Breast Cancer Articles

Correlates of referral practices of general surgeons to plastic surgeons for mastectomy reconstruction

Amy K. Alderman, MD, MPH ^{1 2} *
Sarah T. Hawley, PhD ^{2 3}
Jennifer Waljee, MD ⁴
Monica Morrow, MD ⁵
Steven J. Katz, MD, MPH ^{2 3}

¹ Section of Plastic Surgery, Department of Surgery, the University of Michigan Medical Center, Ann Arbor, Michigan
² Veterans Affairs Center for Practice Management and Outcomes Research, Ann Arbor Veterans Affairs Health Care System, Ann Arbor, Michigan
³ Division of General Medicine, Department of Internal Medicine, the University of Michigan Medical Center, Ann Arbor, Michigan
⁴ Robert Wood Johnson Clinical Scholars Program and Department of Surgery, the University of Michigan Medical Center, Ann Arbor, Michigan
⁵ Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania

email: Amy K. Alderman (aalder@umich.edu)
* Correspondence to Amy K. Alderman, Section of Plastic Surgery, Department of Surgery, University of Michigan, 2130 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0340

The ideas and opinions expressed herein are those of the author, and no endorsement by the State of California, Department of Health Services is intended or should be inferred.
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Funded by:
National Cancer Institute; Grant Number: R01 CA8837-A1
National Institutes of Health
Department of Health and Human Services; Grant Number: N01-PC-35139, N01-PC-65064
California Department of Health Services as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885
 

Keywords
breast reconstruction • practice patterns • surgical decision-making • Surveillance • Epidemiology • End Results
 

Abstract

BACKGROUND
General surgeons' attitudes toward breast reconstruction may affect referrals to plastic surgeons. The propensity to refer to plastic surgeons prior to surgical treatment decisions for breast cancer varies markedly across general surgeons and is associated with receipt of reconstruction. In this study, the authors used data from a large physician survey to examine factors associated with general surgeons' propensity to refer breast cancer patients to plastic surgeons prior to mastectomy.

METHODS
The authors surveyed all attending general surgeons (N = 456 surgeons) from a population-based sample of breast cancer patients who were diagnosed in Detroit and Los Angeles during 2002 (N = 1844 patients), with a surgeon response rate of 80%. The dependent variable was surgeon report of the percentage of their mastectomy patients in the past 2 years who they referred to plastic surgeons prior to initial surgery (referral propensity). Referral propensity was collapsed into 3 categories (<25%, 25-75%, and >75%) and regressed on the following covariates using logistic regression: Surveillance, Epidemiology, and End Results registry; number of years in clinical practice; surgeons' sex; annual breast surgery volume; and hospital setting.

RESULTS
Only 24% of surgeons referred >75% of their patients to plastic surgeons prior to surgery (high referral propensity). High referral propensity was associated independently with surgeons who were women (odds ratio [OR], 2.3; P = .03), high clinical breast surgery volume (OR, 4.1; P < .01), and working in cancer centers (OR, 2.4; P = .01). High-referral surgeons and low-referral surgeons also had different beliefs about women's preferences for reconstruction, with the low-referral surgeons perceiving more access barriers (cost, availability of plastic surgeons) and a lower patient priority for reconstruction.

CONCLUSIONS
A large proportion of surgeons do not refer breast cancer patients to plastic surgery at the time of surgical decision-making. Surgeons who have a high referral propensity are more likely to be women, to have a high clinical breast volume, and to work in cancer centers. These data support the importance of comanagement through multidisciplinary care models. Women need more opportunities to discuss reconstructive options to make informed surgical treatment decisions about their breast cancer. Cancer 2007. © 2007 American Cancer Society.


Received: 30 October 2006; Revised: 12 January 2007; Accepted: 19 January 2007

Source:  Wiley InterScience

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