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Original Investigation | SURGICAL CARE OF THE AGING POPULATION

Surgeon Specialization and Use of Sentinel Lymph Node Biopsy for Breast Cancer

Tina W. F. Yen, MD, MS1; Purushuttom W. Laud, PhD2; Rodney A. Sparapani, PhD2; Ann B. Nattinger, MD, MPH3
[+] Author Affiliations
1Division of Surgical Oncology, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
2Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
3Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
JAMA Surg. 2014;149(2):185-192. doi:10.1001/jamasurg.2013.4350.
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Importance  Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema.

Objective  To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon’s operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer.

Design, Setting, and Population  A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined.

Main Outcome and Measure  Type of axillary surgery performed.

Results  Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB.

Conclusions and Relevance  Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.

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Figure 1.
Distribution of Surgeon Volume and Percentage of Breast Cancer Cases

A, Surgeon volume. B, Surgeon percentage; 2 surgeons with a percentage greater than 60% were excluded. The sum of the first 4 percentages (24%, 30%, 17%, and 8%) shows that 79% of surgeons performed less than 10% of their operative cases for treatment of breast cancer. The remaining 21% of surgeons performed 10% or more of their operative cases for treatment of breast cancer.aPercentage values less than 1%.

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Figure 2.
Relationship Between Surgeon Volume, Surgeon Percentage, and the Odds Ratio (OR) of Undergoing Sentinel Lymph Node Biopsy (SLNB) vs Axillary Lymph Node Dissection (ALND)

Annual Medicare surgeon volume and the OR of undergoing SLNB vs ALND are depicted relative to the baseline odds of undergoing SLNB for a surgeon who performed 6 annual incident Medicare breast cancer operations and 3% of all surgical procedures for treatment of breast cancer. At each of the surgeon volumes (6, 12, and 24 cases), 4 surgeon percentages are shown. For each box, the black line represents the OR estimate, the box represents the 50% CI, and the vertical error bars represent the 95% CI.

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