Annals of Surgical Oncology

, Volume 20, Issue 1, pp 7–14 | Cite as

Surgeon-Level Variation in Patients’ Appraisals of Their Breast Cancer Treatment Experiences

  • Sarah T. HawleyEmail author
  • Sarah E. Lillie
  • Arden Morris
  • John J. Graff
  • Ann Hamilton
  • Steven J. Katz
Health Policy


Background and Purpose

While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.


Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.


Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4 % for access to care, 3.3 % for care coordination, and 7.5 % for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.


Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.


Breast Cancer Breast Cancer Treatment Care Coordination Breast Cancer Specialization Decision Satisfaction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Funding for this research comes from R01CA109696 and R01CA08870 to the University of Michigan.

Conflict of interest



  1. 1.
    Institute of Medicine, Commission on life Sciences National Research Council. Ensuring quality cancer care. National Academy Press: Washington DC; 1999.Google Scholar
  2. 2.
    Malin, JL, Schneider EC, Epstein AM, Adams J, Emanuel E, Kahn KL. Results of the national initiative for cancer care quality: how can we improve the quality of cancer care in the United States? J Clin Oncol. 2006;24(4):626–34.PubMedCrossRefGoogle Scholar
  3. 3.
    Schneider EC, Malin JL, Kahn KL, Emanuel EJ, Epstein AM. Developing a system to assess the quality of cancer care: ASCO’s national initiative on cancer care quality. J Clin Oncol. 2004;22(15):2985–91.PubMedCrossRefGoogle Scholar
  4. 4.
    Malin JL., Diamant AL, Leake B, et al. Quality of care for breast cancer for uninsured women in California under the breast and cervical cancer prevention treatment act. J Clin Oncol. 2010;28(21):3479–8434.PubMedCrossRefGoogle Scholar
  5. 5.
    Chen F, Puig M, Yermilov I, et al. Using breast cancer quality indicators in a vulnerable population. Cancer. 2011;117(15):3311–21.PubMedCrossRefGoogle Scholar
  6. 6.
    Pieters HC, Heilemann MV, Grant M, Maly RC. Older women’s reflections on accessing care across their breast cancer trajectory: navigating beyond the triple barriers. Oncol Nurs Forum. 2011;38(2):175–84.PubMedCrossRefGoogle Scholar
  7. 7.
    McCahill LE, Privette A, James T, et al. Quality measures for breast cancer surgery: initial validation of feasibility and assessment of variation among surgeons. Arch Surg. 2009;144(5):455–62.PubMedCrossRefGoogle Scholar
  8. 8.
    Katz SJ, Hawley ST. From policy to patients and back: surgical treatment decision making for patients with breast cancer. Health Affairs. 2007;26(3):761–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Katz SJ, Hawley ST, Abrahamse P, et al. Does it matter where you go for breast surgery: attending surgeon’s influence on variation in receipt of mastectomy for breast cancer. Med Care. 2010;48(10):892–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Hawley ST, Hofer TP, Janz NK, et al. Correlates of between surgeon variation in breast cancer treatments. Med Care. 2006;44(7):609–16.PubMedCrossRefGoogle Scholar
  11. 11.
    Hershman DL, Buone D, McBride RB, Tsai WY, Neugut Al. Influence of private practice setting and physician characteristics on the use of breast cancer adjuvant chemotherapy for elderly women. Cancer. 2009;115(17):3848–57.Google Scholar
  12. 12.
    Hershman DL, Buone D, Jacobson JS, McBride RB, Tsai WY, Joseph KA, Neugut Al. Surgeon characteristics and use of breast conservation surgery in women with early stage breast cancer. Ann. Surg. 2009;249(5):828–33.Google Scholar
  13. 13.
    Keating NL, Kouri E, He Y, Weeks JC, Winer EC. Racial differences in definitive breast cancer therapy in older women: are they explained by the hospitals where patients undergo surgery? Med Care. 2009;47(7):765–73.PubMedCrossRefGoogle Scholar
  14. 14.
    Spinks T, Albright HW, Feely R, et al. Ensuring quality cancer care: a follow up review of the Institute of Medicine’s 10 recommendation for improving the quality of cancer care in America. Cancer. 2011. doi: 10.1002/cncr.26536.
  15. 15.
    Hillner BE, Smith RJ, Desch CE. Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care. J Clin Oncol. 2000;18(11):2327–40.PubMedGoogle Scholar
  16. 16.
    Dilts DM. Practice variation: the Achilles’ heel in quality cancer care. J Clin Oncol. 2005; 23(25): 5881–2.PubMedCrossRefGoogle Scholar
  17. 17.
    Hawley ST, Janz NK, Lillie SE. Perceptions of care coordination in a population-based sample of diverse breast cancer patients. Patient Educ Counsel. 2010;81 Suppl:S34–40.CrossRefGoogle Scholar
  18. 18.
    Hawley ST, Janz NK, Hamilton A, Griggs JJ, Alderman AK, Mujahid M, et al. Latina patient perspectives about informed treatment decision making for breast cancer. Patient Educ Counsel. 2008;73(2):363–70.CrossRefGoogle Scholar
  19. 19.
    Hamilton AS, Hofer TP, Hawley ST, et al. Latinas and breast cancer outcomes: population-based sampling, ethnic identity and acculturation assessment. Cancer Epidemiol Biomarkers Prev. 2009;18(7):2022–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009;302(14):1551–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Hawley ST, Griggs JJ, Hamilton AS., et al. Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients. J Natl Cancer Inst. 2009;101(19):1337–47.PubMedCrossRefGoogle Scholar
  22. 22.
    Katz SJ, Hawley ST, Morrow MM, et al. Coordinating cancer care: patient and practice management processes among surgeons who treat breast cancer. Med Care. 2010;48(1):45–51.PubMedCrossRefGoogle Scholar
  23. 23.
    Word D. Perkins JR. Building a Spanish Surname List for the 1990’s—a new approach to an old problem. U.S. Census Bureau, Technical Working Paper No. 13. 1996.Google Scholar
  24. 24.
    Dillman DA, Smyth DA, Christian LM. Internet, mail and mixed-mode surveys: the tailored design method. Hoboken, NJ: Wiley; 2009.Google Scholar
  25. 25.
    Anema MG, Brown BE. Increasing survey responses using the total design method. J Continuing Educ Nurs. 1995;26(3):109–4.Google Scholar
  26. 26.
    Holmes-Rovner, M, Kroll J, Schmitt DR, et al. Patient satisfaction with health care decisions: the satisfaction with decision scale. Med Decis Making. 1996;16(1):58–64.PubMedCrossRefGoogle Scholar
  27. 27.
    Marin G, Sabogal BV, Marin R, Otero-Sabogal R, Perez-Stable E. Development of a short acculturation scale for hispanics. Hispanic J Behav Sci.1987; 9(2): 183-205.CrossRefGoogle Scholar
  28. 28.
    Snijders TAB, Boster RJ. Multilevel Analysis. Thousand Oaks, CA: Sage; 1999.Google Scholar
  29. 29.
    Tariman JD, Berry B, Cochrane A, Doorenbos A, Schepp K. Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review. Ann Oncol. 2010;21(6):45–51.CrossRefGoogle Scholar
  30. 30.
    Vargas RB, Ryan GW, Jackson CA, Rodriguez R, Freeman HP. Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer. Cancer. 2008;3(2):426–33.CrossRefGoogle Scholar
  31. 31.
    Nápoles-Springer AM, Livaudais JC, Bloom J, Hwang S, Kaplan CP. Information exchange and decision making in the treatment of Latina and White women with ductal carcinoma in situ. J Psychosocial Oncol. 2007;25(4):19–36.CrossRefGoogle Scholar
  32. 32.
    Polacek GN, Ramos MC, Ferrer RL. Breast cancer disparities and decision-making among U.S. women. Patient Educ Counsel. 2007;65(2):158–65.CrossRefGoogle Scholar
  33. 33.
    Waljee JF, Hawley ST, Alderman AK, Morrow M, Katz SJ. Patient satisfaction with treatment of breast cancer: does surgeon specialization matter? J Clin Oncol. 2007; 24(24):3694–8.CrossRefGoogle Scholar
  34. 34.
    Liang W, Burnett CB, Rowland JH, et al. Communication between physicians and older women with localized breast cancer: implications for treatment and patient satisfaction. J Clin Oncol. 2002;20(4):1008–16.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Sarah T. Hawley
    • 1
    Email author
  • Sarah E. Lillie
    • 2
  • Arden Morris
    • 3
  • John J. Graff
    • 4
  • Ann Hamilton
    • 5
  • Steven J. Katz
    • 6
  1. 1.Division of General Medicine, University of Michigan Health SystemCenter for Clinical Management Research, Ann Arbor VA Medical CenterAnn ArborUSA
  2. 2.Department of Health Behavior and Health EducationUniversity of Michigan School of Public HealthAnn ArborUSA
  3. 3.Department of SurgeryUniversity of Michigan Health SystemAnn ArborUSA
  4. 4.Cancer Institute of New JerseyNew Jersey State Cancer RegistryNew BrunswickUSA
  5. 5.Keck School of MedicineUniversity of Southern CaliforniaLos AngelesUSA
  6. 6.Division of General MedicineUniversity of Michigan Health SystemAnn ArborUSA

Personalised recommendations