Institutional Variation in the Surgical Treatment of Breast Cancer

Abstract

Objective To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer. Background Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON. Methods Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care. Results Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = −0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction. Conclusions Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.

Breast conserving therapy for DCIS—Does size matter?

“…In a study of 10,607 patients with stage 0, I, and II breast cancer at NCCN institutions from 2000 to 2006, institution factors were found to be more important than all other patient factors except age in predicting receipt of reconstruction or BCS [37].…”

Regional Variation in the Management of Metastatic Gastric Cancer in Ontario

“…Despite attempts to standardize practice, variations in the provision of gastric cancer care have been demonstrated for multiple health care system variables, especially between geographic regions and centres of care [29][30][31][32][33] . Geographic variation in practice patterns commonly occurs when accepted standards of care do not exist for a particular disease, or if resources are limited or unavailable and alternative approaches are required [1][2][3]5,32,34 . Even in the presence of clear recommendations for clinical care, uptake of clinical guidelines can be greatly influenced by geographic location and prevailing health care system characteristics 1,2 .…”

“…Geographic variation in the provision of cancer care is observed both between and within countries 1 . Variation in care provided can occur at any point along the cancer care continuum, including diagnostic workup, multimodal treatment, and end-of-life care or symptom palliation.…”

“…Where multiple, non-superior protocols for managing a single clinical scenario exist, physician and patient preference dominate decision-making 2 . Practice variation can be especially common when randomized controlled trial evidence is not available to inform optimal patient management or when a disease is rare and defined protocols do not exist [1][2][3][4][5] .…”

Breast Cancer Surgery

“…At present, modified radical mastectomy remains necessary only in certain situations, mandatory in advanced stages, but not a standard, being replaced by conservative treatment (2).…”