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© 2003 American Society for Clinical Oncology Consultation With a Medical Oncologist Before Surgery and Type of Surgery Among Elderly Women With Early-Stage Breast Cancer
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 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.
CLINICAL GUIDELINES and consensus statements for the local treatment of early-stage breast cancer state that breast conservation produces survival rates equivalent to those of mastectomy, mastectomy and breast conservation should include axillary node dissection, and patients undergoing breast-conserving surgery should also receive radiation therapy.1,2 Previous research has demonstrated large variations in breast cancer treatments,3–8 particularly for elderly women. For example, rates of breast-conserving surgery decrease with increasing age.7–11 Moreover, many women with breast cancer, particularly elderly women, do not receive recommended axillary dissection or radiation therapy after breast-conserving surgery.12–16 The reasons for these variations in care are poorly understood. Because many women defer to their physicians when making decisions about breast cancer treatment,8,17–20 the attitudes and beliefs of providers with whom they discuss surgical options may influence treatments. Such attitudes and beliefs may differ by physician specialty. For example, several studies have found that medical oncologists may be more likely than surgeons to recommend breast-conserving surgery.21–23 Although women report that surgeons are the most influential physicians in their decisions,18 many women discuss surgical treatments with a medical oncologist before surgery,24 and such discussions may be associated with higher rates of breast-conserving surgery in some areas.24 In this study we examined care for a large cohort of elderly women with early-stage breast cancer living in various regions of the United States. We specifically assessed the proportion of women who had inpatient or outpatient consultations with a medical oncologist before surgery and whether such consultations were associated with receipt of definitive surgery (mastectomy or breast-conserving surgery with radiation therapy v breast-conserving surgery without radiation), axillary node dissection, or type of surgery received (breast-conserving surgery v mastectomy among women who underwent definitive surgery).
Data We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare data for this analysis.25 The SEER program of the National Cancer Institute collects uniformly reported data from 11 population-based cancer registries covering approximately 14% of the United States population.26 For each incident cancer, the SEER registries collect information on month and year of diagnosis, cancer site, histologic type, American Joint Committee on Cancer stage,27 and patient demographic characteristics. Since 1991, the SEER data have been merged with Medicare administrative data by a matching algorithm that has successfully linked files for more than 94% of SEER registry patients diagnosed at age 65 or older.25 The Medicare claims data used in this study include the Hospital Outpatient Standard Analytic file (claims for outpatient facility services), the 100% Physician/Supplier file (claims for physicians’ services and other medical services), and the Medicare Provider Analysis and Review file (inpatient claims).
Study Cohort
Patient and Hospital Characteristics
Visits With a Medical Oncologist We examined whether women saw a medical oncologist before surgical treatment. We used two methods to identify medical oncologists: any doctor reporting a specialty of medical oncology, or hematology/oncology, according to the HCFA specialty code or the Medicare Physician Registry; or any physician billing Medicare for providing chemotherapy to any breast cancer patient during the study period.31,32 This allowed for identification of both board-certified oncologists and noncertified physicians who practice oncology. In sensitivity analyses, we also repeated analyses using each definition separately.
Treatments Two sources of information about each treatment were available. The SEER registries report data on treatments delivered or planned within 4 months of diagnosis and the Medicare claims document reimbursed procedures. For type of surgery, studies have found high agreement between the two sources,33 and our findings were similar. When the two sources disagreed (3%), we selected the most definitive procedure. In a sensitivity analysis, we repeated analyses defining surgery on the basis of the SEER definition alone and then on the basis of the Medicare claims definition alone. We identified axillary surgery based on evidence from either source (registry data or claims). For 5% of patients, one source reported axillary dissection when the other did not. In sensitivity analyses, we defined axillary dissection first from the claims alone and second from the registry data alone.
We identified radiation therapy if we found evidence for radiation in either source, which provides more complete ascertainment than either the registry data or Medicare claims alone.34 For 8% of patients one source identified radiation therapy when the other did not. In sensitivity analyses, we defined radiation therapy from the claims data alone because we were interested in radiation given, not just planned, as may have been reported in the registry data. International Classification of Diseases (version 9) and Current Procedural Terminology codes for the various procedures are listed in Table 1
Analyses Consultation with a medical oncologist before surgery. We used  2 tests to examine bivariate associations between patient characteristics and consultation with a medical oncologist before surgery and used logistic regression to assess the association between patient characteristics and such consultations. Independent variables included age (66 to 69, 70 to 74, 75 to 79, 80 to 84, or  85 years); marital status (married, unmarried); residence in a metropolitan county; race (white, black, other); Hispanic ethnicity; history of cancer other than breast cancer; SEER registry; tumor size; tumor grade; median household income and proportion of high school graduates for zip code of residence (both in quartiles); comorbidity score (in quartiles); being cared for at teaching hospital, a hospital with a cancer program approved by the American College of Surgeons, or a hospital with a radiation facility; and the number of hospital beds (< 100, 100 to 249, 250 to 499, or 500 beds). Indicator variables for having missing zip code data (missing for < 0.5% of women) or missing hospital characteristics (missing for 12% of women) were used to allow inclusion of these women in the model. We used the likelihood ratio test to assess the overall effect of the multilevel variables on visits to a medical oncologist before surgery. For each of the independent variables, we calculated the adjusted proportion of women who had visits with a medical oncologist before surgery with direct standardization.39,40 Association between consultation with a medical oncologist before surgery and treatment. We analyzed three multivariable logistic regression models to assess the associations between visits with a medical oncologist before surgery and definitive surgery, axillary node dissection, and breast-conserving surgery versus mastectomy (among women who underwent definitive surgery). Each model included all patient and hospital variables described for the model above. To explore potential explanations for our findings, we examined whether the results differed according to whether women had seen a surgeon before their medical oncologist visit. A visit with a surgeon first may reflect referral to the medical oncologist by the surgeon. We repeated bivariate and logistic regression analyses examining differences between women who did not see a medical oncologist before surgery, women who saw a medical oncologist before surgery before seeing a surgeon, and those who saw a medical oncologist before surgery after seeing a surgeon. All tests of statistical significance were two sided. We conducted analyses using SAS statistical software (SAS/STAT User’s Guide, Version 8, 1990; SAS Institute, Cary, NC). The study protocol was approved by the Harvard Medical School Committee on Human Studies.
The mean age of the population was 75 years, 91% were white, and 43% were married (Table 2  ). Sixty-three percent had stage I disease and the remaining patients had stage II disease. Overall, 19% of women consulted with a medical oncologist before surgery.
Factors Associated With Having a Consultation With a Medical Oncologist Before Surgery In adjusted analyses, younger women, women with a prior cancer other than breast cancer, women with larger or more poorly differentiated cancers, women with greater comorbidity, and women cared for at teaching hospitals more often consulted with a medical oncologist before surgery (Table 2  ). There was also significant variation by SEER registry, with the highest rates among women living in San Jose and Michigan and the lowest rates among women in Georgia, San Francisco, Connecticut, Utah, and Iowa.
Consultation With a Medical Oncologist and Treatment
Overall, 79% of women underwent axillary dissection, including 86% of women who consulted with a medical oncologist and 78% of women who did not (P < .001). In adjusted analyses, women who consulted with a medical oncologist were more likely than other women to undergo axillary dissection (adjusted OR, 1.44; 95% CI, 1.19 to 1.73; Table 3 ).
Among women who underwent definitive surgery, 42% underwent breast-conserving surgery with radiation therapy and 58% underwent mastectomy. Women who had visits with a medical oncologist had lower rates of breast-conserving surgery (39% v 42%; P < .01). In analyses adjusting for patient, community, and hospital characteristics, women who had visits with a medical oncologist before surgery were less likely than other women to undergo breast-conserving surgery (OR, 0.84; 95% CI, 0.75 to 0.95; Table 2
Timing of Medical Oncologist Visit Relative to Visit With a Surgeon
Unadjusted rates of definitive surgery were 88% for women who did not see a medical oncologist before surgery, 90% for women who saw the medical oncologist before seeing a surgeon, and 94% for women who saw a surgeon before the medical oncologist visit (P = .001). Unadjusted rates of axillary dissection were 78% for women who did not see a medical oncologist before surgery, 81% for women who saw the medical oncologist before seeing a surgeon, and 89% for women who saw a surgeon before the medical oncologist visit (P = .001). Finally, among women undergoing definitive surgery, the unadjusted rate of breast-conserving surgery was 42% for women who did not see a medical oncologist before surgery, 43% for women who saw the medical oncologist before seeing a surgeon, and 36% for women who saw a surgeon before the medical oncologist visit (P = .01). These patterns were consistent in multivariable analyses, with women who saw a surgeon before seeing a medical oncologist most likely to have definitive surgery and axillary dissection and least likely to undergo breast-conserving surgery (Table 4
Sensitivity Analyses In a sensitivity analysis, we added stage to each model to ensure that we adequately accounted for stage of disease and the findings did not change. In other sensitivity analyses, we redefined our medical oncologist specialty variable first using the definition that was based on specialty codes and second using the definition that was based on provision of chemotherapy, and our results were similar for all analyses. In a final set of sensitivity analyses, we used different definitions of the surgery and radiation variables that were based on sources of the data (claims or registry data), and results were similar.
We examined patterns of care for a large cohort of elderly women with early-stage breast cancer and found that one fifth of women consulted with a medical oncologist before surgery, with decreasing rates of consultations as age increased. Women who had a history of cancer other than breast cancer, larger or more poorly differentiated tumors, and greater comorbidity were more likely than others to visit a medical oncologist before surgery. Those who saw a medical oncologist before surgery were more likely to undergo definitive surgery and axillary node dissection but were less likely to undergo breast-conserving surgery (among women undergoing definitive surgery). Our finding that older women were less likely visit with a medical oncologist before surgery is consistent with other studies examining access to medical oncologists among women with breast cancer9,24,41 and may be a sign of more aggressive care for younger women. Our finding that women with larger and more poorly differentiated tumors and women with greater comorbidity were more likely to visit with a medical oncologist before surgery suggests that patients, surgeons, or primary care physicians are recognizing more complicated patients or more advanced tumors and thus are seeking input from a medical oncologist before surgery. Despite these variations by age and clinical factors, visits with medical oncologists varied most substantially by SEER region, even in adjacent regions such as San Francisco and San Jose, highlighting the importance of local practice patterns. Variations in HMO enrollment by SEER region42 is not likely to explain this finding, given that the proportion of women visiting medical oncologists was high in some areas of high managed care penetration (eg, Seattle and Hawaii) and low in other areas where penetration also was high (San Francisco). Finally, we found no significant differences in visits with a medical oncologist on the basis of race, ethnicity, income, or education; these factors are often associated with access to medical care. Women who had consultations with a medical oncologist before surgery had higher rates of definitive surgery and axillary node dissection. Others have found that multidisciplinary care is associated with increased satisfaction43,44 and psychosocial gains45,46; benefits may extend to better care. Our exploratory analysis examining rates of definitive surgery and axillary dissection according to whether women saw a surgeon before their visit with a medical oncologist demonstrated that women who saw a surgeon before their visit with the medical oncologist were more likely to have definitive surgery and axillary dissection than were other women. This finding suggests that some surgeons may be sorting and referring women who they think may benefit most from more definitive treatment, and these surgeons may also collaborate more regularly with medical oncologists in preoperative decision making. Despite generally high rates of radiation therapy after breast-conserving surgery and axillary dissection, many women did not receive these treatments. There are several possible reasons. Patients may refuse the treatments because of the inconvenience of radiation therapy or fear of lymphedema. Alternatively, providers may not be aware of current guidelines or may not agree that these treatments are necessary for all elderly women. Preliminary clinical trial data suggest that for elderly women undergoing breast-conserving surgery, it may be safe to omit radiation therapy in women taking tamoxifen.47 In addition, some physicians have questioned whether all women require axillary dissection.48–51 However, these treatments were the standard of care during the time period that we studied. Future studies are necessary to develop a better understanding of patients’ and providers’ beliefs about these treatments as well as the content of the discussions about breast cancer treatments that physicians have with their patients. Despite higher rates of definitive surgery and axillary node dissection among women consulting with a medical oncologist before surgery, such women were less likely than other women to undergo breast-conserving surgery, even after adjustment for more advanced tumors and greater comorbidity. This finding is inconsistent with prior data suggesting that medical oncologists may be more likely to recommend breast-conserving surgery,21–23 and with data from Minnesota showing increases in rates of breast-conserving surgery among women who discussed surgical treatments with a medical oncologist before surgery.24 However, these prior studies examined care primarily for younger women, for whom breast preservation may be more important, or for whom completing a full course of radiation therapy is less difficult. The difference in rates of breast-conserving surgery among women who did and did not consult with a medical oncologist suggests that there may be differences in the type or amount of information that is discussed with patients. For example, medical oncologists may be more likely than surgeons to emphasize the need for radiation with breast-conserving surgery, which may cause more elderly women to select mastectomy. Another explanation is that surgeons are identifying patients who they believe will benefit most from mastectomy, and also are referring them to medical oncologists before surgery to help with planning adjuvant treatment. This explanation is consistent with the results of our exploratory analysis demonstrating that women who saw a medical oncologist before surgery, but after seeing a surgeon, were less likely to undergo breast-conserving surgery than those who saw the surgeon after seeing the medical oncologist. The strengths of our study include the large population-based sample of women and our ability to examine cancer care with a combination of registry and claims data. Our study also has several limitations. First, in using SEER-Medicare data, we examined care only among elderly women in the fee-for-service sector. However, most breast cancers occur in elderly women, and few Medicare beneficiaries were enrolled in HMOs at the time of the study.48 Second, the HCFA specialty code, which is useful for identifying the specialty of the physician at the time and place that the service was provided, may fail to identify some medical oncologists.32 Thus, we also classified physicians who had provided chemotherapy as medical oncologists.31,32 In sensitivity analyses, results were similar when we classified medical oncologists using either of the two definitions as opposed to the combined definition. Third, in using administrative claims data, visits may have been overlooked if services were not covered or bills were not submitted. Fourth, we do not have information on the content of the visits with medical oncologists; in particular, whether the type of surgery was actually discussed. Finally, given the cross-sectional nature of our analysis, we cannot conclude that visits with a medical oncologist before surgery will result in higher rates of definitive treatment, only that an association exists. In summary, we found that elderly women who had visits with a medical oncologist before surgery were more likely to receive care that was consistent with evidence-based national guidelines, but they also were less likely to undergo breast-conserving surgery. Our findings suggest that differences may exist in the content of discussions that elderly women have about local breast cancer treatments with providers of different specialties. More research is needed to increase our understanding of the reasons that some women visit with a medical oncologist before surgery as well as the quality and content of discussions that elderly women have with physicians who are guiding their decisions about breast cancer treatments.
The following authors or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Acted as a consultant within the last 2 years: John Z. Ayanian, DxCG Inc, Research Triangle Institute, NC. Received more than $2,000 a year from a company for either of the last 2 years: John Z. Ayanian, DxCG Inc.
We thank Yang Xu, and Laurie M. Meneades for expert programming assistance.
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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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
