Journal of the American College of Surgeons
Volume 209, Issue 4 , Pages 425-433.e2, October 2009

Breast-Conserving Surgery in Older Patients with Invasive Breast Cancer: Current Patterns of Treatment Across the United States

  • Grace L. Smith, MD, PhD

      Affiliations

    • Department of Radiation Oncology, the Section of Health Services Research, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Ying Xu, MD, MS

      Affiliations

    • Department of Biostatistics, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Ya-Chen T. Shih, PhD

      Affiliations

    • Department of Biostatistics, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Sharon H. Giordano, MD, MPH

      Affiliations

    • Department of Breast Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Benjamin D. Smith, MD

      Affiliations

    • Department of Radiation Oncology, the Section of Health Services Research, the University of Texas MD Anderson Cancer Center, Houston, TX
    • Radiation Oncology Flight, Wilford Hall Medical Center, Lackland AFB, TX
    • ,
  • Kelly K. Hunt, MD, FACS

      Affiliations

    • Department of Surgical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Eric A. Strom, MD

      Affiliations

    • Department of Radiation Oncology, the Section of Health Services Research, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • George H. Perkins, MD

      Affiliations

    • Department of Radiation Oncology, the Section of Health Services Research, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Gabriel N. Hortobagyi, MD

      Affiliations

    • Department of Breast Medical Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX
    • ,
  • Thomas A. Buchholz, MD

      Affiliations

    • Department of Radiation Oncology, the Section of Health Services Research, the University of Texas MD Anderson Cancer Center, Houston, TX
    • Corresponding Author InformationCorrespondence address: Thomas A Buchholz, MD, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 97, Houston, TX 77030

Received 19 May 2009; received in revised form 15 June 2009; accepted 16 June 2009. published online 20 August 2009.

Background

Breast-conserving surgery (BCS) followed by radiotherapy is as effective as mastectomy for treatment of early invasive breast cancer. But earlier studies report low BCS use rates of 12% to 43% nationally, especially in older patients. We sought to determine current patterns and predictors of BCS use.

Study Design

In a national Medicare database of all beneficiaries (age greater than 65 years) with incident invasive breast cancer treated with operation in 2003, claims codes identified BCS versus mastectomy and demographic, treatment, and geographic region covariates. The 2003 Area Resource File provided socioeconomic covariates. Logistic regression modeled predictors of BCS.

Results

In 56,725 women, 59% were treated with BCS versus 41% with mastectomy. BCS was more likely in women who were younger than 70 years (odds ratio [OR], 1.37; 95% CI, 1.31 to 1.44; p < 0.001) and had lymph node-negative disease (OR, 1.60; 95% CI, 1.52 to 1.68; p < 0.001). Socioeconomic factors influenced use, with BCS more likely in areas with low poverty (OR, 1.05; 95% CI, 1.00 to 1.09; p = 0.03), high education (OR, 1.13; 95% CI, 1.08 to 1.19), high density of radiation oncologists (OR, 1.30; 95% CI, 1.06 to 1.59), and in metropolitan areas (OR, 1.20; 95% CI, 1.14 to 1.26). Significant geographic variation existed: 70% of women were treated with BCS in northeastern New England compared with only 48% to 50% in the South (p < 0.001).

Conclusions

Currently, more than half of older women across the US diagnosed with nonmetastatic invasive breast cancer treated surgically receive BCS, representing a substantial increased use compared with historical data. Lack of BCS use appears in part associated with socioeconomic disadvantage, suggesting that persistent barriers to breast conservation exist.

Abbreviations and Acronyms: BCS, breast-conserving surgery, NSABP, National Surgical Adjuvant Breast and Bowel Project, OR, odds ratio, RT, radiotherapy, SEER, Surveillance, Epidemiology, and End Results

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 Disclosure Information: Nothing to disclose.

 Supported by the Department of Defense Multidisciplinary Postdoctoral Award and the Odyssey Program and Theodore N Law Endowment for Scientific Achievement at the University of Texas MD Anderson Cancer Center (GL Smith).

PII: S1072-7515(09)00940-5

doi:10.1016/j.jamcollsurg.2009.06.363

Journal of the American College of Surgeons
Volume 209, Issue 4 , Pages 425-433.e2, October 2009

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