title: Variation in receipt of radiation therapy after breast-conserving surgery: assessing the impact of physicians and geographic regions.
abstract: BACKGROUND
  Among older women with early-stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups.
  
  
  OBJECTIVE
  To determine the relative contribution of patient, physician, and regional factors on the use of RT.
  
  
  METHODS
  Retrospective cohort.
  
  
  METHODS
  Women aged 67-94 years diagnosed with stage I breast cancer between 1998 and 2007 receiving breast-conserving surgery.
  
  
  METHODS
  We evaluated patient, physician, and regional factors for their association with RT across strata of LE using a 3-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region.
  
  
  RESULTS
  Approximately 43.6% of the 2253 women with a short LE received RT, compared with 90.8% of the 11,027 women with a long LE. Among women with a short LE, the probability of receiving RT varied substantially across primary surgeons; RSTRs ranged from 27.7% to 67.3% (mean, 43.9%). There was less variability across geographic regions; RSTRs ranged from 42.0% to 45.2% (mean, 43.6%). Short LE patients were more likely to receive RT in areas with high radiation oncologist density (odds ratio, 1.59; 95% confidence interval, 1.07-2.36).
  
  
  CONCLUSIONS
  Although there is a wide variation across geographic regions in the use of RT among women with breast cancer and short LE, the regional variation was substantially diminished after accounting for the operating surgeon.
authors.affiliation: Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Comprehensive Cancer Center, New Haven, CT, USA.
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Feinstein
authors.forename: Pamela R
authors.initials: PR
authors.lastname: Soulos
authors.forename: Jessica B
authors.initials: JB
authors.lastname: Long
authors.forename: Jeph
authors.initials: J
authors.lastname: Herrin
authors.forename: Kenneth B
authors.initials: KB
authors.lastname: Roberts
authors.forename: James B
authors.initials: JB
authors.lastname: Yu
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000453:epidemiology / Q000532:radiotherapy* / Q000601:surgery*; D015331:Cohort Studies; D005260:Female; D005843:Geography; D054625:Healthcare Disparities; D006801:Humans; D015994:Incidence; D008017:Life Expectancy; D008137:Longitudinal Studies; D015412:Mastectomy, Segmental; D006278:Medicare / Q000706:statistics & numerical data; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology