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Physicians' reasons for failing to deliver effective breast cancer care: a framework for underuse
Nina A Bickell1, Mary Dee McEvoy
1Mount Sinai School of Medicine, Department of Health Policy, New York, New York 10029, USA. Nina_Bickell@mountsinai.org
Objective:
Despite numerous randomized trials showing the health benefits of systemic and local therapies for early-stage breast cancer, underuse of these therapies remains a significant quality problem. Little is known about causes of underuse of effective cancer treatments. We sought to understand these causes to design effective interventions to improve care.
Research Design:
To identify categories of causes of underuse, semistructured interviews were performed with physicians of breast cancer patients who did not receive effective adjuvant care in the 4 years following surgery. Underuse was defined by expert consensus based on evidence-based guidelines.
Subjects:
Surgeons (n = 13) of all early-stage breast cancer cases who underwent surgical treatment at a tertiary care hospital and had underuse of local or systemic adjuvant therapies.
Results:
Of all the 275 women with early-stage breast cancer, there were 44 episodes of underuse of effective therapies (16%). In 48% of cases, physicians thought treatment should occur but the treatment failed to take place (32%) or the patient refused (16%). For the other 52% of cases, physicians thought treatment should not occur because evidence did not support treatment in clinical circumstances such as older age (32%), a good prognosis based on tumor size or histology (11%), a second primary breast cancer (5%), or because of comorbidities (5%). All surgeons were aware of the benefits of adjuvant treatments.
Conclusions:
Causes of underuse can be identified and categorized. Using these categories, a framework of causes of underuse was constructed and interventions targeting the specific causes to improve the quality of care are suggested.
Insights
Underuse of effective early-stage breast cancer therapies occurred in 16% of cases. Causes included patient refusal, physician judgment, and patient-specific factors, highlighting a need for targeted interventions to improve care quality.
Area of Science:
- Oncology
- Health Services Research
- Clinical Quality Improvement
Background:
- Systemic and local therapies offer significant health benefits for early-stage breast cancer.
- Underuse of these evidence-based treatments is a persistent quality issue in cancer care.
Purpose of the Study:
- To identify and categorize the causes of underuse of effective adjuvant therapies for early-stage breast cancer.
- To inform the development of targeted interventions aimed at improving treatment delivery and patient outcomes.
Main Methods:
- Semistructured interviews were conducted with 13 surgeons treating early-stage breast cancer patients.
- Underuse was defined by expert consensus based on evidence-based guidelines for adjuvant therapies.
- Physicians' reasons for non-treatment or patient refusal were analyzed.
Main Results:
- Of 275 early-stage breast cancer cases, 44 episodes (16%) involved underuse of effective adjuvant therapies.
- In 48% of underuse cases, treatment was not administered due to physician decision (32%) or patient refusal (16%).
- In 52% of cases, physicians deemed treatment inappropriate due to patient age, tumor prognosis, comorbidities, or secondary cancers.
Conclusions:
- Causes of underuse of adjuvant breast cancer therapies are identifiable and can be categorized.
- A framework for understanding underuse has been developed, guiding the creation of specific interventions.
- Targeted interventions are proposed to address identified causes and enhance the quality of breast cancer care.
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