Outcomes of Older Women with Early Stage Breast Cancer

描述(申请人提供)：美国的乳腺癌手术几乎没有地区性，有大量的低量提供者。现在有几项研究表明，外科医生数量越多，5年生存率越高。这些研究表明，每年至少进行15-30次乳腺癌手术的外科医生的患者全因死亡率降低25%。虽然这些发现很重要，但在提出重大政策倡议之前，外科医生数量与结果的关系需要进一步调查。选择偏差对观察到的关系的可能贡献还需要更多的研究。体量较大的外科医生为社会经济地位较高的患者提供护理，其影响仅从生态角度加以控制。疾病复发是一种比全因死亡率更少受偏见影响的结果，尚未进行研究。目前对哪些护理过程对体积-结果关联的影响知之甚少。这项建议旨在： 具体目的1.在控制了年龄、民族和种族、患者水平的社会经济地位和保险覆盖范围、疾病程度和合并症的情况下，研究外科医生数量与女性意外乳腺癌手术的总死亡率和疾病复发的5年结果的关系。 具体目的2.检验长期激素辅助治疗(如他莫昔芬)在老年乳腺癌患者中的有效性和成本效益，以及荷尔蒙治疗在多大程度上解释了观察到的外科医生数量-结果关系。 具体目标3.研究老年妇女在接受偶发乳腺癌手术时接受护理的差异，以及在18个月、30个月、48个月和60个月时多个初始护理过程与结果(死亡、复发疾病、生活质量、功能状态)之间的关系。 具体目标4.描述老年妇女乳腺癌护理替代初始过程的费用与结果之间的关系，以及这些关系对政策倡议的影响。 这些目标将通过研究以人群为基础的乳腺癌老年妇女样本来实现，包括从联邦医疗保险文件、患者调查和肿瘤登记数据中得出的措施。这一结果将对指导政策倡议至关重要，包括确定如何最好地减少乳腺癌结果中的社会经济差异。

DESCRIPTION (provided by applicant): Breast cancer surgery in the U.S. exhibits little regionalization, with a large number of low volume providers. Several studies now show that higher surgeon volume of cases is associated with better 5-year survival. These studies suggest that the patients of surgeons performing at least 15-30 breast cancer operations annually have a 25% lower risk of all cause mortality. While these findings are important, the surgeon volume-outcome relationship requires further investigation before major policy initiatives are proposed. The possible contribution of selection bias to the observed relationship requires more study. Higher volume surgeons care for patients of higher socioeconomic status, the effect of which has been controlled for only ecologically. Disease recurrence, an outcome less subject to bias than is all-cause mortality, has not been studied. There is little understanding of what processes of care contribute to the volume-outcome association. This proposal aims: Specific Aim 1. To examine the relationship of surgeon volume and the 5-year outcomes of overall mortality and disease recurrence among women undergoing incident breast cancer surgery, controlling for age, ethnicity and race, patient-level SES and insurance coverage, extent of disease, and comorbidity. Specific Aim 2. To examine the effectiveness and cost-effectiveness of long-term hormonal adjuvant therapy (e.g. tamoxifen) among a population-based sample of older women with incident breast cancer, as well as the extent to which hormonal therapy accounts for any observed surgeon volume-outcome relationship. Specific Aim 3. To examine variations in care received by older women undergoing incident breast cancer surgery, and to examine the relationship between multiple initial processes of care and outcomes (death, recurrent disease, quality of life, functional status) at 18, 30, 48, and 60 months. Specific Aim 4. To describe the relationship between cost of alternative initial processes of breast cancer care and outcomes among older women, as well as the implications of these relationships for policy initiatives. These aims will be accomplished by studying a population-based sample of older women with incident breast cancer including measures derived from Medicare files, patient survey, and tumor registry data. The results will be critical to informing policy initiatives, including determination of how to best reduce socioeconomic disparities in breast cancer outcomes.