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Originally published as JCO Early Release 10.1200/JCO.2004.06.919 on August 2 2004 © 2004 American Society of Clinical Oncology.
Crossing the Quality Chasm in Breast Cancer CareBoston University Medical Center, Boston, MA Underuse of systemic adjuvant therapies in early-stage breast cancer care is not news. Although diminishing in magnitude,1 even at the best of centers, some degree of underuse persists.2 Although variations in breast cancer care have been documented for decades, particularly in relation to age, linking these variations to outcomes has been a methodologic challenge. Breast cancer is a relatively rare disease; its outcomes, especially among those with early-stage disease, are relatively low frequency and occur most commonly up to 5 to 10 years after diagnosis. In the United States, at least, complete information on disease characteristics and treatments is difficult to collect, given lack of integrated clinical care and information systems.3
Two recent studies from Canada have overcome many of these methodologic challenges by investigating the impact of adjuvant systemic therapies in women with node-negative disease cared for in community settings. In the first study, investigators from the British Columbia Cancer Agency report findings from their Breast Cancer Outcomes Database.4 This database includes high-quality demographic, pathologic, staging, treatment, and outcome data for about three fourths of the women diagnosed with breast cancer in British Columbia. More than 1,100 node-negative women not treated with systemic adjuvant therapies who were diagnosed from 1989 through 1991were stratified according to tumor size ( In this issue of the Journal of Clinical Oncology, Hébert-Croteau et al5 extend these findings by comparing node-negative women treated and not treated with systemic adjuvant therapies. They took advantage of multiple, high-quality linked sources of data in Québec and addressed a central treatment effectiveness question: Do patients for whom treatment guidelines on the basis of randomized clinical trials are followed in clinical practice do better than those for whom guidelines are not followed? Rather than examining the independent effects of tumor size and grade, these investigators categorized patients according to the 1992 St Gallen criteria for risk of recurrence and applied treatment guidelines based on these risk categories.6 These guidelines were used because the study population of more than 1,500 women was diagnosed between 1988 and 1994. These investigators demonstrated that treatment does make a difference and is an independent predictor of all-cause mortality. With a median follow-up time of 6.8 years, patients at moderate to high risk of recurrence who did not receive guideline therapy were more likely to experience disease relapse and to die. Both risk category and adherence to guidelines were independently associated with survival. The findings also extend to breast cancer–specific mortality, although the confidence intervals are wide because of the small number of end points. Most of the nonadherence to guidelines was because patients did not receive systemic adjuvant therapy and was concentrated in those at moderate or high risk of recurrence; 26% of those at moderate risk and 30% of those at high risk of recurrence received no adjuvant therapy. For the low-risk population, 98% were treated according to guidelines. Because the findings derive from analyses of existing administrative and medical record data, the underuse of systemic adjuvant therapies (particularly chemotherapy) could not be specifically ascertained, whether due to systems, provider, or patient reasons. Indeed, the Institute of Medicine, in its volume Ensuring Quality Cancer Care, notes that "there is very limited evidence on the way structures and technical processes of care affect cancer care outcomes."7 It is also well known that clinical guidelines are not followed in clinical practice, and this is not unique to cancer care.8 Among Medicare beneficiaries, use of accepted effective therapies such as angiotensin-converting enzyme inhibitors for congestive heart failure or anticoagulation for atrial fibrillation is in the 50% to 75% range.9 As our scientific portfolio of effective therapies has burgeoned, our abilities to translate these findings into clinical practice have not kept up. The reasons for this are legion, suggesting that interventions must be multidimensional to effectively influence clinical care and outcomes.10,11 As the experience of industry has taught us, it is not enough to expect providers to work hard and "do the right thing." Bickell et al2 have identified provider, systems, and patient factors as contributing to the underuse of effective breast cancer treatments. At the provider level, our strategies to influence physicians' practice styles have been modestly effective at best. As Hébert-Croteau et al note, especially in the setting of breast cancer, the scientific community has been diligent in regularly reviewing evidence and updating guidelines for care based on this evidence.5 Although evidence-based guidelines are a necessary beginning, and disseminating them can influence physician knowledge and awareness, they are not sufficient to change practice. Indeed, our traditional and time-honored strategies for imparting information (eg, medical grand rounds, continuing medical education courses, special lectures) have little impact on clinical practice.12 What is required is a much more comprehensive approach that incorporates not only knowledge, but also builds skills and affects attitudes. Small-group, case-based approaches that incorporate time for role-playing and discussion have been shown to be effective in improving provider behaviors.13 These approaches alone, however, are not sufficient. They must be complemented by patient-specific decision support and reminders for physicians, as well as comprehensive information systems. Although electronic medical records are now more widely used, they are not universal. Furthermore, we are a long way from electronic linkages across care settings that facilitate collaborative and coordinated approaches to care among providers from different specialties. Not only are such linkages necessary for facilitating optimal communication among clinicians, they are essential for real-time tracking and monitoring of care. We should be grateful for the evidence that underuse of adjuvant therapies has negative consequences for node-negative breast cancer patients, but this evidence reflects care provided more than a decade ago. Although we might hope that we are doing better now, particularly in light of regular consensus conference updates,14,15 we do not have the information technology infrastructure to monitor care and to understand the reasons for variations in care in real time. Did the surgeon recommend systemic therapy, but was the patient never referred or seen by the medical oncologist? Were there insurance obstacles? Did a patient miss an appointment and not reschedule? Was a consultation note ever sent? The development of such an information infrastructure will require the will, commitment, and resources of health care organizations and well as those who pay for care, including federal and state governments. Other systems changes are also required. In addition to multidisciplinary care conferences, many centers have developed "one-stop shopping" for cancer patients as a strategy to decrease fragmentation of care and to minimize the very real barriers of transportation and opportunity costs that many patients face. In such systems, appointments for tests and all relevant specialists are coordinated and scheduled together. Others have trained care navigators to help patients cope with complicated care systems and treatment regimens that even physicians find challenging. More effective use of nonphysician members of the team can maximize efficiency and effectiveness, and undoubtedly improve patient satisfaction. In this regard, patients must also to be part of the solution. The news of a potentially life-threatening illness, coupled with the need for a series of complicated decisions about treatment, demands multiple conversations about treatment options. Confronted with these challenges, many breast cancer patients opt out of treatment decision making, and some opt out of conventional medical care entirely.16 Although most breast cancer patients desire a collaborative role in treatment decision making,17,18 fewer than half achieve their desired role.19 Patients who achieve their desired role are more likely to adhere to prescribed treatments,20 receive definitive breast cancer therapy,21 be satisfied with their care,21 and have superior health outcomes.20 The observational design of the study by Hébert-Croteau et al warrants caution in its interpretation, of course. Nevertheless, our patients deserve to be treated in systems of care that are designed to achieve optimal outcomes. We cannot afford not to work together to create such systems, even in the face of increasing time and financial pressures. Author’s Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Hébert-Croteau N, Brisson J, Latreille J, et al: Time trends in systemic adjuvant treatment for node-negative breast cancer. J Clin Oncol 17:1458-1464, 1999 2. Bickell NA, McEvoy MD: Physicians' reasons for failing to deliver effect breast cancer care: A framework for underuse. Med Care 41:442-446, 2003[CrossRef][Medline] 3. Lash TL, Silliman RA, Guadagnoli E: The effect of less than definitive care on breast carcinoma recurrence and mortality. Cancer 89:1739-1747, 2000[CrossRef][Medline]
4. Chia SK, Speers CH, Bryce CJ, et al: Ten-year outcomes in a population-based cohort of node-negative early breast cancers with out adjuvant systemic therapies. J Clin Oncol 22:1630-1637, 2004
5. Hébert-Croteau N, Brisson J, Latreille J, et al: Compliance with consensus recommendations for systemic therapy is associated with improved survival of women with node-negative breast cancer. J Clin Oncol 22:3685-3693, 2004
6. Glick JH, Gelber RD, Goldhirsch A, et al: Meeting highlights: Adjuvant therapy for primary breast cancer. J Natl Cancer Inst 84:1479-1485, 1992 7. Hewitt M, Simone JV, eds. Ensuring Quality Cancer Care: National Cancer Policy Board, Institute of Medicine and Commission on Life Sciences, National Research Council. Washington, DC, National Academy Press, 1999
8. Lenfant C: Clinical research to clinical practice: Lost in translation? N Engl J Med 349:868-874, 2003
9. Jencks SF, Huff ED, Cuerdon T: Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001. JAMA 289:305-312, 2003
10. Ockene JK, Zapka JG: Provider education to promote implementation of clinical practice guidelines. Chest 118:33S-39S, 2000 11. Grol R: Improving the quality of medical care: Building bridges among professional pride, payer profit, and patient satisfaction. JAMA 284:2578-2585, 2001
12. Davis D, O'Brien MT, Freemantle N: Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health outcomes? JAMA 282:867-874, 1999 13. Ockene I, Hebert J, Ockene J, et al: Effect of training and a structured office practice on physician-delivered nutrition counseling: The Worcester-Area Trail for Counseling in Hyperlipidemia (WATCH). Am J Prev Med 12:252-258, 1996[Medline]
14. National Institutes of Health Consensus Development Conference Statement: Adjuvant Therapy for Breast Cancer, November 1-3, 2000. J Natl Cancer Inst 93:979-989, 2001
15. Goldhirsh A, Glick JH, Gelber RD, et al: Meeting highlights: International consensus panel on the treatment of primary breast cancer. J Clin Oncol 19:3817-3827, 2001 16. Verboef MJ, White MA: Factors in making the decision to forgo conventional cancer treatment. Cancer Practice 10:201-207, 2002[CrossRef][Medline] 17. Charles C, Gafni A, Whelan T: Decision-making in the physician-patient encounter: Revisiting the shared treatment decision-making model. Soc Sci Med 49:651-661, 1999 18. Schou I, Ekeberg O, Ruland CM, et al: Do women diagnosed with breast cancer and consulting surgeon assess decision-making equally? Breast 11:434-441, 2002[CrossRef][Medline] 19. Degner LF, Kristjanson LJ, Bowman D, et al: Information needs and decisional preferences in women with breast cancer. JAMA 277:1485-1492, 1997[Abstract] 20. Petersen S, Heesacker M, Marsh RD: Medical decision-making among cancer patients. J Counsel Psychol 48:239-244, 2001[CrossRef]
21. Liang W, Burnett CB, Rowland JH, et al: Communication between physicians and older women with localized breast cancer: Implications for treatment and patient satisfaction. J Clin Oncol 20:1008-1016, 2002 Related Article
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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1, 1.1 to 2, and 2.1 to 5 cm) and observed for a median of 10.4 years. Within these tumor size strata, 10-year survival rates for node-negative women were 82%, 75%, and 66%, and overall survival rates were 79%, 78%, and 66%, respectively. Survival was independently associated with tumor size and grade.
