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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*

doi: 10.1097/SLA.0b013e3182263bb0
Original Articles

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.

Data from the National Comprehensive Cancer Network (NCCN) was used to investigate institutional variation in the utilization of breast conserving surgery and post-mastectomy reconstruction to treat early stage breast cancer. We demonstrate a significant correlation between the supply of sub-specialty care and the type of surgical procedure preferentially performed at a given institution.

* Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA

Department of Breast and Soft Tissue Surgery, Roswell Park Cancer Center, Buffalo, NY

§ Department of Breast Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX

Department of Surgery, The Ohio State University Comprehensive Cancer Center, Columbus, OH

** H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL

†† University of Michigan Comprehensive Cancer Center, Ann Arbor, MI

‡‡ Department of Biostatistics, City of Hope Medical Center, Duarte, CA.

Reprints: Caprice C. Greenberg, MD, MPH, Brigham and Women's Hospital, Center for Surgery and Public Health, One Brigham Circle, 1620 Tremont Street, Boston, MA 02120. E-mail:

Supported in part by grant P50 CA092203 from the National Cancer Institute to Dana-Farber Cancer Institute. Dr. Greenberg receives support from the American Surgical Association Foundation Fellowship.

© 2011 Lippincott Williams & Wilkins, Inc.