Results of the Lynn Sage Second-Opinion Program for local therapy in patients with breast carcinoma : Changes in management and determinants of where care is delivered

To define patterns of care for the local therapy of stage I and II breast cancer and to identify factors used to select patients for breast-conserving therapy (BCT). A convenience sample of 16,643 patients with stage I and II breast cancer treated in 1994 was obtained from hospital-based tumor registries. Histologic variables were determined from original pathology reports. BCT was performed in 42.6% of patients. Multivariate analysis demonstrated that living in the Northeast United States (odds ratio [OR], 2.48; 95% confidence interval [CI], 2.16 to 2.84), having a clinical T1 tumor (OR, 2.51; 95% CI, 2.27 to 2.78), and having a tumor without an extensive intraductal component (OR, 2.07; 95% CI, 1.81 to 2.37) were the strongest predictors of breast-conserving surgery. Radiation therapy was given to 86% of patients who had breast-conserving surgery. Age less than 70 years was the most significant predictor of receiving radiation (OR, 2.11; 95% CI, 1.77 to 2.25). Tumor variables did not correlate with the use of radiation, but favorable tumor characteristics were associated with the use of breast-conserving surgery. Despite strong evidence supporting the use of BCT, the majority of women continue to be treated with mastectomy. Predictors of the use of BCT do not correspond to those suggested in guidelines.

Relatively little is known about the size and makeup of the growing population of cancer survivors or about the social implications of a diagnosis of cancer. To explore these issues, we analyzed cancer survivorship information from the 1992 National Health Interview Survey (NHIS), and resulting cancer prevalence estimates were compared with those derived from cancer registry data. According to the NHIS, there were an estimated 7.2 million adult survivors of cancer-excluding nonmelanoma skin cancer-in 1992, representing 3.9% of the U.S. adult population. Comparisons with prevalence estimates from cancer registry data suggest that cancer is underreported in the NHIS. Nearly three fifths (58.0%) of cancer survivors self-identified on the NHIS reported that their cancer was first detected when they noticed something wrong and went to a doctor. The majority (55.7%) of cancer survivors had obtained a second opinion or multiple opinions regarding their treatment. Most (58.0%) had received patient educational materials from a health care provider. However, relatively few had received counseling or participated in support groups (14.2%), contacted cancer organizations after their diagnosis (10.9%), or participated in a research study or clinical trial as part of their cancer treatment (4.7%). One ninth (10.7%) of the survivors had been denied health or life insurance coverage because of their cancer. Nearly one fifth (18.2%) of the cancer survivors who worked before or after their cancer was diagnosed experienced employment problems because of their cancer. While cancer appears to be underreported on the 1992 NHIS, the survey provides valuable information about the medical, insurance, and employment experience of cancer survivors selected from a nationally representative sample of U.S. households.

The objectives of the study were (a) to determine psychosocial determinants of two measures of health care use: seeking a second opinion and alternative medicine use, and (b) to assess whether changes in these two measures of health care use had taken place during the past 4 to 5 years. All patients attending a university-based gastroenterology clinic were asked to complete a self-administered questionnaire. The response rate was 83% (N = 341). Health locus of control, scepticism toward medicine, satisfaction with health care, and perceived health status were included as potential determinants. Sixteen percent (21) of the new patients (95% confidence interval, 10.0-22.8) sought a second opinion compared to 7.5% (95% confidence interval, 4.3-10.7) 5 years ago. Seeking a second opinion was negatively related to internal locus of control, perceived health status, and demanding to know all details of treatment. Eight percent (28) of all patients (95% confidence interval, 5.3-11.1) saw an alternative practitioner for the same problem for which they saw the gastroenterologist compared to 9% (95% confidence interval, 6.2-12.8) 4 years ago. Using alternative medical care was positively related to scepticism toward conventional medicine and negatively related to perceived health status and satisfaction with clinic physicians. Knowledge about the incidence and determinants of these behaviors provides valuable information for clinicians in communicating with their patients and may eventually result in cost containment.