Background: In patients with early stage breast cancer treated with curative intent, follow-up guidelines vary widely among national organizations. We sought to evaluate patterns and predictors of provider follow-up care within the first five years following diagnosis. Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset, we evaluated patients diagnosed with stages I and II breast cancer who underwent breast-conserving surgery from 2002–2007 with follow-up until 2012. We defined discontinuation of follow-up as >12 months from the prior physician visit without a visit claim from either a surgeon, medical oncologist (MO) or radiation oncologist (RO). We performed a multivariable logistic regression and Cox proportional hazards analysis to determine factors associated with discontinuation of follow-up care. Results: Of the 30,053 patients in our initial cohort, 25,781 (85.8%) saw a MO and 21,612 (71.9%) saw a RO in the first year in addition to a surgeon. During the five years, 6,302 (21.0%) patients discontinued follow-up visits. Discontinuation of physician visits increased with increasing age. Women with stage II cancer (vs. stage I) were less likely to discontinue follow-up visits (OR 0.78, 95% CI 0.73–0.83). Time to early discontinuation was greater for patients with hormone receptor-negative tumors (HR 1.14 , 95% CI 1.05–1.24). Women diagnosed more recently were less likely to discontinue seeing any physician. Conclusions: Twenty-one percent of early stage breast cancer patients discontinued seeing any oncology provider during the five years following diagnosis. Coordination of follow-up care between oncology specialists may reduce discontinuation rates and increase clinical efficiency.
Introduction: In patients with early stage breast cancer (BC) treated with curative intent, multidisciplinary teams (MDT) have emerged as a way to involve a wide range of specialists and encourage effective communication to formulate an optimal treatment strategy for patients. We sought to evaluate the frequency and predictors of MDT evaluation in patients with BC. Methods: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset to evaluate patients diagnosed with stages I and II breast cancer who underwent primary surgery from 2002-2007 and were followed through 2012. We evaluated claims for outpatient visits and characterized the treating physician as a surgeon, radiation oncologist (RO) or medical oncologist (MO). We defined MDT as having seen a physician in each of the three specialties within 12 months of diagnosis. We used multivariable logistic regression to evaluate factors associated with MDT. Results: A total of 35,484 stage I and II breast cancer patients were included in the analysis. Within the first year, 77.5% visited a medical oncologist, 57.8% visited a radiation oncologist, and 47% of women were seen by all 3 specialists. Prior to surgery, 4.9% of patients were seen by all 3 physicians, with 14.8% seen by a MO and 16.4% seen by a RO in addition to the surgeon. Evaluation by a MDT was more frequent in women who had a lumpectomy vs mastectomy (57.1% vs 28.4%, p<0.0001), Caucasian race as opposed to black and Hispanic (47.4% vs 42.1% vs 37.4%, p<0.0001), those that lived in an urban setting versus rural (48.1% vs 36.25%, p<0.0001), and those that were married versus unmarried (50.8% vs 43.1%, p<0.0001). As age increased, the number of patients who saw all three physicians decreased. As socioeconomic status improved, more patients saw all three physicians. In a multivariate model, evaluation by a MDT was higher in patients with Stage II disease (OR [95% CI] = 1.10 [1.04-1.18]), diagnosed in 2006-2007 (as compared to 2002-2005) (OR = 1.73 [1.63-1.85]), and those who received chemotherapy (OR = 1.51 [1.39-1.64]) and was less likely for older women (OR = 0.77 [0.71-0.84]), those who underwent mastectomy (OR = 0.73 [0.68-0.78]), and those in the lowest socioeconomic quintile (OR = 0.88 [0.80-0.97]). Of those seen by all 3 physicians in the first year, 20.4%, 10.1%, 6.1%, and 3.9% were seen by all 3 specialists in years 2, 3, 4 and 5 respectively. Only 2.2% of patients saw all three specialists all five years. Conclusions: Early stage breast cancer patients are evaluated by a medical oncologist, surgeon and radiation oncologist less than 50% of the time in the first year after diagnosis. Prior to surgery, where decision making may be most important, only 5% of patients were evaluated by all three specialties. Further research is needed to determine if MDT improves quality of care delivered, treatment adherence, patient satisfaction or breast cancer survival. Citation Format: Quyyumi F, Accordino MK, Buono DL, Neugut AI, Hillyer GC, Wright JD, Hershman DL. Factors associated with multidisciplinary care in the management of early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-14.
Introduction: In patients with early stage breast cancer treated with curative intent, optimal follow-up guidelines vary widely among national organizations. NCCN guidelines suggest patients should be followed by a medical oncologist (MO) every 3-6 months and by a radiation oncologist (RO) every 6-12 months for the first 5 years. These recommendations are not evidence based and have an unknown effect on cancer outcomes. We sought to evaluate the patterns of follow-up care and predictors of discontinuation of follow-up care. Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset, we evaluated patients diagnosed with stage I and II breast cancer who underwent surgery from 2002-2007 with follow-up to 2012. Patients who died in the 5-year period following diagnosis were excluded. We evaluated patterns of follow-up visits for the 5 years after diagnosis among surgeon, MO and RO. We defined discontinuation of follow-up care as >12 months without a visit claim from any of the three providers. We performed a Cox-proportional hazards multivariate analysis to determine factors associated with discontinuation of follow-up care. Patients were censored if a new cancer was diagnosed. Results: A total of 35,484 stage I and II breast cancer patients were included in the analysis. In addition to the surgeon, 77.5% saw a MO, and 57.8% saw RO in the first year. The mean number of total physician appointments for years 1-5 were 9.4, 3.3, 2.4, 2.0 and 1.7, respectively. During the 5 years, 13,908 (39.6%) patients discontinued follow-up visits. The discontinuation rate averaged about 12% per year for years 2-5. Discontinuing physician visits increased with increasing age. Patients who saw all 3 physicians in year 1 were less likely to discontinue follow-up visits (OR = 0.54, 0.51-0.57). Patients were more likely to discontinue physician visits if they were hormone receptor negative (HR = 1.41, 1.33-1.49), were black (HR = 1.14, 1.06-1.22) or Hispanic (HR = 1.36, 1.17-1.58) compared to white, lived in a rural as opposed to urban setting (HR 1.12, 1.05-1.18), were unmarried (HR = 1.16, 1.12-1.20), had a higher comorbidity score (HR = 1.15, 1.10-1.21), or were in a lower SES quintile (HR = 1.08, 1.02-1.15). Women who had a mastectomy (vs lumpectomy) (HR =0.83, 0.80-0.87) and those who were receiving chemotherapy (HR = 0.55, 0.52-0.59) or radiation therapy (OR = 0.60, 0.57-0.62) were less likely to discontinue physician visits. Conclusions: Clinical practice guidelines for surveillance of breast cancer after primary treatment are based on expert opinion and have an unclear effect on long-term outcomes. Coordination of follow-up care may reduce discontinuation. More research is needed to determine the optimal follow-up for maintaining adherence to therapy, reducing over-testing and encouraging secondary cancer screening guidelines. Citation Format: Hershman DL, Quyyumi F, Accordino MK, Buono DL, Neugut AI, Hillyer GC, Wright JD. Factors associated with follow up medical care among women with early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-06.
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