BACKGROUND/RATIONALE:
Women represent one of the fastest growing segments of new healthcare users in the Department of Veterans Affairs (VA). In recent years, efforts have been made to provide women veterans with gender-appropriate comprehensive care services within VA, such as obstetrics and gynecology care and mammography screening. As part of this increased emphasis on women's health care, the number of women Veterans receiving primary treatment for breast cancer has grown since the 1990s. In this study we leveraged the extensive resources of secondary data available in the VA to investigate the quality of care for early stage (locoregional) breast cancer.

OBJECTIVE(S):
The objectives of this study were to: 1) Compare surgical procedures and outcomes for locoregional breast cancer between women treated at VA and non-VA facilities; 2) To determine facility characteristics and patient characteristics associated with quality, as measured by type of surgery and adherence to guidelines for adjuvant care.

METHODS:
This retrospective cross-sectional (2000-2006) study used secondary data analysis to investigate the quality of care for treatment of locoregional breast cancer in the VA. Data were combined from different sources to develop a comprehensive overview of the structure of care, processes of care, and outcomes associated with breast cancer treatment. Surgical outcome variables for the study included the use of breast conserving surgery (BCS), sentinel lymph node biopsy (SLNB) and immediate or early delayed (within 30 days) breast reconstruction. Non-surgical outcome variables were related to levels of guideline adherence for radiation therapy after BCS and adjuvant endocrine therapy. A series of patient and structural variables were used as independent (predictor) variables. Bivariable (chi square and t-tests) and multivariable (regression) analyses were employed.

FINDINGS/RESULTS:
Over the study period 843 patients received a definitive treatment for breast cancer. After accounting for patients reported in the Fee Basis files, rates of use of BCS in the VA were comparable to the private sector. However, rates of use of SLNB and immediate or early reconstructions were lower than reported in the private sector. The use of adjuvant endocrine therapy (Tamoxifen) in the VA was comparable to reported rates in the private sector but the use of adjuvant radiation therapy was nearly 30% lower than private sector reports. An important limitation is that the current study did not include data from Medicare, Medicaid or private insurance. Women eligible for breast cancer care in the VA often moved back and forth between VA and private sector providers. Inclusion of these data could have had a significant impact on the results described. This fragmented system made it difficult to track the process of care for newly diagnosed breast cancer patients even with the extensive resources of the VACCR and other VA administrative databases.

IMPACT:
The organization of treatment of breast cancer is an example of the challenges for the VA healthcare system serving a growing number of women Veterans. An integrated tracking system for women diagnosed and treated for breast cancer in the VA would seem warranted to support ongoing monitoring of quality of care.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Matsen CB, Luther SL, Stewart AK, Henderson WG, Kim H, Neumayer LA. A match made in heaven? Trying to combine ACS-NSQIP and NCDB databases. The Journal of surgical research. 2012 Jun 1; 175(1):6-11. [view]
2. Luther SL, Neumayer L, Henderson WG, Foulis P, Richardson M, Haun J, Mikelonis M, Rosen A. The use of breast-conserving surgery for women treated for breast cancer in the Department of Veterans Affairs. American journal of surgery. 2013 Jul 1; 206(1):72-9. [view]

Conference Presentations

1. Luther SL, Neumayer L, Henderson W, Richardson MR, Lapcevic WA, Matsen C. The Quality of Locoregional Breast Cancer Treatment for Breast Cancer in the VHA. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 14; Arlington, VA. [view]
2. Luther SL. Utilization of Breast Conserving Surgery for Treatment of Locoregional Breast Cancer in the VHA. Presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 14; Arlington, VA. [view]

DRA: Health Systems Science
DRE: Treatment - Observational
Keywords: Cancer, Outcomes, Women - or gender differences
MeSH Terms: none