The Breast Surgery study group began its work in March 2000 and concluded in April 2003. Comprised primarily of breast surgeons, the group chose to include representation of both a medical oncologist and a radiation oncologist as well. The panel explored what drives variation found in early stage breast cancer treatment in West Virginia to identify patterns that called for a change. The group postulated three hypotheses on what is driving variation in West Virginia- access to care, patient influences, and physician influences.

Hypothesis number one is that access to care is driving the treatment decision in early stage breast cancer. A map was created in order to illustrate and analyze the access to care issue in West Virginia. Beginning with a map of West Virginia, we identified all the Radiation Treatment Centers in the state and bordering states where West Virginia patients would likely travel for their treatment.

Using 1991-1998 early stage breast cancer data obtained from the West Virginia Cancer Registry, we sorted by zip code and aggregated into large groups of data by zip code prefix (example: Wheeling area prefix includes all zip codes beginning with 260xx). An overlay was created for this map divided into our designated zip code regions. We placed population statistics obtained from the Census bureau onto this overlay along with the cancer registry data calculated by percentage for lumpectomy and mastectomy.

The map demonstrates wide variation in the treatment of early stage breast cancer across West Virginia, which does not appear to be driven by access to radiation treatment centers as originally postulated by the group.

The second hypothesis postulates that woman’s treatment decisions are influenced by a number of different factors. A study entitled, “Determinants of Woman’s Choice for Treatment of Early Stage Breast Cancer in West Virginia”, was designed by our physicians to identify which factors are most influential in a woman’s decision of which treatment option is right for her. The study utilized a patient questionnaire. IRB approval was received in October and the study began on November 1, 2001. It was originally scheduled to run for a period of one year but was extended due to a smaller sample than anticipated. Research Assistants were recruited from WVU’s Schools of Medicine and Nursing. Research Assistants received a two-day training geared to helping the RA assist the patient in completion of the questionnaire.

After receiving IRB approval for the study, 53 Breast Surgeons from around the state were recruited to enroll their Stage 1 and 2a breast cancer patients into the patients factor study. Recruiting of breast surgeons, training of site coordinators in their offices, and training of research assistants were done by Coalition staff. 60+ patients were enrolled into the study.

Lastly, the third hypothesis involves the issue of physician factors influencing treatment decisions in breast cancer treatment. The literature is full of studies identifying physician factors such as age of the surgeon, being a determinant factor in variation of treatment. The group has completed a study specific to West Virginia physicians using data obtained from the Board of Medicine and the Board of Osteopathic Medicine. According to our Consultant, Dr. John Combes, there appears to be no correlation with the variation seen in the treatment of early stage breast cancer in West Virginia to the age or sex of the surgeon, date of graduation from medical school, or year training was completed.

Mastectomies
for Breast Cancer per 1,000 Female Medicare Enrollees by Hospital Referral Region
(1995-1996)
2.43 to 3.60
2.11 to <2.43
1.91 to <2.11
1.70 to <1.91
0.89 to <1.70

Lumpectomies
for Breast Cancer per 1,000 Female Medicare Enrollees by Hospital Referral Region
(1995-1996)
0.72 to 1.29
0.59 to <0.72
0.48 to <0.59
0.39 to <0.48
0.24 to <0.39