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Do financial incentives affect the type of breast cancer surgery a patient receives?

There are two treatment options for patients with breast cancer.  The first is a breast conserving surgery (BCS) which removes the cancerous lump (lumpectomy) followed by irradiation treatment.  The second option is a mastectomy which removes the entire breast.  Lecia Apantaku claims in the American Family Physician journal in 2002, that “survival rates following breast conservation surgery plus radiation are equivalent to those following mastectomy.” 

A 2003 Health Services Research paper by Hadley, et al. hypothesizes that differences in Medicare fees for the two procedures affects the probability that one or the other procedure will be used by the physician.  To prove this point, the authors use 1994 Medicare claims data for a sample of 1,787 Medicare patients who were treated for early stage breast cancer.  The authors compare Medicare fee rates in various geographic areas.  The prediction is that in areas with relatively higher physician compensation for BCS, there will be more BCS procedures performed.  In areas with relatively higher surgery fees for mastectomies, the opposite will hold.   The authors also take into account: input costs using HCFA values of the Geographic Adjustment Factor (GAF), physician year of graduation to control for surgical preferences of a cohort, whether the patient had supplemental insurance, as well as various demographic variables.  A mutinomial logit regression framework was use in which the dependent variables were: 1) BCS only, 2) BCS with radiation, and 3) mastectomy. 


The authors find that Medicare fees were significant factors in the choice between mastectomy and breast conserving surgery with radiation.  A ten percent increase in the BCS with radiation fee (i.e.: about $30) increased the relative odds of BCS with radiation relative to a mastectomy to 1.34 (p-value 0.02).  A 10% decrease in the mastectomy fee increased the relative odds of BCS with radiation relative to a mastectomy to 1.84 (p-value <0.01).  The affect of fees for 'BCS only' did not lead to a statistically significantly impact on the probability of having a BCS only procedure, but this may be due to the fact that BCS only procedures are relatively infrequent. 


The authors claim that this evidence “is consistent with the hypothesis that physicians are responsive to financial incentives when the alternative procedures have clinically equivalent outcomes, and patient clinical condition does not dominate the treatment choice” [my emphasis].  The authors wisely note there could be a reverse causality here.  Physicians may tend to charge more for the procedure which is performed most often in the region.  Other problems are that the data sample is small, the data are over ten years old, and the authors do not model patient preference for one procedure over the other. 

Hadley; Mandelblatt; Mitchell; Weeks; Guadagnoli; Hwang; (2003) “Medicare breast surgery fees and treatment received by older women with localized breast cancer” Health Services Research vol 28, no. 2, pp. 553-573.


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  2. The American Society of Clinical Oncologists (ASCO) says oncologists should make chemotherapy treatment recommendations on the basis of published reports of clinical trials and a patient’s health status and treatment preferences.

    So what about those published reports of clinical trials?

    More chemotherapy is given for breast cancer than for any other form of cancer and there have been more published reports of clinical trials for breast cancer than for any other form of cancer.

    According to the National Cancer Institute’s March 31, 2006 official cancer information website on “state of the art” chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment. At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance (1).

    In the total absence of guidance from published reports of clinical trials then, what basis are treatment regimens selected instead? ASCO says that this should be further based on a patient’s health status and patient treatment preferences.

    So what is being done?

    Recently published in the journal Health Affairs is a joint Harvard/Michigan study entitled, “Does reimbursement influence chemotherapy treatment for cancer patients?” The authors documented a clear association between reimbursement to the oncologists for the chemotherapy of breast, lung, and colorectal cancer and the regimens which the oncologists selected for the patients. In other words, oncologists tended to base their treatment decisions on which regimen provided the greatest financial remuneration to the oncologist (2).

    A March 8, 2006 New York Times article described the study. One of the more interesting aspects of the story was a comment from an executive with ASCO, Dr. Joseph S. Bailes, who disputed the study’s findings, saying that cancer doctors select treatments only on the basis of clinical evidence (3).

    So ASCO’s Dr. Bailes maintains that drugs are chosen only on the basis of “clinical evidence.”

    Yet Dr. Neil Love reported a survey of breast cancer oncologists based in academic medical centers and community based, private practice medical oncologists. The former oncologists do not derive personal profit from the administration of infusion chemotherapy, the latter oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy.

    The results of the survey could not have been more clear-cut. For first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists (who are motivated to keep off-protocol patients out of their chemotherapy infusion rooms to reserve these rooms for on-protocol patients) prescribed an oral-dose drug (capecitabine), while only 13% prescribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel.

    In contrast, among the commuity-based oncologists, only 18% prescribed the non-remunerative oral-dose drug (capecitabine), while 75% prescribed remunerative infusion drugs, and about 40% prescribed the expensive, highly remunerative drug docetaxel (4).

    While the Michigan/Harvard study showed results before the new Medicare reform, the Patterns of Care study showed results that the Medicare reforms are still not working. It is still an impossible conflict of interest.

    And the existence of this profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy based on testing the cancer biology.

    Two scientific studies giving us a dose of reality that once a decision to give chemotherapy is taken, oncologists receiving more-generous Medicare reimbursements used more-costly treatment regimens.

    It’s not that all oncologists are bad people. It’s just that it is still an impossible conflict of interest (i.e. it’s the SYSTEM which is rotten). Some oncologists prescribe chemotherapy drugs with equal efficacies and toxicities. I would imagine that some are influenced by the whole state of affairs, possibly without even entirely admitting it. There are so many ways for humans to rationalize their behavior. The solution is not to put the doctors in jail, it’s to change the system.





    (4) (figure 37, volume 2, issue 1, 2005)

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