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Are Many Community Hospitals Undertreating Breast Cancer?: Lessons From 24,834 Patients

Gutierrez, Juan C. MD*; Hurley, Judith D. MD; Housri, Nadine BA*; Perez, Eduardo A. MD*; Byrne, Margaret M. PhD; Koniaris, Leonidas G. MD*

doi: 10.1097/SLA.0b013e31816c4030

Objective: To compare treatment patterns and long-term outcomes between teaching and community hospitals treating patients with infiltrating ductal carcinoma (IDC).

Methods: All IDCs from the Florida Cancer Data System from 1994 to 2000 were examined.

Results: Overall, 24,834 operative cases of IDC were identified. Teaching hospitals treated 11.3% of patients with a larger proportion of stage III and IV disease (39.8% vs. 33.0%). Five- and 10-year overall survival rates at teaching hospitals were 84% and 72%, compared with 81% and 69% at high-volume community hospitals and 77% and 63% at low-volume hospitals (P < 0.001). The greatest differences on survival were observed in patients with advanced IDC. Examination of practice patterns demonstrated that multimodality therapy was most frequently administered in teaching hospitals. Breast-conserving surgery was more frequently performed at teaching hospitals (41.5% vs. 38.9% P = 0.008). On multivariate analysis, it was found that treatment at a teaching hospital was a significant independent predictor of improved survival (hazard ratio = 0.763, P < 0.001). This survival benefit was greater and independent of high-volume center status (hazard ratio = 0.903, P < 0.02).

Conclusions: Patients with IDC treated at teaching hospitals have significantly better survival than those treated at high-volume centers or community hospitals, particularly in the setting of advanced disease. Poorer long-term outcomes for IDC at community hospitals seem to be, at least in part, because of decreased use of proven life-extending adjuvant therapies. These results should encourage community hospitals to institute changes in treatment approaches to invasive breast cancer to optimize patient outcomes.

Relationships between hospital characteristics and patient outcomes have been described for various diseases. We show increased use of multimodality therapy, including breast-conserving surgery, and improved overall survival for patients with breast cancer treated at teaching hospitals. Quality improvement measures to improve use of chemotherapy and other adjuvant therapies are needed to improve outcomes for community hospital-treated breast cancer.

From the *DeWitt Daughtry Family Department of Surgery, Division of Surgical Oncology; †Department of Medicine, Division of Hematology/Oncology; and ‡Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, Florida.

Supported by a grant from The James & Esther King Florida Biomedical Research Program.

Reprints: Leonidas G. Koniaris, MD, FACS, University of Miami School of Medicine, 3550 Sylvester Comprehensive Cancer Center (310T), 1475 NW 12th Ave., Miami, FL 33136. E-mail:

© 2008 Lippincott Williams & Wilkins, Inc.