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Variation in Receipt of Radiation Therapy After Breast-conserving Surgery: Assessing the Impact of Physicians and Geographic Regions

Feinstein, Aaron J. MD, MHS*; Soulos, Pamela R. MPH*,†; Long, Jessica B. MPH*,†; Herrin, Jeph PhD*,‡,§; Roberts, Kenneth B. MD*,∥; Yu, James B. MD*,∥; Gross, Cary P. MD*,†

doi: 10.1097/MLR.0b013e31827631b0
Original Articles

Background: Among older women with early-stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups.

Objective: To determine the relative contribution of patient, physician, and regional factors on the use of RT.

Design: Retrospective cohort.

Subjects: Women aged 67–94 years diagnosed with stage I breast cancer between 1998 and 2007 receiving breast-conserving surgery.

Measures: We evaluated patient, physician, and regional factors for their association with RT across strata of LE using a 3-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region.

Results: Approximately 43.6% of the 2253 women with a short LE received RT, compared with 90.8% of the 11,027 women with a long LE. Among women with a short LE, the probability of receiving RT varied substantially across primary surgeons; RSTRs ranged from 27.7% to 67.3% (mean, 43.9%). There was less variability across geographic regions; RSTRs ranged from 42.0% to 45.2% (mean, 43.6%). Short LE patients were more likely to receive RT in areas with high radiation oncologist density (odds ratio, 1.59; 95% confidence interval, 1.07–2.36).

Conclusions: Although there is a wide variation across geographic regions in the use of RT among women with breast cancer and short LE, the regional variation was substantially diminished after accounting for the operating surgeon.

Supplemental Digital Content is available in the text.

*Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Comprehensive Cancer Center

Section of General Internal Medicine

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT

§Health Research and Educational Trust, Chicago, IL

Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the National Cancer Institute at the National Institutes of Health (5R01CA149045); and a grant from the Doris Duke Charitable Foundation to Yale University to fund Clinical Research Fellow A.J.F.

Disclaimer: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA149045. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Cary P. Gross receives funding from FAIR Health, Inc. and Medtronic. All other authors declare no conflicts of interest.

Reprints: Cary P. Gross, MD, Yale University School of Medicine, 333 Cedar Street, P.O. Box 208025, New Haven, CT 06520-8025. E-mail:

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