January 23, 2007

Assertive women get better surgeons, treatment centers

Breast cancer patients who take control of choosing their own surgeon are more likely to be treated by an experienced one and at an accredited center than those who do not, researchers report.

Although characteristics of surgeons and their hospitals have been linked to cancer treatment and outcome, factors that influence who and where a woman is referred to have been rarely explored, the team explains.

Addressing this issue, Steven Katz (University of Michigan, Ann Arbor, USA) and co-workers studied 1844 women up to 79 years of age who were diagnosed with ductal carcinoma in situ or invasive breast cancer between December 2001 and January 2003.

The women, who were from the greater metropolitan areas of Detroit in Michigan and Los Angeles in California, were identified from the Surveillance, Epidemiology, and End Results database.

Katz et al surveyed how the women's breast surgeon was selected, with answer options such as "The surgeon was one of the only surgeons available through my health care plan," "I was referred to the surgeon by another doctor," "I chose this surgeon because I wanted to be treated at the medical institution where he/she worked," and "I wanted a surgeon who practiced near my home."

Based on their answers, the patients were categorized as being referred to their surgeon, or selecting their surgeon based on reputation or proximity. Overall, about a quarter said they chose their surgeon based on reputation, 15% chose their surgeon because of the institution, and 13% on the recommendation of family or friends.

Better educated and wealthier women were more likely to select their surgeons based on reputation or proximity, the authors note.

Women whose choices were informed by the surgeon's reputation were more likely to have been treated by a high-volume surgeon (adjusted odds ratio [OR] = 2.2), and in an American College of Surgeons-approved cancer program (OR = 2.0) or a National Cancer Institute (NCI)-designated cancer center (OR = 3.4), the team reports in the Journal of Clinical Oncology.

By contrast, patients who were referred to their surgeon were half as likely as the others to be treated at an NCI-designated center.

"Women with breast cancer should be aware that referrals from another doctor or their health plan may not connect them with the most experienced surgeons or the most comprehensive practice settings in their community," said Katz. "Patients might consider seeking a second opinion, especially if they are advised to undergo a particular treatment without a full discussion of the options," he added.

However, Katherine Kahn from the University of Los Angeles at California, USA, commented in a related editorial: "For breast cancer, evidence does not currently support improved patient outcomes from replacing physician judgement and expertise with strict volume criteria as a strategy for identifying surgical referrals."

J Clin Oncol 2007; 25: 244-245; 271-276


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