Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer

Surgeon and Care Team Network Measures and Timely Breast Cancer Treatment

Importance

Cancer treatment delay is a recognized marker of worse outcomes. Timely treatment may be associated with physician patient-sharing network characteristics, yet this remains understudied.

Objective

To examine the associations of surgeon and care team patient-sharing network measures with breast cancer treatment delay.

Design, Setting, and Participants

This cross-sectional study of Medicare claims in a US population-based setting was conducted from 2017 to 2020. Eligible participants included patients with breast cancer who received surgery and the subset who went on to receive adjuvant therapy. Patient-sharing networks were constructed for treating physicians. Data were analyzed from September 2023 to February 2024.

Exposures

Surgeon linchpin score (a measure of local uniqueness or scarcity) and care density (a measure of physician team familiarity) were assessed. Surgeons were considered linchpins if their linchpin score was in the top 15%. The care density of a patient's physician team was calculated on preoperative teams for surgically-treated patients and postoperative teams for adjuvant therapy-receiving patients.

Main Outcomes and Measures

The primary outcomes were surgical and adjuvant delay, which were defined as greater than 60 days between biopsy and surgery and greater than 60 days between surgery and adjuvant therapy, respectively.

Results

The study cohort included 56 433 patients (18 004 aged 70-74 years [31.9%]) who were mostly from urban areas (44 931 patients [79.6%]). Among these patients, 8009 (14.2%) experienced surgical delay. Linchpin surgeon status (locally unique surgeon) was not statistically associated with surgical delay; however, patients with high preoperative care density (ie, high team familiarity) had lower odds of surgical delay compared with those with low preoperative care density (odds ratio [OR], 0.58; 95% CI, 0.53-0.63). Of the 29 458 patients who received adjuvant therapy after surgery, 5700 (19.3%) experienced adjuvant delay. Patients with a linchpin surgeon had greater odds of adjuvant delay compared with those with a nonlinchpin surgeon (OR, 1.30; 95% CI, 1.13-1.49). Compared with those with low postoperative care density, there were lower odds of adjuvant delay for patients with high postoperative care density (OR, 0.77; 95% CI, 0.69-0.87) and medium postoperative care density (OR, 0.85; 95% CI, 0.77-0.94).

Conclusions and Relevance

In this cross-sectional study of Medicare claims, network measures capturing physician scarcity and team familiarity were associated with timely treatment. These results may help guide system-level interventions to reduce cancer treatment delays.

Early access to a cardio-oncology clinic in an Australian context: a qualitative exploration of patient experiences

Background

Dedicated cardio-oncology services are emerging rapidly around the world in order to provide cardiovascular care (CV) for cancer patients. The perspectives of patients regarding their experience of cardiac surveillance during their cancer journey has not been qualitatively evaluated.

Methods

An interpretative qualitative study. Fifteen, in-depth qualitative interviews were conducted with a diverse range of community dwelling patients who attended a newly established cardio-oncology clinic in a large regional city in Australia. Data were analysed using an inductive thematic approach.

Results

Key themes were identified: (1) Access to a cardio-oncology clinic promotes information and understanding, (2) The experience of early CV intervention, (3) Factors promoting integrated care, (4) Balancing cancer treatment and CV symptoms and (5) Managing past and emerging CV risk factors.

Conclusion

As cardio oncology clinics continue to emerge, this study confirms the benefit of early access to a cardiologist for management of existing or emerging CV risk factors and diseases in the context of cancer treatment. Participants valued the opportunity for regular monitoring and management of CV issues that enabled them to continue cancer treatment. However, we identified gaps in education and support towards making positive lifestyle changes that reduce the risk of CV diseases in cancer patients.

Improving Breast Cancer Surgical Treatment Decision Making: The iCanDecide Randomized Clinical Trial

Purpose This study was conducted to determine the effect of iCanDecide, an interactive and tailored breast cancer treatment decision tool, on the rate of high-quality patient decisions-both informed and values concordant-regarding locoregional breast cancer treatment and on patient appraisal of decision making. Methods We conducted a randomized clinical trial of newly diagnosed patients with early-stage breast cancer making locoregional treatment decisions. From 22 surgical practices, 537 patients were recruited and randomly assigned online to the iCanDecide interactive and tailored Web site (intervention) or the iCanDecide static Web site (control). Participants completed a baseline survey and were mailed a follow-up survey 4 to 5 weeks after enrollment to assess the primary outcome of a high-quality decision, which consisted of two components, high knowledge and values-concordant treatment, and secondary outcomes (decision preparation, deliberation, and subjective decision quality). Results Patients in the intervention arm had higher odds of making a high-quality decision than did those in the control arm (odds ratio, 2.00; 95% CI, 1.37 to 2.92; P = .0004), which was driven primarily by differences in the rates of high knowledge between groups. The majority of patients in both arms made values-concordant treatment decisions (78.6% in the intervention arm and 81.4% in the control arm). More patients in the intervention arm had high decision preparation (estimate, 0.18; 95% CI, 0.02 to 0.34; P = .027), but there were no significant differences in the other decision appraisal outcomes. The effect of the intervention was similar for women who were leaning strongly toward a treatment option at enrollment compared with those who were not. Conclusion The tailored and interactive iCanDecide Web site, which focused on knowledge building and values clarification, positively affected high-quality decisions largely by improving knowledge compared with static online information. To be effective, future patient-facing decision tools should be integrated into the clinical workflow to improve decision making.

Evaluating a Decision Aid for Improving Decision Making in Patients with Early-stage Breast Cancer

BACKGROUND

Early-stage breast cancer patients face a series of complex treatment decisions, with the first typically being choice of locoregional treatment. There is a need for tools to support patients in this decision-making process.

METHODS

We developed an innovative, online locoregional treatment tool based on International Patient Decision Aids Standards criteria. We evaluated its impact on patient knowledge about treatment and appraisal of decision making in a pilot study using a clinical sample of newly diagnosed, breast cancer patients who were randomized to view the decision aid website first or complete a survey prior to viewing the decision aid. Differences in knowledge and decision appraisal between the two groups were compared using t-tests and chi-square tests. Computer-generated preferences for treatment were compared with patients' stated preferences using chi-square tests.

RESULTS

One hundred and one newly diagnosed patients were randomized to view the website first or take a survey first. Women who viewed the website first had slightly higher, though not significantly, knowledge about surgery (p = 0.29) and reconstruction (p = 0.10) than the survey-first group. Those who viewed the website first also appraised their decision process significantly more favorably than did those who took the survey first (p < 0.05 for most decision outcomes). There was very good concordance between computer-suggested and stated treatment preferences.

CONCLUSION

This pilot study suggests that an interactive decision tool shows promise for supporting early-stage breast cancer patients with complicated treatment decision making.

Individual, Area, and Provider Characteristics Associated With Care Received for Stages I to III Breast Cancer in a Multistate Region of Appalachia

PURPOSE

We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania.

METHODS

Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER) -positive/progesterone receptor (PR) -positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type.

RESULTS

Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission.

CONCLUSION

Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.

Surgeon specialization and use of sentinel lymph node biopsy for breast cancer

IMPORTANCE

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema.

OBJECTIVE

To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer.

DESIGN, SETTING, AND POPULATION

A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined.

MAIN OUTCOME AND MEASURE

Type of axillary surgery performed.

RESULTS

Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB.

CONCLUSIONS AND RELEVANCE

Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.

Surgeon-level variation in patients' appraisals of their breast cancer treatment experiences

BACKGROUND AND PURPOSE

While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.

METHODS

Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.

RESULTS

Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4% for access to care, 3.3% for care coordination, and 7.5% for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.

CONCLUSIONS

Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.

The influence of non-clinical patient factors on medical oncologists' decisions to recommend breast cancer adjuvant chemotherapy

The extent to which medical oncologists consider non-clinical patient factors when deciding to recommend adjuvant chemotherapy is unknown. Medical oncologists who treated a population-based sample of early stage breast cancer patients reported to the Los Angeles and Detroit Surveillance, Epidemiology, and End Results registries 2005-2007 were asked how strongly they consider a patient's ability to follow instructions, level of social support, and level of work support/flexibility in decisions to recommend adjuvant chemotherapy. Responses of 4 (Quite strongly) or 5 (Very strongly) on a five-point Likert scale defined strong consideration. Associations between oncologist/practice characteristics and strong consideration of each non-clinical factor were examined. 134 oncologists (66 %) reported strong consideration of one or more factor. Ability to follow instructions was strongly considered by 120 oncologists (59 %), social support by 78 (38 %), and work support/flexibility by 73 (36 %). Larger percent of practice devoted to breast cancer was associated with lower likelihood of strongly considering ability to follow instructions [odds ratio (OR) 0.98, 95 % confidence interval (CI) 0.97-0.99; P = 0.04]. Increased years in practice was associated with lower likelihood of strongly considering social support (OR 0.96, CI 0.93-0.99; P = 0.011), while non-white race (OR 2.1, CI 1.03-4.26; P = 0.041) and tumor board access (OR 2.04, CI 1.01-4.12; P = 0.048) were associated with higher likelihood. Non-white race was associated with strongly considering work support/flexibility (OR 2.44, CI 1.21-4.92; P = 0.013). Tumor board access (OR 2, CI 1.00-4.02; P = 0.051) was borderline significant. Non-clinical patient factors play a role in medical oncologist decision-making for breast cancer adjuvant chemotherapy recommendations.

Coordination of breast cancer care between radiation oncologists and surgeons: a survey study

PURPOSE

To assess whether radiation oncologists and surgeons differ in their attitudes regarding the local management of breast cancer, and to examine coordination of care between these specialists.

METHODS AND MATERIALS

We surveyed attending surgeons and radiation oncologists who treated a population-based sample of patients diagnosed with breast cancer in metropolitan Detroit and Los Angeles. We identified 419 surgeons, of whom 318 (76%) responded, and 160 radiation oncologists, of whom 117 (73%) responded. We assessed demographic, professional, and practice characteristics; challenges to coordinated care; and attitudes toward management in three scenarios.

RESULTS

92.1% of surgeons and 94.8% of radiation oncologists indicated access to a multidisciplinary tumor board. Nevertheless, the most commonly identified challenge to radiation oncologists, cited by 27.9%, was failure of other providers to include them in the treatment decision process early enough. Nearly half the surgeons (49.7%) stated that few or almost none of the breast cancer patients they saw in the past 12 months had consulted with a radiation oncologist before undergoing definitive surgery. Surgeons and radiation oncologists differed in their recommendations in management scenarios. Radiation oncologists were more likely to favor radiation than were surgeons for a patient with 3/20 lymph nodes undergoing mastectomy (p = 0.03); surgeons were more likely to favor more widely clear margins after breast conservation than were radiation oncologists (p = 0.001).

CONCLUSIONS

Despite the widespread availability of tumor boards, a substantial minority of radiation oncologists indicated other providers failed to include them in the breast cancer treatment decision-making process early enough. Earlier inclusion of radiation oncologists may influence patient decisions, and interventions to facilitate this should be considered.

Integrated oncogeriatric approach: a systematic review of the literature using concept analysis

OBJECTIVES

The purpose of this study was to provide a more precise definition of an integrated oncogeriatric approach (IOGA) through concept analysis.

DATA SOURCES

The literature was reviewed from January 2005 to April 2011 integrating three broad terms: geriatric oncology, multidisciplinarity and integrated care delivery models.

STUDY ELIGIBILITY CRITERIA

Citation selection was based on: (1) elderly cancer patients as the study population; (2) disease management and (3) case studies, intervention studies, assessments, evaluations and studies. Inclusion and exclusion criteria were refined in the course of the literature search.

INTERVENTIONS

Initiatives in geriatric oncology that relate to oncology services, social support services and primary care services for elderly cancer patients.

PARTICIPANTS

Elderly cancer patients aged 70 years old or more.

STUDY APPRAISAL AND SYNTHESIS METHODS

Rodgers' concept analysis method was used for this study. The analysis was carried out according to thematic analysis based on the elements of the Chronic Care Model.

RESULTS

The search identified 618 citations. After in-depth appraisal of 327 potential citations, 62 articles that met our inclusion criteria were included in the analysis. Three IOGA main attributes were identified, which constitute IOGA's core aspects: geriatric assessment (GA), comorbidity burden and treatment outcomes. The IOGA concept comprises two broad antecedents: coordinated healthcare delivery and primary supportive care services. Regarding the consequents of an integrated approach in geriatric oncology, the studies reviewed remain inconclusive.

CONCLUSIONS

Our study highlights the pioneering character of the multidimensional IOGA concept, for which the relationship between clinical and organisational attributes, on the one hand, and contextual antecedents, on the other, is not well understood. We have yet to ascertain IOGA's consequents. IMPLICATIONS OF KEY FINDINGS: There is clearly a need for a whole-system approach to change that will provide direction for multilevel (clinical, organisational, strategic) interventions to support interdisciplinary practice, education and research.

Dissemination of Quality-of-Care Research Findings to Breast Oncology Surgeons

PURPOSE

In this era of rapidly evolving clinical knowledge, clinicians need to be aware of current research and how it might affect their practice. The Internet is a widely available, under-assessed tool for providing this information. In this two-phase pilot study, a novel Web site (www.cansortsurgeons.org) was developed to specifically disseminate relevant clinical information to community breast oncology surgeons.

METHODS

The first phase targeted a sample of community surgeons identified from Surveillance, Epidemiology, and End Results catchment areas in Los Angeles, CA and Detroit, MI. The second phase broadened availability by linking the site through the American College of Surgeons (ACoS) Commission on Cancer (CoC) homepage. An eight-question, Web-based survey was used to obtain feedback regarding the Web site's utility and potential application to clinical practice. Journal continuing medical education credit was also offered through ACoS.

RESULTS

For phase 1, of the 315 community surgeons invited to view the site, 114 (36%) participated in the study and 98 (86%) responded to the survey. Overall, there was a strongly supportive response, with 79 (81%) recommending the site to other clinicians. For phase 2, of the 516 site hits, 411 came from the ACoS site. Only 10 individuals completed the survey during this phase, but all positively endorsed the utility of the site.

CONCLUSION

The implication for clinical practice is that the Internet is a useful tool for providing relevant clinical research to providers. In the future, this could be tailored to an individual's needs, aiding synthesis and, hopefully, improving the quality of clinical care.

A review and characterization of the various perceptions of quality cancer care

BACKGROUND

It is important to maintain high-quality cancer care while reducing spending. This requires an understanding of how stakeholders define "quality." The objective of this literature review was to understand the perceptions patients, physicians, and managed care professionals have about quality cancer care, especially chemotherapy.

METHODS

A computerized literature search was conducted for articles concerning quality cancer care in patients who received chemotherapy. Among >1100 identified sources, 25 presented interviews/survey results from stakeholders.

RESULTS

Patients defined quality cancer care as being treated well by providers, having multiple treatment options, and being part of the decision-making process. Waiting to see providers, having problems with referrals, going to different locations for treatment, experiencing billing inaccuracies, and navigating managed care reimbursement negatively affected patients' quality-of-care perceptions. Providers perceived quality cancer care as making decisions based on the risks-benefits of specific chemotherapy regimens and patients' health status rather than costs. Providers objected to spending substantial time interacting with payers instead of delivering care to patients. Payers must control the costs of cancer care but do not want an adversarial relationship with providers and patients. Payers' methods of managing cancer more efficiently involved working with providers to develop assessment and decision-assist tools.

CONCLUSIONS

Delivering quality cancer care is increasingly difficult because of the shortage of oncologists and rising costs of chemotherapy agents, radiation therapy, and imaging tests. The definition of quality cancer care differed among stakeholders, and healthcare reform must reflect these various needs to maintain and improve quality while controlling costs.

Perceptions of care coordination in a population-based sample of diverse breast cancer patients

OBJECTIVE

To identify factors associated with perceptions of care coordination in a diverse sample of breast cancer patients.

METHODS

Breast cancer patients reported to the metropolitan SEER registries of Detroit or Los Angeles from 6/05 to 2/07 were surveyed after diagnosis (N=2268, RR=72.4%). Outcomes were two dichotomous measures reflecting patient appraisal of care coordination during their treatment experience. Primary independent variables were race/ethnicity (white, African American, Latina-high acculturated, Latina-low acculturated) and health literacy (low, moderate, high). Logistic regression was used to evaluate factors associated with both measures of care coordination.

RESULTS

2148 subjects were included in the analytic dataset. 16.4% of women perceived low care coordination and 12.5% reported low satisfaction. Race/ethnicity was not significantly associated with care coordination. Women with low subjective health literacy were 3-4 times as likely as those with high health literacy to perceive low care coordination and low satisfaction with care coordination (OR=3.88; 95% CI: 2.78-5.41; OR=3.19 95% CI: 2.25-4.52, respectively).

CONCLUSIONS

Many breast cancer patients positively appraised their care coordination, but patients with low health literacy perceived low care coordination.

PRACTICE IMPLICATIONS

Providers should be aware of the health literacy deficits that may contribute to their patients' attitudes towards their breast cancer care coordination.

Employment of nurse practitioners and physician assistants in breast cancer care

PURPOSE

We sought to examine the employment of nurse practitioners (NPs) and physician assistants (PAs) in surgical, medical, and radiation oncology practices and to identify correlates of NP and PA employment.

METHODS

We conducted a mailed survey of attending surgeons, medical oncologists, and radiation oncologists who cared for a population-based sample of women diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles, CA, and Detroit, MI. In addition to information about whether practices employed NPs and/or PAs, physician and practice characteristics were obtained. We estimated the likelihood of the employment of NPs and PAs with multivariable logistic regression.

RESULTS

Overall, 39.6% of physicians reported that NPs and PAs were employed in their practice, although there were significant differences across specialty: medical oncologists (56.3%), radiation oncologists (40.0%), and surgeons (28.7%; P < .01). The likelihood of NP and PA employment increased for medical oncologists (compared with surgeons; odds ratio [OR], 2.63; 95% CI, 1.73 to 3.99), physicians with 10 or fewer years in practice (OR, 1.94; 95% CI, 1.18 to 3.16), and practices with university affiliations (OR, 2.20; 95% CI, 1.44 to 3.37). Physicians with fewer than 25% of their patients diagnosed with breast cancer (OR, 0.48; 95% CI, 0.25 to 0.92) and practices with fewer than three physicians (OR, 0.14; 95% CI 0.09, to 0.24) were less likely to employ NPs and PAs.

CONCLUSIONS

NP and PA employment was higher with newer physicians and in more heavily resourced practices. Employment of NPs and PAs was relatively modest, which suggests an opportunity for physicians to employ these providers to alleviate workloads.

Does it matter where you go for breast surgery?: attending surgeon's influence on variation in receipt of mastectomy for breast cancer

BACKGROUND

Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon's influence on the variation in receipt of these procedures.

OBJECTIVES

To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer.

METHODS

Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment.

RESULTS

Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th-95th percentile, 9%-65%) then for mastectomy (median, 18%; 5th-95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%).

CONCLUSION

Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.

Challenges and economics of private breast cancer surgery practice

The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.