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Annals of Surgery:
doi: 10.1097/SLA.0b013e3182263bb0
Original Articles

Institutional Variation in the Surgical Treatment of Breast Cancer: A Study of the NCCN

Greenberg, Caprice C. MD, MPH*,†; Lipsitz, Stuart R. ScD; Hughes, Melissa E. MSc*; Edge, Stephen B. MD; Theriault, Richard DO, MBA§; Wilson, John L. PhD; Carter, W. Bradford MD**; Blayney, Douglas W. MD††; Niland, Joyce PhD‡‡; Weeks, Jane C. MD, MSc*

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Abstract

Objective: To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer.

Background: Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON.

Methods: Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care.

Results: Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = −0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction.

Conclusions: Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.

© 2011 Lippincott Williams & Wilkins, Inc.

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