Surgeon Attitudes and Use of MRI in Patients Newly Diagnosed with Breast Cancer

BACKGROUND

Usage of magnetic resonance imaging (MRI) in newly diagnosed breast cancer patients is increasing, despite scant evidence that it improves outcomes. Little is known about the knowledge, perspectives, and clinical characteristics of surgeons associated with MRI use.

METHODS

Women with early-stage breast cancer undergoing definitive surgery between July 2013 and August 2015 were identified from the Los Angeles and Georgia Surveillance, Epidemiology and End Results (SEER) registries and were asked to name their attending surgeons. The 489 surgeons were sent a questionnaire; 77% (n = 377) responded. Questions that addressed the likelihood of ordering an MRI in different scenarios were used to create a scale to measure surgeon propensity for MRI use. Knowledge and practice characteristics also were assessed.

RESULTS

Mean surgeon age was 54 years, 25% were female, and median number of years in practice was 21. Wide MRI use variation was observed, with 26% obtaining MRI for a clinical stage I screen-detected breast cancer and 72% for infiltrating lobular cancer. High users of MRI were significantly more likely to be higher-volume surgeons (p < 0.001) and to have misconceptions about MRI benefits (p < 0.001). Of surgeons who felt they used MRI more often, 60% were high MRI users; only 6% were low MRI users.

CONCLUSIONS

Our findings suggest relatively frequent use of MRI, even in uncomplicated clinical scenarios, in the absence of evidence of benefit, and use was more common among high-volume surgeons. A substantial number of surgeons who are high MRI users harbor misconceptions about MRI benefit, suggesting an opportunity for education and consensus building regarding appropriate use.

Patient Reactions to Surgeon Recommendations About Contralateral Prophylactic Mastectomy for Treatment of Breast Cancer

Importance

Guidelines assert that contralateral prophylactic mastectomy (CPM) should be discouraged in patients without an elevated risk for a second primary breast cancer. However, little is known about the impact of surgeons discouraging CPM on patient care satisfaction or decisions to seek treatment from another clinician.

Objective

To examine the association between patient report of first-surgeon recommendation against CPM and the extent of discussion about it with 3 outcomes: patient satisfaction with surgery decisions, receipt of a second opinion, and receipt of surgery by a second surgeon.

Design, Setting, and Participants

This population-based survey study was conducted in Georgia and California. We identified 3880 women with stages 0 to II breast cancer treated in 2013-2014 through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles County. Surveys were sent approximately 2 months after surgery (71% response rate, n = 2578). In this analysis conducted from February to May 2016, we included patients with unilateral breast cancer who considered CPM (n = 1140). Patients were selected between July 2013 and September 2014.

Main Outcomes and Measures

We examined report of surgeon recommendations, level of discussion about CPM, satisfaction with surgical decision making, receipt of second surgical opinion, and surgery from a second surgeon.

Results

The mean (SD) age of patients included in this study was 56 (10.6) years. About one-quarter of patients (26.7%; n = 304) reported that their first surgeon recommended against CPM and 30.1% (n = 343) reported no substantial discussion about CPM. Dissatisfaction with surgery decision was uncommon (7.6%; n = 130), controlling for clinical and demographic characteristics. One-fifth of patients (20.6%; n = 304) had a second opinion about surgical options and 9.8% (n = 158) had surgery performed by a second surgeon. Dissatisfaction was very low (3.9%; n = 42) among patients who reported that their surgeon did not recommend against CPM but discussed it. Dissatisfaction was substantively higher for those whose surgeon recommended against CPM with no substantive discussion (14.5%; n = 37). Women who received a recommendation against CPM were not more likely to seek a second opinion (17.1% among patients with recommendation against CPM vs 15.1% of others; P = .52) nor to receive surgery by a second surgeon (7.9% among patients with recommendation against CPM vs 8.3% of others; P = .88).

Conclusions and Relevance

Most patients are satisfied with surgical decision making. First-surgeon recommendation against CPM does not appear to substantively increase patient dissatisfaction, use of second opinions, or loss of the patient to a second surgeon.

Treatment-associated toxicities reported by patients with early-stage invasive breast cancer

BACKGROUND

Patient-reported toxicities help to appraise the breast cancer treatment experience. Yet extant data come from clinical trials and health care claims, which may be biased. Using patient surveys, the authors sought to quantify the frequency, severity, and burden of treatment-associated toxicities.

METHODS

Between 2013 and 2014, the iCanCare study surveyed a population-based sample of women residing in Los Angeles County and Georgia with early-stage, invasive breast cancer. The authors assessed the frequency and severity of toxicities; correlated toxicity severity with unscheduled health care use (clinic visits, emergency department visits/hospitalizations) and physical health; and examined patient, tumor, and treatment factors associated with reporting increased toxicity severity.

RESULTS

The overall survey response rate was 71%. From the analyzed cohort of 1945 women, 866 (45%) reported at least 1 toxicity that was severe/very severe, 9% reported unscheduled clinic visits for toxicity management, and 5% visited an emergency department or hospital. Factors associated with reporting higher toxicity severity included receipt of chemotherapy (odds ratio [OR], 2.2; 95% confidence interval [95% CI], 2.0-2.5), receipt of both chemotherapy and radiotherapy (OR, 1.3; 95% CI, 1.0-1.7), and Latina ethnicity (OR vs whites: 1.3; 95% CI, 1.1-1.5). A nonsignificant increase in at least 1 severe/very severe toxicity report was observed for bilateral mastectomy recipients (OR, 1.2; 95% CI, 1.0-1.4).

CONCLUSIONS

Women with early-stage invasive breast cancer report substantial treatment-associated toxicities and related burden. Clinicians should collect toxicity data routinely and offer early intervention. Toxicity differences observed by treatment modality may inform decision making. Cancer 2017;123:1925-1934. © 2017 American Cancer Society.

Axillary management in early breast cancer: Surgeon attitudes in a population-based study

561

Background: The ACOSOG Z0011 trial established the safety of omitting axillary dissection (ALND) for patients with 1‒2 sentinel node (SN) metastases having breast-conserving therapy (BCT) to reduce treatment-related morbidity. Little is known about surgeon uptake of this practice. Methods: Women with stage I and II breast cancer diagnosed between 7/13‒8/15 (n=3729) reported to the Los Angeles and Georgia SEER registries were surveyed about 2 months after diagnosis. All attending surgeons identified by the patients (n=489) were sent a questionnaire and 77% (n=377) responded. Pathology reports for SN positive patients are under review. Results: Mean surgeon age was 54 years, 25% were female, and median years in practice was 21. 49% and 63% endorsed ALND for Z0011 eligible patients with 1 or 2 SN macrometastases, respectively. Surgeons were classified as low (n=92), selective (n=178), or high (n=91) users of ALND based on responses to case scenarios with SN involvement ranging from isolated tumor cells in 1 SN (12% would do ALND) to macrometastasis in 3 SNs (92% would do ALND). 93% of high-use surgeons would perform ALND for any SN macrometastasis vs 40% of selective surgeons and 1% of low-use surgeons (p<.001). High-use surgeons were older, male, saw fewer breast cancer patients, and were less likely to discuss cases in tumor board (Table). High-ALND users were substantially less likely to endorse BCT margins of no ink on tumor (40%) than selective (63%) or low users (83%; p<.001). Conclusions: Wide variation exists in acceptance of Z011 results with one-quarter of surgeons endorsing routine ALND. Surgeons favoring ALND also endorse wider margins for BCT, suggesting an overall more aggressive surgical approach. Lower breast volume and lack of tumor board participation identify surgeons who should be targeted for educational interventions. [Table: see text]

Mastectomy rates in relation to adoption of a margin guideline

508

Background: Surgery after initial lumpectomy to obtain a bigger negative margin is common and may lead to mastectomy. The impact of a 2014 consensus statement endorsing a minimal negative margin for invasive breast cancer on surgeon attitudes, re-excision rates, and final surgical procedure is uncertain. Methods: Women with stage I and II breast cancer diagnosed between 7/13–8/15 and reported to the Los Angeles and Detroit SEER registries were surveyed about 2 months post diagnosis, and 70% responded; 3729 comprise the analytic sample. All attending surgeons identified by the patients (n=489) were sent a questionnaire at the end of the patient survey period, and 376 (77%) responded. Pathology reports were reviewed for margin status. Multinomial regression models were used to assess trends. Results: The 67% initial lumpectomy rate was unchanged during the study. The final lumpectomy rate increased by 13% (to 65% from 52%) from 2013–2015, accompanied by a decrease in unilateral (to 18% from 27%) and bilateral (to 16% from 21%) mastectomy (p=0.002). Surgery after lumpectomy, both re-excision and mastectomy, declined by 16% (p<0.001). Pathology review showed no association between date of treatment and positive margins. Patient report of surgeon-recommended mastectomy after initial lumpectomy declined to 8% from 20% (p<0.001). 69% of surgeons endorsed a margin of no ink on tumor to avoid re-excision in ER+PR+ cancer and 63% for ER-PR- cancer. Surgeons treating >50 breast cancers annually were more likely to accept this margin than those treating <20 cases (p<0.001). Conclusions: Additional surgery after initial lumpectomy markedly decreased between 2013‒2015 after publication of a margin guideline endorsinga minimal negative margin. This resulted in a substantial increase in lumpectomy as the definitive surgical procedure, which illustrates that guidelines can be an effective, low-cost approach to addressing clinical controversies.

Size and influence of the decision support networks of women newly diagnosed with breast cancer

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Background: Little is known about the size and characteristics of informal decision support networks of women diagnosed with breast cancer and whether involvement of informal decision supporters (DSP) influences breast cancer treatment decisions. Methods: A population-based sample of newly diagnosed breast cancer patients reported to the Georgia and Los Angeles SEER registries in 2014-15 were surveyed approximately 6 months after diagnosis (N = 2,502, 68% response rate). Network size was estimated by asking women to list up to 3 of the most important DSPs who helped them with locoregional therapy decisions. For each individual DSP listed, respondents reported how important each DSP’s opinion was in treatment decision making, and how satisfied they were with their involvement (5 pt. scales, “not at all” to “very”). Decision deliberation was measured using 5-items assessing degree patients thought through the decision, with higher scores reflecting more deliberative treatment decisions. We compared network size (0-3 or more) across patient-level characteristics and estimated the association between network size and deliberation using multivariable linear regression. Results: Of the 2,502 women in this analysis, 51% reported having 3 or more DSPs, 20% reported 2, 18% reported 1, and 11% reported not having any DSPs. Married/partnered women, those younger than 45 years old, and black women were all more likely to report larger networks (all p < 0.001). Partnered women most often reported their partner as their main DSP (37.9%), whereas not partnered/unmarried women most often reported children (38.4%). The majority of women were highly satisfied with their DSP being involved in their decisions (76.5%) and 68.6% felt their DSP was very important in their decision making. Larger support networks were associated with more deliberative surgical treatment decision-making (p < 0.001). Conclusions: Most women engaged multiple DSPs in their treatment decision making, including spouses, children, and friends. Involving more DSPs was associated with more deliberative treatment decisions. Future initiatives to improve breast cancer treatment decision making should acknowledge and engage informal DSPs.

Surgeon influence on receipt of contralateral prophylactic mastectomy for breast cancer

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Background: Rates of contralateral prophylactic mastectomy (CPM) have markedly increased but virtually nothing is known about the influence of surgeons on variability of the procedure in the community. We quantified the influence of attending surgeon on rates of CPM and clinician attitudes that explained it. Methods: Population-based sample of 7810 patients newly diagnosed with curable breast cancer (BC) in Georgia and Los Angeles County treated in 2013-15 were surveyed (response rate 70%, n = 5018) and responses were linked to 488 attending surgeons through patient report. Surveys were sent to surgeons towards the end of the patient data collection period and 377 completed them (response 77%). We linked 3718 respondent patients with unilateral disease to 365 respondent surgeons. Two surgeon attitudes scales were developed based on a scenario of a patient with early stage BC at average risk of a 2nd primary cancer: 1) favors initial breast conservation and, 2) reluctance to perform CPM if patient asks. We did multilevel analyses using information from patient and surgeon reports merged to SEER data. Results: A model including patient clinical factors and surgeon id predicted CPM extremely well as it explained 37% of the variability in the likelihood of CPM. Patient factors explained 16% of the variability but the surgeon identifier alone explained even more (21%). The odds of a patient receiving CPM increased 3-fold (95% CI 1.9, 4.7) if she saw a surgeon with a practice approach one standard deviation above a surgeon with the average CPM rate (15%). One quarter (24%) of the surgeon influence was explained by attending attitudes about initial recommendations for surgery and responses to patient requests for CPM. The rate of CPM was 34% for surgeons who least favored initial breast conservation and were least reluctant to perform CPM. By contrast, the estimated rate was 5% for surgeons who most favored initial breast conservation and were most reluctant to perform CPM if asked. Conclusions: Attending surgeons exert strong influence on the likelihood of receipt of CPM for breast cancer. Variations in surgeon attitudes about recommendation for surgery and response to patients request for CPM explain a substantial amount of this influence.

Recent time trends in chemotherapy use and oncologists' chemotherapy recommendations for early-stage, hormone receptor-positive breast cancer

541

Background: Advances in tumor genomic profiling enable increasingly precise estimates of the benefit of adjuvant chemotherapy in early-stage breast cancer. However, little is known about how chemotherapy use, medical oncologists’ (MO) perspectives and recommendations have changed in recent years, particularly in key clinical subgroups such as node-negative and node-positive. Methods: We surveyed 5,080 women (70% response rate), newly diagnosed with breast cancer in 2013-2015 and accrued through two population-based SEER registries (Georgia and Los Angeles), about their MOs’ chemotherapy recommendations and whether they received chemotherapy. Using patient report, we identified 470 attending MOs and surveyed them (n=310, 66% response) about approaches to chemotherapy recommendation, using node-negative and node-positive case scenarios. We evaluated factors associated with chemotherapy receipt over time using multi-level logistic regression. Results: The analytic sample was 2,926 patients with stages I-II, estrogen receptor-positive, HER2-negative breast cancer. Chemotherapy use declined to 21% from 34% during the study period (2013-2015, p<.001). For node-positive patients, chemotherapy use declined to 64% from 81% and for node-negative/micrometastasis patients to 14% from 27%. Based on patient report, MOs’ recommendations for chemotherapy declined during the study period to 32% from 45% (p<.001). Recommendations reported by MOs were generally guideline-concordant. MOs were much more likely to order tumor genomic profiling when patient preferences were discordant with recommendations [67%, standard error (SE) 3% versus 18% (SE 2%) without discordance], and they adjusted chemotherapy recommendations based on patient preferences and genomic profiling results. Conclusions: For both node-negative/micrometastasis and node-positive patients, chemotherapy receipt and oncologists’ recommendations for chemotherapy declined markedly in recent years. The results of ongoing clinical trials of genomic profiling will be essential to confirm the quality of this approach to breast cancer care. Funded by NCI P01CA163233.

Primary outcomes analysis of a multicenter randomized controlled trial of an interactive decision tool for patients with breast cancer

6500

Background: High quality treatment decisions require that patients are well informed about treatment and that their values are considered. Yet studies show that patient knowledge about breast cancer treatment trade-offs is low and appraisal of decision-making is not optimal. Methods: We conducted a randomized controlled trial (RCT) of a tailored, comprehensive (locoregional and systemic treatment) and interactive decision tool (iCanDecide), compared with static online information. 537 newly diagnosed, early stage breast cancer patients were enrolled at the first visit in 22 surgical practices. Participants were surveyed 5 weeks (N = 496; RR 92%) post enrollment after locoregional treatment decision-making. The primary outcome was a high quality decision, including two components: high knowledge about treatment options and a values concordant treatment decision. The main secondary outcome was preparation for decision making. We evaluated the distribution of participants in each arm, and conducted logistic regression modeling to assess the association between the intervention and the outcomes controlling for patient characteristics and strength of treatment preference at enrollment. Results: Significantly more intervention than control patients had high knowledge (60% vs. 42%, p < 0.001), although the majority of both groups reported values concordant treatment (~84%). Intervention patients also reported feeling prepared for decision making significantly more often than controls (45% vs. 32%, P < 0.01). Patients randomized to the interactive intervention had higher knowledge (OR: 2.2; 95% CI 1.2-4.0) and preparation for decision making (OR: 1.5; 95% CI 1.1-1.4), even after adjusting for age, education, race, stage and clinical site. Conclusions: In this large RCT, a tailored, interactive treatment decision tool for breast cancer improved knowledge and prepared patients for complicated decision making, more than access to static online information. Future work to further integrate such tools into the clinical workflow is needed. Clinical trial information: NCT01840163.

Treatment decisions and employment of breast cancer patients: Results of a population-based survey

10052

Background: Many patients with breast cancer work for pay at time of diagnosis, and the treatment plan may threaten their livelihood. Given rapidly evolving policies, evidence, and treatment options, we evaluated work experiences in a contemporary population-based sample of breast cancer patients to inform initiatives to reduce the burden of cancer care. Methods: We surveyed women aged 20-79 years diagnosed with stages 0-II breast cancer as reported to the SEER registries of Georgia and Los Angeles in 2014-15. Of 3672 eligible women, 2502 responded (68%); we analyzed 1006 who reported working prior to diagnosis. Multivariable models evaluated correlates of missing > 1 month and stopping work altogether vs missing ≤1 month. Results: In this diverse sample (48% white, 19% black, 20% Latina, 11% Asian), most pts (62%) received lumpectomy; 16% had unilateral mastectomy (8% with reconstruction); 23% had bilateral mastectomy (19% with reconstruction). One third (33%) received chemotherapy. The vast majority (84%) worked full time at diagnosis, but only 50% had paid sick leave, 39% disability benefits, and 38% flexible work schedules. Surgical treatment was strongly associated with missing > 1 month of work (OR 7.8 for bilateral mastectomy with reconstruction vs lumpectomy) and with stopping altogether (OR 3.1 for bilateral mastectomy with reconstruction vs lumpectomy). Chemotherapy receipt (OR 1.3 for missing > 1 month; OR 3.9 for stopping altogether) and race (OR 2.0 for missing > 1 month and OR 1.7 for stopping altogether, blacks vs whites) also correlated. Those with paid sick leave were less likely to stop working (OR 0.5), as were those with flexible schedules (OR 0.3). Those with disability benefits were more likely to stop working (OR 1.6) or miss > 1 month of work (OR 2.7). Conclusions: Working patients who received more aggressive treatments, particularly surgery, were much more likely to experience substantial employment disruptions. Given the growing choice of bilateral mastectomy by patients seeking peace of mind, particularly among young women with years of potential employment ahead, these findings suggest the importance of discussing impact of treatment decisions on employment. Funded by NCI P01CA163233.

Gaps in integrating genetic testing into management of breast cancer

160

Background: Genetic testing for breast cancer risk is evolving rapidly, with surging use of multiple-gene panels. However, little is known about the extent to which testing is effectively integrated into management after diagnosis of breast cancer. Methods: A population-based sample of 3930 patients diagnosed with breast cancer in 2014-15 and identified by two SEER registries (Georgia and Los Angeles) were sent surveys 2 months after surgery and responses merged to SEER data. A subgroup at higher pre-test risk of pathogenic mutation carriage (vs average risk) was defined according to testing guidelines. Results: Among 2502 eligible patients with unilateral breast cancer (response rate 70%), 666 (27%) reported genetic testing. The Table shows wide variability in patient report of which professional ordered the test and discussed the results. Few (18-21%) patients had testing ordered by a genetic counselor and approximately half (57% high-risk, 42% average-risk) discussed results with one. One third of patient received testing after they had surgery. In a multivariable model adjusted for age, race, education, pre-test risk of mutation carriage, stage, co-morbidities and study site, the only factor significantly associated with delayed testing was insurance status: Compared to private insurance, patients were more likely to be tested after surgery if they had Medicare (OR 2.1, 95% CI 1.1-4.2) or no insurance (OR 3.0, CI 1.6-5.3). Conclusions: There is wide variability in which professionals order genetic testing and discuss results. Many breast cancer patients who receive genetic testing never see a genetic counselor. Many patients do not get tested early enough to consider the results in surgery management. These findings suggest enormous challenges in personalizing communication about genetic testing after diagnosis of breast cancer. [Table: see text]

Worry about recurrence and patient preferences for provider roles in collaborative breast cancer care

158

Background: Prior studies have shown that worry about recurrence is a common problem during cancer treatment and survivorship and may be associated with symptom response and surveillance after primary treatment. However, whether worry about recurrence influences patient preferences for which provider to see for their continuing care remains unknown. Methods: A random sample of patients newly diagnosed with breast cancer in 2014-15 as reported to the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (N = 2,502, 70% response rate). Frequency of worry about recurrence was defined by asking women to indicate on a 5-pt scale how often they worried about their cancer coming back in the past month (not at all-always) and was then dichotomized as frequent worry (sometimes/often/almost always) vs. less worry (almost never/rarely). Patient preferences for which provider manages certain aspects of care after treatment were ascertained for: follow-up mammograms, screening for other cancers, general preventive care, and treatment of comorbidities. Response categories included primary care clinician (PCP), cancer doctors, either or both. The associations between patient-reported worry about recurrence with preferences for provider roles were assessed using multinomial logistic regression. Results: In this sample, 37% of women reported worrying frequently about recurrence. Controlling for patient and clinical factors, women who reported more frequent worry (vs. less worry) were more likely to prefer to see both clinicians (vs. PCP only) for mammograms (OR: 2.3, 95%CI: 1.5, 3.6), screening for other cancers (OR: 2.3, 95%CI: 1.5, 3.5), general preventive care (OR: 1.6, 95%CI: 1.1, 2.3) and comorbidity care (OR: 1.5, 95%CI: 1.03, 2.2). Conclusions: Frequent worry about recurrence was common in this sample of women with favorable prognosis breast cancer. More frequent worry about breast cancer recurrence was associated with stronger preferences for seeing both PCPs and oncologists for continuing care after treatment. Assessing and managing worry about recurrence early in survivorship may improve collaborative cancer care and reduce duplicated services after treatment.

Decision support networks of women newly diagnosed with breast cancer

157

Background: Prior studies suggest that women often involve a network of family and friends in their cancer treatment decision making, yet very little is known about the size and characteristics of these decision support networks and whether their involvement leads to high-quality breast cancer treatment decisions. Methods: A weighted random sample of patients newly diagnosed with breast cancer in 2014-15 as reported to the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (N = 2,502, 70% response rate). Network size was estimated by asking women to list up to 3 of the most important decision support people (DSP) who helped them make their locoregional therapy decisions. Decision deliberation was measured using 4-items assessing degree to which patients thought through the decision, with higher scores reflecting more deliberative breast cancer treatment decisions. We compared the size of the network (0-3+ people) across patient-level characteristics and estimated the adjusted mean deliberation scores across levels of network size using multivariable linear regression. Results: Of the 2,502 women included in this analysis, 51% reported having at least 3 DSPs, 20% reported 2, 18% reported 1, and 10% reported not having any DSPs. Among women who were not partnered (N = 961), 51% had 3 DSPs, 18% had 2, 16% had 1 and 16% had 0 DSPs. Of the DSPs that the respondents identified, the majority were children (30%), followed by partners/spouses (23%), friends (15%), siblings (10%), other family members (6%), and parents (5%). Married/partnered women (p < 0.001), those younger than 45 years old (p < 0.001), those with more than 1 comorbidity (p < 0.001), and black women (p = 0.02) were all more likely to report larger networks on average. Larger support networks were associated with more deliberative surgical decisions (p < 0.001). Conclusions: In this population-based sample, the majority of women engaged DSPs in their treatment decision making and for non-partnered patients, DSPs still played a key role in decision making. Larger size decision support networks were associated with higher quality decisions, underscoring the importance of efforts to identify and engage DSPs in the breast cancer decision making process.

Second Opinions From Medical Oncologists for Early-Stage Breast Cancer: Prevalence, Correlates, and Consequences

IMPORTANCE

Advances in the evaluation and treatment of breast cancer have made the clinical decision-making context much more complex. A second opinion from a medical oncologist may facilitate decision making for women with breast cancer, yet little is known about second opinion use.

OBJECTIVE

To investigate the patterns and correlates of second opinion use and the effect on chemotherapy decisions.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1901 women newly diagnosed with stages 0 to II breast cancer between July 2013 and September 2014 (response rate, 71.0%) were accrued through 2 population-based Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles County, California) and surveyed about their experiences with medical oncologists, decision making, and chemotherapy use.

MAIN OUTCOMES AND MEASURES

Factors associated with second opinion use were evaluated using logistic regression. Also assessed was the association between second opinion and chemotherapy use, adjusting for chemotherapy indication and propensity for receiving a second opinion. Multiple imputation and weighting were used to account for missing data.

RESULTS

A total of 1901 patients with stage I to II breast cancer (mean [SD] age, 61.6 [11.0] years; 1071 [56.3%] non-Hispanic white) saw any medical oncologist. Analysis of multiply imputed, weighted data (mean n = 1866) showed that 168 (9.8%) (SE, 0.74%) received a second opinion and 54 (3.2%) (SE, 0.47%) received chemotherapy from the second oncologist. Satisfaction with chemotherapy decisions was high and did not differ between those who did (mean [SD], 4.3 [0.08] on a 1- to 5-point scale) or did not (4.4 [0.03]) obtain a second opinion (P = .29). Predictors of second opinion use included college education vs less education (odds ratio [OR], 1.85; 95% CI, 1.24-2.75), frequent use of internet-based support groups (OR, 2.15; 95% CI, 1.12-4.11), an intermediate result on the 21-gene recurrence score assay (OR, 1.85; 95% CI, 1.11-3.09), and a variant of uncertain significance on hereditary cancer genetic testing (OR, 3.24; 95% CI, 1.09-9.59). After controlling for patient and tumor characteristics, second opinion use was not associated with chemotherapy receipt (OR, 1.04; 95% CI, 0.71-1.52).

CONCLUSIONS AND RELEVANCE

Second opinion use was low (<10%) among patients with early-stage breast cancer, and high decision satisfaction regardless of second opinion use suggests little unmet demand. Along with educational level and use of internet support groups, uncertain results on genomic testing predicted second opinion use. Patient demand for second opinions may increase as more complex genomic tests are disseminated.

Contralateral Prophylactic Mastectomy Decisions in a Population-Based Sample of Patients With Early-Stage Breast Cancer

Importance

Contralateral prophylactic mastectomy (CPM) use is increasing among women with unilateral breast cancer, but little is known about treatment decision making or physician interactions in diverse patient populations.

Objective

To evaluate patient motivations, knowledge, and decisions, as well as the impact of surgeon recommendations, in a large, diverse sample of patients who underwent recent treatment for breast cancer.

Design, Setting, and Participants

A survey was sent to 3631 women with newly diagnosed, unilateral stage 0, I, or II breast cancer between July 2013 and September 2014. Women were identified through the population-based Surveillance Epidemiology and End Results registries of Los Angeles County and Georgia. Data on surgical decisions, motivations for those decisions, and knowledge were included in the analysis. Logistic and multinomial logistic regression of the data were conducted to identify factors associated with (1) CPM vs all other treatments combined, (2) CPM vs unilateral mastectomy (UM), and (3) CPM vs breast-conserving surgery (BCS). Associations between CPM receipt and surgeon recommendations were also evaluated. All statistical models and summary estimates were weighted to be representative of the target population.

Main Outcomes and Measures

Receipt of CPM was the primary dependent variable for analysis and was measured by a woman's self-report of her treatment.

Results

Of the 3631 women selected to receive the survey, 2578 (71.0%) responded and 2402 of these respondents who did not have bilateral disease and for whom surgery type was known constituted the final analytic sample. The mean (SD) age was 61.8 (12) years at the time of the survey. Overall, 1301 (43.9%) patients considered CPM (601 [24.8%] considered it very strongly or strongly); only 395 (38.1%) of them knew that CPM does not improve survival for all women with breast cancer. Ultimately, 1466 women (61.6%) received BCS, 508 (21.2%) underwent UM, and 428 (17.3%) received CPM. On multivariable analysis, factors associated with CPM included younger age (per 5-year increase: odds ratio [OR], 0.71; 95% CI, 0.65-0.77), white race (black vs white: OR, 0.50; 95% CI, 0.34-0.74), higher educational level (OR, 1.69; 95% CI, 1.20-2.40), family history (OR, 1.63; 95% CI, 1.22-2.17), and private insurance (Medicaid vs private insurance: OR, 0.47; 95% CI, 0.28-0.79). Among 1569 patients (65.5%) without high genetic risk or an identified mutation, 598 (39.3%) reported a surgeon recommendation against CPM, of whom only 12 (1.9%) underwent CPM, but among the 746 (46.8%) of these women who received no recommendation for or against CPM from a surgeon, 148 (19.0%) underwent CPM.

Conclusions and Relevance

Many patients consider CPM, but knowledge about the procedure is low and discussions with surgeons appear to be incomplete. Contralateral prophylactic mastectomy use is substantial among patients without clinical indications but is low when patients report that their surgeon recommended against it. More effective physician-patient communication about CPM is needed to reduce potential overtreatment.

Abstract P2-02-06: Genetic counseling, germline genetic testing, and impact of results in patients with newly diagnosed breast cancer

The surge in BRCA1/2 and multiple-gene panel testing after a diagnosis of breast cancer has fueled concerns about how genetic testing results will be integrated into patient management. However, there is virtually no research about the timing or extent of genetic counseling before or after testing or the impact of genetic results on bilateral mastectomy (BLM) use since the advent of more widespread testing.

Methods: A population-based sample of 3600 patients newly diagnosed with breast cancer identified by two SEER registries (Georgia and Los Angeles County) were sent surveys two months after surgery (Dx dates 2014-15) about their genetic testing and treatment experiences. Survey information was merged with SEER data. We examined patterns and correlates of counseling and genetic testing and the impact of results on patient preferences for BLM and receipt of BLM.

Results: Among 2388 patients with unilateral breast cancer (response 70%), 697 (29.2%) had elevated pre-test risk of a germline mutation (based on age, family cancer history, ancestry, and tumor subtype). One-quarter of these higher risk patients (25.6%) did not discuss whether to have testing with any provider, 26.1% discussed it with clinicians only, and 48.3% had a visit with a genetic counselor. Half of patients with elevated pre-test risk (51.2%) were tested: 6.6% before diagnosis, 65.4% after diagnosis but before surgery and 28.0% after surgery. Higher risk patients who underwent testing were younger (p&lt;.001) and had higher income (p=.029) but rates did not differ significantly by race, education, insurance, marital status, cancer stage, comorbidities, or geographic site after controlling for all covariates. There was wide variation in the type of professional who discussed test results with patients: discussed with surgeon only (17.8%), medical oncologist only (19.7%), both physicians but no counselor (4.8%), or genetic counselors (56.8%). Among all testers in the total sample (n=667), 54 (9.4%) reported a pathogenic mutation (12.1% of higher risk patients vs 5.7% of low risk patients) and 59 (10.0%) reported a variant of unknown significance (VUS) (10.2% of higher risk patients vs 9.9% of lower risk patients), p=.027 for differences between groups. Two-thirds (60.4%) of patients with pathogenic mutations reported that the test made them more interested in BLM vs 8.8% of those with a VUS, and 11.4% of those with negative tests, p&lt;.001. Two-thirds (69.2%) of those with pathogenic mutations received BLM vs 21.9% of those with VUS and 27.9% of those with negative tests, p&lt;.001.

Conclusions: Many patients newly diagnosed with breast cancer at higher risk of carrying a pathogenic mutation do not receive pre-test counseling or genetic testing and disparities are observed. There is wide variability in the timing of genetic testing after diagnosis and with which clinician the findings are discussed. Taken together, these results suggest that germline genetic testing after a diagnosis of breast cancer is poorly integrated into practice. However, the impact of genetic test results on patient attitudes and receipt of bilateral mastectomy suggests that genetic testing does help target prevention to a patient's future risk for a new primary breast cancer.

Citation Format: Katz SJ, Morrow M, Jagsi R, Kurian A. Genetic counseling, germline genetic testing, and impact of results in patients with newly diagnosed breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-02-06.

Patient preferences for provider roles in collaborative breast cancer survivorship care

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Background: Prior studies have explored barriers to collaborative cancer care and suggest a need for greater clarity about clinician roles. However, little is known about patient’s preferences and expectations for which clinicians handle various aspects of care after primary cancer treatment. Methods: A weighted random sample of patients newly diagnosed with breast cancer in 2014-15 as reported to the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (N = 2,342, 70% response rate). Patient preferences for which clinician handles the following aspects of care after treatment were ascertained: follow-up mammograms, screening for other cancers, general preventive care, treatment of comorbidities and reassurance about their breast cancer. Response categories included primary care clinician (PCP), cancer doctors, either or both. The associations between patient demographic and clinical factors with preferences for clinician roles were assessed using multinomial logistic regression. Results: The majority of women preferred to see oncologists for mammograms (65%), other cancer screening (64%), and reassurance about their cancer (69%), and PCPs for general preventive care (76%) and comorbidity care (79%). Black women and Hispanic women (vs. White) were more likely to prefer to see both clinicians (vs. PCP) for mammograms (Black OR: 2.8, 95%CI: 1.5, 5.1; Hispanic OR: 1.9, 95%CI: 1.1, 3.3), screening for other cancers (Black OR: 3.3, 95%CI: 1.8, 6.1; Hispanic OR: 1.8, 95%CI: 1.0, 3.1), general preventive care (Black OR: 3.5, 95%CI: 2.0, 6.0; Latina OR: 2.5, 95%CI: 1.4, 4.3) and comorbidity care (Black OR: 2.1, 95%CI: 1.3, 3.6; Hispanic OR: 2.0, 95%CI: 1.2, 3.3). Less than a high school education was also associated with a preference for seeing both clinicians for mammograms. Conclusions: While patients report clear preferences for which clinicians handle various aspects of their collaborative survivorship care, variation exists by race and education. Targeting these patients to clarify clinician roles may be particularly effective in interventions to improve collaborative cancer care.

Study protocol: A Randomized Controlled Trial of a Comprehensive Breast Cancer Treatment Patient Decision Tool (iCanDecide)

Background

Patients newly diagnosed with breast cancer face a series of complex decisions regarding locoregional and systemic treatment. There is a need to improve the quality of locoregional and systemic decisions for breast cancer patients, and to help patients understand the role of evaluative tests in this decision process. We are now conducting a randomized controlled trial (RCT) of an online decision tool—called iCanDecide, which we expect will help patients with these difficult decisions. Furthermore, the results of this RCT will be highly relevant to future breast cancer patients making these decisions and to their clinicians.

Methods

This is a two-arm randomized controlled trial with the target of 222 participants per arm. Participants are recruited from 25 surgical practices (total 40 surgeons) and 2 medical oncology practices (total 2 oncologists) in Michigan, Georgia, Tennessee, and California. Participants are newly-diagnosed female breast cancer patients between 21 and 84 years, with stage I-II invasive breast cancer or ductal carcinoma in situ (DCIS) and who are eligible for and considering either mastectomy or lumpectomy with radiation, and who may be eligible for adjuvant systemic treatment.

The RCT tests an interactive, tailored website, called iCanDecide (intervention arm), compared to a static version of the website (control arm). The static control arm is designed to include the same basic content as the intervention version, but without tailoring and interactive features. The primary outcome includes the rate of making a high-quality decision. The hypothesis is that patients randomized to the interactive version of iCanDecide will have higher rates of high quality decisions (informed and values-concordant), and will appraise their decision-making process more positively, for both surgical and systemic treatment.

Discussion

The goal of this study is to evaluate the impact of the iCanDecide interactive website on decision-making for locoregional and systemic breast cancer treatments. The results of this study will be important for future breast cancer patients and their clinicians as we determine how to better individualize decision making across this complex treatment landscape.

Trial registration

ClinicalTrials.gov ID NCT01840163.

The impact of doctor-patient communication on patients' perceptions of their risk of breast cancer recurrence

PURPOSE

Doctor-patient communication is the primary way for women diagnosed with breast cancer to learn about their risk of distant recurrence. Yet little is known about how doctors approach these discussions.

METHODS

A weighted random sample of newly diagnosed early-stage breast cancer patients identified through SEER registries of Los Angeles and Georgia (2013-2015) was sent surveys about ~2 months after surgery (Phase 2, N = 3930, RR 68%). We assessed patient perceptions of doctor communication of risk of recurrence (i.e., amount, approach, inquiry about worry). Clinically determined 10-year risk of distant recurrence was established for low and intermediate invasive cancer patients. Women's perceived risk of distant recurrence (0-100%) was categorized into subgroups: overestimation, reasonably accurate, and zero risk. Understanding of risk and patient factors (e.g. health literacy, numeracy, and anxiety/worry) on physician communication outcomes was evaluated in multivariable regression models (analytic sample for substudy = 1295).

RESULTS

About 33% of women reported that doctors discussed risk of recurrence as "quite a bit" or "a lot," while 14% said "not at all." Over half of women reported that doctors used words and numbers to describe risk, while 24% used only words. Overestimators (OR .50, CI 0.31-0.81) or those who perceived zero risk (OR .46, CI 0.29-0.72) more often said that their doctor did not discuss risk. Patients with low numeracy reported less discussion. Over 60% reported that their doctor almost never inquired about worry.

CONCLUSIONS

Effective doctor-patient communication is critical to patient understanding of risk of recurrence. Efforts to enhance physicians' ability to engage in individualized communication around risk are needed.

Recurrence risk perception and quality of life following treatment of breast cancer

PURPOSE

Little is known about different ways of assessing risk of distant recurrence following cancer treatment (e.g., numeric or descriptive). We sought to evaluate the association between overestimation of risk of distant recurrence of breast cancer and key patient-reported outcomes, including quality of life and worry.

METHODS

We surveyed a weighted random sample of newly diagnosed patients with early-stage breast cancer identified through SEER registries of Los Angeles County & Georgia (2013-14) ~2 months after surgery (N = 2578, RR = 71%). Actual 10-year risk of distant recurrence after treatment was based on clinical factors for women with DCIS & low-risk invasive cancer (Stg 1A, ER+, HER2-, Gr 1-2). Women reported perceptions of their risk numerically (0-100%), with values ≥10% for DCIS & ≥20% for invasive considered overestimates. Perceptions of "moderate, high or very high" risk were considered descriptive overestimates. In our analytic sample (N = 927), we assessed factors correlated with both types of overestimation and report multivariable associations between overestimation and QoL (PROMIS physical & mental health) and frequent worry.

RESULTS

30.4% of women substantially overestimated their risk of distant recurrence numerically and 14.7% descriptively. Few factors other than family history were significantly associated with either type of overestimation. Both types of overestimation were significantly associated with frequent worry, and lower QoL.

CONCLUSIONS

Ensuring understanding of systemic recurrence risk, particularly among patients with favorable prognosis, is important. Better risk communication by clinicians may translate to better risk comprehension among patients and to improvements in QoL.

The influence of 21-gene recurrence score assay on chemotherapy use in a population-based sample of breast cancer patients

PURPOSE

To quantify the influence of RS assay on changing chemotherapy plans in a general practice setting using causal inference methods.

METHODS

We surveyed 3880 newly diagnosed breast cancer patients in Los Angeles and Georgia in 2013-14. We used inverse propensity weighting and multiple imputations to derive complete information for each patient about treatment status with and without testing.

RESULTS

A half of the 1545 women eligible for testing (ER+ or PR+, HER2-, and stage I-II) received RS. We estimate that 30% (95% confidence interval (CI) 10-49%) of patients would have changed their treatment selections after RS assay, with 10% (CI 0-20%) being encouraged to undergo chemotherapy and 20% (CI 10-30%) being discouraged from chemotherapy. The subgroups whose treatment selections would be changed the most by RS were patients with positive nodes (44%; CI 24-64%), larger tumor (43% for tumor size >2 cm; CI 23-62%), or younger age (41% for <50 years, CI 23-58%). The assay was associated with a net reduction in chemotherapy use by 10% (CI 4-16%). The reduction was much greater for women with positive nodes (31%; CI 21-41%), larger tumor (30% for tumor size >2 cm; CI 22-38%), or younger age (22% for <50 years; CI 9-35%).

CONCLUSION

RS substantially changed chemotherapy treatment selections with the largest influence among patients with less favorable pre-test prognosis. Whether this is optimal awaits the results of clinical trials addressing the utility of RS testing in selected subgroups.

Evaluating a Decision Aid for Improving Decision Making in Patients with Early-stage Breast Cancer

BACKGROUND

Early-stage breast cancer patients face a series of complex treatment decisions, with the first typically being choice of locoregional treatment. There is a need for tools to support patients in this decision-making process.

METHODS

We developed an innovative, online locoregional treatment tool based on International Patient Decision Aids Standards criteria. We evaluated its impact on patient knowledge about treatment and appraisal of decision making in a pilot study using a clinical sample of newly diagnosed, breast cancer patients who were randomized to view the decision aid website first or complete a survey prior to viewing the decision aid. Differences in knowledge and decision appraisal between the two groups were compared using t-tests and chi-square tests. Computer-generated preferences for treatment were compared with patients' stated preferences using chi-square tests.

RESULTS

One hundred and one newly diagnosed patients were randomized to view the website first or take a survey first. Women who viewed the website first had slightly higher, though not significantly, knowledge about surgery (p = 0.29) and reconstruction (p = 0.10) than the survey-first group. Those who viewed the website first also appraised their decision process significantly more favorably than did those who took the survey first (p < 0.05 for most decision outcomes). There was very good concordance between computer-suggested and stated treatment preferences.

CONCLUSION

This pilot study suggests that an interactive decision tool shows promise for supporting early-stage breast cancer patients with complicated treatment decision making.

Self-reported use of natural health products among rheumatology patients: A cross-sectional survey

OBJECTIVES

To describe the self-reported use of natural health products (NHPs) and identify characteristics that predict selected NHP use in rheumatology patients.

METHODS

We conducted a cross-sectional survey of consecutive rheumatology patients in two major clinics in Edmonton, Alberta. Survey items included demographic data, rheumatologic diagnoses, prescribed medications, NHPs, and information regarding patients' use of NHPs. Selected NHPs of interest - defined to include joint-specific products, oils with putative joint benefits, and other non-vitamin, non-mineral products - were classified by 2 reviewers. The characteristics of selected NHP users and non-users were compared using chi-squared and ANOVA tests, followed by multivariable-adjusted logistic regression.

RESULTS

1063 patients completed the survey (response rate = 36%, mean age 53 [sd 15], 70% female). 36% of respondents reported using one or more of a wide range of selected NHPs (mean 1.8, range 1-9). The most common source of NHP recommendations for selected NHP users were physicians (42%). Significant predictors of selected NHP use were: being female (aOR 1.41, 95%CI [1.05-1.90], p = 0.02), having a post-secondary degree (aOR 1.60 [1.15-2.22], p = 0.005), and the number of non-rheumatic medications (aOR 1.08 [ 1.00-1.15], p = 0.03) and NSAIDs (aOR 1.32 [1.06, 1.63], p = 0.01). Similar findings were observed among only inflammatory arthritis patients.

CONCLUSIONS

Our study confirms the frequent use of selected NHPs, possibly to mitigate persistent symptoms of rheumatologic illness. Rheumatologists appear to be trusted sources of advice and recommendations on NHP use and should provide balanced counselling for their patients.