Article Figures & Data
Tables
Characteristic Value Total ambulatory primary care physician visits, n (%) 0–1 21,469 (20.4) 2–4 19,355 (18.4) 5–10 33,364 (31.7) ≥11 30,917 (29.4) Total ambulatory non–primary care physician visits, n (%) 0–1 39,031 (37.1) 2–4 23,308 (22.2) 5–10 23,230 (22.1) ≥11 19,536 (18.6) Age at diagnosis, y (%) 67–75 51,290 (48.8) 76–85 42,913 (40.83) ≥86 10,902 (10.37) Race/ethnicity, n (%) White, non-Hispanic 90,372 (86.0) Black, non-Hispanic 6,694 (6.4) Hispanic 3,931 (3.7) Asian/American Indian/Pacific Islander 3,425 (3.3) Other 683 (0.7) Marital status, n (%) Single (never married) 7,564 (7.2) Married 43,030 (40.9) Separated/divorced 6,913 (6.6) Widowed 43,280 (41.2) Unknown 4,318 (4.1) MSA of residence, n (%) Large metropolitan 60,122 (57.2) Metropolitan 29,272 (27.9) Urban 6,360 (6.1) Less urban 7,632 (7.3) Rural 1,714 (1.6) Year of diagnosis, n (%) 1994–1997 24,139 (23.0) 1998–2000 23,597 (22.5) 2001–2005 57,369 (54.6) Histologic type, n (%) Ductal 74,760 (71.1) Lobular 17,176 (16.3) Ductal/lobular 347 (0.3) Favorable 5,961 (5.7) Unfavorable 1,315 (1.3) Undefined 5,546 (5.3) Estrogen receptors, n (%) Positive/borderline 49,010 (46.6) Negative 9,147 (8.7) Missing 46,948 (44.7) Progesterone receptor, n (%) Positive/borderline 40,265 (38.3) Negative 17,027 (16.2) Missing 47,813 (45.5 Tumor size, mm Mean (SD) 20.2 (20.6) Median (minimum-maximum) 15 (0–990) AJCC stage at diagnosis, n (%) 0 (in situ) 14,568 (13.9) I 42,830 (40.8) II 27,602 (26.3) III 6,012 (5.7) IV 3,399 (3.2) Unknown 10,694 (10.2) Charlson comorbidity index, n (%)a 0 61,466 (58.5) 1 24,979 (23.8) ≥2 18,660 (17.8) Influenza vaccination, n (%) No 46,673 (44.4) Yes 58,432 (55.6) -
AJCC = American Joint Commission on Cancer; MSA = metropolitan statistical area.
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↵a Scored on a range from 3–35, where higher scores indicate increased morbidity.
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Characteristic Adjusted ORa 95% Wald CL P Value Total ambulatory primary care physician visits 0–1 (referent) 1.00 – – 2–4 2.78 2.65, 2.92 <.001 5–10 3.67 3.51, 3.83 <.001 ≥11 4.04 3.86, 4.23 <.001 Total ambulatory non– primary care physician visits 0–1 (referent) 1.00 – – 2–4 1.72 1.65, 1.78 <.001 5–10 2.15 2.06, 2.23 <.001 ≥11 3.31 3.16, 3.46 <.001 Age at diagnosis 67–75 y (referent) 1.00 76–85 y 0.61 0.59, 0.63 <.001 ≥86 y 0.25 0.24, 0.27 <.001 Race/ethnicity White, non-Hispanic (referent) 1.00 – – Black, non-Hispanic 1.01 0.95, 1.08 .66 Hispanic 0.80 0.73, 0.86 <.001 Asian/American Indian/Pacific 0.73 0.66, 0.81 <.001 Islander Other 0.95 0.79, 1.15 .62 Marital status Married (referent) 1.00 – – Never married 0.77 0.72, 0.81 <.001 Separated/divorced 0.71 0.67, 0.75 <.001 Widowed 0.72 0.69, 0.74 <.001 Unknown 0.73 0.67, 0.79 <.001 Education level of residence Quintile 1 (lowest) (referent) 1.00 – – Quintile 2 1.04 0.99, 1.09 0.17 Quintile 3 1.16 1.10, 1.23 <.001 Quintile 4 1.23 1.16, 1.30 <.001 Quintile 5 1.34 1.25, 1.43 <.001 Income level of residence Quintile 1 (lowest) (referent) 1.00 – – Quintile 2 0.99 0.94, 1.04 .71 Quintile 3 0.97 0.92, 1.02 .26 Quintile 4 0.95 0.90, 1.01 .13 Quintile 5 0.96 0.90, 1.03 .28 MSA of residence Large metropolitan (referent) 1.00 – – Metropolitan 1.01 0.97, 1.06 .55 Urban 0.99 0.92, 1.06 .73 Less urban 0.93 0.86, 1.00 .04 Rural 1.05 0.92, 1.19 .48 Year of diagnosis 1994–1997 (referent) 1.00 – – 1998–2000 1.35 1.29, 1.41 <.001 2001–2005 1.64 1.58, 1.71 <.001 Charlson comorbidity index 0 (referent) 1.00 – – 1 0.74 0.72, 0.77 <.001 ≥2 0.49 0.47, 0.51 <.001 Influenza vaccination No (referent) 1.00 – – Yes 1.69 1.64, 1.75 <.001 -
CL=confidence limits; MSA = metropolitan statistical area.
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Note: Patients with stage 0 carcinoma (in situ) were excluded.
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↵a The multivariable logistic models also included indicator variables for specific cancer registry (data not presented).
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- Table 3
Adjusted Associations of Late-Stage Diagnosis (AJCC III, IV) of Breast Cancer (n = 79,843)
Characteristic Adjusted ORa 95% Wald CL P Value Total ambulatory primary care physician visits 0–1 (referent) 1.00 – – 2–4 0.57 0.53, 0.61 <.001 5–10 0.49 0.46, 0.52 <.001 ≥11 0.50 0.47, 0.53 <.001 Total ambulatory non– primary care physician visits 0–1 (referent) 1.00 – – 2–4 0.62 0.58, 0.66 <.001 5–10 0.55 0.51, 0.58 <.001 ≥11 0.46 0.42, 0.49 <.001 Age at diagnosis 67–75 (referent) 1.00 – – 76–85 1.21 1.15, 1.27 <.001 ≥86 1.67 1.55, 1.79 <.001 Race/ethnicity White, non-Hispanic (referent) 1.00 – – Black, non-Hispanic 1.38 1.27, 1.50 <.001 Hispanic 1.32 1.19, 1.48 <.001 Asian/American Indian/Pacific 0.84 0.72, 0.98 .03 Islander Other 0.76 0.53, 1.08 .13 Marital status Married (referent) 1.00 – – Never married 1.38 1.27, 1.50 <.001 Separated/divorced 1.25 1.14, 1.37 <.001 Widowed 1.24 1.18, 1.31 <.001 Unknown 1.23 1.08, 1.39 .001 Education level of residence Quintile 1 (lowest) (referent) 1.00 – – Quintile 2 0.98 0.91, 1.05 .54 Quintile 3 0.94 0.86, 1.02 .12 Quintile 4 0.87 0.79, 0.95 .002 Quintile 5 0.81 0.73, 0.90 <.001 Income level of residence Quintile 1 (lowest) (referent) 1.00 – – Quintile 2 1.00 0.93, 1.08 .90 Quintile 3 1.05 0.97, 1.14 .22 Quintile 4 1.08 0.99, 1.19 .09 Quintile 5 1.06 0.95, 1.18 .28 MSA of residence Large metropolitan (referent) 1.00 – – Metropolitan 0.97 0.91, 1.04 .42 Urban 0.96 0.86, 1.08 .49 Less urban 0.84 0.75, 0.95 .004 Rural 0.83 0.68, 1.00 .06 Year of diagnosis 1994–1997 (referent) 1.00 – – 1998–2000 0.90 0.84, 0.97 .004 2001–2005 1.09 1.02, 1.16 .01 Charlson comorbidity index 0 (referent) 1.00 – – 1 1.02 0.96, 1.08 .52 ≥2 1.21 1.13, 1.29 <.001 Influenza vaccination No (referent) 1.00 – – Yes 0.72 0.69, 0.76 <.001 -
AJCC = American Joint Commission on Cancer; CL = confidence limits; MSA = metropolitan statistical area; PCP = primary care physician.
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Note: Patients with stage 0 carcinoma (in situ) or missing were excluded.
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↵a Odds ratios indicate odds of late-stage (AJCC stages III, IV) diagnosis of breast cancer relative to early stage (AJCC stages I, II). Logistic models also include indicator variables for cancer registry (data not presented).
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Characteristic Unadjusted Hazard Ratio (95% CI) Adjusted Excluding Stage and Tumor Sizea Hazard Ratio (95% CI) Adjusted Including Stage and Tumor Sizea Hazard Ratio (95% CI) Total ambulatory primary care physician visits 0–1 (referent) 1.00 1.00 1.00 2–4 0.55 (0.52–0.59) 0.68 (0.64–0.73) 0.89 (0.82–0.95) 5–10 0.50 (0.47–0.53) 0.61 (0.58–0.65) 0.83 (0.77–0.89) ≥11 0.50 (0.47–0.53) 0.59 (0.55–0.63) 0.80 (0.74–0.86) Total ambulatory non– primary care physician visits 0–1 (referent) 1.00 1.00 1.00 2–4 0.62 (0.58–0.65) 0.72 (0.68–0.76) 0.87 (0.81–0.93) 5–10 0.56 (0.53–0.59) 0.66 (0.62–0.72) 0.83 (0.77–0.89) ≥11 0.55 (0.51–0.58) 0.60 (0.56–0.64) 0.83 (0.76–0.89) Age at diagnosis 67–75 y (referent) 1.00 1.00 76–85 y 1.36 (1.30–1.43) 1.28 (1.21–1.35) ≥86 y 2.19 (2.05–2.33) 1.85 (1.71–2.00) Race/ethnicity White, non-Hispanic (referent) 1.00 1.00 Black, non-Hispanic 1.15 (1.06–1.25) 1.03 (0.94–1.14) Hispanic 1.03 (0.93–1.16) 0.91 (0.80–1.03) Asian/American Indian/Pacific Islander 0.86 (0.74–1.01) 0.97 (0.81–1.15) Other 0.52 (0.36–0.77) 1.09 (0.94–1.26) Marital status Married (referent) 1.00 1.00 Never married 1.36 (1.25–1.48) 1.22 (1.11–1.35) Separated/divorced 1.35 (1.24–1.48) 1.27 (1.14–1.40) Widowed 1.33 (1.26–1.40) 1.21 (1.14–1.28) Unknown 1.15 (1.03–1.29) 1.09 (0.94–1.26) Education level of residence Quintile 1 (lowest) (referent) 1.00 1.00 Quintile 2 1.02 (0.95–1.09) 1.08 (0.99–1.16) Quintile 3 0.94 (0.87–1.01) 0.97 (0.89–1.06) Quintile 4 0.92 (0.84–1.00) 0.98 (0.89–1.08) Quintile 5 0.88 (0.80–0.97) 0.92 (0.82–1.03) Income level of residence Quintile 1 (lowest) (referent) 1.00 1.00 Quintile 2 1.00 (0.93–1.07) 0.97 (0.90–1.05) Quintile 3 1.02 (0.95–1.11) 0.96 (0.88–1.05) Quintile 4 1.00 (0.92–1.09) 0.98 (0.89–1.08) Quintile 5 1.03 (0.93–1.14) 1.03 (0.92–1.16) MSA of residence Large metropolitan (referent) 1.00 1.00 Metropolitan 0.99 (0.92–1.06) 0.98 (0.90–1.06) Urban 0.95 (0.85–1.06) 0.97 (0.86–1.10) Less urban 0.92 (0.82–1.02) 0.96 (0.84–1.09) Rural 0.78 (0.65–0.94) 0.81 (0.66–1.00) Year of diagnosis 1994–1997 (referent) 1.00 1.00 1998–2000 1.05 (0.99–1.11) 0.97 (0.91–1.04) 2001–2005 1.06 (1.00–1.13) 0.93 (0.87–1.00) Histology type Ductal (referent) 1.00 1.00 Lobular 0.79 (0.74–0.84) 0.88 (0.82–0.94) Ductal/lobular 1.09 (0.78–1.51) 1.18 (0.83–1.68) Favorable 0.29 (0.24–0.34) 0.45 (0.38–0.54) Unfavorable 1.98 (1.78–2.21) 1.10 (0.89–1.35) Undefined 0.88 (0.78–1.00) 1.09 (0.95–1.25) Tumor grade Well differentiated (referent) 1.00 1.00 Moderately differentiated 2.16 (1.96–2.39) 1.66 (1.49–1.85) Poorly differentiated 4.62 (4.19–5.10) 2.78 (2.50–3.10) Undifferentiated 4.73 (4.04–5.53) 2.71 (2.28–3.23) Unknown 5.07 (4.58–5.62) 2.23 (1.98–2.51) Estrogen receptor status Positive/borderline (referent) 1.00 1.00 Negative 1.52 (1.41–1.64) 1.62 (1.49–1.75) Unknown 1.36 (1.13–1.64) 1.37 (1.09–1.71) Progesterone receptor status Positive/borderline (referent) 1.00 1.00 Negative 1.40 (1.31–1.50) 1.37 (1.27–1.47) Unknown 1.21 (1.00–1.46) 1.01 (0.81–1.27) Tumor size (continuous, mm) 1.006 (1.006–1.006) Stage at diagnosis I (referent) – 1.00 II – 3.38 (3.13–3.64) III – 8.90 (8.12–9.75) IV – 32.34 (29.51–35.43) Unknown – 3.60 (3.25–4.00) Charlson comorbidity index 0 (referent) 1.00 1.00 1 1.15 (1.08–1.21) 1.20 (1.13–1.28) ≥2 1.51 (1.42–1.60) 1.53 (1.43–1.64) Influenza vaccination No (referent) 1.00 1.00 Yes 0.79 (0.76–0.83) 0.92 (0.87–0.97) -
MSA = metropolitan statistical area; SEER = Surveillance Epidemiology and End Results.
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Note: Patients with stage 0 carcinoma (in situ) were excluded in the multivariable analysis.
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↵a Multivariable Cox proportional models also included indicator variables for SEER Registry location (data not presented).
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Additional Files
The Article in Brief
Richard G. Roetzheim , and colleagues
Background Despite the important role played by primary care physicians in preventive care, the actual effect of primary care on cancer outcomes has not been well studied. This study looks at the relationship between primary medical care and breast cancer outcomes in Medicare beneficiaries.
What This Study Found Medicare beneficiaries with breast cancer who make more visits to primary care physicians in the 2 years before their diagnosis have better breast cancer outcomes, including greater use of mammography, reduced odds of late-stage diagnosis, and lower overall and breast cancer mortality. Among 105,000 female Medicare beneficiaries with breast cancer, those with 10 or more office visits are 50 percent less likely to have late-stage cancer diagnosed. They have 41 percent lower breast cancer mortality and 27 percent lower overall mortality, compared with women having 1 or no visit.
Implications
- Improved outcomes are partly explained by greater use of mammography and resultant earlier stage diagnosis.
- Access to primary medical care may be an important factor in achieving optimal outcomes for breast cancer patients.
