areas. While the ROC curve demonstrates that the model can produce levels of sensitivity and specificity above 90%, the positive predictive value is comparatively low (67-70%). This low predictive value is largely the result of the model's limitation in distinguishing recurrent and secondary malignancies from incident cases and possibly from the model identifying true incident cases not identified by SEER. Nevertheless, the logistic regression approach is a useful method for ascertaining incident cases because it allows for greater flexibility in changing the performance characteristics by selecting different cut-points depending on the application (e.g., high sensitivity for registry validation, high specificity for outcomes research). It also allows us to make specific adjustments to population based estimates of breast cancer incidence with claims.
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Affiliation(s)
- J L Freeman
- Division of Geriatric Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA.
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Guadagnoli E, Soumerai SB, Gurwitz JH, Borbas C, Shapiro CL, Weeks JC, Morris N. Improving discussion of surgical treatment options for patients with breast cancer: local medical opinion leaders versus audit and performance feedback. Breast Cancer Res Treat 2000; 61:171-5. [PMID: 10942103 DOI: 10.1023/a:1006475012861] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We studied whether a hospital intervention utilizing medical opinion leaders and performance feedback reduced the proportion of women who reported that surgeons did not discuss options prior to surgery for early stage breast cancer. Opinion leaders provided clinical education to their peers using a variety of strategies and were selected for their ability to influence their peers. Performance feedback involved distributing performance reports that contained data on the outcomes of interest as well as on other treatment patterns. Twenty-eight hospitals in Minnesota were randomized to the intervention or to a control group that received performance feedback only. The proportion of patients at intervention hospitals who said that their surgeon did not discuss options decreased significantly (p < 0.001) from 33% to 17%, but a similar decrease was observed among control hospitals. Using medical opinion leaders to intervene in hospitals appeared as effective as performance feedback.
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Affiliation(s)
- E Guadagnoli
- Departmnent of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
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50
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Morris CR, Cohen R, Schlag R, Wright WE. Increasing trends in the use of breast-conserving surgery in California. Am J Public Health 2000; 90:281-4. [PMID: 10667193 PMCID: PMC1446135 DOI: 10.2105/ajph.90.2.281] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The purpose of this study was to determine temporal trends in breast-conserving surgery in California from 1988 through 1995. METHODS Logistic regression was used to analyze data on 104,466 cases of early-stage breast cancer reported to the California Cancer Registry. RESULTS A monotonically increasing trend in breast-conserving surgery was detected after adjustment for age, race/ethnicity, stage at diagnosis, and neighborhood education level. Breast-conserving surgery increased at similar rates among all racial/ethnic groups. Older age, Asian or Hispanic race/ethnicity, late-stage diagnosis, and residence in an undereducated neighborhood were factors associated with lower use of breast-conserving surgery. CONCLUSIONS Although disparities are evident, use of breast-conserving surgery increased steadily in all groups examined in this study.
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Affiliation(s)
- C R Morris
- California Cancer Registry, Public Health Institute, Sacramento, Calif. 95815-4402, USA.
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