One-Third of Patients Skip Local Hospital for Breast Cancer Surgery

About a third of patients with breast cancer bypassed their nearest hospital when deciding on where to have the procedure done, while patients who were younger had fewer other health conditions, White or living in a rural area being more likely to travel for their surgery, according to recent research published in the journal, Cancer.

“Policies allowing patients a choice of where they are treated have been introduced across many high-income countries including the US, UK and many parts of Europe. These policies are meant to make the health system more responsive to patients but also drive quality as those centers losing patients from their local catchment area to other providers are expected to improve their quality to retain patients,” study author, Dr. Ajay Aggarwal, professor at the London School of Hygiene and Tropical Medicine, said in an interview with CURE®. “In addition, all patients irrespective of their age, ethnicity or socioeconomic status should be able to make choices regarding their care.”

Aggarwal and his team analyzed data from 101,750 patients who received a diagnosis of breast cancer between Jan. 2016 and December 2018 and underwent breast cancer surgery with curative intent. Among these patients:

• 69,153 underwent an elective breast cancer surgery, and 33,686 underwent an elective mastectomy.
• 23,563 had a mastectomy without reconstruction.
• 9,055 had immediate reconstruction and 1,095 had delayed reconstruction.

Among the entire population who underwent breast cancer surgery, 32.7% chose not to have the procedure at the nearest eligible hospital. Similarly, among the patients who were undergoing a mastectomy without reconstruction, 30.5% bypassed their nearest hospital.

Findings showed that this proportion was higher among patients in rural areas (36.3% for surgery and 34.1% for mastectomy without reconstruction). Additionally, patients were more likely to have their surgery at a center that specialized in breast reconstruction and were less likely to choose the hospital with the shortest waiting time — this was especially true for women who were undergoing reconstruction, with those patients being five times more likely to receive care at a breast reconstruction specialist center. Patients were also found to be more likely to travel to centers with media reputations.

Aggarwal explained that two aspects of these findings were surprising to him.

“(The first is that) brand reputation were stronger drivers of where patients received treatment compared to measures of hospital quality,” he said. “(Secondly), waiting times — access to quicker treatment — were not a driver of where patients received treatment. Instead, other perceived measures of quality are more important (such as) seeing the right surgeon or going to a particular hospital.”

The researchers also observed that patients who were older, ethnic minorities, with comorbidities or more advanced disease stages were less likely to travel beyond their nearest hospital for breast cancer surgery.

These findings are similar to prior research. For example, 2021 data published by the American Society of Clinical Oncology found that disparities in breast cancer treatment and survival exist between African American and White women.

“Research in this area has repeatedly shown that the willingness to travel is lower in patients at the greatest risk of socioeconomic inequalities. This can relate to issues of health literacy, financial support to travel and the ability to take time off work or other caregiving activities,” Aggarwal said.

Moving forward, Aggarwal and his colleagues outlined guidance for patients when choosing a breast cancer treatment center. This includes access to a breast clinical nurse specialist to help guide options; being provided information on the types of procedures available — and the training and skillset needed by clinicians to undergo those procedures; being provided support based on the treatment center they choose, which may include transportation to and from said institution.

READ MORE: Educating Patients About Cancer Disparities Can Empower Them in Screening and Treatment Decisions

All this information, according to Aggarwal, may help patients make the best decisions for themselves.

“Information asymmetry is one of the major issues in most health care markets. Rather than quality and experience driving patient choice, we see that reputation of hospitals/clinicians and the availability of technology are major drivers which are no guarantee for quality,” he said. “It is hard to control access to popular media however more work can be done by government agencies/insurers to provide high-quality comparative data on hospital outcomes and patient experience of care to inform choices. At present there is little accredited data available publicly.”
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