Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA
Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
J Oncol Pract. 2015 Jan;11(1):e9-e18. doi: 10.1200/JOP.2014.001397. Epub 2014 Sep 16.
We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania.
Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER) -positive/progesterone receptor (PR) -positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type.
Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission.
Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.
我们描述了与肯塔基州、北卡罗来纳州、俄亥俄州和宾夕法尼亚州阿巴拉契亚县早期乳腺癌的护理模式相关的个体、地区和提供者特征。
将 2006 年至 2008 年的 I 期至 III 期乳腺癌病例与诊断后 1 年内发生的医疗保险索赔相关联。研究了内分泌治疗（n=1429）、化疗（n=1480）和保乳手术后放射治疗（RT）的指南一致性；在年龄≥70 岁且雌激素受体（ER）阳性/孕激素受体（PR）阳性的 I 期癌症患者中研究了 RT（n=1108），对于其他所有符合 RT 指南的患者（n=1422），研究了 RT 的指南一致性。进行了单变量和多变量分析。自变量包括年龄、种族、县经济状况、州、外科医生毕业年份和数量、合并症、诊断年份、医疗补助/医疗保险双重身份、组织学、肿瘤大小、肿瘤序列、阳性淋巴结、ER/PR 状态、分期、曲妥珠单抗使用和手术类型。
人群平均年龄为 74 岁；97%为白人。内分泌治疗、化疗和 RT 的指南一致性分别为 76%、48%和 83%。在可选的情况下，77%的患者接受了 RT。北卡罗来纳州的内分泌治疗指南一致性低于宾夕法尼亚州（比值比[OR]，0.60；95%置信区间[CI]，0.41 至 0.88），如果外科医生毕业于 1984 年至 1988 年之间，而非 1989 年及以后，一致性更高（OR，1.58；95%CI，1.06 至 2.34）。化疗的指南一致性因州、县经济状况和外科医生数量而异。在指南一致的 RT 中，较低的外科医生数量（与最高相比）预测 RT 使用（比值比[OR]，1.63；95%CI，1.61 至 2.36）。在可选的 RT 中，北卡罗来纳州的居住地（宾夕法尼亚州；OR，0.29；95%CI，0.17 至 0.48）和经济地位较高的县（OR，0.61；95%CI，0.40 至 0.94）预测 RT 遗漏。
地理和外科医生特征的护理模式存在显著差异，为服务不足地区的进一步研究提供了目标。
