Physician Characteristics Determine Quality of Cancer Care

Allison Gandey

February 01, 2008

February 1, 2008 — A provocative new study suggests that a doctor's sex and medical training determine the quality of care that breast cancer patients receive. Characteristics such as a patient's race and their distance from a radiation-therapy facility have already been shown to influence whether or not a patient receives postsurgical radiation. In this latest study, published online in the Journal of the National Cancer Institute, researchers measured the impact of physician traits on quality of care.

"Physicians have more influence than they maybe even realize," lead author Dawn Hershman, MD, from the Herbert Irving Comprehensive Cancer Center at Columbia University in New York, told Medscape Oncology. "We need to better understand how this influence is affecting care and investigate all of the factors that are contributing to the differences." It is an area that has not been thoroughly investigated to date, she noted.

To help shed light on this issue, Dr. Hershman and her team investigated whether surgeon characteristics were associated with a patient receiving radiation after breast cancer surgery. Using the Surveillance, Epidemiology and End Results (SEER) Medicare database, they analyzed data on nearly 30,000 women 65 years and older. Patients had breast cancer and received breast-conserving surgery.

The investigators also collected information on the more than 4400 surgeons who operated on these women. Using the American Medical Association Masterfile, they collected data on physician's sex, year of graduation, medical-school location, patient volume, and type of medical degree.

Postsurgical Radiation Offered More Often by American-Trained Female MDs

About 75% of the women received radiation after surgery. Each year from 1991 to 2002, the proportion of women receiving radiation increased. But black women, the elderly, the unmarried, and those living outside urban areas were less likely to receive radiation.

After adjustment for patient and tumor characteristics, the researchers found that women who received radiation were more likely to have a surgeon who was female (79% vs 73%), had a medical degree rather than a doctorate in osteopathic medicine (75% vs 68%), and was trained in the United States (75% vs 70%).

"Our finding of associations between this procedure and referring-physician characteristics may therefore support other evidence [suggesting] that certain subgroups of breast surgeons have deficiencies in training or continued education and practice," the authors write. "Moreover, breast cancer is not unique in this regard. In a survey of 30 health conditions, ranging from osteoarthritis to breast cancer, McGlynn et al (N Engl J Med. 2003; 348:2635-2645) estimated that, on average, Americans received about half (54.9%) of the recommended medical-care processes for basic care," they add.

But the researchers note that the individual effect sizes in the current study are small. "Further research is essential to confirm these associations." And if confirmed, they note, more research is needed on whether they reflect surgeon behavior, patient response, or physician–patient interactions."

Dr. Hershman points out that the database did not provide information on a number of potentially important surgeon- and patient-related variables. For example, it did not include physical condition, performance status, psychological outlook, communication by the patient with her physician, or health behaviors. Nor did it enable researchers to differentiate between lack of referral and patient refusal as the reason for not receiving radiotherapy.

The researchers also note that the database used to collect physician characteristics did not provide information on the race, ethnicity, or board-certification status of the surgeons. "In addition," they write, "our study was limited to patients over the age of 65 and may not be generalizable to younger populations."

The researchers have disclosed no relevant financial relationships.

J Natl Cancer Inst. 2008; 100:199-206.

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