VARIATIONS IN BREAST-CANCER-TREATMENT BY PATIENT AND PROVIDER CHARACTERISTICS

Guidelines for the optimal treatment of breast cancer have been public ized over the past 15 years, yet clinical practices continue to vary s ubstantially in the United States. This article reviews the literature on variations in local and systemic treatment of breast cancer by pat ient and provider characteristics. Studies of local therapy have consi stently demonstrated that older women are less likely than younger wom en to receive radiation therapy after breast-conserving surgery. Some studies have noted that black women are less likely than white women t o receive breast-conserving surgery and less likely to receive radiati on therapy after breast-conserving surgery. Rates of breast-conserving surgery vary three-fold among geographic regions and between teaching and non-teaching hospitals. Patients at smaller hospitals appear less likely to receive indicated radiation therapy. Patterns of systemic t herapy have not been well described. Women over age 75 may not be rece iving adequate hormonal therapy, but recent data are not available. Li mited data suggest that rates of systemic therapy do not vary substant ially by race or Hispanic ethnicity, but women without health insuranc e may not be receiving appropriate chemotherapy. Studies relating hosp ital and physician characteristics to the use of systemic therapy are sparse and inconclusive. In order to increase the proportion of women who receive optimal treatment for breast cancer and ensure greater equ ity, a more sophisticated understanding of variations in clinical prac tice will be required. These variations may arise from insufficient kn owledge of or disagreement with guidelines among physicians, inadequat e communication between physicians and patients, and individual prefer ences or clinical attributes of patients. Future studies will need to explore the dialogue between women and their physicians that leads to decisions about treatment of breast cancer.