Physicians' reasons for failing to deliver effective breast cancer care - A framework for underuse

OBJECTIVE. Despite numerous randomized trials showing the health benefits of systemic and local therapies for early-stage breast cancer, underuse of these therapies remains a significant quality problem. Little is known about causes of underuse of effective cancer treatments. We sought to understand these causes to design effective interventions to improve care. RESEARCH DESIGN. To identify categories of causes of underuse, semistructured interviews were performed with physicians of breast cancer patients who did not receive effective adjuvant care in the 4 years following surgery. Underuse was defined by expert consensus based on evidence-based guidelines. SUBJECTS. Surgeons (n = 13) of all early-stage breast cancer cases who underwent surgical treatment at a tertiary care hospital and had underuse of local or systemic adjuvant therapies. RESULTS. Of all the 275 women with early-stage breast cancer, there were 44 episodes of underuse of effective therapies (16%). In 48% of cases, physicians thought treatment should occur but the treatment failed to take place (32%) or the patient refused (16%). For the other 52% of cases, physicians thought treatment should not occur because evidence did not support treatment in clinical circumstances such as older age (32%), a good prognosis based on tumor size or histology (11%), a second primary breast cancer (5%), or because of comorbidities (5%). All surgeons were aware of the benefits of adjuvant treatments. CONCLUSIONS. Causes of underuse can be identified and categorized. Using these categories, a framework of causes of underuse was constructed and interventions targeting the specific causes to improve the quality of care are suggested.