Breast Cancer Research and Treatment

, Volume 160, Issue 1, pp 153–162 | Cite as

Patterns of multidisciplinary care in the management of non-metastatic invasive breast cancer in the United States Medicare patient

  • Thomas M. Churilla
  • Brian L. Egleston
  • Colin T. Murphy
  • Elin R. Sigurdson
  • Shelly B. Hayes
  • Lori J. Goldstein
  • Richard J. BleicherEmail author



Multidisciplinary care (MDC) in managing breast cancer is resource-intensive and growing in prevalence anecdotally, although care patterns are poorly characterized. We sought to determine MDC patterns and effects on care in the United States Medicare patient.


Patients diagnosed with non-metastatic invasive breast cancer from 1992–2009 were reviewed using the Survival, Epidemiology, and End Results (SEER)-Medicare linked dataset. MDC was defined as a post-diagnosis, preoperative visit with a surgical, medical, and radiation oncologist. Same-day MDC (MDCSD) was the MDC subset having all three visits on one date.


Among 88,865 patients, MDC was utilized in 2.9 %, with 14.1 % of these having MDCSD. MDC use did not vary by stage, but MDC patients were more likely to be younger, black, receive lumpectomy, have fewer nodes examined, and receive radiotherapy. MDCSD patients were more likely than non-MDC patients to be black, receive mastectomy, and receive radiotherapy. MDC and MDCSD use increased over time and varied by geographic region, with rural patients less likely to receive MDC (OR 0.54 [95 % CI 0.45–0.65]) and MDCSD (OR 0.32 [95 % CI 0.19–0.54]). Radiotherapy after breast conserving surgery, used in 86.5 % of non-MDC patients, was administered to 90.2 % of MDC (p = 0.001) and 92.6 % of MDCSD (p = 0.019) patients. Post-mastectomy radiotherapy was administered in 52.0 % of non-MDC patients, 63.8 % of MDC (p = 0.050), and 89.1 % of MDCSD (p = 0.298) after propensity score adjustment.


While increasing, few Medicare patients undergo MDC and MDCSD is rare. MDC may improve quality and MDCSD should be considered for patient convenience. While not yet widespread, efforts should integrate MDC and MDCSD across the U.S.


Multidisciplinary care Medical oncology Surgical oncology Radiation oncology Breast cancer 



This work was supported by the United States Public Health Services grant P30 CA006927 for analysis of the data via support of our biostatistics facility, and by generous private donor support from the Marlyn Fein Chapter of the Fox Chase Cancer Center Board of Associates, for analysis and interpretation of the data. This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database. The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement #U55/CCR921930-02 awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California, Department of Public Health the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred. The authors would like to thank Yanqun Dong, M.D., Ph.D. for feedback during manuscript preparation.

Author contributions

Planning: T Churilla, B Egleston, R Bleicher. Conduct: T Churilla, B Egleston, C Murphy, E Sigurdson, S Hayes, L Goldstein, R Bleicher. Reporting: T Churilla, B Egleston, C Murphy, E Sigurdson, S Hayes, L Goldstein, R Bleicher.Guarantor of overall content: R Bleicher.


This work was supported by the United States Public Health Services grant P30 CA006927 for analysis of the data via support of our biostatistics facility, and by generous private donor support from the Marlyn Fein Chapter of the Fox Chase Cancer Center Board of Associates, for analysis and interpretation of the data.

Compliance with ethical standards

Conflicts of interest

The authors have no conflicts of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Supplementary material

10549_2016_3982_MOESM1_ESM.docx (89 kb)
Supplementary material 1 (DOCX 90 kb)


  1. 1.
    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Peto R, Davies C et al (2012) Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials. Lancet Lond Engl 379:432–444. doi: 10.1016/S0140-6736(11)61625-5 CrossRefGoogle Scholar
  2. 2.
    EBCTCG (Early Breast Cancer Trialists’ Collaborative Group), McGale P, Taylor C (2014) Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet Lond Engl 383:2127–2135. doi: 10.1016/S0140-6736(14)60488-8 CrossRefGoogle Scholar
  3. 3.
    Baldwin L-M, Taplin SH, Friedman H, Moe R (2004) Access to multidisciplinary cancer care: is it linked to the use of breast-conserving surgery with radiation for early-stage breast carcinoma? Cancer 100:701–709. doi: 10.1002/cncr.20030 CrossRefPubMedGoogle Scholar
  4. 4.
    Lamb BW, Brown KF, Nagpal K et al (2011) Quality of care management decisions by multidisciplinary cancer teams: a systematic review. Ann Surg Oncol 18:2116–2125. doi: 10.1245/s10434-011-1675-6 CrossRefPubMedGoogle Scholar
  5. 5.
    Gomella LG, Lin J, Hoffman-Censits J et al (2010) Enhancing prostate cancer care through the multidisciplinary clinic approach: a 15-year experience. J Oncol Pract Am Soc Clin Oncol 6:e5–e10. doi: 10.1200/JOP.2010.000071 CrossRefGoogle Scholar
  6. 6.
    Chang JH, Vines E, Bertsch H et al (2001) The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 91:1231–1237CrossRefPubMedGoogle Scholar
  7. 7.
    Korman H, Lanni T, Shah C et al (2013) Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience. Am J Clin Oncol 36:121–125. doi: 10.1097/COC.0b013e318243708f CrossRefPubMedGoogle Scholar
  8. 8.
    Newman EA, Guest AB, Helvie MA et al (2006) Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer 107:2346–2351. doi: 10.1002/cncr.22266 CrossRefPubMedGoogle Scholar
  9. 9.
    Gabel M, Hilton NE, Nathanson SD (1997) Multidisciplinary breast cancer clinics. Do they work? Cancer 79:2380–2384CrossRefPubMedGoogle Scholar
  10. 10.
    Devitt B, Philip J, McLachlan S-A (2010) Team dynamics, decision making, and attitudes toward multidisciplinary cancer meetings: health professionals’ perspectives. J Oncol Pract Am Soc Clin Oncol 6:e17–e20. doi: 10.1200/JOP.2010.000023 CrossRefGoogle Scholar
  11. 11.
    Bunnell CA, Weingart SN, Swanson S et al (2010) Models of multidisciplinary cancer care: physician and patient perceptions in a comprehensive cancer center. J Oncol Pract Am Soc Clin Oncol 6:283–288. doi: 10.1200/JOP.2010.000138 CrossRefGoogle Scholar
  12. 12.
    American College of Surgeons (2014)interdisciplinary patient management Section 2.1. national accreditation program for breast centers. Standard Manual, Chicago.Google Scholar
  13. 13.
    Bleicher RJ, Ruth K, Sigurdson ER et al (2012) Preoperative delays in the US Medicare population with breast cancer. J Clin Oncol Off J Am Soc Clin Oncol 30:4485–4492. doi: 10.1200/JCO.2012.41.7972 CrossRefGoogle Scholar
  14. 14.
    CoC quality of care measures. In: American College of Surgeons Accessed 27 Sep 2015.
  15. 15.
    NAPBC Standards. In: American College of Surgeons. Accessed 27 Sep 2015
  16. 16.
    Lunceford JK, Davidian M (2004) Stratification and weighting via the propensity score in estimation of causal treatment effects: a comparative study. Stat Med 23:2937–2960. doi: 10.1002/sim.1903 CrossRefPubMedGoogle Scholar
  17. 17.
    Robins JM, Hernán MA, Brumback B (2000) Marginal structural models and causal inference in epidemiology. Epidemiol Camb Mass 11:550–560CrossRefGoogle Scholar
  18. 18.
    Elixhauser A, Steiner C, Harris DR, Coffey RM (1998) Comorbidity measures for use with administrative data. Med Care 36:8–27CrossRefPubMedGoogle Scholar
  19. 19.
    van Walraven C, Austin PC, Jennings A et al (2009) A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care 47:626–633. doi: 10.1097/MLR.0b013e31819432e5 CrossRefPubMedGoogle Scholar
  20. 20.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383CrossRefPubMedGoogle Scholar
  21. 21.
    Fine JP, Gray RJ (1999) A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc 94:496–509. doi: 10.2307/2670170 CrossRefGoogle Scholar
  22. 22.
    Harrell FE Jr (2001) General aspects of fitting regression models. In: regression modeling strategies. Springer, New York, pp 11–40CrossRefGoogle Scholar
  23. 23.
    European Partnership Action Against Cancer consensus group, Borras JM, Albreht T et al (2014) Policy statement on multidisciplinary cancer care. Eur J Cancer Oxf Engl 1990(50):475–480. doi: 10.1016/j.ejca.2013.11.012 Google Scholar
  24. 24.
    Komatsu H, Nakayama K, Togari T et al (2011) Information sharing and case conference among the multidisciplinary team improve patients’ perceptions of care. Open Nurs J 5:79–85. doi: 10.2174/1874434601105010079 CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Bensenhaver J, Winchester DP (2014) Surgical leadership and standardization of multidisciplinary breast cancer care: the evolution of the National Accreditation Program for Breast Centers. Surg Oncol Clin N Am 23:609–616. doi: 10.1016/j.soc.2014.03.005 CrossRefPubMedGoogle Scholar
  26. 26.
    Bleicher RJ, Ruth K, Sigurdson ER et al (2016) Time to surgery and breast cancer survival in the United States. JAMA Oncol 2:330–339. doi: 10.1001/jamaoncol.2015.4508 CrossRefPubMedGoogle Scholar
  27. 27.
    Aizer AA, Paly JJ, Efstathiou JA (2013) Multidisciplinary care and management selection in prostate cancer. Semin Radiat Oncol 23:157–164. doi: 10.1016/j.semradonc.2013.01.001 CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Thomas M. Churilla
    • 1
  • Brian L. Egleston
    • 2
  • Colin T. Murphy
    • 1
  • Elin R. Sigurdson
    • 3
  • Shelly B. Hayes
    • 1
  • Lori J. Goldstein
    • 4
  • Richard J. Bleicher
    • 3
    Email author
  1. 1.Department of Radiation OncologyFox Chase Cancer CenterPhiladelphiaUSA
  2. 2.Department of BiostatisticsFox Chase Cancer CenterPhiladelphiaUSA
  3. 3.Department of Surgical OncologyFox Chase Cancer CenterPhiladelphiaUSA
  4. 4.Department of Medical OncologyFox Chase Cancer CenterPhiladelphiaUSA

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