Regional differences are part of breast cancer care
August 1, 2001 5 minutes read
Regional differences are part of breast cancer care
One in nine women will get breast cancer sometime in her life. For those women and their families, finding the best care is vital. But getting the best treatment may be as much a matter of where you live as anything else.
According to a new clinical research study conducted by Solucient, a health care consulting firm based in Baltimore, less than half the women in the South are likely to receive breast conserving surgeries (lumpectomies). In the West, only 50.2% of women have it, in the North Central region, 51.1%. The Northeast does best, with 60.5% of women having that surgery. The overall rate for the study was 50.8%.
The gold standard of care for those receiving lumpectomies is to have radiation therapy afterward. Overall, only 45.7% of the patients had it. The West was best in this category, with 51.8% of lumpectomy patients receiving radiation follow-up. That compares to 49.3% in the Northeast, 46.2% in the North Central, and only 39.8% in the South.
The study commentary notes that radiation therapy is "greatly underutilized," even among teaching hospitals, larger hospitals, those in the West, and among the better performing hospitals in the study.
But there may be one good reason for the lack of follow-up radiation, says Barbara Hawkins, RN, MS, OCN, manager of the breast care program at Southwest Washington Medical Center (SWMC) in Vancouver. Her facility was one of the top 100 hospitals named in the Solucient study.
"Certainly, early detection may make lumpectomy alone a viable treatment option," she says. At SWMC, the focus is on getting people in early for diagnosis. "We have received support from the Susan G. Komen Foundation to provide free mammograms, and we are a prime contractor for the Breast and Cervical Health Program through the Centers for Disease Control and Prevention," Hawkins explains. "That means that we can have any woman, regardless of age, insurance, or even citizenship come in for detection, diagnosis, and treatment. We get them in the system early and follow them through."
One reason Hawkins contends there may be regional differences in the kinds of breast cancer treatments offered is that when a mastectomy is done, it is more likely to be the complete treatment. If chemotherapy is required, it’s simply a monthly treatment for four to six months. If a patient chooses a lumpectomy, it usually requires radiation therapy five days a week for five to six weeks.
"Part of it is the location of the patient and the location of services. If the patient lives in a rural area or there are transportation issues, then getting her in that often can be a real challenge," she says. "Offering a lumpectomy in that circumstances isn’t the right thing to do."
SWMC treats about 200 breast cancers a year from a six-county area. Out of those, about 60 result in mastectomies. And of that number, maybe a quarter opt to have immediate breast reconstruction surgery.
In the Solucient study, 13.2% of the 168,000 patients included had such surgery immediately. The rates regionally varied from a low of 9.5% in the West to 15.1% in the Northeast. Bigger hospitals were more likely to offer the surgery (21.3% of facilities with more than 500 beds, but only 6.9% of those with less than 200 beds). Patients with private insurance were more than 10 times likely to receive it than women on Medicare: 23.6% of the former, and 2.1% of the latter.
Too many decisions at once for patients
Judging a facility based on its immediate reconstruction rates may be misleading, says Hawkins. "We always ask if they want it done up front," she says. "But often, we are asking [patients] to do so much all at once [that] it can be a hard decision to make. It can take up to a year to complete the reconstructive surgery process. Some women just prefer to wait."
Helen K. Chew, MD, director of the division of hematology/oncology, at the University of California (UC), Davis Cancer Center in Sacramento presides over another one of the 100 top hospitals listed in the study. She says having hard data on what is common practice is important in learning what areas need improvement. "We found out from data that access to the breast clinic after a positive mammogram was something we had to work on," Chew explains. "That’s a really anxiety-ridden period for patients. We have been able to cut the turnaround time in pathology and cut that time to a week or two."
Team approach creates top performers
Being a large academic institution is certainly helpful in keeping the UC Davis facility at the top of the heap. "A real key to our success is being multidisciplinary," Chew says. "We allow patients to seek multiple opinions, from surgeons to oncologists to radiologists. That helps make for well-informed patients. They know all their options. And in an academic institution, we can offer trials," she adds. "We are doing sentinel lymph-node biopsy study, which is even less disfiguring than lumpectomies," Chew points out. "It’s new and exciting, but it is still unproven. Even when something is sexy, we like to see the data to prove its worth."
There are two things that SWMC does, Hawkins says, which makes it stand out from other facilities and improves breast cancer care:
1. There is a twice-monthly breast cancer conference in which every positive breast pathology of the previous two weeks is discussed by a multidisciplinary team including the radiation and medical oncologists, pathologists, radiologists, surgeons, cancer researchers, and primary care physicians.
"For 14 months, this has served as a good learning venue for us and provided a way for the various disciplines to talk together about what is happening in specific cases. This isn’t like a tumor board where only three or four cases are selected. This is all of them," she adds.
2. The facility provides a strong patient focus. There is a breast cancer library for patients, which is funded by donations and grants. It includes research journals and mainstream books, as well as two computers with Internet connections. There is a breast peer program that links survivors with newly diagnosed patients. There are support groups for patients, caregivers, and children of patients.
"We try to link patients with their peers in all cases," Hawkins says. "That is where the most powerful connections come. We are only trained professionally and technically. The peers are the ones who are there for the whole journey."
Chew says it’s important to remember the patient. "We all offer pretty good medical care in this country," she notes. "It’s the rest of the stuff that becomes so important to improve upon. We can always do better on things like psychosocial support, which isn’t necessarily thought of as medicine, but which can make a lot of difference to the patient."
[For more information, contact:
• Helen K. Chew, MD, Director, Division of Hematology/Oncology, UC, Davis Cancer Center, 4501 X St., Suite 3016, Sacramento, CA 95817. Telephone: (916) 734-3772.
• Barbara Hawkins, RN, MS, OCN, Manager, Breast Care Program, Southwest Washington Medical Center, PO Box 1600, Vancouver, WA 98668. Telephone: (360) 514-6171.]
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