Quality Of Care And Patient Outcomes In Breast Cancer

1. Quality Of Care And Patient Outcomes In Breast Cancer Steven Katz M.D., M.P.H. Professor Departments of Medicine and Health Management and Policy Sarah Hawley Ph.D. Assistant Professor Department of Medicine University of Michigan

2. Research Goals • Advance methods to use cancer registries to perform population studies of quality of cancer care • Describe the context, process, and outcomes of cancer treatment decisions • Evaluate the impact of clinician and delivery system factors on the treatment experiences of patients • Design interventions to improve quality

3. The Quality Gap Optimal Practice Health outcomes Structure Patient perspectives about care Quality Gap Community Practice use of effective treatment

4. Opportunities • Partnered with SEER registries to perform population-based research to evaluate quality of care • Engaged patients and their clinicians in the community • Promoted the use of SEER cancer registries • Advanced research • Measures • Sampling • Data collection • Informed Clinical and Health Policy

5. Research Team MD

6. Articles- Katz et al R01CA12345-01

8. Breaking The Mastectomy Over-treatment Myth

9. Compared to BCS w/radiation No difference in survival Little difference in local recurrence NCI, professional groups and advocates have endorsed BCS

10. Receipt of Mastectomy1 by Race and Year 1. % for women with early stage disease, Source: SEERstat

11. U.S. legislation on “informed consent” • 20 states have passed legislation that mandate physician disclosure of treatment alternatives for breast cancer • Physician are required to give patients oral and written summaries of alternative Lantz P, Zemencuk J, Katz SJ. Is Mastectomy Over-Utilized?: A Call for a New Perspective. Health Services Research. 2002; 37(2): 417-431

13. Etiology of Overuse “High variation in patterns of [surgical] treatment for breast cancer is evidence of failure to involve women about the treatment they prefer.”1 “Persistent widespread regional variation in the performance of breast conserving surgery would appear to indicate that many women are not being offered a choice”2 • Wennberg JE. 13th annual Coggeshall lecture at the Univ of Chicago, April 2002. • Institute of Medicine, National Research Council 1999

14. Research Questions • What is the relationship between patient involvement and receipt of surgical therapy? • Why do women receive mastectomy?

15. Research Design • Retrospective survey of patients recently diagnosed with breast cancer and reported to Detroit and Los Angeles SEER in 2002 • Over-sampled DCIS and African American women • Surveyed attending surgeons • Medical record and survey data combined

16. Patients 2,384 selected 1844 responded 77.3% response rate Surgeons 456 identified 365 responded 80.0% response rate Response Rate

17. Patient Sample Characteristics (N=1835) Figures are weighted to account for differential selection by stage, ethnicity, and non-response

18. Who made the surgery decision? Percent Doctor 10% Doctor, considered patient opinion 13% Made decision together 37% Patient, considered doctor opinion 40% Patient 3%

19. Receipt of Mastectomy by Decision Control and Ethnicity % Women with AJCC stage 0,1 or 2 . Proportions adjusted for age, marital status, education, number of surgeons visited, medical comorbidity, tumor behavior, tumor size, histological grade, and SEER site. Interaction between racial groups and decision control groups is significant (Wald test 14.1, p=.007) Katz et al. J Clin Onc. 2005;23(4):5526-5533; Katz et al. J Clin Onc.2005;23(13):3001-3007.

20. Level Of Patient Concern By Dimension Women with AJCC stage 0,1 or 2 and who perceived choice between surgical treatment alternatives (N=1079).

21. Receipt Of Mastectomy By Level of Patient Concern p<.001 p<.001 % p=.231 p=.014 Among women with AJCC stage 0,1 or 2 and who perceived choice between surgical treatment alternatives (N=1079), adjusted by age, education, ethnicity, medical comorbidity, tumor behavior, tumor size, histological grade..

22. New Studies • 3800 patients with breast cancer diagnosed in 2006 will be accrued in Detroit and Los Angeles metro areas • Patients will be surveyed shortly after diagnosis • SEER data will be merged to survey data • All attending surgeons and oncologists will be surveyed • Preliminary findings on LA sample presented

23. Surgery Option Los Angeles Preliminary Sample n=1106

24. Surgeon Recommendations

25. Outcome of Attempted BCS

26. Limitations • Preliminary sample • Later stage disease could not be excluded • Findings unadjusted for over-sampling of selected racial/ethnic groups • Patient self-report of treatment experience

27. Conclusions • Receipt of mastectomy is largely the result of clinical contraindications to BCS and, to a lesser extent, patient preferences • Infrequent discordance in surgical opinions about the need for mastectomy and low rates of mastectomy after BCS suggest that surgeons have accepted BCS and standard contra-indications to the procedure • Initiatives to improve surgical treatment decision-making should focus on patient perspectives about risks and benefits of surgical options and predictors of failure of re-excision after initial attempts at BCS

28. Latina Patient Perspectives about Informed Decision Making for Surgical Breast Cancer TreatmentSarah T. Hawley, PhD, MPH

29. Research Questions • What is the degree to which Latina women (Spanish and English speaking) with breast cancer participate in informed treatment decision making relative to Caucasian women? • What factors are associated with achieving the desired amount of involvement in and informed decision making for breast cancer treatment among racial/ethnic minority women with breast cancer?

30. Decision Outcomes • Involvement in the decision from Control Preferences Scale (surgeon-based, shared, patient based) • Concordance between actual-preferred amount of involvement (too little, just right, too much) • Decision satisfaction 5-item scale • Decision regret 5-item scale

31. Decision Satisfaction Scale • I am satisfied I was adequately informed about the issues important to the decision about what kind of surgery to have • I am satisfied with the decision about what kind of surgery to have • I wish I had given more consideration to other surgical treatment options • I would have liked more information when the decision about surgery was made • I would like to have participated more in making the decision about what kind of surgery to have

32. Decision Regret Scale If I had to do it over… • I would make a different decision about what type of surgery to have • I would choose a different surgeon for my surgery • I would take more time to make decisions about my treatment • I would consult more doctors about my treatment before making a decision • I would do everything the same

33. Patient Variables • Race/ethnicity (Latina-Spanish speaking, Latina-English speaking, African American, Caucasian) • Education (less than high school, high school graduate, some college, college graduate or more) • Age

34. Analysis • Descriptive and bivariate associations between independent variables and involvement and decision outcomes • Multinomial and logistic regression of involvement and discordance to confirm results of bivariate analyses

35. Patient Characteristics Mean age 57 yrs (25-81) Race/ethnicity (%) Latina-SP 25 Latina-E 19 African American 25 Caucasian 28 Education (%) Less than high school 25 High school graduate 18 Some college 33 College graduate 23

36. Decision Involvement Percentages adjusted for age and education

37. Discordance Between Actual and Preferred Involvement Adjusted percentages controlling for age and education; P<0.001

38. Decision Dissatisfaction Adjusted percentages controlling for age and education; P<0.001

39. Decision Regret Adjusted percentages controlling for age and education; P<0.001

40. Conclusions • Latina women, especially those who prefer Spanish, are particularly vulnerable to poor breast cancer treatment decisions • These disparities may be related to insufficient match in decision involvement, lower satisfaction with the decision process, and more decision regret

41. Limitations • Preliminary data • Self-reported information • Need to tease apart the relationship between race/ethnicity, language and acculturation

42. Implications • Large racial/ethnic disparities in decision outcomes raise concerns about the quality of treatment decisions and care • There is a need to explore the mechanisms underlying these racial/ethnic disparities; for example health literacy, language and acculturation