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Lost Opportunities: Physicians' Reasons and Disparities in Breast Cancer Treatment

Nina A. Bickell, Felice LePar, Jason J. Wang, Howard Leventhal

From the Department of Health Policy and Department of Medicine, Mount Sinai School of Medicine, New York, NY; and the Center for the Study of Health Beliefs and Behaviors, Rutgers State University of New Jersey, New Brunswick, NJ

Address reprint requests to Nina A. Bickell, MD, MPH, Mount Sinai School of Medicine, Department of Health Policy, 1 Gustave L. Levy Place, Box 1077, New York, NY 10029; e-mail: Nina.Bickell{at}mssm.edu

Purpose: Women with breast cancer do not consistently receive adjuvant treatments that have been shown to increase survival. Acquiring an understanding of the reasons for these lost opportunities may inform strategies for quality improvement.

Methods: Interviews were conducted with surgeons treating 119 women who did not receive guideline-recommended adjuvant therapy to ascertain reasons underlying treatment omission. Primary reason for underuse was categorized as not recommended, recommended but declined, or system failure (treatment recommended, not refused but did not ensue). Logistic regression identified patient characteristics, and surgeons' practice and referral patterns associated with underuse.

Results: Surgeons did not recommend adjuvant treatment for 41 (34%) of 119 women, most often because perceived risks exceeded benefits (37 of 119; 31%); unawareness of treatment benefits was rare (four of 119; 3%). Among the 78 (66%) of 119 for whom surgeons recommended treatment, 37 (31%) declined therapy; 41 (34%) system failures occurred. System failures occurred more commonly among minority than white women (73% v 54%; P < .01), and more commonly in women who were receiving Medicaid or were uninsured than those with Medicare or commercial insurance (54% v 19%; P < .01). Women treated by a surgeon who works closely with oncologists were less likely to experience a system failure (84% v 68%; P < .05).

Conclusion: One third of underuse episodes were attributable to surgeons' perceptions that treatment was not indicated, one third because women did not accept recommendations, and one third were the result of system failures. Reasons for underuse of adjuvant breast cancer treatments appear multifactorial and this heterogeneity suggests the need for simultaneous development of different strategies to improve care.

Supported by the Agency for Healthcare Research and Quality Grant No. P-01HS10859-02, the Commonwealth Fund Grant No. 20010102, and the National Center on Minority Health and Health Disparities Grant No. P60 MD00270.

The funders did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript.

Presented at the Annual Meeting of the Society of General Internal Medicine, New Orleans, LA, May 2005.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.