Division of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut; Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota.
Breast J. 2013 Nov-Dec;19(6):627-36. doi: 10.1111/tbj.12177. Epub 2013 Sep 9.
While magnetic resonance imaging (MRI) is frequently used following breast cancer diagnosis, routine use of breast MRI for preoperative evaluation remains contentious. We identified factors associated with preoperative breast MRI utilization and investigated the variation among physicians. We used the surveillance, epidemiology, and end Results (SEER)-Medicare linked database to analyze the preoperative breast MRI utilization among patients with stage 0, I, or II breast cancer diagnosed between 2002 and 2007. Multilevel logistic regression models were used to identify patient- and physician-level predictors of preoperative MRI utilization. Of 56,743 women with early-stage breast cancer who were treated with surgery and evaluated by a preoperative mammogram and/or ultrasound during the study period, 8.7% (n = 4,913) received preoperative breast MRI. While patient and tumor characteristics did predict preoperative breast MRI utilization, they explained only 15.4% of the variation in utilization rates. Differences in preoperative breast MRI utilization across physicians were large, after controlling patient-level factors and physicians' volumes. Accounting for clustering of patients within individual physicians (n = 3,144), the multilevel logistic regression models explained 36.4% of variation. The median odds ratio of 3.2, corresponding with the median value of the relative odds of receiving preoperative breast MRI between two randomly chosen physicians, indicated a large individual physician effect. Our study found that preoperative breast MRI has been adopted rapidly and variably. Although patient characteristics were associated with preoperative breast MRI utilization, physician practice was a major determinant of whether women received preoperative breast MRI. Future studies should evaluate whether routine use of preoperative breast MRI in newly diagnosed early-stage breast cancer improves clinical outcomes.
虽然磁共振成像（MRI）常用于乳腺癌诊断后，但术前评估常规使用乳腺 MRI 仍存在争议。我们确定了与术前乳腺 MRI 使用相关的因素，并调查了医生之间的差异。我们使用监测、流行病学和最终结果（SEER）-医疗保险数据库，分析了 2002 年至 2007 年间诊断为 0 期、I 期或 II 期乳腺癌的患者术前乳腺 MRI 的使用情况。使用多水平逻辑回归模型确定患者和医生水平预测术前 MRI 使用的因素。在研究期间接受手术治疗并接受术前乳房 X 线摄影和/或超声检查评估的 56743 名早期乳腺癌女性中，8.7%（n=4913）接受了术前乳腺 MRI。尽管患者和肿瘤特征确实预测了术前乳腺 MRI 的使用，但它们仅解释了使用率变化的 15.4%。在控制患者水平因素和医生数量后，医生之间术前乳腺 MRI 使用的差异很大。考虑到患者在单个医生内的聚类（n=3144），多水平逻辑回归模型解释了 36.4%的变化。中位数优势比为 3.2，对应于两名随机选择的医生之间接受术前乳腺 MRI 的相对优势的中位数，表明医生个体的影响很大。我们的研究发现，术前乳腺 MRI 已经迅速且不同地被采用。尽管患者特征与术前乳腺 MRI 的使用相关，但医生的实践是女性是否接受术前乳腺 MRI 的主要决定因素。未来的研究应评估在新诊断的早期乳腺癌中常规使用术前乳腺 MRI 是否改善临床结果。
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