Indu Lakhani

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.

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.

Surgeon Perspectives about Local Therapy for Breast Carcinoma

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.

Characteristics of the Pediatric Hospitalist Workforce: Its Roles and Work Environment

OBJECTIVE. Over the past 10 years, the use of hospitalists has grown in both the adult and pediatric setting as a response to pressure to deliver cost-effective, high-quality care. However, there is a paucity of information regarding the variation in the clinical roles, educational responsibilities, work patterns, and employment characteristics of pediatric hospitalists. This lack of information hampers efforts to define the nature of the field and determine whether any formalized, additional training or experience should be required for physicians in this clinical practice domain. DESIGN. We conducted a telephone survey of a national sample of pediatric hospitalist program directors (n = 116). Questionnaire items focused on exploring the clinical roles, work patterns, employment characteristics, and training of pediatric hospitalists within each institution. Results were stratified by teaching hospitals, urban/rural location, hospital size, and membership in the National Association of Childrens Hospitals and Related Institutions. RESULTS. The response rate was 97%. The majority of hospitals surveyed (70%) reported that hospitalists do not generate enough income from professional billing to pay their salaries. Fewer than half (39%) of respondents reported that their hospital measures pediatric clinical outcomes associated with hospitalist care. A total of 42% of hospitalist program directors reported that most of their hospitalists had an average duration of employment of <3 years. In programs with residents, hospitalists serve as teaching attendings for pediatric patients in almost all cases (89%). CONCLUSIONS. Hospital medicine is a rapidly growing enterprise. A better understanding of both its participants, as well as those affected by its practice, will enable planning for a future that meets as many needs as possible while ensuring the best possible care for children.

Shared decision-making and surgical treatment for breast cancer

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].