Journal of the National Cancer Institute Advance Access originally published online on January 29, 2008
JNCI Journal of the National Cancer Institute 2008 100(3):199-206; doi:10.1093/jnci/djm320
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© The Author 2008. Published by Oxford University Press.
ARTICLES |
Surgeon Characteristics and Receipt of Adjuvant Radiotherapy in Women With Breast Cancer
Affiliations of authors: Departments of Medicine (DLH, VRG) and Surgery (KAJ) and the Herbert Irving Comprehensive Cancer Center (DLH, WYT, KAJ, VRG, JSJ), College of Physicians and Surgeons, and the Departments of Epidemiology (DLH, DB, RBM, VRG, JSJ) and Biostatistics (WYT), Mailman School of Public Health, Columbia University; New York Presbyterian Hospital, New York
Correspondence to: Dawn L. Hershman, MD, MS, Herbert Irving Comprehensive Cancer Center, Rm 1068, 161 Fort Washington, New York 10032 (e-mail: dlh23{at}columbia.edu).
Background: Adjuvant radiotherapy following breast conservation surgery (BCS) is considered to be an indicator of quality of care for the majority of women with breast cancer, but many women do not receive adjuvant radiotherapy. We investigated the association of surgeon-related factors with receipt of adjuvant radiotherapy after BCS.
Methods: We used the linked Surveillance, Epidemiology and End Results (SEER)–Medicare database to identify women aged 65 years or older with stage I/II breast cancer who were diagnosed between 1991 and 2002 and underwent BCS. We collected demographic and clinical data from SEER and treatment information from Medicare claims data. The American Medical Association Masterfile was used to obtain information on surgeons’ characteristics, including sex, medical school location (United States or elsewhere), and type of degree (MD or Doctorate in Osteopathic Medicine [DO]). The associations of patient (age, race, rural vs urban residence, comorbidities, marital status), tumor (hormone receptor status, grade, stage), and surgeon-related factors with receipt of adjuvant radiotherapy were analyzed using Generalized Estimating Equations to control for clustering. All statistical tests were two-sided.
Results: Of 29760 women in our sample, 22207 (75%) received radiotherapy. Patients who received adjuvant radiotherapy were younger, had fewer comorbidities, and were more likely to be white, married, from an urban area, and diagnosed in a later year compared with those who did not. They were also more likely to have a surgeon who was female (79% vs 73%), had an MD degree (75% vs 68%), or was US trained (75% vs 70%). The multivariable analysis confirmed the association of radiotherapy with having a surgeon who was female (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.06 to 1.27), had an MD degree (OR = 1.55; 95% CI = 1.24 to 1.91), was US trained (OR = 1.12; 95% CI = 1.01 to 1.25), or had more than 15 patients (OR = 1.18; 95% CI = 1.10 to 1.28).
Conclusions: Surgeon characteristics were associated with patients’ receipt of adjuvant radiotherapy after BCS after controlling for patient and tumor characteristics, although the individual effect sizes were small for surgeon sex, location of training, and type of medical degree. More research is warranted to confirm the associations to determine whether they reflect surgeon behavior, patient response, or physician–patient interactions.
| CONTEXT AND CAVEATS Prior knowledge The extent to which such surgeon characteristics as sex, location of medical education, and type of degree are associated with their patients’ receipt of adjuvant radiotherapy following breast conservation surgery was unknown. Study design Generalized Estimating Equations were used to analyze the association of patient and surgeon characteristics based on information from the American Medical Association Masterfile and the linked Surveillance, Epidemiology and End Results–Medicare database. Contribution After controlling for patient characteristics, this study found associations between surgeon characteristics and an indicator of the quality of breast cancer care, receipt of adjuvant therapy after breast conservation surgery. Implications More research is warranted to confirm the observed associations and to determine whether they are reflective of surgeon behavior, patient response, or physician–patient interaction. Limitations The database did not provide information on a number of potentially important surgeon- and patient-related variables and did not allow investigators to differentiate between lack of referral or patient refusal as the reason for not receiving radiotherapy.
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This study used the linked SEER–Medicare database. The analysis, interpretation and reporting of the data, writing of the manuscript, and decision to publish were the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Branch, Division of Cancer Prevention and Population Science, NCI; the Office of Information Services, and the Office of Strategic Planning, HCFA; Information Management Services, Inc; and the SEER Program tumor registries in the creation of the SEER–Medicare database.
Manuscript received June 18, 2007; revised December 7, 2007; accepted December 17, 2007.
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J Natl Cancer Inst 2008 100: 157.
J Natl Cancer Inst 2008 100: 157.