Original Article
Geographic Variation in the Use of Breast-Conserving Treatment for Breast Cancer
N Engl J Med 1992; 326:1102-1107April 23, 1992
- Abstract
- Abstract
Background.
In the past decade there has been an increase in the use of treatment designed to conserve the breast for women with breast cancer. The extent to which such treatment has been adopted in various regions of the country and whether characteristics of hospitals and patients predict its use are not known, however.
Methods.
We used national data on Medicare claims for inpatient care provided in 1986 to study 36,982 women 65 to 79 years of age, who had local or regional breast cancer and underwent either mastectomy or breast-conserving treatment (local excision, quadrantectomy, or subtotal mastectomy). Information about the hospitals at which these women were treated was obtained from an American Hospital Association survey.
Results.
Of the 36,982 women, 12.1 percent had breast-conserving surgery and 87.9 percent had a mastectomy. The frequency of breast-conserving surgery ranged from 3.5 percent to 21.2 percent in various states. The highest rate of use was in the Middle Atlantic states (20.0 percent) and New England (17.2 percent), and the lowest was in the East South Central states (5.9 percent) and the West South Central states (7.3 percent). Breast-conserving treatment was used more often in urban than in rural areas, in teaching hospitals than in nonteaching hospitals, in large hospitals than in small hospitals, and in hospitals with on-site radiation therapy or geriatric services than in others. Most of the geographic variation persisted after adjustment for the characteristics of hospitals and patients for which data were available.
Conclusions.
There is substantial geographic variation in the use of breast-conserving surgery, which cannot be explained by differences in hospital characteristics. Hospital characteristics that were independently predictive of greater use of breast-conserving surgery were the size of the metropolitan area, the status of the institution as a teaching hospital, and the availability of radiation therapy and geriatric services. (N Engl J Med 1992;326:1102–7.)
Media in This Article
Figure 1
Rates of Breast-Conserving Surgery among Women 65 to 79 Years of Age Who Were Covered by Medicare and Who Underwent Surgery for Local or Regional Breast Cancer in 1986, According to State.Table 1
Use of Breast-Conserving Surgery According to Geographic Region.*Article Activity
- Article
SURGICAL treatment for local and regional breast cancer has changed considerably during the past decade. Until the early 1980s, the standard treatment was mastectomy. Then reports of several trials were published, showing that breast-conserving surgery followed by radiation therapy was a valid alternative for many women.1 2 3 By 1985, a consensus report on the subject stated that breast-conserving surgery was "appropriate in many patients with early breast cancer,"4 a conclusion echoed by other experts.5 , 6
It remains unclear, however, how these findings and recommendations have been translated into actual clinical practice. Few population-based data are available to answer this question. One study from New Mexico found that many surgeons began to use breast-conserving surgery between 1981 and 1985 and that 25 percent of women with localized breast cancer in that state received breast-conserving treatment in 1985.7
In 1981 there was little geographic variation in the rate of mastectomy among Medicare patients with breast cancer8 and probably little use of breast-conserving surgery at all. Data on the recent use of the two types of surgery therefore offer an opportunity to study geographic patterns in the assimilation of a new treatment. The purpose of our study was to assess the degree to which the use of breast-conserving surgery for breast cancer in Medicare patients in 1986 differed according to the region of the country and according to characteristics of the hospital. In addition, we undertook to assess the degree to which this variation could be explained by characteristics of both hospitals and patients.
Methods
Sources of Data
Information on patients and their treatment was obtained from the national records on Medicare claims for inpatient hospital care provided in 1986 that are maintained by the Health Care Financing Administration (HCFA). Information on hospitals was obtained from the 1986 annual survey of hospitals conducted by the American Hospital Association.
We had information for each 1986 hospital discharge for which a claim was processed by April 1987. Each hospital record included the patient's age, sex, race (black, white, other, or unknown), and dates of admission and discharge, a hospital provider code, and the codes for five diagnoses and three procedures from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9CM). The HCFA's national records of claims contain data for virtually all elderly residents of the United States, except those who undergo surgery at Veterans Affairs hospitals.9
The 1986 American Hospital Association survey contains information on hospitals' size, facilities, ownership, and teaching status.10 One or more of the hospital's characteristics were missing for 2255 (6.1 percent) of the 36,982 study patients. Such patients were excluded from analyses involving the missing hospital characteristics.
Study Population
Of the almost 11 million inpatient hospitalization records for 1986, we initially selected those with a diagnosis or procedure code possibly related to breast cancer (ICD-9-CM diagnostic codes 174 through 174.9, 196.3, 198.81, and 233 and procedure codes 40.3, 40.51, 85.1, 85.11, 85.12, 85.19, 85.2 through 85.23, 85.4, and 85.41 through 85.48). Men were excluded from the study. Women under the age of 65 who are covered by Medicare generally are disabled or have renal disease; thus, we excluded all women under 65 years of age, leaving 92,702 hospitalizations. For patients with multiple admissions, we identified the admission with the most invasive operation, leaving 87,544 hospitalizations for different patients.
We eliminated 26,428 patients who underwent only a diagnostic biopsy or no breast surgery, 1114 who underwent bilateral mastectomy, 17,454 without a code for primary breast cancer at the time of the most invasive operation, 1718 with a diagnosis of carcinoma in situ, and 16,020 with metastases to regions other than the axillary lymph nodes. Some patients had more than one reason for exclusion.
After these exclusions, a study cohort of 47,690 women remained. In this paper, we report our analyses for the 36,982 women who were 65 to 79 years of age; the percentage of women who had breast-conserving surgery was constant within this age range, whereas for women above the age of 79 it increased progressively.
Definition of Variables
In this study, breast-conserving treatment was defined as local excision, quadrantectomy, or subtotal mastectomy (ICD-9-CM codes 85.2 through 85.23). We coded the cancer as localized if only a diagnosis of primary breast cancer was recorded and as regional if a code for secondary cancer of the axillary lymph nodes was also present. We chose to analyze the patients with local disease and those with regional disease together, because the Medicare files probably report some regional cases as local (Whittle J: personal communication). However, the pattern of results did not change when only the 28,956 patients with local disease were analyzed.
We identified the hospital at which each patient was treated and the state in which the hospital was located by using the HCFA provider codes. For analyses according to geographic region, we grouped the states into the regions used by the American Hospital Association (the District of Columbia is included with the states in these analyses; Puerto Rico is not included). The size of the metropolitan area in which each hospital was located was taken from the American Hospital Association survey as a variable with seven categories for univariate analysis, but this variable was collapsed into three categories (population < 100,000, 100,000 to 1,000,000, or > 1,000,000) in multivariate analyses. We categorized hospitals according to number of beds in our univariate analyses ( 1 to 49, 50 to 99, 100 to 199, 200 to 299, 300 to 399, 400 to 499, and ≥500 beds), but we used the actual numbers of beds in multivariate models.
We coded variables related to the facilities or services available at the hospitals (radiation therapy, cancer center, and so on, coded as present or absent), the number of resident physicians on the house staff (any vs. none), and hospital ownership (investor-owned or not-for-profit, including both private and public hospitals).
Statistical Analysis
For the univariate analyses, we report odds ratios with 95 percent confidence intervals. The observed number of breast-conserving operations in a state or region was compared with the number that would be expected if the national rate of breast-conserving surgery were applied to that state. Chi-square statistics were calculated; a P value <0.001 was chosen to indicate statistical significance because multiple comparisons were made.
In the multivariate analyses with logistic regression,11 the use of breast-conserving surgery was the dependent variable. In an initial model we included variables for axillary-node metastases, black race, and the hospital characteristics found to be significant in the univariate analyses. The regression was stepped backward, with variables that were not significant at the level of P<0.05 individually removed.
To estimate the amount of the variation among the states that was explained by the variables available, the states were divided into five groups according to quintiles for the rate of breast-conserving surgery in each state. Indicator variables for the four groups with the highest rates of breast-conserving surgery were entered in the model. We report the odds ratios for undergoing breast-conserving surgery for the states in each of the quintile groups. The first set of odds ratios results from a model (model A) in which only the states' quintile groups were used as predictors of breast-conserving surgery. The second set of odds ratios results from a model (model B) in which the states' quintile groups and the characteristics of patients and hospitals were used as predictors.
Results
Of the 36,982 women 65 to 79 years of age who had local or regional breast cancer, 12.1 percent had breast-conserving surgery, 80.2 percent had modified radical mastectomy, 4.8 percent had simple mastectomy, and 2.9 percent had radical or extended radical mastectomy. Women with a diagnosis of metastasis to the axillary lymph nodes were less likely to undergo a breast-conserving procedure; of the 8026 patients with this diagnosis, only 7.5 percent underwent such surgery.
The percentages of patients who had breast-conserving surgery differed only slightly according to race. Of the 33,516 white women, 12.1 percent had this type of surgery. The comparable values were 11.3 percent for the 1933 black women, 12.0 percent for the 390 women of other races, and 11.2 percent for the 1143 women whose race was unknown (χ2 = 2.10, P = 0.55).
The percentage of patients who had breast-conserving surgery was similar throughout the 65-to-79-year age range. Of the 13,773 women who were 65 to 69 years of age, 12.2 percent had breast-conserving surgery; the comparable rates were 11.8 percent for the 12,850 women who were 70 to 74 years of age and 12.2 percent for the 10,359 women who were 75 to 79 years of age (χ2 = 1.3, P = 0.51).
Geographic Variation
There was substantial variation among the states in the proportion of women with local or regional breast cancer who underwent breast-conserving surgery (Fig. 1Figure 1
Rates of Breast-Conserving Surgery among Women 65 to 79 Years of Age Who Were Covered by Medicare and Who Underwent Surgery for Local or Regional Breast Cancer in 1986, According to State.); this proportion ranged from a low of 3.5 percent in Kentucky to a high of 21.2 percent in Massachusetts. In 11 states (Alabama, Georgia, Kentucky, Minnesota, North Carolina, Nebraska, South Carolina, Tennessee, Texas, Virginia, and Wisconsin), the rate of use of this treatment was significantly below the national mean, and in 3 states (Massachusetts, New York, and Pennsylvania), it was significantly above the national mean (P<0.001 for all comparisons).Substantial variation in the percentage of women who had breast-conserving surgery persisted when we grouped the states into the regions recognized by the American Hospital Association (Table 1Table 1
Use of Breast-Conserving Surgery According to Geographic Region.*). The rate of breast-conserving surgery was significantly higher than the mean in the New England and Middle Atlantic states and significantly lower than the mean in the South Atlantic, South Central, and West North Central states.There was also substantial variation in the use of breast-conserving surgery when the rates were analyzed according to the size of the metropolitan area where the hospital was located (Table 2Table 2
Use of Breast-Conserving Surgery According to the Size of the Metropolitan Area.*). Nonmetropolitan (i.e., rural) areas and metropolitan areas with populations of less than 100,000 had the lowest rate of breast-conserving surgery, those with populations of 100,000 to 1,000,000 had an intermediate rate, and those with populations of more than 1,000,000 had the highest rate of such treatment.Hospital Characteristics
The teaching status of the hospital was assessed in several ways. Women were more likely to undergo breast-conserving surgery when they received care in hospitals with a medical school affiliation, in hospitals reporting membership in the Council of Teaching Hospitals, or in hospitals that reported the employment of any full-time house staff (Table 3Table 3
Use of Breast-Conserving Surgery According to Hospital Characteristics.*).Patients treated in hospitals with 500 or more beds were more likely to undergo breast-conserving surgery than those treated in hospitals with fewer than 50 beds. Similarly, those treated in hospitals with more than 6000 Medicare discharges per year were more likely to undergo breast-conserving surgery than those treated in hospitals with fewer than 1500 discharges per year.
We studied several special services offered by hospitals. Women treated in hospitals with facilities for radiation therapy were slightly more likely than others to have breast-conserving surgery, as were those treated in hospitals with geriatric services or a cancer center. However, there was no difference between hospitals that reported having a women's center and those that did not or between investor-owned hospitals and not-for-profit hospitals.
Multivariate Analysis
In a logistic-regression model, the hospital characteristics that independently predicted the use of breast-conserving surgery were the size of the metropolitan area where the hospital was located, the status of the institution as a teaching hospital, the availability of radiation therapy, and the availability of geriatric services (Table 4Table 4
Logistic-Regression Model Incorporating Hospital and Patient Characteristics as Predictors of the Use of Breast-Conserving Surgery.*). Black race and the presence of axillary metastases were significant predictors in this model as well; both factors were associated with a lower likelihood of undergoing breast-conserving surgery.We divided the states into five groups according to quintiles for the rate of breast-conserving surgery. State quintile group 1 was made up of the states with the lowest rate of such surgery, and state quintile group 5 of the states with the highest rate. To estimate the amount of geographic variation that was explained by characteristics of the hospitals, we constructed a logistic-regression model (model A) in which only the state quintile groups were entered as predictors of the use of breast-conserving surgery and another model (model B) in which both the state quintile groups and hospital and patient characteristics were entered (Table 5Table 5
Effect of Hospital and Patient Characteristics in Explaining Geographic Variation in the Use of Breast-Conserving Surgery.*). There was only a slight decrease in the odds ratios for the state quintile groups when the other variables were added to the regression analysis.Discussion
We found substantial geographic variation in the use of breast-conserving surgery in older women. In addition, women treated at larger hospitals, urban hospitals, teaching hospitals, and hospitals with radiation or geriatric services were more likely to undergo breast-conserving surgery. However, marked variation among geographic regions persisted even after we adjusted for these hospital characteristics, for the size of the metropolitan area, for race, and for the presence of axillary-lymph-node metastases.
Our study had several limitations. We could not determine which patients were appropriate candidates for breast-conserving surgery, since we did not have information about tumor size or detailed information about the patients. Geographic differences in tumor size would have to be large, however, to account for the differences in practice patterns that we observed. We did examine geographic variation in the percentage of patients with axillary-lymph-node metastases, which is another indicator of the extent of disease. We found minimal variation among geographic regions, no significant variation according to the size of the metropolitan area, and no correlation among states between the proportion of patients with axillary metastases and the proportion undergoing breast-conserving surgery. Thus, we have no evidence of geographic variation in the extent of disease at presentation.
Could geographic differences in concurrent diseases explain our results? There is no reason to suspect such large variations in the presence of diseases other than breast cancer. Also, a substantial amount of geographic variation in the rate of breast-conserving therapy among younger women has been found by Farrow et al., as reported in this issue of the Journal 12; among these women large regional differences in the extent of concurrent illness would be even less likely than in the population we studied. Even if subtle differences existed, there is no obvious hypothesis about which surgical procedure would be favored in women with concurrent illness.
We do not know how many patients were offered breast-conserving surgery or whether there are regional differences in patients' attitudes about the procedure. Appropriateness of care does not always correlate with high or low rates of use,13 and the optimal percentage of breast-conserving surgery for women with breast cancer is unknown. However, a recent consensus statement on early-stage breast cancer recommended this type of surgery for the majority of women with Stage I and II breast cancer.14
Physicians' attitudes may also affect the choice of breast surgery,6 , 15 and differences in physicians' attitudes may explain the geographic variation we found. Physicians in the Northeast may have had earlier experience with breast-conserving surgery during clinical trials and thus have adopted it more rapidly. However, the U.S. multicenter study report listed more than 80 participating institutions, distributed widely across the country.3 The use of breast-conserving surgery requires little investment in either equipment or training above that required for performing mastectomies. The surgical techniques are well known to surgeons performing breast operations, although judgment is required to select patients likely to have a cosmetically acceptable result.14
We used a claims data base for our patient information. Such data bases are fairly reliable with respect to surgical procedures, although diagnostic information is more problematic.16 Because breast cancer is a pathological diagnosis, however, there should be fewer problems in making this diagnosis correctly than is the case for diagnoses requiring more subjective clinical judgment. There is no reason to think that any diagnostic error would be systematic enough to account for our results. An advantage of the Medicare claims data base is that almost all patients in this age group are covered by Medicare payments,9 minimizing bias based on the patient's insurance plan or socioeconomic status.
Black women were found to be less likely to undergo breast-conserving surgery than other women in the multivariate analysis. Black women with breast cancer have poorer survival overall than white women, even when disease stage is controlled for,17 , 18 and one study found that black women with regional or distant disease were less likely to have surgery than white women.18
Randomized clinical trials and consensus conference recommendations do not necessarily lead to rapid or appropriate changes in clinical practice.19 20 21 Local professional groups and opinion leaders are important in determining the rate at which new treatments are assimilated.19 , 22 This phenomenon presumably accounts in large part for geographic variations between small areas, but it appears unlikely to explain variations between larger geographic areas. Breast-conserving surgery provides a model for studying the adoption of new treatments. If the geographic patterns we found for breast-conserving surgery are observed in the assimilation of other new treatments, this variation should be considered in programs undertaken by national health authorities to promote new therapies.
Supported by an American Cancer Society Institutional Grant to the Medical College of Wisconsin and by a grant (1–R01–CA54676–01) from the National Cancer Institute. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the American Cancer Society.
Presented in part at the annual meeting of the American Society for Clinical Investigation, Washington, D.C., May 4–8, 1990.
We are indebted to A.A. Rimm, Ph.D., for initial assistance with access to the data sets; to A.L. Greer, Ph.D., for helpful comments on an earlier draft of the manuscript; to B.E. Nattinger, M.S., for technical assistance; and to Ms. Susan Goodman for assistance in the preparation of the manuscript.
Source Information
From the Departments of Medicine (A.B.N.) and Biostatistics and Clinical Epidemiology (M.S.G., J.V., D.Y.) of the Medical College of Wisconsin, Milwaukee, and the Department of Medicine of the University of Wisconsin Medical School Milwaukee Campus (J.S.G.). Address reprint requests to Dr. Nattinger at the Division of General Internal Medicine, Medical College of Wisconsin, 8700 W. Wisconsin Ave., Box 135, Milwaukee, WI 53226.
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