title: Individual, Area, and Provider Characteristics Associated With Care Received for Stages I to III Breast Cancer in a Multistate Region of Appalachia.
abstract: We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania.
  
  
  
  Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER) -positive/progesterone receptor (PR) -positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type.
  
  
  
  Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission.
  
  
  
  Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA gretchen.kimmick@duke.edu.
authors.forename: Gretchen G
authors.initials: GG
authors.lastname: Kimmick
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Fabian
authors.initials: F
authors.lastname: Camacho
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Heath B
authors.initials: HB
authors.lastname: Mackley
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Teresa
authors.initials: T
authors.lastname: Kern
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Nengliang
authors.initials: N
authors.lastname: Yao
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Matthews
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Steven
authors.initials: S
authors.lastname: Fleming
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Lipscomb
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Jason
authors.initials: J
authors.lastname: Liao
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Wenke
authors.initials: W
authors.lastname: Hwang
authors.affiliation: Duke University Medical Center, Durham, NC; Penn State College of Medicine, State College, PA; Virginia Commonwealth University School of Medicine, Richmond, VA; University of Kentucky College of Public Health, Lexington, KY; and Emory University, Atlanta, GA.
authors.forename: Roger T
authors.initials: RT
authors.lastname: Anderson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D015897:Comorbidity; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007629:Kentucky / Q000453:epidemiology; D015412:Mastectomy, Segmental; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D009657:North Carolina / Q000453:epidemiology; D009820:Ohio / Q000453:epidemiology; D010414:Pennsylvania / Q000453:epidemiology; D012959:Socioeconomic Factors; D066231:Surgeons / Q000706:statistics & numerical data; D014481:United States