title: Institutional variation in the surgical treatment of breast cancer: a study of the NCCN.
abstract: OBJECTIVE
  To investigate the relationship between supply of subspecialty care and type of procedure preferentially performed for early stage breast cancer.
  
  
  BACKGROUND
  Three surgical options exist for early stage breast cancer: (1) breast conserving surgery (BCS), (2) mastectomy with reconstruction (RECON), and (3) mastectomy alone. Current guidelines recommend that surgical treatment decisions should be based on patient preference if a patient is eligible for all 3. However, studies demonstrate persistent variation in the use of BCS and RECON.
  
  
  METHODS
  Patients undergoing an operation for DCIS or stage I or II breast cancer at NCCN institutions between 2000 and 2006 were identified. Institutional procedure rates were determined. Spearman correlations measured the association between procedure types. Patient-level logistic regression models investigated predictors of procedure type and association with institutional supply of subspecialty care.
  
  
  RESULTS
  Among 10,607 patients, 19% had mastectomy alone, 60% BCS, and 21% RECON. The institutional rate of BCS and RECON were strongly correlated (r = -0.80, P = 0.02). Institution was more important than all patient factors except age in predicting receipt of RECON or BCS. RECON was more likely for patients treated at an institution with a greater supply of reconstructive surgeons or where patients live further from radiation facilities. RECON was less likely at institutions with longer waiting times for surgery with reconstruction.
  
  
  CONCLUSIONS
  Even within the NCCN, a consortium of multidisciplinary cancer centers, the use of BCS and mastectomy with reconstruction substantially varies by institution and correlates with the supply of subspecialty care.
authors: Center for Outcomes and Policy Research, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. ccgreenberg@partners.org
authors: Caprice C
authors: CC
authors: Greenberg
authors: Stuart R
authors: SR
authors: Lipsitz
authors: Melissa E
authors: ME
authors: Hughes
authors: Stephen B
authors: SB
authors: Edge
authors: Richard
authors: R
authors: Theriault
authors: John L
authors: JL
authors: Wilson
authors: W Bradford
authors: WB
authors: Carter
authors: Douglas W
authors: DW
authors: Blayney
authors: Joyce
authors: J
authors: Niland
authors: Jane C
authors: JC
authors: Weeks
mesh_terms: D000046:Academic Medical Centers / Q000600:supply & distribution; D000328:Adult; D000367:Age Factors; D000368:Aged; D001943:Breast Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000453:epidemiology / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000453:epidemiology / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D003131:Combined Modality Therapy; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D016462:Mammaplasty / Q000706:statistics & numerical data*; D008408:Mastectomy / Q000706:statistics & numerical data*; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D010348:Patient Care Team / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians'; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States; D014600:Utilization Review / Q000706:statistics & numerical data; D000078329:Workforce