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    Original Investigation
    October 2018

    Association of Attending Surgeon With Variation in the Receipt of Genetic Testing After Diagnosis of Breast Cancer

    Author Affiliations
    • 1Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
    • 2Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
    • 3Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
    • 4Rollins School of Public Health, Emory University, Atlanta, Georgia
    • 5Keck School of Medicine, University of Southern California, Los Angeles
    • 6Memorial Sloan Kettering Cancer Center, New York, New York
    • 7Department of Medicine, Stanford University, Stanford, California
    • 8Department of Health Research and Policy, Stanford University, Stanford, California
    • 9Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
    JAMA Surg. 2018;153(10):909-916. doi:10.1001/jamasurg.2018.2001
    Key Points

    Question  To what extent is attending surgeon associated with receipt of genetic testing after diagnosis of breast cancer?

    Findings  In this population-based study of 7810 women, the attending surgeon explained 17.4% of the variation in testing. If a patient at higher pretest risk saw a surgeon at the 5th percentile of the surgeon distribution, she would have a 26.3% probability of testing compared with 72.3% if she saw a surgeon at the 95th percentile.

    Meaning  Attending surgeons have an association with variation in the receipt of genetic testing after diagnosis of breast cancer.

    Abstract

    Importance  Genetic testing after diagnosis of breast cancer is common, but little is known about the influence of the surgeon on the variation in testing.

    Objectives  To quantify and explain the association of attending surgeon with rates of genetic testing after diagnosis of breast cancer.

    Design, Setting, and Participants  This population-based study identified 7810 women with stages 0 to II breast cancer treated between July 1, 2013, and August 31, 2015, through the Surveillance, Epidemiology, and End Results registries for the state of Georgia, as well as Los Angeles County, California. Surveys were sent approximately 2 months after surgery. Also surveyed were 488 attending surgeons identified by the patients.

    Main Outcomes and Measures  The study examined the association of surgeon with variation in the receipt of genetic testing using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results and genetic testing data obtained from 4 laboratories.

    Results  In total, 5080 women (69.6%) of 7303 who were eligible (mean [SD] age, 61.4 [0.8] years) and 377 surgeons (77.3%) of 488 (mean [SD] age, 53.8 [10.7] years) responded to the survey. Approximately one-third (34.5% [1350 of 3910] of patients had an elevated risk of mutation carriage, and 27.0% (1056 of 3910) overall had genetic testing. Surgeons had practiced a mean (SE) of 20.9 (0.6) years, and 28.9% (107 of 370) treated more than 50 cases of new breast cancer per year. The odds of a patient receiving genetic testing increased more than 2-fold (odds ratio, 2.48; 95% CI, 1.85-3.31) if she saw a surgeon with an approach 1 SD above that of a surgeon with the mean test rate. Approximately one-third (34.1%) of the surgeon variation was explained by patient volume and surgeon attitudes about genetic testing and counseling. If a patient with higher pretest risk saw a surgeon at the 5th percentile of the surgeon distribution, she would have a 26.3% (95% CI, 21.9%-31.2%) probability of testing compared with 72.3% (95% CI, 66.7%-77.2%) if she saw a surgeon at the 95th percentile.

    Conclusions and Relevance  In this study, the attending surgeon was associated with the receipt of genetic testing after a breast cancer diagnosis. Variation in surgeon attitudes about genetic testing and counseling may explain a substantial amount of this association.

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