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Consultation With a Medical Oncologist Before Surgery and Type of Surgery Among Elderly Women With Early-Stage Breast Cancer

Nancy L. Keating, Mary Beth Landrum, John Z. Ayanian, Eric P. Winer, Edward Guadagnoli

From the Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital; the Department of Health Care Policy, Harvard Medical School; and the Department of Adult Oncology, Dana-Farber Cancer Institute, Boston, MA.

Address reprint requests to Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115; e-mail: keating{at}hcp.med.harvard.edu.

Purpose: Prior studies have documented variation in breast cancer treatment and care that does not follow guideline recommendations, particularly for elderly women. We assessed whether consultation with a medical oncologist before surgery was associated with use of definitive surgery, axillary node dissection, and type of surgery.

Methods: We conducted a retrospective cohort study of a population-based sample of 9,630 women aged 66 years diagnosed with breast cancer during 1995 to 1996. We measured the adjusted proportion visiting a medical oncologist before surgery, identified factors associated with such visits, and assessed the association between visits with a medical oncologist and use of definitive surgery (mastectomy or breast-conserving surgery with radiation v breast-conserving surgery without radiation); axillary dissection; and breast-conserving surgery versus mastectomy among women undergoing definitive surgery.

Results: Nineteen percent of women visited a medical oncologist before surgery; these women were younger, more often had larger or more poorly differentiated cancers, had more comorbid illnesses, and were treated more often at a teaching hospital (all P < .05). Women who saw a medical oncologist before surgery were more likely than others to undergo definitive surgery (adjusted odds ratio [OR], 1.28; 95% CI, 1.05 to 1.56) and axillary dissection (adjusted OR, 1.44; 95% CI, 1.19 to 1.73), but less likely to undergo breast-conserving surgery among women undergoing definitive surgery (OR, 0.84; 95% CI, 0.75 to 0.95).

Conclusion: Elderly women who consulted with a medical oncologist before surgery were more likely to receive guideline-recommended care. Additional research is needed allow a better understanding of the quality and content of discussions that elderly women have with various providers about breast-conserving surgery and mastectomy.

Supported by a Clinical Scientist Development Award (to N.L.K.) from the Doris Duke Charitable Foundation.

This study used the Linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. We acknowledge the efforts of the Applied Research Program, National Cancer Institute; the Office of Information Services, and the Office of Strategic Planning, Centers for Medicare and Medicaid Services; Information Management Services (IMS), Inc; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

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