Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor.
Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor.
JAMA Surg. 2018 Jan 1;153(1):29-36. doi: 10.1001/jamasurg.2017.3415.
Rates of contralateral prophylactic mastectomy (CPM) have markedly increased but we know little about the influence of surgeons on variability of the procedure in the community.
To quantify the influence of the attending surgeon on rates of CPM and clinician attitudes that explained it.
DESIGN, SETTING, AND PARTICIPANTS: In this population-based survey study, we identified 7810 women with stages 0 to II breast cancer treated in 2013 to 2015 through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery. Surveys were also sent to 488 attending surgeons identified by the patients.
We conducted multilevel analyses to examine the impact of surgeon influence on variations in patient receipt of CPM using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results data.
A total of 5080 women responded to the survey (70% response rate), and 377 surgeons responded (77% response rate). The mean (SD) age of responding women was 61.9 (11) years; 28% had an increased risk of second primary cancer, and 16% received CPM. Half of surgeons (52%) practiced for more than 20 years and 30% treated more than 50 new patients with breast cancer annually. Attending surgeon explained a large amount (20%) of the variation in CPM, controlling for patient factors. The odds of a patient receiving CPM increased almost 3-fold (odds ratio, 2.8; 95% CI, 2.1-3.4) if she saw a surgeon with a practice approach 1 SD above a surgeon with the mean CPM rate (independent of age, diagnosis date, BRCA status, and risk of second primary). One-quarter (25%) of the surgeon influence was explained by attending attitudes about initial recommendations for surgery and responses to patient requests for CPM. The estimated rate of CPM was 34% for surgeons who least favored initial breast conservation and were least reluctant to perform CPM vs 4% for surgeons who most favored initial breast conservation and were most reluctant to perform CPM.
In this study, attending surgeons exerted influence on the likelihood of receipt of CPM after a breast cancer diagnosis. Variations in surgeon attitudes about recommendations for surgery and response to patient requests for CPM explain a substantial amount of this influence.
对侧预防性乳房切除术 (CPM) 的比率显著增加，但我们对社区中外科医生对该手术的变异性的影响知之甚少。
量化主治外科医生对 CPM 比率的影响以及解释这种影响的临床医生态度。
设计、环境和参与者：在这项基于人群的调查研究中，我们通过佐治亚州和洛杉矶县的监测、流行病学和最终结果登记处，确定了 2013 年至 2015 年间接受治疗的 7810 名 0 期至 2 期乳腺癌女性。手术大约两个月后发出调查。还向患者确定的 488 名主治外科医生发送了调查。
我们进行了多水平分析，使用来自患者和外科医生调查的信息，结合监测、流行病学和最终结果数据，检查外科医生对患者接受 CPM 的影响。
共有 5080 名女性对调查做出回应（70%的回应率），377 名外科医生做出回应（77%的回应率）。接受调查的女性的平均（SD）年龄为 61.9（11）岁；28%有第二原发癌的高风险，16%接受了 CPM。一半的外科医生（52%）从业超过 20 年，每年治疗超过 50 名新的乳腺癌患者。主治外科医生解释了很大一部分（20%）CPM 的变化，控制了患者因素。如果患者看到一位手术方法比平均 CPM 率的外科医生高出 1 个标准差的外科医生，那么接受 CPM 的可能性几乎增加了两倍（比值比，2.8；95%置信区间，2.1-3.4）（独立于年龄、诊断日期、BRCA 状态和第二原发癌的风险）。25%的外科医生影响可以通过主治医生对手术初始建议的态度以及对患者 CPM 请求的反应来解释。最不赞成初始乳房保留且最不愿意进行 CPM 的外科医生的 CPM 估计率为 34%，而最赞成初始乳房保留且最不愿意进行 CPM 的外科医生的 CPM 估计率为 4%。
在这项研究中，主治外科医生对乳腺癌诊断后接受 CPM 的可能性产生了影响。外科医生对手术建议的态度以及对患者 CPM 请求的反应的变化解释了这种影响的很大一部分。
