What Explains 'Sobering' Variations in Breast Cancer Care?

Kathy D. Miller, MD


April 28, 2022

This transcript has been edited for clarity.

I'm Kathy Miller from Indiana University, and I want to make sure you saw a fascinating brief report in the March edition of JAMA Oncology.

Dr Michael Hassett and his colleagues used the SEER-Medicare database and looked at multiple different regions and the variability in treatment of patients with stage I breast cancer. They tried to determine how much of that variability was pure random chance; how much could be attributed to differences in patient factors, such as age, socioeconomic status, race, and comorbidities; and how much was just based on geography — differences in where you live.

The results are sobering. Only about 1%-4% of the variability in treatment could be attributed to patient factors, whereas 24%-48% was attributed to geography — simply where you lived. What health service area did you reside in? The biggest difference and the biggest impact of geography was on hormone therapy, including initiation of hormone therapy within the first year and continuing hormone therapy beyond years 3- 5.

That's sobering. In the majority of our patients with hormone-sensitive disease, that's the biggest component of their treatment, and yet there's as much as a twofold difference in the receipt of hormone therapy based simply on where you live.

That also suggests that when we look at quality improvement initiatives, we should focus on those low-penetrance areas. That's going to have a bigger impact than focusing on patient factors and focusing on patients.

There's some key information that this sort of study can't tell us, namely, why is there such geographic variation? Are these differences in the local culture? Is this a difference in who manages patients with breast cancer? Just looking at the map, it did not seem closely tied to proximity to a major academic medical center.

There's a huge amount of work to be done here based on really sobering results. Take a look. I'd love to know your thoughts and what you think might account for this geographic disparity.

Kathy D. Miller, MD, is associate director of clinical research and co-director of the breast cancer program at the Melvin and Bren Simon Cancer Center at Indiana University. Her career has combined both laboratory and clinical research in breast cancer.

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