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Some women with breast cancer do not receive adjuvant treatments recommended by guidelines

Women with breast cancer do not consistently receive adjuvant treatments that have been shown to increase survival. Such treatments include radiotherapy after breast-conserving surgery, adjuvant chemotherapy for estrogen receptor-negative tumors, and hormonal therapies for estrogen receptor-positive tumors larger than 1 cm.

A survey of surgeons at 6 New York hospitals treating 119 women, who did not receive guideline-recommended adjuvant therapy, points out some contributing factors contributing to this. In one-third (34 percent) of cases, surgeons did not recommend adjuvant treatment, most often because they perceived the risks exceeded the benefits (for example, due to patient frailty or age).

Among the two-thirds of cases for whom surgeons did recommend therapy, 31 percent of the women declined treatment and in 34 percent of cases, the women didn't refuse, but care did not ensue and the physicians could not explain why care failed to happen. Such system failures occurred more commonly among minority than white women (73 vs. 54 percent), and more commonly in women who were insured by Medicaid or were uninsured than those with Medicare or commercial insurance (54 vs. 19 percent). Women treated by a surgeon who worked closely with oncologists were less likely to experience a system failure (84 vs. 68 percent) than those treated by other surgeons.

These findings underscore the need for simultaneous development of different strategies to improve breast cancer treatments, conclude the researchers. They interviewed surgeons because surgeons typically perform the initial treatment for breast cancer, determine tumor stage, and review the findings with the patient. Their recommendations for subsequent referral to either radiation or medical oncology or willingness to prescribe hormonal therapy are pivotal. Yet, in many cases, surgeons were unaware whether their patient was resistant to taking adjuvant therapy (56 percent of patients), understood the risks and benefits of adjuvant treatment (54 percent), or could not tolerate adjuvant treatment (52 percent).

The study was supported in part by the Agency for Healthcare Research and Quality (HS10859).

More details are in "Lost opportunities: Physicians' reasons and disparities in breast cancer treatment," by Nina A. Bickell, M.D., M.P.H., Felice LePar, M.D., Jason J. Wang, Ph.D., and Howard Leventhal, Ph.D., in the June 20, 2007, Journal of Clinical Oncology 25(18), pp. 2516-2521.

Editor's Note: Another AHRQ-supported study on breast cancer (HS15756) describes the Breast Global Health Initiative to create an international health alliance to develop evidence-based guidelines for countries with limited resources to improve health outcomes. For more details, see: Anderson, B.O. and Carlson, R.W. (2007, March). "Guidelines for improving breast health care in limited resource countries: The breast health global initiative." Journal of the National Comprehensive Cancer Network 5(3), pp. 349-356.

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