title: Are many community hospitals undertreating breast cancer?: lessons from 24,834 patients.
abstract: OBJECTIVE
  To compare treatment patterns and long-term outcomes between teaching and community hospitals treating patients with infiltrating ductal carcinoma (IDC).
  
  
  METHODS
  All IDCs from the Florida Cancer Data System from 1994 to 2000 were examined.
  
  
  RESULTS
  Overall, 24,834 operative cases of IDC were identified. Teaching hospitals treated 11.3% of patients with a larger proportion of stage III and IV disease (39.8% vs. 33.0%). Five- and 10-year overall survival rates at teaching hospitals were 84% and 72%, compared with 81% and 69% at high-volume community hospitals and 77% and 63% at low-volume hospitals (P < 0.001). The greatest differences on survival were observed in patients with advanced IDC. Examination of practice patterns demonstrated that multimodality therapy was most frequently administered in teaching hospitals. Breast-conserving surgery was more frequently performed at teaching hospitals (41.5% vs. 38.9% P = 0.008). On multivariate analysis, it was found that treatment at a teaching hospital was a significant independent predictor of improved survival (hazard ratio = 0.763, P < 0.001). This survival benefit was greater and independent of high-volume center status (hazard ratio = 0.903, P < 0.02).
  
  
  CONCLUSIONS
  Patients with IDC treated at teaching hospitals have significantly better survival than those treated at high-volume centers or community hospitals, particularly in the setting of advanced disease. Poorer long-term outcomes for IDC at community hospitals seem to be, at least in part, because of decreased use of proven life-extending adjuvant therapies. These results should encourage community hospitals to institute changes in treatment approaches to invasive breast cancer to optimize patient outcomes.
authors.affiliation: DeWitt Daughtry Family Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Gutierrez
authors.forename: Judith D
authors.initials: JD
authors.lastname: Hurley
authors.forename: Nadine
authors.initials: N
authors.lastname: Housri
authors.forename: Eduardo A
authors.initials: EA
authors.lastname: Perez
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Byrne
authors.forename: Leonidas G
authors.initials: LG
authors.lastname: Koniaris
mesh_terms: D000328:Adult; D000368:Aged; D001707:Biopsy, Needle; D001943:Breast Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D018270:Carcinoma, Ductal, Breast / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D005260:Female; D005431:Florida; D019538:Health Care Surveys; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006785:Hospitals, University / Q000706:statistics & numerical data*; D006801:Humans; D007150:Immunohistochemistry; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D018714:Radiotherapy, Adjuvant; D012042:Registries; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome