Variation in type of adjuvant chemotherapy received among patients with stage I breast cancer: A multi-institutional study

BACKGROUND

Among patients with stage I breast cancer, there is significant uncertainty concerning the optimal threshold at which to consider chemotherapy, and when considered, there is controversy regarding whether to consider non-intensive versus intensive regimens. The authors examined the types and costs of adjuvant chemotherapy received among patients with stage I breast cancer.

METHODS

The current study was a prospective cohort study including patients with stage I breast cancer who were treated at a National Comprehensive Cancer Network center from 2000 through 2009. Stage was defined according to the version of the American Joint Committee on Cancer Staging Manual applicable at the time of diagnosis. Stratifying by human epidermal growth factor receptor 2 (HER2), the authors examined the percentage of patients receiving intensive versus non-intensive chemotherapy regimens and the factors associated with type of chemotherapy administered using multivariable logistic regression. Costs of the most common regimens were estimated.

RESULTS

Of 8907 patients, 33% received adjuvant chemotherapy. Among those individuals, there was an increase in the use of intensive chemotherapy within the last decade, from 31% in 2000 through 2005 to 63% in 2008 through 2009 (including an increase in the use of the combination of docetaxel, carboplatin, and trastuzumab) among patients with HER2-positive disease and from 15% in 2000 through 2005 to 41% in 2008 through 2009 among patients with HER2-negative disease (32% of patients with hormone receptor-positive and 59% of patients with triple-negative disease). Among patients treated with non-intensive regimens, there was an increase in the use of the combination of docetaxel and cyclophosphamide noted, with a decrease in the use of the doxorubicin and cyclophosphamide combination. The choice of regimen varied significantly by institution. The major drivers of cost variation were the incorporation of biologics (eg, trastuzumab) and growth factors, with significant variation even within non-intensive and intensive regimens.

CONCLUSIONS

Over time, there was an increase in use of intensive regimens among Stage I breast cancer, with striking institutional and cost variations.

Abstract P2-13-03: Variation in the use of mastectomy (MAST) in women with small node negative breast cancer (BC) treated at US academic institutions

Background: More than two decades ago several trials have shown equivalent survival between breast conserving surgery (BCS) and MAST. Among a contemporary cohort of patients (pts) with Stage I BC who would be expected to be candidates for BCS; we examined the initial choice of surgery and factors associated with it.

Pts and methods: Prospective cohort study including pts with clinical Stage I BC treated at a National Comprehensive Cancer Network center that participated in the BC outcomes database from 2000-09. Descriptive analyses were performed examining the proportion of pts who initially underwent MAST vs BCS. Factors associated with initial surgery were analyzed using multivariable logistic regression.

Results: Of 10,249 pts with clinical Stage I BC, 2,361(23%) underwent MAST as the initial surgery and 7,888 (77%) BCS. Of those, 8% were ultimately converted to MAST. The median time from diagnosis to initial surgery was longer among the MAST group (4 vs. 6 weeks).

Patient, tumor, care and institutional factors were associated with higher rates of initial MAST: 30% of pts with <50 years of age had a MAST vs. 17% of those ≥70; 41% of pts with body mass index (BMI) < 18.5 kg/m2 (underweight) had a MAST vs. 20% of those with a BMI >30 kg/m2 (obese). There was significant institutional variation, with rates of initial MAST ranging from 14-30%. The use of preoperative magnetic resonance imaging (MRI) was associated with a higher rate of initial MAST (32% vs.22%). Differences by tumor subtype were observed, 38% of pts with HER2+/HR- tumors had initial MAST vs. 22-28% among other subtypes. In the multivariate model, age, BMI, comorbidity, income, center, stage, tumor subtype, grade, histology and preoperative MRI were associated with the choice of initial surgery.

Multivariate logistic model to investigate factors associated with initial MAST MAST vs BCS OR95%CIPAge  <0.01<501  50-590.70.6 - 0.8 60-690.70.6 - 0.8 70+0.60.5 - 0.7 BMI (kg/m2)  <0.01<18.51.81.3 - 2.6 18.5-<251  25-<300.80.7 - 0.9 ≥300.70.6 - 0.8 Unknown0.80.6 - 1.0 Comorbidity  0.0501  1+1.11.0 - 1.3 Race  0.8Non Hispanic white1  Non Hispanic black10.8-1.2 Hispanic10.8-1.3 Other1.10.9-1.4 Insurance  0.16Manged care/ Indemnity1  Medicare10.9-1.2 Self-pay/Medicaid1.31-1.6 Other10.6-1.6 Median Household income  0.021 (low)1  20.90.8-1.1 30.90.8-1.1 40.90.8-1.0 5 (high)0.80.6-0.9 Year of diagnosis11-10.35Center  <0.01A1  B0.90.7-1.1 C0.70.6-0.9 D1.41.1-1.7 E0.40.3-0.6 F0.80.6-1.1 G1.31-1.6 H0.60.4-0.8 Clinical Stage  <0.01T1a1  T1b0.80.6-0.9 T1c10.8-1.2 T1NOS1.10.9-1.4 Tumor Subtype  <0.01HER2+HR+1  HER2+HR-1.51.1-1.9 HER2-HR+0.90.7-1.0 HER-HR-0.70.6-0.9 Grade  <0.01Low Intermediate1  High1.21.1-1.4 Histology   Ductal1 <0.01Lobular1.41.2-1.7 Mixed1.31.1-1.5 Other0.70.5-0.8 Preoperative MRI   No1 <0.01Yes1.81.6-2.1 

Conclusions: Among a cohort of pts with small node negative BC, 23% elected to have MAST with significant variation associated with choice of treatment, while some of this variation is likely appropriate and clinically indicated, further studies to assess pt understanding of the tradeoffs between BCS and MAST is warranted. These findings need to be considered in light of the increasing number of pts who are choosing MAST/bilateral MAST.

Citation Format: Ines Vaz Luis, Melissa E Hughes, Angel Cronin, Hope S Rugo, Stephen B Edge, Beverly Moy, Richard Theriault, Michael J Hassett, Eric P Winer, Nancy U Lin. Variation in the use of mastectomy (MAST) in women with small node negative breast cancer (BC) treated at US academic institutions [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-03.

High-Priority Topics for Cancer Quality Measure Development: Results of the 2012 American Society of Clinical Oncology Collaborative Cancer Measure Summit

Addressing the high-priority topics identified by this effort will help fill the gaps left by existing cancer quality measures, including care coordination and transitions, quality of life, safety, experience of care, and outcomes.

What does breast cancer treatment cost and what is it worth?

The costs of breast cancer care are substantial and growing, and they extend across the spectrum of care. Medical therapies and hospitalizations account for a significant proportion of these costs. Cost-effectiveness analysis (CEA) is the preferred method for assessing the health benefits of medical interventions relative to their costs. Although many CEAs have been conducted for a wide range of breast cancer treatments, these analyses are not used routinely to guide coverage or utilization decisions in the United States. Currently, patients and providers may not consider costs when making most treatment decisions; this is likely to change as payment reform spreads.

Implementation of chemotherapy treatment plans (CTP) in a large comprehensive cancer center (CCC): The key roles of infrastructure and data sharing

20

Background: ASCO recommends that prior to initiating chemotherapy, a synoptic CTP should be created. At a large CCC, there was no tool to consistently or clearly communicate chemotherapy plans within the electronic health record (EHR). Methods: In 2011, a structured tool was created in the EHR to document patient diagnosis, tumor characteristics, planned regimen, side effects, performance status, and other elements when starting a new chemotherapy. Completion of a CTP generates a synoptic note in the EHR, pre-populates a chemotherapy consent form and computerized chemotherapy ordering template, helping to integrate CTPs into normal workflow and removing steps for possible errors. Completed CTPs can be accessed by care team members and sent to external referring providers. Implementation strategy included education on the importance of and how to complete CTPs and sending monthly compliance reports to disease centers (DC) and regional sites (RS). Compliance was defined as number completed CTPs / number new chemotherapy starts. Results: The CTP tool was introduced in a staggered rollout in mid-2011 (compliance reporting began in 2012). Six DC and 3 RS presently complete and use CTPs. 3,569 CTPs were completed since 2012. The table shows compliance by quarter, demonstrating significant variation among DC and RS. We attribute increased compliance to introduction of formal feedback reports that allow for identification of high-volume providers not completing CTPs, triggering individual interventions, especially targeted re-education. We also suspect shared reporting led to competition among providers, further improving performance. No incentives were provided for CTP completion. Conclusions: By creating a tool within the existing workflow and providing formal feedback, CTPs have been implemented as a communication tool at a CCC. [Table: see text]

Utilization of cardiac monitoring tests in women with nonmetastatic breast cancer treated with trastuzumab

AIMS

Trastuzumab, one of the best known examples of personalized medicine, requires regular cardiac monitoring because it can cause heart failure. We aimed to assess the utilization of cardiac monitoring in women with nonmetastatic breast cancer receiving trastuzumab-based chemotherapy in routine clinical practice.

PATIENTS & METHODS

The medical records of women continuously enrolled in a large national health insurance plan who were diagnosed with nonmetastatic breast cancer and treated with trastuzumab from 2006 to 2008 were reviewed (n = 109). The primary outcome variables were the use and type of cardiac monitoring testing before and during trastuzumab therapy. An exploratory multivariable logistic regression analysis was performed to identify predictors for receiving cardiac monitoring both at baseline and during trastuzumab treatment.

RESULTS

Monitoring both before and during therapy was less common (62%), although 74% had cardiac monitoring before therapy and 80% had at least one test during therapy. Radionuclide ventriculogram was utilized more often than echocardiography (48 vs 42%). Only the use of anthracycline (odds ratio: 2.39; 95% CI: 1.01-5.71) was significantly associated with use of a cardiac monitoring both at baseline and during trastuzumab treatment.

CONCLUSION

The use of cardiac monitoring testing was variable and opportunities to improve quality and reduce cost are evident. These results have clinical implications for other personalized medicine interventions requiring regular laboratory monitoring.

Modeling the effectiveness of initial management strategies for ductal carcinoma in situ

BACKGROUND

The prevalence of ductal carcinoma in situ (DCIS) and the marked variability in patterns of care highlight the need for comparative effectiveness research. We sought to quantify the tradeoffs among alternative management strategies for DCIS with respect to disease outcomes and breast preservation.

METHODS

We developed a disease simulation model integrating data from the published literature to simulate the clinical events after six treatments (lumpectomy alone, lumpectomy with radiation, lumpectomy with radiation and tamoxifen, lumpectomy with tamoxifen, and mastectomy with and without breast reconstruction) for women with newly diagnosed DCIS. Outcomes included disease-free, invasive disease-free, and overall survival and breast preservation.

RESULTS

For a cohort of 1 million simulated women aged 45 years at diagnosis, both mastectomy and lumpectomy with radiation and tamoxifen were associated with a 12-month improvement in overall survival relative to lumpectomy alone. Adding radiation therapy to lumpectomy resulted in a 6-month improvement in overall survival but decreased long-term breast-preservation outcomes (likelihood of lifetime breast preservation = 0.781 vs 0.843 for lumpectomy alone). This decrement with radiation therapy was mitigated by the addition of tamoxifen (likelihood of lifetime breast preservation = 0.846).

CONCLUSIONS

Overall survival benefits of the six management strategies for DCIS are within 1 year, suggesting that treatment decisions can be informed by the patient's preference for breast preservation and disutility for recurrence. Our delineation of personalized outcomes for each strategy can help patients understand the implications of their treatment choice, so their decisions may reflect their own personal values and help improve the quality of care for patients with DCIS.

Patterns of disparities in breast cancer care

6565

Background: Studies have documented disparities in breast cancer care for decades, but disparities in outcomes have not improved. Previous disparity investigations included relatively small, potentially biased samples of disadvantaged populations, or focused only on selected aspects of care. We sought to describe the relative importance of race/ethnicity versus Medicaid insurance status as determinants of suboptimal quality across the spectrum of care using two population-based samples of women with non-metastatic breast cancer. Methods: From two state registry datasets (NY and CA), we identified adult women diagnosed with stage 0-III breast cancer from 2004-2009. To these data, we merged enrollment and claims files from Medicaid and Medicare. Quality was assessed relative to 35 underuse and overuse measures derived from clinical practice guidelines. We compared measures across race/ethnic and Medicaid enrollment groups, and used logistic regression models to assess the relationships between race/ethnicity, Medicaid status, and quality relative to surgery, chemotherapy, radiation, and endocrine measures. Analyses were conducted in parallel for NY and CA, and for women <65 and ≥65 years old. Results: The sample, which comprised 80,079 from NY and 121,098 from CA, included 14%/6% blacks, 8%/15% Hispanics, 5%/12% API’s, and 19%/14% Medicaid enrollees, respectively from NY/CA. There was moderate-high correlation in measure performance across states and race/ethnic groups. Multivariable models demonstrated that blacks had lower odds of receiving recommended surgery versus whites, and whites had lower odds of receiving chemotherapy, whether recommended or not, versus other race/ethnic groups. Medicaid status was associated with lower odds of receiving recommended surgery, radiation therapy, and anti-estrogen therapy, but not chemotherapy, for patients <65 and ≥65. Conclusions: Medicaid status, a surrogate for socio-economic status, was associated with lower odds of receiving recommended care across a broad spectrum of breast cancer treatments. Understanding patterns of disparities will facilitate efforts to design and disseminate real world solutions that foster improvements in outcomes for the most disadvantaged populations.

Regional variation in spending and survival for older adults with advanced cancer

BACKGROUND

Medicare spending varies substantially across the United States. We evaluated the association between mean regional spending and survival in advanced cancer.

METHODS

We identified 116 523 subjects with advanced cancer from 2002 to 2007, using Surveillance, Epidemiology and End Results (SEER)-Medicare linked data. Subjects were aged 65 years and older with non-small cell lung, colon, breast, prostate, or pancreas cancer. Of these subjects, 61 083 had incident advanced-stage cancer (incident cohort) and 98 935 had death from cancer (decedent cohort); 37% of subjects were included in both cohorts. Subjects were linked to one of 80 hospital referral regions within SEER areas. We estimated mean regional spending in both cohorts. We assessed the primary outcome, survival, in the incident cohort; the exposure measure was the quintile of regional spending in the decedent cohort. Survival in quintiles 2 through 5 was compared with that in quintile 1 (lowest spending quintile) using Cox regression models.

RESULTS

From quintile 1 to 5, mean regional spending increased by 32% and 41% in the incident and decedent cohorts (incident cohort: $28 854 to $37 971; decedent cohort: $27 446 to $38 630). The association between spending and survival varied by cancer site and quintile; hazard ratios ranged from 0.92 (95% confidence interval [CI] = 0.82 to 1.04, pancreas cancer quintile 5) to 1.24 (95% CI = 1.11 to 1.39, breast cancer quintile 3). In most cases, differences in survival between quintile 1 and quintiles 2 through 5 were not statistically significant.

CONCLUSION

There is substantial regional variation in Medicare spending for advanced cancer, yet no consistent association between mean regional spending and survival.

Cost of cancer care: The impact of disclosure on willingness to pay and treatment preferences

15

Background: Little is known about patients’ views regarding the costs of cancer care and its effect on treatment selection. Even less is known about how patients view information about conflicts of interest, such as disclosure of a clinic’s profit from cancer therapy. In the setting of health care reform and rising costs, we sought to understand how out-of-pocket costs and disclosure of profit impact patient treatment preferences. Methods: Previous breast cancer patients were invited to complete a web-based survey that presented four scenarios outlining cancer care treatment benefits and risks (MRI, pegfilgrastim, cold cap, and chemotherapy drugs). Initially, respondents were asked their preference for each treatment over a standard of care alternative and their out-of-pocket willingness to pay. After providing information about first, the total cost per treatment and second, the profit to the clinic, respondents were asked if their preference changed. Results: 40 women responded, all whom had previous diagnoses of breast cancer. In each of the four scenarios, respondents were less interested in the treatment option after being informed about cost or disclosure of a clinic profit. While 45.5% of respondents said they consider costs all or most of the time, only 9.1% considered clinic profit. However, 66.7% of respondents said they would be less interested in a treatment if they knew their provider received a profit from the treatment. Conclusions: Patients are less likely to prefer treatments after disclosure of total cost and clinic profit data. Communication about the costs and profits associated with cancer care may be an essential component of informed decision making in an era of growing patient involvement and escalating health care costs. [Table: see text]

Impact of oncology-related direct-to-consumer advertising: association with appropriate and inappropriate prescriptions

BACKGROUND

Little is known about the impact of direct-to-consumer advertising (DTCA) on appropriate versus inappropriate prescribing. Aromatase inhibitor (AI) therapy for breast cancer provides an ideal paradigm for studying this issue, because AIs have been the focus of substantial DTCA, and because they should only be used in postmenopausal women, age can serve as a simple surrogate marker of appropriateness.

METHODS

Data regarding national DTCA spending for the AIs were obtained from TNS Multimedia; hormonal therapy prescription data were obtained from IMS Health. Time series analyses were performed to characterize the association between monthly changes in DTCA spending for the AIs and monthly changes in the proportion of all new hormonal therapy prescriptions represented by the AIs from October 2005 to September 2007. Analyses were stratified by age, considering prescriptions for women ≤ 40 (likely premenopausal) to be inappropriate and those for women > 60 (likely postmenopausal) to be appropriate.

RESULTS

Monthly dollars spent on AI-associated DTCA varied considerably ($118,600 to $22,019,660). Time series analysis revealed that for every million dollars spent on DTCA for the AIs, there was an associated increase 3 months later in the new AI prescription proportion of 0.15% for all ages (P < .0001) and 0.18% for those > 60 years (P < .0001), but no significant change for those ≤ 40 at any time from 0 to 6 months.

CONCLUSIONS

DTCA for the AIs was associated with increases in appropriate prescriptions with no significant effect on inappropriate prescriptions, suggesting that DTCA may not foster inappropriate medication use for certain drug classes.

Initiation of adjuvant hormone therapy by Medicaid insured women with nonmetastatic breast cancer

Hormone therapy is the mainstay of adjuvant treatment for hormone receptor positive (HR-positive) nonmetastatic breast cancer. We evaluated adjuvant hormone therapy (AHT) initiation among Medicaid-insured women aged 21-64 years with stage I-III HR-positive breast cancer. We used multivariable logistic regression to identify independent predictors of AHT initiation. Within 1 year of diagnosis, 68% (1049/1538) initiated AHT; by 18 months, 80% (1168/1461) initiated AHT. In multivariable analysis, women less likely to initiate AHT had more comorbidity (≥ 2 vs none: adjusted odds ratio (AOR) = 0.55; 95% CI = 0.32 to 0.97), more advanced disease (stage III vs I: AOR = 0.27; 95% CI = 0.18 to 0.39), and no radiation after breast conserving surgery (AOR = 0.15; 95% CI = 0.10 to 0.22). Race, age, and history of mental health disorders were not independently associated with initiation of AHT. Among initiators of AHT, 58% (604/1049) were adherent to treatment for the year after initiation. Despite comprehensive prescription coverage, only 39% (604/1538) received optimal AHT including prompt initiation and adherence for the year after treatment. Partnerships between Medicaid programs and cancer registries may help identify at-risk women and facilitate the implementation of quality improvement strategies.

Adoption of gene expression profile testing and association with use of chemotherapy among women with breast cancer

PURPOSE

Gene expression profile (GEP) testing is a relatively new technology that offers the potential of personalized medicine to patients, yet little is known about its adoption into routine practice. One of the first commercially available GEP tests, a 21-gene profile, was developed to estimate the benefit of adjuvant chemotherapy for hormone receptor-positive breast cancer (HR-positive BC).

PATIENTS AND METHODS

By using a prospective registry data set outlining the routine care provided to women diagnosed from 2006 to 2008 with HR-positive BC at 17 comprehensive and community-based cancer centers, we assessed GEP test adoption and the association between testing and chemotherapy use.

RESULTS

Of 7,375 women, 20.4% had GEP testing and 50.2% received chemotherapy. Over time, testing increased (14.7% in 2006 to 27.5% in 2008; P < .01) and use of chemotherapy decreased (53.9% in 2006 to 47.0% in 2008; P < .01). Characteristics independently associated with lower odds of testing included African American versus white race (odds ratio [OR], 0.70; 95% CI, 0.54 to 0.92) and high school or less versus more than high school education (OR, 0.63; 95% CI, 0.52 to 0.76). Overall, testing was associated with lower odds of chemotherapy use (OR, 0.70; 95% CI, 0.62 to 0.80). Stratified analyses demonstrated that for small, node-negative cancers, testing was associated with higher odds of chemotherapy use (OR, 11.13; 95% CI, 5.39 to 22.99), whereas for node-positive and large node-negative cancers, testing was associated with lower odds of chemotherapy use (OR, 0.11; 95% CI, 0.07 to 0.17).

CONCLUSION

There has been a progressive increase in use of this GEP test and an associated shift in the characteristics of and overall reduction in the proportion of women with HR-positive BC receiving adjuvant chemotherapy.

Pathologic characteristics of second breast cancers after breast conservation for ductal carcinoma in situ

BACKGROUND

The number of women diagnosed with ductal carcinoma in situ (DCIS) is increasing. Although many eventually develop a second breast cancer (SBC), little is known about the characteristics of SBCs. The authors described the characteristics of SBC and examined associations between the pathologic features of SBC and index DCIS cases.

METHODS

Women were identified in the National Comprehensive Cancer Network Outcomes Database who were diagnosed with DCIS from 1997 to 2008 and underwent lumpectomy and who subsequently developed SBC (including DCIS or invasive disease that occurred in the ipsilateral or contralateral breast). The Fisher exact test and the Spearman test were used to examine associations between the pathologic characteristics of SBC and index DCIS cases.

RESULTS

Among 2636 women who underwent lumpectomy for DCIS, 150 (5.7%) experienced an SBC after a median of 55.5 months of follow-up. Of these 150 women, 105 (70%) received adjuvant radiotherapy, and 50 (33.3%) received tamoxifen for their index DCIS. SBCs were ipsilateral in 54.7% of women and invasive in 50.7% of women. Among the index DCIS cases, 60.6% were estrogen receptor (ER)-positive, and 54% were high grade, whereas 77.5% of SBCs were ER-positive, and 48.2% were high grade. Tumor grade (P = .003) and ER status (P = .02) were associated significantly between index DCIS and SBC, whereas tumor size was not (P = .87).

CONCLUSIONS

After breast conservation for DCIS, SBC in either breast exhibited pathologic characteristics similar to the index DCIS, suggesting that women with DCIS may be at risk for developing subsequent breast cancers of a similar phenotype.

Use of annual mammography among older women with ductal carcinoma in situ

BACKGROUND

As ductal carcinoma in situ (DCIS) is a risk factor for invasive breast cancer, ongoing annual mammography is important for cancer control, yet little is known about racial/ethnic and other disparities in use among older women with DCIS.

METHODS

SEER-Medicare data was used to identify women age 65-85 years, diagnosed with DCIS from 1992 to 2005 and treated with surgery, but not bilateral mastectomy. We examined factors associated with receipt of an initial mammogram within 1 year of treatment and subsequent annual mammograms for 3 and 5 years. We examined whether follow-up care, by a primary care physician or cancer specialist, or neighborhood characteristics mediated disparities in mammography use.

RESULTS

Overall, 91.3% of women had an initial mammogram. After adjustment, blacks and Hispanics were less likely than whites to receive an initial mammogram (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.55-0.99 and OR 0.65, CI 0.46-0.93, respectively, as were women of lower socioeconomic status (SES), women who had a mastectomy or breast conserving surgery without radiation therapy, and women who did not have a physician visit. Overall rates of annual mammography decreased over time. Disparities by SES, initial treatment type, and physician visit did not diminish over time. Physician visits had a modest effect on reducing initial racial/ethnic disparities.

CONCLUSIONS

Annual mammography among women age 65 to 85 with DCIS declines as women get further from diagnosis. Interventions should focus on reducing disparities in the use of initial surveillance mammography, and increasing surveillance over time.

US Cancer Center Implementation of ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards

PURPOSE

Because cancer chemotherapy is a high-risk intervention, ASCO and the Oncology Nursing Society (ONS) established in 2009 consensus- and evidence-based national standards for the safe administration of chemotherapy. We sought to assess the implementation status of the ASCO/ONS chemotherapy administration safety standards.

METHODS

A written survey of chemotherapy practices was sent to National Cancer Institute-designated cancer centers. Implementation status of each of 31 chemotherapy administration safety standards was self-reported.

RESULTS

Forty-four (80%) of 55 eligible centers responded. Although the majority of centers have fully implemented at least half of the standards, only four centers reported full implementation of all 31. Implementation varied by standard, with the poorest implementation of standards that addressed documentation of chemotherapy planning, agreed-on intervals for laboratory testing, and patient education and consent before initiation of oral or infusional chemotherapy.

CONCLUSION

Given wide variation in the implementation of ASCO/ONS chemotherapy administration safety standards at US cancer centers, there are significant opportunities for improvement.

Genomic testing and therapies for breast cancer in clinical practice

PURPOSE

Given the likely proliferation of targeted testing and treatment strategies for cancer, a better understanding of the utilization patterns of human epidermal growth factor receptor 2 (HER2) testing and trastuzumab and newer gene expression profiling (GEP) for risk stratification and chemotherapy decision making are important.

STUDY DESIGN

Cross-sectional.

METHODS

We performed a medical record review of women age 35 to 65 years diagnosed between 2006 and 2007 with invasive localized breast cancer, identified using claims from a large national health plan (N = 775).

RESULTS

Almost all women received HER2 testing (96.9%), and 24.9% of women with an accepted indication received GEP. Unexplained socioeconomic differences in GEP use were apparent after adjusting for age and clinical characteristics; specifically, GEP use increased with income. For example, those in the lowest income category (< $40,000) were less likely than those with an income of $125,000 or more to receive GEP (odds ratio, 0.34; 95% CI, 0.16 to 0.73). A majority of women (57.7%) with HER2-positive disease received trastuzumab; among these women, differences in age and clinical characteristics were not apparent, although surprisingly, those in the lowest income category were more likely than those in the high-income category to receive trastuzumab (P = .02). Among women who did not have a positive HER2 test, 3.9% still received trastuzumab. Receipt of adjuvant chemotherapy increased as GEP score indicated greater risk of recurrence.

CONCLUSION

Identifying and eliminating unnecessary variation in the use of these expensive tests and treatments should be part of quality improvement and efficiency programs.

Genomic testing and therapies for breast cancer in clinical practice

OBJECTIVE

Given the likely proliferation of targeted testing and treatment strategies for cancer, a better understanding of the utilization patterns of human epidermal growth factor receptor 2 (HER2) testing and trastuzumab and newer gene expression profiling (GEP) for risk stratification and chemotherapy decision making are important.

STUDY DESIGN

Cross-sectional.

METHODS

We performed a medical record review of women aged 35 to 65 years diagnosed between 2006 and 2007 with invasive localized breast cancer, identified using claims from a large national health plan (N = 775).

RESULTS

Almost all women received HER2 testing (96.9%), and 24.9% of women with an accepted indication received GEP. Unexplained socioeconomic differences in GEP use were apparent after adjusting for age and clinical characteristics; specifically, GEP use increased with income. For example, those in the lowest income category (<$40,000) were less likely than those with an income of $125,000 or more to receive GEP (odds ratio, 0.34; 95% confidence interval, 0.16 to 0.73). A majority of women (57.7%) with HER2-positive disease received trastuzumab; among these women, differences in age and clinical characteristics were not apparent, although surprisingly, those in the lowest income category were more likely than those in the high-income category to receive trastuzumab (P = .02). Among women who did not have a positive HER2 test, 3.9% still received trastuzumab. Receipt of adjuvant chemotherapy increased as GEP score indicated greater risk of recurrence.

CONCLUSION

Identifying and eliminating unnecessary variation in the use of these expensive tests and treatments should be part of quality improvement and efficiency programs.

Chemotherapy-related hospitalization among community cancer center patients

PURPOSE

To describe the frequency, nature, trends, predictors, and outcomes of chemotherapy-related hospitalizations (CRHs) among a nonselected population of cancer patients treated at a community cancer center, and to explore the feasibility of implementing continuous quality improvement methodologies in routine oncology practice.

METHODS

We conducted a prospective cohort study of consecutive adult cancer patients who received chemotherapy at a community cancer center January 2003 to December 2006. Demographic, comorbidity, diagnosis, treatment, and laboratory data were collected via medical record abstraction. Hospitalizations were classified as chemotherapy related or unrelated by a multidisciplinary panel. Patients who experienced CRHs were compared with those who did not. Using a randomly sampled subset of cases and controls, we built a logistic regression model to identify independent predictors of CRH.

RESULTS

Of 2,068 chemotherapy recipients, 179 (8.7%) experienced 262 CRHs. Most hospitalizations were not chemotherapy related (73.7%). The mean monthly rate of CRH was 1.5%, the median length of stay was 5 days, the most common type of CRH was gastrointestinal (46.1%) followed by infectious (31.4%), and 0.9% of chemotherapy recipients had a fatal CRH. Significant predictors of CRH included having a comorbidity score of 3-4 versus 0 and having a higher creatinine level.

CONCLUSIONS

Although the vast majority of chemotherapy recipients did not experience a CRH, these events were, unfortunately, not without serious consequences. Care should be taken when offering chemotherapy to patients with multiple comorbid conditions. Systematic efforts to monitor toxicity can lead directly to improvements in quality of care.

Impact of neoadjuvant chemotherapy on breast reconstruction

BACKGROUND

With advances in oncologic treatment, cosmesis after mastectomy has assumed a pivotal role in patient and provider decision making. Multiple studies have confirmed the safety of both chemotherapy before breast surgery and immediate reconstruction. Little has been written about the effect of neoadjuvant chemotherapy on decisions about reconstruction.

METHODS

The authors identified 665 patients with stage I through III breast cancer who received chemotherapy and underwent mastectomy at Dana-Farber/Brigham & Women's Cancer Center from 1997 to 2007. By using multivariate logistic regression, reconstruction rates were compared between patients who received neoadjuvant chemotherapy (n = 180) and patients who underwent mastectomy before chemotherapy (n = 485). The rate of postoperative complications after mastectomy was determined for patients who received neoadjuvant chemotherapy compared with those who did not.

RESULTS

Reconstruction was performed immediately in 44% of patients who did not receive neoadjuvant chemotherapy but in only 23% of those who did. Twenty-one percent of neoadjuvant chemotherapy recipients and 14% of adjuvant-only chemotherapy recipients underwent delayed reconstruction. After controlling for age, receipt of radiotherapy, and disease stage, neoadjuvant recipients were less likely to undergo immediate reconstruction (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.37, 0.87) but were no more likely to undergo delayed reconstruction (OR, 1.29; 95% CI, 0.75, 2.20). Surgical complications occurred in 30% of neoadjuvant chemotherapy recipients and in 31% of adjuvant chemotherapy recipients.

CONCLUSIONS

The current results suggest that patients who receive neoadjuvant chemotherapy are less likely to undergo immediate reconstruction and are no more likely to undergo delayed reconstruction than patients who undergo surgery before they receive chemotherapy.

Clinical practice patterns and cost effectiveness of human epidermal growth receptor 2 testing strategies in breast cancer patients

BACKGROUND

Testing technologies are increasingly used to target cancer therapies. Human epidermal growth factor receptor 2 (HER2) testing to target trastuzumab for patients with breast cancer provides insights into the evidence needed for emerging testing technologies.

METHODS

The authors reviewed literature on HER2 test utilization and cost effectiveness of HER2 testing for patients with breast cancer. They examined available evidence on: percentage of eligible patients tested for HER2; test methods used; concordance of test results between community and central/reference laboratories; use of trastuzumab by HER2 test result; and cost effectiveness of testing strategies.

RESULTS

Little evidence was available to determine whether all eligible patients are tested, how many are retested to confirm results, and how many with negative HER2 test results still receive trastuzumab. Studies suggested that up to 66% of eligible patients had no documentation of testing in claims records, up to 20% of patients receiving trastuzumab were not tested or had no documentation of a positive test, and 20% of HER2 results may be incorrect. Few cost-effectiveness analyses of trastuzumab explicitly considered the economic implications of various testing strategies.

CONCLUSIONS

There was little information about the actual use of HER2 testing in clinical practice, but evidence suggested important variations in testing practices and key gaps in knowledge exist. Given the increasing use of targeted therapies, it is critical to build an evidence base that supports informed decision making on emerging testing technologies in cancer care.

Factors influencing changes in employment among women with newly diagnosed breast cancer

BACKGROUND

Although studies have demonstrated that women are less likely to work after they are diagnosed with breast cancer, the influence of cancer treatments on employment is less clear. The authors of this report assessed whether chemotherapy or radiation therapy was associated with a disruption in employment during the year after a breast cancer diagnosis.

METHODS

Using a database of health insurance claims that covered 5.6 million US residents, 3,233 women aged <or=63 years were identified who were working full time or part time when they were diagnosed with breast cancer between 1998 and 2002. All changes in employment during the year after a breast cancer diagnosis were identified. Using a Cox proportional hazards model that incorporated time-varying treatment variables, the authors evaluated the impact of chemotherapy and radiation therapy on the likelihood of experiencing an employment disruption.

RESULTS

Although most women (93%) continued to work, chemotherapy recipients were more likely than nonrecipients to go on long-term disability, stop working, or retire (hazards ratio, 1.8; P < .01). Women aged >or=54 years were more likely to experience a change in employment than women aged <or=44 years (P < .01). Radiation therapy did not influence employment (P = .22).

CONCLUSIONS

In this population of employed, insured women, chemotherapy had a negative impact on employment. This finding may aid treatment decision making and could foster the development of interventions that support a patient's ability to continue working after treatment. It also reinforces the need to assess the impact of treatments, especially new treatments, on patient-centered outcomes such as employment.