Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor.
JAMA Surg. 2018 Oct 1;153(10):909-916. doi: 10.1001/jamasurg.2018.2001.
Genetic testing after diagnosis of breast cancer is common, but little is known about the influence of the surgeon on the variation in testing.
To quantify and explain the association of attending surgeon with rates of genetic testing after diagnosis of breast cancer.
DESIGN, SETTING, AND PARTICIPANTS: This population-based study identified 7810 women with stages 0 to II breast cancer treated between July 1, 2013, and August 31, 2015, through the Surveillance, Epidemiology, and End Results registries for the state of Georgia, as well as Los Angeles County, California. Surveys were sent approximately 2 months after surgery. Also surveyed were 488 attending surgeons identified by the patients.
The study examined the association of surgeon with variation in the receipt of genetic testing using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results and genetic testing data obtained from 4 laboratories.
In total, 5080 women (69.6%) of 7303 who were eligible (mean [SD] age, 61.4 [0.8] years) and 377 surgeons (77.3%) of 488 (mean [SD] age, 53.8 [10.7] years) responded to the survey. Approximately one-third (34.5% [1350 of 3910] of patients had an elevated risk of mutation carriage, and 27.0% (1056 of 3910) overall had genetic testing. Surgeons had practiced a mean (SE) of 20.9 (0.6) years, and 28.9% (107 of 370) treated more than 50 cases of new breast cancer per year. The odds of a patient receiving genetic testing increased more than 2-fold (odds ratio, 2.48; 95% CI, 1.85-3.31) if she saw a surgeon with an approach 1 SD above that of a surgeon with the mean test rate. Approximately one-third (34.1%) of the surgeon variation was explained by patient volume and surgeon attitudes about genetic testing and counseling. If a patient with higher pretest risk saw a surgeon at the 5th percentile of the surgeon distribution, she would have a 26.3% (95% CI, 21.9%-31.2%) probability of testing compared with 72.3% (95% CI, 66.7%-77.2%) if she saw a surgeon at the 95th percentile.
In this study, the attending surgeon was associated with the receipt of genetic testing after a breast cancer diagnosis. Variation in surgeon attitudes about genetic testing and counseling may explain a substantial amount of this association.
乳腺癌诊断后的基因检测很常见，但对于外科医生对检测变化的影响知之甚少。
量化并解释主治外科医生与乳腺癌诊断后基因检测率之间的关联。
设计、地点和参与者：这项基于人群的研究通过佐治亚州的监测、流行病学和最终结果登记处以及加利福尼亚州洛杉矶县，确定了 7810 名患有 0 期至 2 期乳腺癌的女性，这些女性在 2013 年 7 月 1 日至 2015 年 8 月 31 日之间接受了治疗。大约在手术后两个月发送了调查。还对 488 名由患者确定的主治外科医生进行了调查。
该研究通过将患者和外科医生调查的信息与监测、流行病学和最终结果合并，并从 4 个实验室获得基因检测数据，研究了外科医生与基因检测接受情况变化之间的关联。
共有 7303 名符合条件的女性（7303 名中的 5080 名，平均[SD]年龄为 61.4[0.8]岁）和 488 名外科医生（488 名中的 377 名，平均[SD]年龄为 53.8[10.7]岁））对调查做出了回应。大约三分之一（3910 名中的 1350 名，34.5%）的患者具有较高的突变携带风险，总体而言，有 27.0%（3910 名中的 1056 名）进行了基因检测。外科医生的平均（SE）从业年限为 20.9（0.6）年，28.9%（107 名中的 370 名）每年治疗的新乳腺癌病例超过 50 例。如果患者接受了一位外科医生的治疗，其治疗方法比平均检测率的外科医生高出 1 个标准差，那么患者接受基因检测的可能性会增加两倍以上（优势比，2.48；95%置信区间，1.85-3.31）。大约三分之一（34.1%）的外科医生变异可以用患者数量和外科医生对基因检测和咨询的态度来解释。如果风险较高的患者接受处于外科医生分布第 5 百分位的外科医生的治疗，那么她进行检测的概率为 26.3%（95%置信区间，21.9%-31.2%），而如果她接受处于第 95 百分位的外科医生的治疗，那么她进行检测的概率为 72.3%（95%置信区间，66.7%-77.2%）。
在这项研究中，主治外科医生与乳腺癌诊断后的基因检测有关。外科医生对基因检测和咨询的态度差异可能解释了这种关联的很大一部分。
