Journal Article
. 2017 Feb; 163(1):167-176.
doi: 10.1007/s10549-017-4158-z.

Oncologist and organizational factors associated with variation in breast cancer multigene testing

Tracy A Lieu 1 G Thomas Ray 2 Stephanie R Prausnitz 2 Laurel A Habel 2 Stacey Alexeeff 2 Yan Li 3 Scott D Ramsey 4 Charles E Phelps 5 Neetu Chawla 2 Suzanne C O'Neill 6 Jeanne S Mandelblatt 6 
  • PMID: 28224383
  •     21 References
  •     5 citations


Purpose: Multigene testing for breast cancer recurrence risk became available in 2007, yet many eligible patients remain untested. This study evaluated variation in testing rates, and oncologist and organizational factors associated with variation, in a setting without financial influences on testing.

Methods: We conducted a retrospective cohort study using electronic data and oncologist surveys within Kaiser Permanente Northern California, a large integrated health care system. Analyses included all 2974 test eligible patients from 2013 to 2015, 113 oncologists, and 15 practice groups. Receipt of multigene testing was evaluated with generalized linear mixed models.

Results: Overall, 39% of eligible patients had multigene testing, but rates varied widely among practice groups, ranging from 24 to 48% after case mix adjustment. This 24% difference among practices was greater than the variation associated with most patient characteristics, including comorbidities and race/ethnicity, and similar to that associated with tumor size. Practice group and oncologist factors were statistically significant contributors to the variation in testing after adjusting for patient factors. Patients were more likely to be tested if they had a female oncologist (aOR 1.60, 95% CI 1.21-2.12) or were in a practice whose chief had a high testing rate (aOR 1.20, 95% CI 1.12-1.29 per 10% increase in the percent tested).

Conclusions: Oncologist and leadership practices play a key role in the variation in genomic test use for cancer recurrence risk even in a healthcare system without financial barriers to testing and could be a leverage point for implementing desired practice changes for new genomic advances.

Keywords: Genetic testing; Genomics; Practice change; Practice variation; Recurrence risk.

The influence of gender on physician practice style.
K D Bertakis, L J Helms, +2 authors, J A Robbins.
Med Care, 1995 Apr 01; 33(4). PMID: 7731281
The Kaiser Permanente Northern California Adult Member Health Survey.
Nancy Gordon, Teresa Lin.
Perm J, 2016 Aug 23; 20(4). PMID: 27548806    Free PMC article.
Adoption of gene expression profile testing and association with use of chemotherapy among women with breast cancer.
Michael J Hassett, Samuel M Silver, +12 authors, Jane C Weeks.
J Clin Oncol, 2012 May 16; 30(18). PMID: 22585699    Free PMC article.
Physician gender bias in clinical decisionmaking: screening for cancer in primary care.
P Franks, C M Clancy.
Med Care, 1993 Mar 01; 31(3). PMID: 8450679
The impact of confounder selection criteria on effect estimation.
R M Mickey, S Greenland.
Am J Epidemiol, 1989 Jan 01; 129(1). PMID: 2910056
Highly Cited.
Are patients of women physicians screened more aggressively? A prospective study of physician gender and screening.
M W Kreuter, V J Strecher, +2 authors, C S Skinner.
J Gen Intern Med, 1995 Mar 01; 10(3). PMID: 7769467
American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer.
Lyndsay Harris, Herbert Fritsche, +7 authors, American Society of Clinical Oncology.
J Clin Oncol, 2007 Oct 24; 25(33). PMID: 17954709
Highly Cited. Review.
Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer.
Andrew J Epstein, Yu-Ning Wong, +6 authors, Peter W Groeneveld.
J Clin Oncol, 2015 Nov 26; 33(36). PMID: 26598749    Free PMC article.
Association Between Use of the 21-Gene Recurrence Score Assay and Receipt of Chemotherapy Among Medicare Beneficiaries With Early-Stage Breast Cancer, 2005-2009.
Michaela A Dinan, Xiaojuan Mi, +2 authors, Lesley H Curtis.
JAMA Oncol, 2015 Aug 28; 1(8). PMID: 26313372
Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians.
Yusuke Tsugawa, Anupam B Jena, +3 authors, Ashish K Jha.
JAMA Intern Med, 2016 Dec 20; 177(2). PMID: 27992617    Free PMC article.
Highly Cited.
Use of Gene Expression Profiling and Chemotherapy in Early-Stage Breast Cancer: A Study of Linked Electronic Medical Records, Cancer Registry Data, and Genomic Data Across Two Health Care Systems.
Anosheh Afghahi, Maya Mathur, +14 authors, Allison W Kurian.
J Oncol Pract, 2016 May 26; 12(6). PMID: 27221993    Free PMC article.
Use and Costs for Tumor Gene Expression Profiling Panels in the Management of Breast Cancer From 2006 to 2012: Implications for Genomic Test Adoption Among Private Payers.
Megan C Roberts, Stacie B Dusetzina.
J Oncol Pract, 2015 Jun 25; 11(4). PMID: 26105668
Invasive breast cancer.
Robert W Carlson, D Craig Allred, +25 authors, National Comprehensive Cancer Network.
J Natl Compr Canc Netw, 2011 Feb 12; 9(2). PMID: 21310842
Breast cancer multigene testing trends and impact on chemotherapy use.
G Thomas Ray, Jeanne Mandelblatt, +4 authors, Tracy A Lieu.
Am J Manag Care, 2016 Jun 09; 22(5). PMID: 27266581    Free PMC article.
21-Gene Recurrence Score Assay As a Predictor of Adjuvant Chemotherapy Administration for Early-Stage Breast Cancer: An Analysis of Use, Therapeutic Implications, and Disparity Profile.
Jagar Jasem, Arya Amini, +4 authors, Peter Kabos.
J Clin Oncol, 2016 Mar 24; 34(17). PMID: 27001563    Free PMC article.
Oncotype Dx assay and breast cancer in the United States: usage and concordance with chemotherapy.
Lindsey Enewold, Ann M Geiger, JoAnne Zujewski, Linda C Harlan.
Breast Cancer Res Treat, 2015 Apr 11; 151(1). PMID: 25859924
Why do patients of female physicians have higher rates of breast and cervical cancer screening?
N Lurie, K L Margolis, +2 authors, J S Slater.
J Gen Intern Med, 1997 Jan 01; 12(1). PMID: 9034944    Free PMC article.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
R A Deyo, D C Cherkin, M A Ciol.
J Clin Epidemiol, 1992 Jun 01; 45(6). PMID: 1607900
Highly Cited.
Preventive care for women. Does the sex of the physician matter?
N Lurie, J Slater, +3 authors, K Margolis.
N Engl J Med, 1993 Aug 12; 329(7). PMID: 8332153
Highly Cited.
Local opinion leaders: effects on professional practice and health care outcomes.
Gerd Flodgren, Elena Parmelli, +4 authors, Martin P Eccles.
Cochrane Database Syst Rev, 2011 Aug 13; (8). PMID: 21833939    Free PMC article.
Highly Cited. Systematic Review.
Evaluating use characteristics for the oncotype dx 21-gene recurrence score and concordance with chemotherapy use in early-stage breast cancer.
Clara Chen, Rahul Dhanda, +2 authors, Debra A Patt.
J Oncol Pract, 2013 Aug 15; 9(4). PMID: 23942918    Free PMC article.
Expected Monetary Impact of Oncotype DX Score-Concordant Systemic Breast Cancer Therapy Based on the TAILORx Trial.
Angela Mariotto, Jinani Jayasekerea, +5 authors, Jeanne S Mandelblatt.
J Natl Cancer Inst, 2019 Jun 06; 112(2). PMID: 31165854    Free PMC article.
Factors Associated With Oncologist Discussions of the Costs of Genomic Testing and Related Treatments.
K Robin Yabroff, Jingxuan Zhao, +6 authors, Carrie N Klabunde.
J Natl Cancer Inst, 2019 Nov 02; 112(5). PMID: 31675070    Free PMC article.
The leadership behaviors needed to implement clinical genomics at scale: a qualitative study.
Stephanie Best, Zornitza Stark, +5 authors, Natalie Taylor.
Genet Med, 2020 May 14; 22(8). PMID: 32398772    Free PMC article.
The impact of gene expression profile testing on confidence in chemotherapy decisions and prognostic expectations.
Laura Panattoni, Tracy A Lieu, +5 authors, Scott D Ramsey.
Breast Cancer Res Treat, 2018 Oct 12; 173(2). PMID: 30306429    Free PMC article.
Feasibility of Measuring Preferences for Chemotherapy Among Early-Stage Breast Cancer Survivors Using a Direct Rank Ordering Multicriteria Decision Analysis Versus a Time Trade-Off.
Laura Panattoni, Charles E Phelps, +4 authors, Scott D Ramsey.
Patient, 2020 May 25; 13(5). PMID: 32447608