Documentations of Advanced Heath Care Directives Where Are They TAI_SEALE
Variation in Mastectomy Rate for Invasive Breast Cancer Results from the Breast Cancer Surgical Outcomes Study FEIGELSON
1. Factors Influencing Initial Total
Mastectomy Rate for
Invasive Breast Cancer
Heather Spencer Feigelson, PhD, MPH
Institute for Health Research
Kaiser Permanente Colorado
2. Purpose
Using a multi-institution Breast Cancer
Surgical Outcomes (BRCASO) database, we
analyzed how practice, patient, and tumor
characteristics contributed to variation in initial
total mastectomy (TM) for invasive breast
cancer.
3. The BRCASO Study
U Vermont
Database established
By McCahill et al KPCO
Chart
VDW
Abstraction
and GHRI
Chart
Abstraction
Van Andel Institute
(Data Coordinating Center)
Marshfield
For detail, see Aiello Bowles, et al, BMC Cancer, 2012
4. BRCASO Database
Female breast cancer cases, 2003–2008
18 years and older at diagnosis
Initial breast cancer surgery performed by a surgeon
employed by a BRCASO study site
Includes 4684 breast cancers in 4580 women
5. Analysis of Variation in Total Mastectomy
Excluded:
stage 0 and stage IV
patients who received neoadjuvant chemotherapy
inflammatory breast cancer
multifocal or multicentric disease
prior breast cancer or prior chest radiation
Included:
2384 breast cancers
397 (16.7%) mastectomies as first procedure
6. Analysis
Bivariate analysis followed by logistic regression
Covariates that were statistically significantly associated with TM rate in bivariate
analysis were included in the multivariate analysis
Random effects models were used to examine the impact of individual
surgeon on TM variation
Due to the greater feasibility of breast conservation with smaller tumors, we
conducted analyses on all tumors and then separately for tumors <20mm
8. Initial Total Mastectomy is Strongly
Associated with Tumor Size
71.88
P for trend<0.0001
48.98
36.54
23.33
11.36
8.49
1
<10mm 10-20mm 20-30mm 30-40mm 40-50mm >50mm
73% of all tumors
9. Frequency of TM by Tumor Characteristics
All
Tumors <20mm
variable N % TM p-value N %TM p-value
Tumor Type IDC 2129 15.64 1556 10.15
ILC 255 25.1 0.0001 156 11.84 0.5873
Grade Low/Medium 1723 13.52 1350 8.96
High 638 24.76 <0.0001 343 14.87 0.0012
Receptor Status ER/PR+ 2044 15.56 1512 9.72
ER/PR- 325 23.08 0.0007 188 14.36 0.0478
10. Frequency of TM by Practice Characteristics
All
Tumors <20mm
variable N % TM p-value N %TM p-value
Use of pre-
operative MRI No 2199 15.55 1585 9.65
Yes 185 29.73 <.0001 127 18.11 0.0025
Site 1 549 10.38 407 5.16
2 849 20.97 579 14.16
3 763 17.82 536 10.63
4 223 11.66 <.0001 190 8.42 <.0001
Surgeon Volume
(cases/yr) <=10 cases 533 18.2 380 13.16
11-25 1035 17.97 738 11.38
26-49 222 14.86 172 7.56
>=50 594 13.64 0.0851 422 6.87 0.0113
11. Multivariate Analysis of Mastectomy Rates
OR 95% CI p-value
Age group <45 1.63 1.00-2.66 0.003
45-54 1.29 0.88-1.88
55-64 ref
65-74 1.36 0.93-1.99
>=75 2.09 1.43-3.05
Ethnicity Caucasian ref
Asian 2.17 1.11-4.27 0.04
Max Tumor Size 1.06 1.05-1.07 <.0001
Tumor Grade low/medium ref 0.004
high 1.6 1.17-2.19
Use of pre-operative MRI No ref
Yes 2.44 1.58-3.77 <.0001
12. Observed and Expected Initial Total
Mastectomy Rates by Surgeon
Median OR=1.86 (95% CI: 1.60-2.47, p<0.001)
13. Conclusions
Tumor size, high nuclear grade and patient age were all
important predictors of initial total mastectomy.
The high variability of TM frequency by individual
surgeon and the influence of pre-operative MRI are of
concern, and deserve further study.
Even when limited to tumors <20mm
Our results are generalizable to the majority of breast
cancer practice patterns in the U.S.
14. Acknowledgements:
Lacks Cancer Center/ Van Andel Research Institute, MI
Laurence McCahill, MD – PI
Tom Barney
University of Vermont:
Ted James, MD, Richard Single, PhD, Hannah Sheehey-Jones, Jordan Bakerman
Marshfield Clinic:
Adedayo Onitilo, MD, Jessica Engel
Group Health:
Erin Aiello Bowles, Gabrielle Gundersen
Kaiser Permanente Colorado:
Kimberly Bischoff, Andrew Sterrett, PhD
This project was supported by ARRA Award RC1CA145402
