Rates of Breast Conserving Surgery Performed in VA for Women Veterans with Breast Cancer Comparable to Private Sector
BACKGROUND:
In recent years, VA has made considerable efforts to provide women Veterans with comprehensive care services, such as obstetrics and gynecology care, as well as mammography screening. In addition, the number of women Veterans receiving primary treatment for breast cancer in the VA healthcare system has grown. Historically, mastectomy was used for the treatment of breast cancer. This standard changed as a result of randomized trials that showed breast conserving surgery (BCS) with radiation therapy resulted in equivalent survival rates. Previous research suggested a lower rate of BCS in VA than in the private sector. Combining VA administrative data with VA Centralized Cancer Registry (VACCR) data, this study analyzed utilization rates of BCS among a cohort of women Veterans, and examined whether patient- or facility-level factors shown to be associated with the use of BCS in other settings might explain BCS use in the VA healthcare system. Using VACCR and Fee Basis file data, investigators identified 843 women Veterans who received surgery in a VA facility and 398 who received surgery in a non-VA facility as part of their treatment for breast cancer between 2000 and 2006. Patient- and facility-level characteristics that were considered in this study included: stage of breast cancer (SEER summary stage 1 through 4: cancer confined to breast or regional lymph nodes); patient demographics; travel distance to VAMC; presence of academic affiliation and/or cancer center at the VAMC; volume of breast cancer treated at the facility; and regional location (Northeast, Southeast/Midwest, and West).
FINDINGS:
- Based on procedures performed solely in VA, rates of breast conserving surgery for women Veterans decreased from 51% in 2000 to 42% in 2006. However, after accounting for procedures conducted in the private sector and paid for by VA, the BCS rate was 60%, which is more in line with private sector data. This suggests that previously reported differences in BCS rates between VA and the private sector may have been caused by the referral of BCS cases to the private sector, but the retention of mastectomies within VA.
- No statistically significant differences in the use of BCS were found based on age, race, income, marital status, or distance to a VAMC. A statistically significant difference was found for the stage of disease, with women Veterans with local disease (SEER summary stages 1 and 2) being more likely to receive breast conserving surgery (83%) than mastectomy (71%).
- None of the facility characteristics (including volume) was found to be significantly associated with the use of breast conserving surgery.
LIMITATIONS:
- Women Veterans treated in the private sector through Medicare, Medicaid, or private insurance were not included in this study.
- This study did not include data about patient preferences regarding breast surgery.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 06-053). Dr. Luther is part of HSR&D's Maximizing Rehabilitation Outcomes Center of Excellence located in Tampa, FL.
Luther S, Neumayer L, Henderson W, et al. The Use of Breast-Conserving Surgery for Women Treated for Breast Cancer in the Department of Veterans Affairs. The American Journal of Surgery July 2013;206(1):72-79.
