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Patterns and Correlates of Patient Referral to Surgeons for Treatment of Breast Cancer

Steven J. Katz, Timothy P. Hofer, Sarah Hawley, Paula M. Lantz, Nancy K. Janz, Kendra Schwartz, Lihua Liu, Dennis Deapen, Monica Morrow

From the Division of General Medicine, Department of Internal Medicine, Department of Health Management and Policy, Department of Health Behavior and Health Education, University of Michigan; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor; Department of Family Medicine and Karmanos Cancer Institute, Wayne State University, Detroit, MI; Department of Preventive Medicine, University of Southern California, Los Angeles, CA; and the Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA

Address reprint requests to Steven J. Katz, MD, MPH, Departments of Medicine and Health Management and Policy, University of Michigan, 300 N Ingalls; Suite 7E12, Box 0429, Ann Arbor, MI 48109-0429; e-mail: skatz{at}umich.edu

PURPOSE: Characteristics of surgeons and their hospitals have been associated with cancer treatments and outcomes. However, little is known about factors that are associated with referral pathways.

METHODS: We analyzed tumor registry and survey data from women with breast cancer diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries (n = 1,844; response rate, 77.4%) and their attending surgeons (n = 365; response rate 80.0%).

RESULTS: About half of the patients (54.3%) reported that they were referred to the surgeon by another provider or health plan; 20.3% reported that they selected the surgeon; and 21.9% reported that they both were referred and were involved in selecting the surgeon. Patients who selected the surgeon based on reputation were more likely to have received treatment from a high-volume surgeon (adjusted odds ratio [OR], 2.2; 95% CI, 1.5 to 3.4) and more likely to have been treated in an American College of Surgeons–approved cancer program or a National Cancer Institute (NCI) –designated cancer center (adjusted OR, 2.0; 95% CI, 1.3 to 3.1; adjusted OR, 3.4; 95% CI, 1.9 to 6.2, respectively). Patients who were referred to the surgeon were less likely to be treated in an NCI-designated cancer center (adjusted OR, 0.5; 95% CI, 0.3 to 0.9).

CONCLUSION: Women with breast cancer who actively participate in the surgeon selection process are more likely to be treated by more experienced surgeons and in hospitals with cancer programs. Patients should be aware that provider or health plan–based referral may not connect them with the most experienced surgeon or comprehensive practice setting in their community.

Supported by the National Cancer Institute (Grant No. RO1 CA8837-A1) to the University of Michigan. Supported in part with federal funds from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, under Contracts No. N01-PC-35139 and NO1-PC-65064. The collection of cancer incidence data used in this publication was supported by the California Department of Health Services as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885.

The ideas and opinions expressed herein are those of the authors, and no endorsement by the State of California, Department of Health Services is intended or should be inferred.

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

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