Association of Attending Surgeon with Variation in the Receipt of Genetic Testing after Diagnosis of Breast Cancer

• Type of Material: Article
• Authors: Steven J. Katz, University of Michigan; Irnia Bondarenko, University of Michigan; Kevin Ward, Emory University; Ann S. Hamilton, University of Southern California; Monica Morrow, Memorial Sloan Kettering Cancer Center; Allison W. Kurian, Stanford University; Timothy P. Hofer, University of Michigan
• Language: English
• Date: 2018-10-01
• Publisher: American Medical Association (AMA)
• Publication Version: Final Published Version
• Copyright Statement: © 2018 American Medical Association. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1001/jamasurg.2018.2001
• Title of Journal or Parent Work: JAMA Surgery
• ISSN: 2168-6254
• Volume: 153
• Issue: 10
• Start Page: 909
• End Page: 916
• Grant/Funding Information: The collection of cancer incidence data in Georgia was supported by contract HHSN261201300015I, task order HHSN26100006 from the National Cancer Institute, and cooperative agreement 5NU58DP003875-04-00 from the Centers for Disease Control and Prevention.; The collection of Los Angeles County (California) cancer incidence data used in this study was supported by the following: the California Department of Public Health pursuant to California Health and Safety Code §103885; the Centers for Disease Control and Prevention’s National Program of Cancer Registries under cooperative agreement 5NU58DP003862-04/DP003862; and the National Cancer Institute’s Surveillance, Epidemiology, and End Results program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the University of Southern California Public Health Institute (Oakland).; This work was funded by grant P01CA163233 to the University of Michigan from the National Cancer Institute. Conducted work was also supported by the University of Michigan Rogel Cancer Center Biostatistics, Analytics and Bioinformatics shared resource (grant P30CA46592).
• Research Categories: Health Sciences, Health Care Management; Health Sciences, Medicine and Surgery

Abstract

Importance: Genetic testing after diagnosis of breast cancer is common, but little is known about the influence of the surgeon on the variation in testing. Objectives: To quantify and explain the association of attending surgeon with rates of genetic testing after diagnosis of breast cancer. Design, Setting, and Participants: This population-based study identified 7810 women with stages 0 to II breast cancer treated between July 1, 2013, and August 31, 2015, through the Surveillance, Epidemiology, and End Results registries for the state of Georgia, as well as Los Angeles County, California. Surveys were sent approximately 2 months after surgery. Also surveyed were 488 attending surgeons identified by the patients. Main Outcomes and Measures: The study examined the association of surgeon with variation in the receipt of genetic testing using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results and genetic testing data obtained from 4 laboratories. Results: In total, 5080 women (69.6%) of 7303 who were eligible (mean [SD] age, 61.4 [0.8] years) and 377 surgeons (77.3%) of 488 (mean [SD] age, 53.8 [10.7] years) responded to the survey. Approximately one-third (34.5% [1350 of 3910] of patients had an elevated risk of mutation carriage, and 27.0% (1056 of 3910) overall had genetic testing. Surgeons had practiced a mean (SE) of 20.9 (0.6) years, and 28.9% (107 of 370) treated more than 50 cases of new breast cancer per year. The odds of a patient receiving genetic testing increased more than 2-fold (odds ratio, 2.48; 95% CI, 1.85-3.31) if she saw a surgeon with an approach 1 SD above that of a surgeon with the mean test rate. Approximately one-third (34.1%) of the surgeon variation was explained by patient volume and surgeon attitudes about genetic testing and counseling. If a patient with higher pretest risk saw a surgeon at the 5th percentile of the surgeon distribution, she would have a 26.3% (95% CI, 21.9%-31.2%) probability of testing compared with 72.3% (95% CI, 66.7%-77.2%) if she saw a surgeon at the 95th percentile. Conclusions and Relevance: In this study, the attending surgeon was associated with the receipt of genetic testing after a breast cancer diagnosis. Variation in surgeon attitudes about genetic testing and counseling may explain a substantial amount of this association.