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JAMA network open 2024 May 01
Authors:
Freeman JQ
Abstract
Declining treatment negatively affects health outcomes among patients with cancer. Limited research has investigated national trends of and factors associated with treatment declination or its association with overall survival (OS) among patients with breast cancer.
To examine trends and racial and ethnic disparities in treatment declination and racial and ethnic OS differences stratified by treatment decision in US patients with breast cancer.
This retrospective cross-sectional study used data for patients with breast cancer from the 2004 to 2020 National Cancer Database. Four treatment modalities were assessed: chemotherapy, hormone therapy (HT), radiotherapy, and surgery. The chemotherapy cohort included patients with stage I to IV disease. The HT cohort included patients with stage I to IV hormone receptor-positive disease. The radiotherapy and surgery cohorts included patients with stage I to III disease. Data were analyzed from March to November 2023.
Race and ethnicity and other sociodemographic and clinicopathologic characteristics.
Treatment decision, categorized as received or declined, was modeled using logistic regression. OS was modeled using Cox regression. Models were controlled for year of initial diagnosis, age, sex, health insurance, median household income, facility type, Charlson-Deyo comorbidity score, histology, American Joint Committee on Cancer stage, molecular subtype, and tumor grade.
The study included 2 837 446 patients (mean [SD] age, 61.6 [13.4] years; 99.1% female), with 1.7% American Indian, Alaska Native, or other patients; 3.5% Asian or Pacific Islander patients; 11.2% Black patients; 5.6% Hispanic patients; and 78.0% White patients. Of 1 296 488 patients who were offered chemotherapy, 124 721 (9.6%) declined; 99 276 of 1 635 916 patients (6.1%) declined radiotherapy; 94 363 of 1 893 339 patients (5.0%) declined HT; and 15 846 of 2 590 963 patients (0.6%) declined surgery. Compared with White patients, American Indian, Alaska Native, or other patients (adjusted odds ratio [AOR], 1.47; 95% CI, 1.26-1.72), Asian or Pacific Islander patients (AOR, 1.29; 95% CI, 1.15-1.44), and Black patients (AOR, 2.01; 95% CI, 1.89-2.14) were more likely to decline surgery; American Indian, Alaska Native, or other patients (AOR, 1.13; 95% CI, 1.05-1.21) and Asian or Pacific Islander patients (AOR, 1.21; 95% CI, 1.16-1.27) were more likely to decline chemotherapy; and Black patients were more likely to decline radiotherapy (AOR, 1.05; 95% CI, 1.02-1.08). Asian or Pacific Islander patients (AOR, 0.81; 95% CI, 0.77-0.85), Black patients (AOR, 0.86; 95% CI, 0.83-0.89), and Hispanic patients (AOR, 0.66; 95% CI, 0.63-0.69) were less likely to decline HT. Furthermore, Black patients who declined chemotherapy had a higher mortality risk than White patients (adjusted hazard ratio [AHR], 1.07; 95% CI, 1.02-1.13), while there were no OS differences between Black and White patients who declined HT (AHR, 1.05; 95% CI, 0.97-1.13) or radiotherapy (AHR, 0.98; 95% CI, 0.92-1.04).
This cross-sectional study highlights racial and ethnic disparities in treatment declination and OS, suggesting the need for equity-focused interventions, such as patient education on treatment benefits and improved patient-clinician communication and shared decision-making, to reduce disparities and improve patient survival.
PMID:
38722630
[PubMed - as supplied by publisher]
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Cancer medicine 2023 Dec 22
Authors:
Fefferman M
Abstract
The objective of this study was to examine the impact of the early part of the COVID-19 pandemic on the number of newly diagnosed breast cancer cases at Commission on Cancer (CoC)-accredited facilities relative to the United States (U.S.) population.
We examined the incidence of breast cancer cases at CoC sites using the U.S. Census population as the denominator. Breast cancer incidence was stratified by patient age, race and ethnicity, and geographic location.
A total of 1,499,806 patients with breast cancer were included. For females, breast cancer cases per 100,000 individuals went from 188 in 2015 to 203 in 2019 and then dropped to 176 in 2020 with a 15.7% decrease from 2019 to 2020. Breast cancer cases per 100,000 males went from 1.7 in 2015 to 1.8 in 2019 and then declined to 1.5 in 2020 with a 21.8% decrease from 2019 to 2020. For both females and males, cases per 100,000 individuals decreased from 2019 to 2020 for almost all age groups. For females, rates dropped from 2019 to 2020 for all races and ethnicities and geographic locations. The largest percent change was seen among Hispanic patients (-18.4%) and patients in the Middle Atlantic division (-18.6%). The stage distribution (0-IV) for female and male patients remained stable from 2018 to 2020.
The first year of the COVID-19 pandemic was associated with a decreased number of newly diagnosed breast cancer cases at Commission on Cancer sites.
PMID:
38140789
[PubMed - as supplied by publisher]
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American journal of surgery 2024 Jan
Authors:
Fefferman M, Kuchta K, Nicholson K, Attai D, Victorson D, Pesce C, Kopkash K, Poli E, Smith TW, Yao K
Abstract
The objective of this study was to describe patient values and personality traits associated with breast surgery choice for patients with breast cancer.
A survey based on qualitative patient interviews and the Big-Five personality trait profile was distributed to Love Research Army volunteers aged 18-70 years old who underwent breast cancer surgery from 2009 to 2020. Multivariable logistic regression analysis was used to determine independent patient values and personality traits for the choice of breast-conserving surgery (BCS), unilateral mastectomy (UM) and bilateral mastectomy (BM).
1497 participants completed the survey. Open-mindedness was associated with UM and sociability was associated with BM. A majority of patients prioritized cancer outcomes. Compared to BM patients, BCS and UM patients were significantly more likely to choose values associated with maintaining their self-image, optimizing surgical recovery, and following their doctor's recommendation.
Other values besides cancer outcomes differentiate patient surgical choice for BCS or mastectomy.
PMID:
37858372
[PubMed - as supplied by publisher]
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Journal of the American College of Radiology : JACR 2024 Mar
Authors:
Oluyemi ET, Grimm LJ, Goldman L, Burleson J, Simanowith M, Yao K, Rosenberg RD
Abstract
To describe the rate and timeliness of diagnostic resolution after an abnormal screening mammogram in the ACR's National Mammography Database.
Abnormal screening mammograms (BI-RADS 0 assessment) in the National Mammography Database from January 1, 2008, to December 31, 2021, were retrospectively identified. The rates and timeliness of follow-up with diagnostic evaluation and biopsy were assessed and compared across patient and facility demographics.
Among the 2,874,310 screening mammograms reported as abnormal, follow-up was documented in 66.4% (n = 1,909,326). Lower follow-up rates were observed in younger women (59.4% in women < 30 years, 63.2% in women 30-39 years), Black (57.4%) and American Indian (59.5%) women, and women with no breast cancer family history (63.0%). The overall median time to diagnostic evaluation was 9 days. Longer median diagnostic evaluation time was noted in Black (14 days), other or mixed race (14 days), and Hispanic women (13 days). Of the 318,977 recalled screening mammograms recommended for biopsy, 238,556 (74.8%) biopsies were documented. Lower biopsy rates were noted in older women (71.5% in women aged ≥80) and Black (71.5%) and American Indian (52.2%) women. The overall median time from diagnostic evaluation to biopsy was 21 days. Longer median biopsy time was noted in older (23 days aged ≥80), Black (25 days), mixed or other race (26 days), and Hispanic women (23 days), and rural (24 days) or community hospital affiliated facilities (22 days).
There is variability in the rates and timeliness of diagnostic evaluation and biopsy in women with abnormal screening mammogram. Subsets of women and facilities could benefit from targeted interventions to promote timely diagnostic resolution and biopsy after an abnormal screening mammogram.
PMID:
37722468
[PubMed - as supplied by publisher]
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Annals of surgical oncology 2023 Oct
Authors:
Lapkus M
Abstract
The American Society of Breast Surgeons released a consensus statement that genetic testing should be made available to all patients with a personal history of breast cancer. However, it is not clear whether physicians feel comfortable with universal genetic testing (UGT) or if they have sufficient knowledge to interpret results and manage them appropriately.
The purpose of this study was to explore breast surgeons' attitudes toward UGT.
Breast surgeons were consented and scheduled for a semi-structured virtual interview. Transcripts were uploaded into qualitative analysis software where they were exhaustively and iteratively coded. Codes were then organized into higher-order categories and themes and data saturation were assessed.
Thirty-one surgeons completed the qualitative interview. Most surgeons practiced in the academic or community setting and most practiced in the Midwest (71.0%). The majority (90.3%) reported having a structured genetics program. The majority (96.8%) referred their patients to genetics for counseling and most preferred ordering testing through a genetic services provider. Some surgeons had concerns about access to genetic services. A minority of surgeons order UGT for all newly diagnosed breast cancer patients. The majority of respondents thought that more training in genetics was needed for surgeons. Many surgeons expressed concern about the psychosocial effects of UGT on patients.
Many surgeons expressed concerns about UGT, mainly related to discomfort with their training, access to genetic services, and the psychosocial impact on their patients. Future work is needed to determine how to improve surgeon's comfort level in implementing UGT.
PMID:
37439952
[PubMed - as supplied by publisher]
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American journal of surgery 2023 Oct
Authors:
Nicholson K, Kuchta K, Fefferman M, Pesce C, Kopkash K, Poli E, Yao K
Abstract
Studies have shown a decrease in bilateral mastectomy (BM) rates over the past five to ten years, but it is not clear if these decreases are the same across different patient races.
Using the National Cancer Database (NCDB) we examined BM rates for patients with AJCC Stage 0-II unilateral breast cancer from 2004 to 2020 for White versus nonwhite races (Blacks, Hispanics, and Asians). Multivariable logistic regression was used to identify patient and facility factors associated with BM by patient race from 2004 to 2006 and 2018-2020.
Of 1,187,864 patients, 791,594 (66.6%) had breast conserving surgery (BCS), 258,588 (21.8%) had unilateral mastectomy (UM) and 137,682 (11.6%) had BM. Our patient population was 927,530 (78.1%) White patients, 124,636 (10.5%) Black patients, 68,048 (5.7%) Hispanic patients, and 48,341 (4.1%) Asian patients. The BM rate steadily increased from 5.6% to 15.6% from 2004 to 2013, at which point the BM rate decreased to 11.3% in 2020. The decrease in BM was seen across all races, and in 2020, 6,487 (11.7%) Whites underwent BM compared to 506 (10.7%) Hispanics, 331 (9.2%) Asians, and 723 (9.1%) Blacks. Race was a significant independent factor for BM in 2004-2006 and 2018-2020 but all races were more likely to undergo BM in 2004 compared to 2020 after adjusting for patient and facility factors. Compared to Whites, the odds of undergoing BM were OR 0.41 (0.37-0.45) in 2004 compared to OR 0.66 (0.63-0.69) in 2020 for Blacks, OR 0.44 (0.38-0.52) and OR 0.61 (0.57-0.65) for Asians and OR 0.59 (0.52-0.66) and OR 0.71 (0.67-0.75) for Hispanics, respectively.
BM rates for all races have declined since 2013, and differences in rates of BM amongst races have narrowed.
PMID:
37429752
[PubMed - as supplied by publisher]
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JAMA network open 2023 Jan 03
Authors:
Fefferman M, Nicholson K, Kuchta K, Pesce C, Kopkash K, Yao K
PMID:
36652251
[PubMed - as supplied by publisher]
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Annals of surgical oncology 2023 Feb
Authors:
Nicholson K, Kuchta K, Pesce C
PMID:
36484903
[PubMed - as supplied by publisher]
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JAMA network open 2022 Nov 01
Authors:
Joung RH, Mullett TW
Abstract
Cancer screening deficits during the first year of the COVID-19 pandemic were found to persist into 2021. Cancer-related deaths over the next decade are projected to increase if these deficits are not addressed.
To assess whether participation in a nationwide quality improvement (QI) collaborative, Return-to-Screening, was associated with restoration of cancer screening.
Accredited cancer programs electively enrolled in this QI study. Project-specific targets were established on the basis of differences in mean monthly screening test volumes (MTVs) between representative prepandemic (September 2019 and January 2020) and pandemic (September 2020 and January 2021) periods to restore prepandemic volumes and achieve a minimum of 10% increase in MTV. Local QI teams implemented evidence-based screening interventions from June to November 2021 (intervention period), iteratively adjusting interventions according to their MTVs and target. Interrupted time series analyses was used to identify the intervention effect. Data analysis was performed from January to April 2022.
Collaborative QI support included provision of a Return-to-Screening plan-do-study-act protocol, evidence-based screening interventions, QI education, programmatic coordination, and calculation of screening deficits and targets.
The primary outcome was the proportion of QI projects reaching target MTV and counterfactual differences in the aggregate number of screening tests across time periods.
Of 859 cancer screening QI projects (452 for breast cancer, 134 for colorectal cancer, 244 for lung cancer, and 29 for cervical cancer) conducted by 786 accredited cancer programs, 676 projects (79%) reached their target MTV. There were no hospital characteristics associated with increased likelihood of reaching target MTV except for disease site (lung vs breast, odds ratio, 2.8; 95% CI, 1.7 to 4.7). During the preintervention period (April to May 2021), there was a decrease in the mean MTV (slope, -13.1 tests per month; 95% CI, -23.1 to -3.2 tests per month). Interventions were associated with a significant immediate (slope, 101.0 tests per month; 95% CI, 49.1 to 153.0 tests per month) and sustained (slope, 36.3 tests per month; 95% CI, 5.3 to 67.3 tests per month) increase in MTVs relative to the preintervention trends. Additional screening tests were performed during the intervention period compared with the prepandemic period (170 748 tests), the pandemic period (210 450 tests), and the preintervention period (722 427 tests).
In this QI study, participation in a national Return-to-Screening collaborative with a multifaceted QI intervention was associated with improvements in cancer screening. Future collaborative QI endeavors leveraging accreditation infrastructure may help address other gaps in cancer care.
PMID:
36383381
[PubMed - as supplied by publisher]
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Journal of the American College of Surgeons 2022 Nov 01
Authors:
Deliere AE, Kuchta KM, Pesce CE, Kopkash KA, Yao KA
Abstract
The delay of elective surgeries by the coronavirus 2019 (COVID-19) pandemic prompted concern among surgeons to delay estrogen receptor (ER)-negative ductal carcinoma in situ (DCIS) for fear of missing an ER-negative invasive cancer and compromising survival of patients.
Female patients ≥40 years old diagnosed with ER-negative DCIS from 2004 to 2017 were examined from the National Cancer Database. Multivariable logistic regression, adjusting for patient and tumor factors, was used to determine factors associated with tumor upstage. Multivariable Cox proportional hazards modeling was used to determine if surgical delay impacted overall survival of ER-negative DCIS patients that were upstaged to invasive disease.
There were 219,731 patients with DCIS of which 24,338 (11.1%) had tumor upstage. Of these patients, 5,675 (16.2%) of ER-negative and 18,663 (10.1%) of ER-positive DCIS patients were upstaged (p ≤ 0.001). From 2004 to 2017, ER-negative DCIS upstage rates increased from 12.9% to 18.9%. Independent factors associated with tumor upstage were younger age (odds ratio [OR] 0.75 [95% CI 0.69 to 0.81]) and Black race (OR 1.34 [95% CI 1.22 to 1.46]). Compared with patients with ≤30 days between biopsy and surgery, patients with a 31- to 60-day interval (OR 1.13 [95% CI 1.05 to 1.20]) and a >60-day interval (OR 1.12 [95% CI 1.02 to 1.23]) had an increased rate of tumor upstage. Among ER-negative DCIS patients whose tumors were upstaged to invasive disease, Cox proportional hazard regression modeling showed no association between the number of days between biopsy and surgery and overall survival.
Delays in surgery were associated with higher tumor upstage rates but not with worse overall survival.
PMID:
36102573
[PubMed - as supplied by publisher]