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Surgeon Characteristics and Use of Breast Conservation Surgery in Women With Early Stage Breast Cancer

Hershman, Dawn L. MD, MS*†‡; Buono, Donna MS; Jacobson, Judith S. PhD, MBA†‡; McBride, Russell B. MPH; Tsai, Wei Yann PhD†§; Joseph, Kathie Ann MD, MPH†¶; Neugut, Alfred I. MD, PhD*†‡

doi: 10.1097/SLA.0b013e3181a38f6f
Original Articles

Background: Most women with localized breast cancer have a choice between mastectomy and breast conserving surgery (BCS). Aside from clinical factors, this decision may be associated with surgeon and patient characteristics. We investigated the effect of surgeon characteristics on the BCS rate.

Methods: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women >65 years, diagnosed with stages I-II BC, between 1991 and 2002, and used the Physician Unique Identification Number linked to the American Medical Association Masterfile to obtain information on surgeons. We investigated the association of patient demographic, tumor, and surgeon-related factors with receipt of BCS, using Generalized Estimating Equations to control for clustering.

Results: Of 56,768 women with breast cancer, 30,006 (53%) underwent BCS, whereas 26,762 (47%) underwent mastectomy. Between 1991 and 2002, the proportion of patients undergoing BCS increased from 35% to 60%. In a multivariate analysis, patients who received BCS were younger, of higher SES, and had more favorable tumor characteristics. They were also more likely to be black and live in metropolitan areas. Women who underwent BCS were more likely to have surgeons who were female (OR = 1.40; 95% CI: 1.25–1.55), US-trained (OR = 1.12; 95% CI: 1.02–1.22), with a larger patient panel (OR = 1.29; 95% CI: 1.21–1.39), and completed training after 1975 (OR = 1.16; 95% CI: 1.08–1.25), than surgeons of patients who underwent mastectomy.

Conclusions: Surgeon characteristics, such as gender, training, year of graduation, and volume, are small but significant independent predictor of BCS. Efforts to differentiate whether these associations reflect patients’ preferences, quality of physician training, surgeon attitudes, physician-patient communication, or other effects on decision-making are warranted.

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women >65 years, diagnosed with stages I-II breast cancer to investigate the association between surgeon characteristics and the rate of breast conservation. In a multivariate analysis, patients who received breast conserving surgery were younger, of higher SES, and had more favorable tumor characteristics. Women who underwent breast conserving surgery were more likely to have surgeons who were female, US-trained, with a larger patient panel, and completed training after 1975, than surgeons of patients who underwent mastectomy.

From the *Department of Medicine and †the Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York Presbyterian Hospital, New York, New York; Departments of ‡Epidemiology and §Biostatistics, Mailman School of Public Health, Columbia University, and from the New York Presbyterian Hospital, New York, New York; and ¶Department of Surgery, College of Physicians and Surgeons, Columbia University, New York Presbyterian Hospital, New York, New York.

Supported by grant (RSGT-08-009-01-CPHPS) from the American Cancer Society and received an ASCO Advanced Clinical Research Award (to D.L.H.), and supported in part by an R25T fellowship from NCI (CA94061) (to R.B.M.).

Reprints: Dawn L. Hershman, MD, MS, Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York Presbyterian Hospital, 161 Ft Washington Ave, Room 1068, New York, NY 10032. E-mail: dlh23@columbia.edu.

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are 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.

© 2009 Lippincott Williams & Wilkins, Inc.