that problems do exist with the quality of care received by many women in the United States. Many women (perhaps as many as 40 percent) do not appear to be receiving indicated radiation therapy after breast conserving surgery. In addition, older women are less likely to receive radiation therapy after breast conserving surgery. Rates of radiation therapy after breast conserving surgery also vary across hospitals, suggesting that some hospitals are providing poorer-quality breast cancer care than others. Of equal concern, many women do not appear to be receiving adjuvant chemotherapy (perhaps as many as 60 percent). These findings must be interpreted with caution, however, since many of the data reported are from the 1980s and are based on cancer registry data, whose accuracy is not known.

Variations in Compliance with American College of Radiology Quality Standards. While many women who undergo breast conserving surgery do not get indicated postoperative radiation therapy, potential quality problems still exist for the women who do get radiation therapy. The 1988 breast cancer Patterns of Care study performed by the American College of Radiology suggests widespread variation in compliance with standards of quality established by the ACR, with academic centers demonstrating the greatest compliance, followed by hospital facilities, and freestanding facilities having the poorest adherence (Kutchner et al., 1996). For example, immobilization of breast cancer patients receiving radiation therapy, in order to obtain consistent irradiation of the desired target, varied from 80 percent at academic centers, to 73 percent in hospital facilities, to only 51 percent in free-standing facilities. Similarly, the use of techniques to decrease the divergence of the radiation beam into lung tissue (in order to decrease pulmonary toxicity) ranged from 93 percent at academic centers to 77 percent at hospital facilities and 67 percent at free-standing facilities. A problem identified in an earlier 1983 Patterns of Care study was the misuse of axillary radiation; 53 percent of axillary node-negative women received radiation therapy. More recent data are needed to assess the state of compliance with radiology quality standards.

Follow-Up Care

Women should have a mammogram within 18 months following definitive surgery for breast cancer. According to one study of care provided to 936 privately insured, nonelderly women diagnosed from 1989 to 1991 in Virginia, only 79 percent had received a mammogram in the first 18 months (see Table 4.4).

The use of bone scans and imaging to search for liver metastases has been shown to have a low yield in clinical Stage I and II disease in numerous studies. Despite good evidence that their use does not improve clinical outcomes or quality of life (GIVIO, 1994), they are commonly done as a standard part of initial evaluation and often in subsequent follow-up care. In the Virginia study, 34 percent of women had a bone scan and 21 percent a computed tomography scan within 36 months of definitive surgery (Hillner et al., 1997).

The intensity of follow-up care appears to vary by site of care. During the same period, Simon et al. (1996) tracked 222 women treated and followed at one university hospital for three years. In the first year, patients treated with radiation or followed by medical oncology had the most frequent visits and intensity of testing. Wide variation in practice that was not explained by patient or provider characteristics was noted.

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