Original Article

Geographic Variation in the Treatment of Localized Breast Cancer

Diana C. Farrow, Ph.D., William C. Hunt, M.A., and Jonathan M. Samet, M.D.

N Engl J Med 1992; 326:1097-1101April 23, 1992

Abstract

Abstract

Background.

Breast-conserving surgery followed by radiation therapy is as effective as modified radical mastectomy in treating women with localized breast cancer, as demonstrated by clinical trials reported during the 1980s. The extent to which breast-conserving surgery has been adopted in various regions of the United States is not known.

Full Text of Background. ...

Methods.

We assessed variations in the use of breast-conserving surgery from 1983 to 1986 in 18,399 non-Hispanic white, 324 Hispanic, and 1174 black women with breast cancer in nine areas of the United States, using data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.

Full Text of Methods. ...

Results.

The proportion of white women with localized breast cancer who underwent breast-conserving surgery ranged from 9.2 percent (Iowa) to 32.1 percent (Seattle) in 1983–1984 and from 19.6 percent (Iowa) to 41.5 percent (Seattle) in 1985–1986. Between 1983 and 1986, the use of breast-conserving surgery increased in each area, but the relative rankings of the areas changed little. The frequency of the use of breast-conserving surgery in black and Hispanic women was comparable to that in white women. The proportion of women who received radiation therapy after breast-conserving surgery also varied geographically and increased from 1983 to 1986 in all areas. Older women in all areas and black women in Atlanta and Detroit were less likely than other women to receive radio-therapy after breast-conserving surgery.

Full Text of Results. ...

Conclusions.

There is marked variation in the United States in the use of breast-conserving surgery for localized breast cancer. The variation is not explained by demographic factors, although race and age affect the use of radiotherapy after breast-conserving surgery. (N Engl J Med 1992;326:1097–101.)

Full Text of Conclusions. ...

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Media in This Article

Table 1Cases of Localized Breast Cancer among White Women and Percentage Treated by Breast-Conserving Surgery, According to SEER Area and Date.

Table 2Percentage of White Women Who Underwent Breast-Conserving Surgery for Localized Breast Cancer, According to SEER Area and Age, 1983 through 1986.

Article Activity

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Article

THERE is substantial geographic variation in the medical and surgical management of disease in the United States.1 2 3 4 5 6 7 8 To date, however, specific variations in cancer treatment have not been comprehensively examined.

Clinical trials published during the 1980s9 10 11 suggested that for women with localized breast cancer, modified radical mastectomy and breast-conserving surgery followed by radiation offer alternative approaches of comparable efficacy. We used data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute to determine the geographic and temporal variation in the use of mastectomy and breast-conserving surgery and radiation in nine areas of the United States from 1983 to 1986 and to assess the variation according to age, race, and ethnic group.

Methods

The data used in this analysis were derived from the SEER Program of the National Cancer Institute.12 Begun in 1973, this program collects information on all cases of cancer occurring in residents of nine areas in the United States: metropolitan Atlanta, metropolitan Detroit, the San Francisco—Oakland Standard Metropolitan Statistical Area, the Seattle—Puget Sound area, and the states of Connecticut, New Mexico, Hawaii, Iowa, and Utah.

Cases are found primarily by reviewing hospital pathology reports and discharge diagnoses; in addition, records kept by pathology laboratories, oncologists, and radiotherapists as well as death certificates are reviewed. The data are checked for accuracy and completeness as part of a routine quality-control program; approximately 99 percent of the cancers occurring in the nine areas are found.13 The data collected include the patient's age, sex, race, and ethnicity (i.e., Hispanic); information about the basis of the diagnosis and the extent of disease at presentation; details of treatment; and the results of an annual follow-up to determine survival.

This analysis was based on data for the years 1983 through 1986, a period during which site-specific treatment codes provided detailed information about the treatment of breast cancer. We initially selected all women residing in any SEER area who had a single primary histologically confirmed localized breast tumor. Localized disease is defined in the SEER Summary Staging Guide 14 as invasive cancer of any size confined to the organ of origin. We determined the proportion of women treated by breast-conserving surgery in each area. For this report, breast-conserving surgery was defined as partial or less-than-total mastectomy (including segmental mastectomy, lumpectomy, quadrantectomy, wedge resection, nipple resection, excisional biopsy, and partial mastectomy that was not otherwise specified), with or without dissection of axillary lymph nodes. The majority of the women who were not treated by breast-conserving surgery underwent modified radical mastectomy. We cross-tabulated treatment variables according to the SEER geographic site, stratifying by age group, ethnic and racial group, and year of diagnosis. All analyses were conducted with programs of the Statistical Analysis System.15

Results

Data for 18,399 non-Hispanic white women were available for analysis from 1983 through 1986 (Table 1Table 1Cases of Localized Breast Cancer among White Women and Percentage Treated by Breast-Conserving Surgery, According to SEER Area and Date.). There were 324 Hispanic women from New Mexico and San Francisco and 1174 black women from Atlanta, Connecticut, Detroit, and San Francisco. The percentages of white women with localized breast cancer who were treated by breast-conserving surgery varied widely among the nine areas (Table 1). For example, in 1985–1986, 41.5 percent of the white women who were treated in Seattle underwent breast-conserving surgery, as compared with 19.6 percent in Iowa. In the other areas, between 20 and 40 percent of the white women who were treated underwent breast-conserving surgery. The geographic variation shown in Table 1 occurred in all age groups; the differences in the distribution of ages at the time of diagnosis in the nine areas do not explain the crude differences in the proportions treated by breast-conserving surgery (Table 2Table 2Percentage of White Women Who Underwent Breast-Conserving Surgery for Localized Breast Cancer, According to SEER Area and Age, 1983 through 1986.). In all areas except Utah, the proportion of women treated by breast-conserving surgery was lowest among women 65 to 74 years of age and higher among both those older than 74 and those younger than 65 (Table 2).

Among the white women, the proportions treated by breast-conserving surgery increased in each of the nine areas from 1983 to 1986 (Table 1). In spite of the overall increase in breast-conserving surgery during the four-year period, the areas tended to maintain their relative rankings in frequency of breast-conserving surgery.

There were sufficient numbers of minority women in five of the nine areas (Atlanta, Connecticut, Detroit, New Mexico, and San Francisco) to permit assessment of the racial and ethnic variation in the proportions treated by breast-conserving surgery (Table 3Table 3Percentage of Women with Localized Breast Cancer Treated by Breast-Conserving Surgery, According to SEER Area and Racial or Ethnic Group, 1983 through 1986.*).16 The minority women were treated by breast-conserving surgery at the same rates as the white women, and the use of such surgery did not vary significantly according to racial or ethnic group in any of these five areas.

The recent large clinical trials comparing breast-conserving surgery with more radical surgery for localized breast cancer incorporated radiation therapy after the breast-conserving surgery.9 10 11 In an analysis of data from New Mexico alone, we found that not all those who underwent a breast-conserving procedure subsequently received radiation.17 We examined the variation among the nine areas in the proportion of women treated by breast-conserving surgery who subsequently received radiation therapy. Table 4Table 4Percentage of White Women Receiving Radiation after Breast-Conserving Surgery for Localized Breast Cancer, According to SEER Area and Date.* shows the proportion of white women receiving radiation therapy after breast-conserving surgery in each of the nine areas. As with the surgery itself, the use of radiation therapy varied widely from one area to another. Seattle had the highest proportion of women who received radiation; it was also the area in which the use of breast-conserving surgery was greatest (Table 1). The lowest proportion of women receiving radiation was in Iowa, where breast-conserving surgery was used the least. In all areas, radiation was used more frequently in 1985–1986 than in 1983–1984.

The proportion of white women receiving radiation therapy after breast-conserving surgery varied with age (Table 5Table 5Percentage of White Women Receiving Radiation after Breast-Conserving Surgery for Localized Breast Cancer, According to SEER Area and Age, 1983 through 1986.). In most areas, the proportion of women treated with radiation decreased initially at the age of 65 years and more sharply at the age of 75 years.

In Detroit and Atlanta, black women were significantly less likely than white women to receive radiation after breast-conserving surgery (Table 6Table 6Percentage of Women Receiving Radiation after Breast-Conserving Surgery for Localized Breast Cancer, According to SEER Area and Racial or Ethnic Group, 1983 through 1986.). In other areas, however, the use of radiotherapy did not vary consistently according to race or ethnic group.

Discussion

These results indicate substantial variability in the treatment of localized breast cancer in the nine areas served by the registries in the SEER Program. The findings are subject to limitations inherent in the SEER data. For example, only treatment delivered or planned within the first four months after the initiation of treatment is recorded. Whereas surgery is an inpatient procedure that is performed as part of the first course of cancer-directed therapy, radiation therapy may be recorded as planned or performed on an outpatient basis, and is thus more difficult to document.

The SEER data do not provide information about coexisting medical conditions that may influence treatment choices. It is unlikely, however, that the geographic variation in cancer treatment can be explained by confounding due to coexisting medical conditions. The pattern of variation among the nine areas was consistent at all ages, even among younger women, who are unlikely to have coexisting medical conditions (Table 2).

Geographic variation of the magnitude found in this study (Table 1) has been documented for measures of health care as diverse as utilization rates among Medicare beneficiaries and hospitalization rates among children.1 , 8 , 18 The regional variation in patterns of medical care remains unexplained and has raised questions about what constitutes the appropriate level of care.19 20 21 22 23 24 Whether the variation reflects underuse or overuse is uncertain.19 It has not been explained by studying the extent of inappropriate care,22 and inappropriate care itself cannot be predicted on the basis of patient demographics or the characteristics of physicians or hospitals.23 The wide geographic variation in the patterns of care for most diseases cannot readily be attributed to a few physicians; however, in a study of variation in the rate of carotid endarterectomy, the actions of a few surgeons in the high-use areas did explain much of the variation.25

For treatment of localized breast cancer, the results of clinical trials suggest that radical and breast-conserving surgery yield comparable outcomes.9 10 11 Thus, treatment choice reflects the preferences of patients and physicians; the appropriateness of the choice is not at issue. The variation among geographic regions indicates that the practices of individual physicians in treating breast cancer cannot explain the findings and implies that treatment choices reflect regional factors. In all regions, the rates of breast-conserving surgery tended to be higher among younger (≤64 years) and older (≥75 years) women. This pattern may represent the avoidance of more disfiguring radical surgery in younger women and of potentially greater morbidity from modified radical mastectomy in older women. Nattinger et al. have found, as reported in this issue of the Journal 26 that the hospital characteristics associated with an increased likelihood of undergoing breast-conserving surgery among women 65 to 79 years of age were large size, an urban location, the presence of a cancer program, a medical-school affiliation, and membership in the council of teaching hospitals.

In an analysis of SEER data for New Mexico, we found that breast-conserving surgery for localized disease was not always followed by radiation and that older women were less likely to receive radiation.17 The present analysis confirmed these findings in all SEER areas and also showed a nationwide temporal trend toward the increasing use of radiation after surgery. Lower rates of use of radiation therapy for breast cancer in older women have been reported in other studies as well27 , 28; however, age does not appear to influence the appropriateness of the radiation therapy itself.29 Although factors influencing the use of radiation therapy in older women with breast cancer have not been well studied, it is likely that the withholding of radiation therapy after breast-conserving surgery reflects the influences of both coexisting medical conditions and patient age on physicians' practices.27 , 30 , 31

We also found that black women were less likely than white women to receive radiation therapy in some but not other areas; race and ethnic background were not strong determinants of the choice of surgical procedure. We reported previously that Hispanic and American Indian patients with cancer in New Mexico were less likely to be treated than white patients32; in that study, however, the differences among the American Indian, Hispanic, and white patients regarding treatment of breast cancer were small. It has also been found that medical care is less common among black patients with ischemic heart disease than white patients.33 Our findings on radiation after breast-conserving surgery suggest that race may have different effects on treatment patterns in various regions of the United States.

Attempts have been made to identify other factors that affect a woman's likelihood of receiving radiation therapy after breast-conserving surgery. In New Mexico, that likelihood was not associated with living in an urban as opposed to a rural area, the length of time the patient had to travel to reach the treatment facility, or the surgeon who performed the operation.17 In a recent Illinois study,34 hospital characteristics associated with the failure to receive radiation therapy were an urban location and limited experience in the treatment of breast cancer.

Finally, we found substantial temporal changes in the treatment of localized breast cancer from 1983 through 1986. In the Seattle area, the use of breast-conserving surgery increased from 1983 to 1985, but then declined slightly for the next four years.35 This pattern was thought to represent a transient response to the publication of the large clinical trial of Fisher et al. in 1985.9 The rapidity of change in the use of breast-conserving surgery mirrors the rapidity of the change from the use of radical mastectomy to modified radical mastectomy during the 1970s.36

Supported by a grant (HS 06879) from the Agency for Health Care Policy and Research and by a contract (NO1-CN-05228) from the Biometry Branch of the National Cancer Institute.

Source Information

From the Departments of Medicine (J.M.S.) and Family and Community Medicine (D.C.F., W.C.H.) and the New Mexico Tumor Registry, Cancer Center (D.C.F., W.C.H., J.M.S.), University of New Mexico Medical Center, Albuquerque. Address reprint requests to Dr. Samet at the New Mexico Tumor Registry, University of New Mexico, Albuquerque, NM 87131–5306.

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