Surgeon specialization and use of sentinel lymph node biopsy for breast cancer. JAMA Surg 2014 Feb;149(2):185-92
Date
12/27/2013Pubmed ID
24369337Pubmed Central ID
PMC4005375DOI
10.1001/jamasurg.2013.4350Scopus ID
2-s2.0-84894540668 (requires institutional sign-in at Scopus site) 29 CitationsAbstract
IMPORTANCE: Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema.
OBJECTIVE: To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer.
DESIGN, SETTING, AND POPULATION: A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined.
MAIN OUTCOME AND MEASURE: Type of axillary surgery performed.
RESULTS: Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB.
CONCLUSIONS AND RELEVANCE: Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.
Author List
Yen TW, Laud PW, Sparapani RA, Nattinger ABAuthors
Purushottam W. Laud PhD Professor in the Institute for Health and Equity department at Medical College of WisconsinAnn B. Nattinger MD, MPH Associate Provost, Professor in the Medicine department at Medical College of Wisconsin
Rodney Sparapani PhD Associate Professor in the Institute for Health and Equity department at Medical College of Wisconsin
Tina W F Yen MD, MS Professor in the Surgery department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
AgedAged, 80 and over
Axilla
Breast Neoplasms
Clinical Competence
Female
Follow-Up Studies
Humans
Lymph Node Excision
Lymphatic Metastasis
Male
Neoplasm Staging
Physicians
Prospective Studies
Registries
Sentinel Lymph Node Biopsy
Specialization
Specialties, Surgical
United States
