Barbara Salem

Patient Involvement in Surgery Treatment Decisions for Breast Cancer

PURPOSE High rates of mastectomy and marked regional variations have motivated lingering concerns about overtreatment and failure to involve women in treatment decisions. We examined the relationship between patient involvement in decision making and type of surgical treatment for women with breast cancer. METHODS All women with ductal carcinoma-in-situ and a 20% random sample of women with invasive breast cancer aged 79 years and younger who were diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries were identified and surveyed shortly after receipt of surgical treatment (response rate, 77.4%; n = 1,844). RESULTS Mean age was 60.1 years; 70.2% of the women were white, 18.0% were African American, and 11.8% were from other ethnic groups. Overall, 30.2% of women received mastectomy as initial treatment. Most women reported that they made the surgical decision (41.0%) or that the decision was shared (37.1%); 21.9% of patients reported that their surgeon made the decision with or without their input. Among white women, only 5.3% of patients whose surgeon made the decision received mastectomy compared with 16.8% of women who shared the decision and 27.0% of women who made the decision (P < .001, adjusted for clinical factors, predisposing factors, and number of surgeons visited). However, this association was not observed for African American women (Wald test 10.0, P = .041). CONCLUSION Most women reported that they made or shared the decision about surgical treatment. More patient involvement in decision making was associated with greater use of mastectomy. Racial differences in the association of involvement with receipt of treatment suggest that the decision-making process varies by racial groups.

The Influence of Race, Ethnicity, and Individual Socioeconomic Factors on Breast Cancer Stage at Diagnosis

OBJECTIVES Previous research has generally found that racial/ethnic differences in breast cancer stage at diagnosis attenuate when measures of socioeconomic status are included in the analysis, although most previous research measured socioeconomic status at the contextual level. This study investigated the relation between race/ethnicity, individual socioeconomic status, and breast cancer stage at diagnosis. METHODS Women with stage 0 to III breast cancer were identified from population-based data from the Surveillance, Epidemiology, and End Results tumor registries in the Detroit and Los Angeles metropolitan areas. These data were combined with data from a mailed survey in a sample of White, Black, and Hispanic women (n=1700). Logistic regression identified factors associated with early-stage diagnosis. RESULTS Black and Hispanic women were less likely to be diagnosed with early-stage breast cancer than were White women (P< .001). After control for study site, age, and individual socioeconomic factors, the odds of early detection were still significantly less for Hispanic women (odds ratio [OR]=0.45) and Black women (OR = 0.72) than for White women. After control for the method of disease detection, the White/Black disparity attenuated to insignificance; the decreased likelihood of early detection among Hispanic women remained significant (OR=0.59). CONCLUSION The way in which racial/ethnic minority status and socioeconomic characteristics produce disparities in womens experiences with breast cancer deserves further research and policy attention.

Population-based study of the relationship of treatment and sociodemographics on quality of life for early stage breast cancer.

Objective: To examine the relationship between cancer stage, surgical treatment and chemotherapy on quality of life (QOL) after breast cancer and determine if sociodemographic characteristics modify the observed relationships. Methods: A population-based sample of women with Stages 0–II breast cancer in the United States (N=1357) completed surveys including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and the Breast Cancer-Specific Quality of Life Questionnaire (QLQ BR-23). Regression models calculated mean QOL scores across primary surgical treatment and chemotherapy. Clinically significant differences in QOL were defined as 10 point difference (out of 100) between groups. Results: Meaningful differences in QOL by surgical treatment were limited to body image with women receiving mastectomy with reconstruction reporting lower scores than women receiving breast conserving surgery (p < 0.001). Chemotherapy lowered QOL scores overall across four QOL dimensions (p values < 0.001), with a disproportionately greater impact on those with lower levels of education. Younger women reported lower QOL scores for seven of nine QOL dimensions (p values < 0.001). Conclusions: Women should be reassured that few QOL differences exist based on surgical treatment, however, clinicians should recognize that the impact of treatment on QOL does vary by a woman’s age and educational level.

Patterns and Correlates of Local Therapy for Women With Ductal Carcinoma-In-Situ

PURPOSE Concerns have been raised about the quality of treatment for women with ductal carcinoma-in-situ (DCIS) because persistent high rates of mastectomy suggest overtreatment, whereas lower than expected rates of radiation therapy after breast-conserving surgery (BCS) suggest undertreatment. PATIENTS AND METHODS All women with DCIS diagnosed in 2002 and who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries were identified and surveyed shortly after receipt of surgery (response rate, 79.7%; n = 817). Analyses were restricted to patients with DCIS (n = 659) indicated by SEER stage data. RESULTS Only 14.0% of patients at lowest risk of recurrence (based on tumor size and histologic grade) received a mastectomy compared with 22.8% and 52.6% of patients at intermediate and highest risk (P < .001). Only 13.1% of patients who were not influenced or slightly influenced by concerns about recurrence received mastectomy compared with 48.8% of women who were greatly influenced by this concern (P < .001). A between-geographic site difference in receipt of radiation after BCS was observed for the lowest risk group (38.9% in Los Angeles v 70.5% in Detroit) but not for the highest risk group (80.2% in Los Angeles v 85.9% in Detroit, P = .006 for site and risk group differences). Between-site differences in receipt of radiation after BCS were consistent with patient recall of surgeon discussions about treatment. CONCLUSION Surgeons are tailoring their recommendations for local therapy options for DCIS based on important clinical factors. Patient attitudes also play an important role in treatment decisions. The substantial influence of both surgeon opinion and patient attitudes should temper concerns about the quality of treatment for women with DCIS.

Latinas and breast cancer outcomes: Population-based sampling, ethnic identity, and acculturation assessment

Purpose: Latinas and African-Americans with breast cancer, especially those of lower socioeconomic status and acculturation, have been underrepresented in studies assessing treatment satisfaction, decision-making, and quality of life. A study was designed to recruit a large and representative sample of these subgroups. Materials and Methods: Incident cases were selected by rapid case ascertainment (RCA) in the Los Angeles Surveillance, Epidemiology, and End Results Registry from 2005 to 2006, with oversampling of Latinas and African-Americans. Patients were mailed a questionnaire and

Surgeon Perspectives about Local Therapy for Breast Carcinoma

10 incentive 5 to 6 months after diagnosis; nonrespondents were contacted by telephone. Multivariate analysis was used to assess possible response bias. The RCA definition of Hispanic origin was validated by self-reports. The Short Acculturation Scale for Hispanics index for Latina respondents was used. Results: One thousand six hundred and ninety-eight eligible breast cancer cases were selected and 1,223 participated, for a response rate of 72.0%, which varied little by race/ethnicity. Age, race/ethnicity, and clinical factors were not associated with response; however, respondents were slightly more likely to be married and from higher socioeconomic status census tracts than nonrespondents. The RCA definition of Hispanic identity was highly sensitive (94.6%) and specific (90.0%). Lower acculturation was associated with lower education and literacy among Latinas. Discussion: High response rates among all subgroups were achieved due to the use of RCA, an incentive, extensive telephone follow-up, a native Spanish-speaking interviewer, and a focused questionnaire. The low acculturation index category identified a highly vulnerable subgroup. This large sample representing subgroups with greater problems will provide a basis for developing better interventions to assist these women. (Cancer Epidemiol Biomarkers Prev 2009;18(7):2022–9)

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample

Geographic variations in the use of mastectomy and the use of radiation therapy (RT) after breast‐conserving surgery (BCS) have motivated concerns that surgeons are not uniformly adhering to treatment standards.

Shared decision-making and surgical treatment for breast cancer

PURPOSE Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample. PATIENTS AND METHODS Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt. RESULTS The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt. CONCLUSION In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Surgical treatment satisfaction among women with breast cancer: The role of preferences regarding shared decision making

556 Background: Persistent high rates of mastectomy (mast) use for breast cancer have motivated lingering concerns about over-treatment. Policy makers have suggested that large regional variation in patterns of treatment is evidence of failure to involve women about the treatment they prefer. To address these issues, we examined the relationship between patient involvement in decision-making and receipt of surgical treatment for women with breast cancer. METHODS All women with DCIS and a 20% random sample of women with invasive breast cancer aged 79 and younger diagnosed in 2002 and reported to the Detroit and Los Angeles metropolitan SEER registries were identified and surveyed shortly after receipt of surgical treatment. Response rate was 74.3% (N=1489). RESULTS The mean age was 59.9 years; 68.7% were Caucasian, 17.0% were African American and 14.3% were of other ethnic groups. Overall, 26.4% of women received mast as initial treatment (23.6% of Caucasians, 30.2% of African Americans and 34.6% of other ethnic groups). One fifth of patients reported that their surgeon made the decision; 37.9% that the decision was shared; and 41.0% said they made the decision. The table below shows percent of patients (stages 0-2) who received mast by perceived levels of involvement and race, controlling for stage, tumor size, histologic grade, contra-indication to lumpectomy, age, and education. Patient involvement was positively associated with receipt of mast as initial surgical treatment. However, this was observed largely for Caucasian women (p=.01). CONCLUSIONS Most women reported that they made or shared the decision about surgical treatment. Results suggest that patient preferences may partly explain persistently high rates of mastectomy and regional variation in surgical treatment. Racial differences in the association of involvement with receipt of treatment suggest that the decision-making process varies by racial groups. [Figure: see text] [Table: see text].

Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer.

6033 Background: Although shared decision-making for surgical treatment of breast cancer is promoted as ideal, patient preferences for level of involvement may vary. We used data from a population-based sample of breast cancer patients to examine the relationship between decision context for surgical treatment and two key satisfaction outcomes. METHODS Study subjects were breast cancer patients reported to Detroit and Los Angeles SEER registries in 2002. All DCIS patients and a 20% random sample with non-metastatic invasive disease were mailed a questionnaire shortly after diagnosis (n=1,489; response rate 74.3%). Logistic regression was used to estimate the odds of having low satisfaction on validated scales for two dimensions of satisfaction: a) surgery received; and b) the process by which the surgery decision was made. Models included controls for age, race, stage, preferences regarding shared decision making, and the degree to which this preference was achieved. RESULTS 37.9% of women reported the surgery decision was shared, 21.1% that it was primarily made by the surgeon, and 41.0% that it was primarily made by themselves. Compared with how they wanted to make the decision, 65.1% experienced the amount of participation preferred while 12.5% had less and 22.4% had more. The strongest predictor of low satisfaction on both dimensions was incongruence between the amount of participation preferred and experienced. For example, the odds of having low satisfaction with the surgical outcome were 2.7 (p<.001) for those with less participation than preferred, and 1.4 (p<.05) for those with more than preferred. Women who received mastectomy were just as satisfied on both dimensions as those with lumpectomy. African American women had significantly lower levels of satisfaction than other women (p<.01). CONCLUSIONS A salient factor associated with two important dimensions of satisfaction is the match between patient preferences and the actual degree of participation in the surgery decision. Thus, increased promotion of shared decision making will not automatically lead to increased satisfaction among all breast cancer patients. No significant financial relationships to disclose.