title: Case-mix analysis and variation in rates of non-surgical treatment of older women with operable breast cancer.
abstract: BACKGROUND
  Non-surgical management of older women with oestrogen receptor (ER)-positive operable breast cancer is common in the UK, with up to 40 per cent of women aged over 70 years receiving primary endocrine therapy. Although this may be appropriate for frailer patients, for some it may result in treatment failure, contributing to the poor outcomes seen in this age group. Wide variation in the rates of non-operative management of breast cancer in older women exists across the UK. Case mix may explain some of this variation in practice.
  
  
  METHODS
  Data from two UK regional cancer registries were analysed to determine whether variation in treatment observed between 2002 and 2010 at hospital and clinician level persisted after adjustment for case mix. Expected case mix-adjusted surgery rates were derived by logistic regression using the variables age, proxy Charlson co-morbidity score, deprivation quintile, method of cancer detection, tumour size, stage, grade and node status.
  
  
  RESULTS
  Data on 17,129 women aged 70 years or more with ER-positive operable breast cancer were analysed. There was considerable variation in rates of surgery at both hospital and clinician level. Despite adjusting for case mix, this variation persisted at hospital level, although not at clinician level.
  
  
  CONCLUSIONS
  This study demonstrates variation in selection criteria for older women for operative treatment of early breast cancer, indicating that some older women may be undertreated or overtreated, and may partly explain the inferior disease outcomes in this age group. It emphasizes the urgent need for evidence-based guidelines for treatment selection criteria in older women with breast cancer.
authors.affiliation: Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK.
authors.forename: J
authors.initials: J
authors.lastname: Morgan
authors.affiliation: Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: P
authors.initials: P
authors.lastname: Richards
authors.affiliation: Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: S
authors.initials: S
authors.lastname: Ward
authors.affiliation: Knowledge and Intelligence Team (West Midlands), Public Health England, Birmingham, UK.
authors.forename: M
authors.initials: M
authors.lastname: Francis
authors.affiliation: Knowledge and Intelligence Team (West Midlands), Public Health England, Birmingham, UK.
authors.forename: G
authors.initials: G
authors.lastname: Lawrence
authors.affiliation: Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK.
authors.forename: K
authors.initials: K
authors.lastname: Collins
authors.affiliation: Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK.
authors.forename: M
authors.initials: M
authors.lastname: Reed
authors.affiliation: Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK.
authors.forename: L
authors.initials: L
authors.lastname: Wyld
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000378:metabolism; D001943:Breast Neoplasms / Q000378:metabolism / Q000601:surgery* / Q000628:therapy; D003131:Combined Modality Therapy; D003953:Diagnosis-Related Groups; D005260:Female; D006801:Humans; D016015:Logistic Models; D018579:Patient Selection; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011960:Receptors, Estrogen / Q000378:metabolism; D012042:Registries; D006113:United Kingdom
chemical_list: D014408:Biomarkers, Tumor; D011960:Receptors, Estrogen