Individual, area, and provider characteristics associated with care received for stages I to III breast cancer in a multistate region of Appalachia

Gretchen G. Kimmick, Fabian Camacho, Heath B. Mackley, Teresa Kern, Nengliang Yao, Stephen A. Matthews, Steven Fleming, Joseph Lipscomb, Jason Liao, Wenke Hwang, Roger T. Anderson

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Purpose: We describe individual, area, and provider characteristics associated with care patterns for early-stage breast cancer in Appalachian counties of Kentucky, North Carolina, Ohio, and Pennsylvania. Methods: Cases of stages I to III breast cancer from 2006 to 2008 were linked to Medicare claims occurring within 1 year of diagnosis. Rates of guideline-concordant endocrine therapy (n = 1,429), chemotherapy (n = 1,480), and radiation therapy (RT) after breast-conserving surgery were studied; RT was studied in women age ≥ 70 years with stage I estrogen receptor (ER)-positive/progesterone receptor (PR)-positive cancer, for whom RT was optional (n = 1,108), and in all others, for whom RT was guideline concordant (n = 1,422). Univariable and multivariable analyses were performed. Independent variables included age, race, county-level economic status, state, surgeon graduation year and volume, comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, trastuzumab use, and surgery type. Results: Population mean age was 74 years; 97% were white. For endocrine therapy, chemotherapy, and RT, guideline concordance was 76%, 48%, and 83%, respectively. Where it was optional, 77% received RT. Guideline-concordant endocrine therapy was lower in North Carolina versus Pennsylvania (odds ratio [OR], 0.60; 95% CI, 0.41 to 0.88) and higher if surgeon graduated between 1984 and 1988 versus ≥ 1989 (OR, 1.58; 95% CI, 1.06 to 2.34). Guideline-concordant chemotherapy varied significantly by state, county-level economic status, and surgeon volume. In guideline-concordant RT, lower surgeon volume (v highest) predicted RT use (OR, 1.63; 95% CI, 1.61 to 2.36). In optional RT, North Carolina residence (v Pennsylvania; OR, 0.29; 95% CI, 0.17 to 0.48) and counties with higher economic status (OR, 0.61; 95% CI, 0.40 to 0.94) predicated RT omission. Conclusion: Notable variation in care by geographic and surgical provider characteristics provides targets for further research in underserved areas.

Original languageEnglish (US)
Pages (from-to)e9-e18
JournalJournal of oncology practice
Issue number1
StatePublished - Jan 1 2015

All Science Journal Classification (ASJC) codes

  • Oncology
  • Oncology(nursing)
  • Health Policy


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