Breast Cancer Patients Prefer Surgeons with Expertise

ANN ARBOR, Mich., Jan 17 -- Women who took more control over choosing the surgeon and hospital for breast cancer treatment were likely to receive more experienced care, researches reported.

When women were involved in selecting their breast cancer surgeon, they were twice as likely to opt for a high-volume practitioner at an experienced center than were patients who left those decisions to a doctor or health plan, according to a study in the Jan. 20 issue of the Journal of Clinical Oncology.

But the investigators did not link these patients' decisions to outcomes, said Steven Katz, M.D., M.P.H., of the University of Michigan here, and colleagues, who conducted the retrospective study. An outcomes study is the next step, they said.

In the meantime, women with breast cancer should be aware that provider-based referral may not connect them with the most experienced surgeons or the most comprehensive practice setting in their community, the researchers said.

The study included tumor registry and survey data from 1,844 women diagnosed with breast cancer in 2002 and 365 attending surgeons (80% response rate) collected from the Detroit and Los Angeles Surveillance, Epidemiology and End Results Registry (SEER). Data were weighted to account for sampling size and non-response.

The women were 79 and younger, diagnosed from 2001 to 2003 with invasive breast cancer (about 80%) or ductal carcinoma in-situ (about 20%). Their mean age was 59.7 years; two-thirds were white, while 18.7% were African American. Almost two-thirds of the patients had at least some college education, and 18.2% reported incomes below ,000.

In tracking referral patterns, the women were given choices such as, "I was referred by another doctor," "I chose this surgeon because of his or her reputation," or "I wanted a surgeon who practices near my home."

Nearly two-thirds of the patients reported that they were referred to their surgeon by another doctor, 14.9% were referred by their health plan; 15.3% selected their surgeon on the basis of the institution; 12.9% chose their surgeon by recommendation of family or friends, and 8.7% chose a surgeon on the basis of proximity. Percentages overlapped in some cases because patients could select all items that applied.

When the researchers combined the responses, they found that about half the patients (54.3%) were referred by another provider or health plan but did not select their surgeon.

By comparison, more than 40% of women were involved in the selection: 20.3% selected their surgeon but were not referred by another provider or plan; and 21.9% reported that they were referred and were involved in selecting their surgeon.

Patients who selected their surgeon on the basis of reputation were more than twice as likely to have been treated by a high-volume operator, defined as having more than 50% of total practice devoted to breast cancer surgery (adjusted odds ratio 2.2, 95% CI 1.5, 3.4).

They were also at least twice as likely to have been treated in an American College of Surgeons-approved cancer program or an NCI-designated cancer center (adjusted odds ratio 2.0, CI 1.3- 3.1; 3.4, CI 1.9- 6.2, respectively).

Women who said their doctor or health plan referred them to the surgeon were less likely to be treated at an NCI-designated cancer center (adjusted OR 0.5; CI 0.3, 0.9).

"We can only speculate about these referral patterns," Dr. Katz said. Organizational factors such as restricted provider networks within health maintenance organizations or preferred provider organizations, as well as informal professional and social network factors may play an important role in making a choice.

Most surgeons who perform breast surgery are general surgeons with diverse clinical practices. Patient referral to these surgeons may reflect provider relationships built on general surgical practice availability and performance rather than the surgeon's specific expertise in treatment of breast cancer. Also, the researchers noted, physicians may be concerned about losing patients and continuity of care.

Several limitations of the study merit comment, the investigators said. Breast surgery volume was determined by surgeon self-report of the percentage of their total practice devoted to breast cancer and may have lacked accuracy.

Lack of detail about health insurance may have introduced unmeasured confounding because some health plans limit patient referral to contracted provider networks. However, this option was listed among reasons why the treating surgeon was selected and was endorsed by only 14.9% of respondents.

Finally, although the sample size was large and patient and surgeon response rates were high, differences in respondent characteristics between those included versus those excluded from the analyses may limit generalizability.

Given the limited literature linking the structure of cancer care delivery to patient outcomes, community physicians may not be convinced that targeting referral to high-volume surgeons or hospitals with cancer programs would add clinically important value for most newly diagnosed patients with breast cancer seen in their practice, Dr. Katz said.

At this point, more research is needed to address the quality implication of the referral patterns found in this study, he said. This research should address the relationship between provider characteristics and key delivery-system factors, such as patient-provider communication, provider-provider communication, patient decision and care support, and practice management initiatives.

Ultimately, these factors should be linked to outcomes such as the use of effective treatments, patient satisfaction, and quality of life, Dr. Katz said.

Patients might consider a second opinion, they added, especially if they are advised to undergo a particular procedure without a full discussion of treatment options or a clear medical rationale for the recommendation.