351
|
Ramey SJ, Rich BJ, Kwon D, Mellon EA, Wolfson A, Portelance L, Yechieli R. Demographic disparities in delay of definitive chemoradiation for anal squamous cell carcinoma: a nationwide analysis. J Gastrointest Oncol 2018; 9:1109-1126. [PMID: 30603130 PMCID: PMC6286932 DOI: 10.21037/jgo.2018.08.07] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/23/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Prolonged time to treatment initiation (TTI) for patients with curable anal cancer may reduce tumor control. This study investigated demographic disparities in TTI for patients receiving definitive chemoradiation (CRT) for anal squamous cell carcinoma (A-SCC). METHODS Adult patients with A-SCC diagnosed from 2004 to 2014 and treated with definitive CRT were identified in the National Cancer Database (NCDB). TTI was defined as days from diagnosis to start of CRT. A negative binomial regression model estimated predicted TTI (pTTI) values. Cox proportional hazards model evaluated the impact of TTI on overall survival (OS). RESULTS Overall, 12,546 patients were included with 9% Non-Hispanic Black patients and 4% Hispanic patients. Multivariable analysis (MVA) showed that pTTI varied significantly by race/ethnicity with Non-Hispanic Black patients having a pTTI of 50 vs. 38 days for Non-Hispanic White patients [relative risk (RR), 1.21; 95% confidence interval (CI), 1.17-1.25]. For Hispanic patients, pTTI was 48 days, significantly longer than that of Non-Hispanic White patients (RR, 1.19; 95% CI, 1.14-1.24). Gender, insurance status, education level, urban category, distance to reporting facility, treatment facility type, intensity-modulated radiation therapy (IMRT)/proton use, T/N classification, and comorbidity status were all also associated with significant variation in TTI. TTI was not independently associated with changes in OS on MVA [hazard ratio (HR), 0.999; 95% CI, 0.997-1.002]. CONCLUSIONS Non-Hispanic Black and Hispanic patients have longer delays in starting definitive CRT for A-SCC. While TTI was not associated with OS, future analyses should explore the impact of TTI on local control, metastases, and patient-reported outcomes.
Collapse
Affiliation(s)
- Stephen J. Ramey
- Department of Radiation Oncology, Georgia Cancer Center, Augusta University, Augusta, Georgia, USA
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| | - Benjamin J. Rich
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Core, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| | - Eric A. Mellon
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| | - Aaron Wolfson
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| | - Lorraine Portelance
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| | - Raphael Yechieli
- Department of Radiation Oncology, Sylvester Comprehensive Cancer Center/University of Miami Miller School of Medicine, Miami, USA
| |
Collapse
|
352
|
Bleicher RJ, Chang C, Wang CE, Goldstein LJ, Kaufmann CS, Moran MS, Pollitt KA, Suss NR, Winchester DP, Tafra L, Yao K. Treatment delays from transfers of care and their impact on breast cancer quality measures. Breast Cancer Res Treat 2018; 173:603-617. [DOI: 10.1007/s10549-018-5046-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/08/2018] [Indexed: 11/25/2022]
|
353
|
Adult Primary Bone Sarcoma and Time to Treatment Initiation: An Analysis of the National Cancer Database. Sarcoma 2018; 2018:1728302. [PMID: 30533997 PMCID: PMC6252187 DOI: 10.1155/2018/1728302] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/14/2018] [Indexed: 02/06/2023] Open
Abstract
Objective The time to treatment interval (TTI), defined as the period from diagnosis to first definitive treatment, has very limited descriptions toward understanding delays in primary bone sarcoma (PBS) care. Our primary goal was to determine the national standard for time to treatment initiation (TTI) in PBS in adults and to identify characteristics associated with TTI variability. Methods An analysis of the National Cancer Database identified 15,083 adult patients with PBS diagnosed from 2004 to 2013. Kruskal–Wallis analysis identified differences between covariates regarding TTI and regression modeling identified covariates that independently influenced TTI. Results The median TTI was 22 days. Approximately 60% of patients were definitively treated in the same center where the index diagnosis was made. Increased TTI was correlated with a transition in care institution (incidence rate ratio (IRR) = 1.89; P < 0.001), being uninsured (IRR = 1.36; P < 0.001), primary tumor site in the pelvis (IRR = 1.26; P < 0.001), Medicaid insurance status (IRR = 1.22; P < 0.001), care at an academic center (IRR = 1.14; P < 0.001), non-white race (IRR = 1.12; P=0.002), and Medicare insurance status (IRR = 1.08; P=0.017). Decreased TTI was correlated with a diagnosis of chondrosarcoma (IRR = 0.85; P < 0.001), having surgery as the index treatment (IRR = 0.88; P < 0.001), a primary tumor site of the lower (IRR = 0.91; P=0.001) or upper extremity (IRR = 0.92; P=0.023), and stage II or stage III disease (IRR = 0.91; P=0.010). Conclusions TTI is associated with tumor, treatment, and socioeconomic and healthcare system characteristics. Transitions in care between institutions are responsible for the greatest increase in TTI. As TTI is more commonly used as a quality metric, physicians need to be aware of the causes for prolonged TTI, as we work to improve national delays in diagnosis and treatment initiation.
Collapse
|
354
|
Racial disparities in breast cancer persist despite early detection: analysis of treatment of stage 1 breast cancer and effect of insurance status on disparities. Breast Cancer Res Treat 2018; 173:597-602. [PMID: 30390216 DOI: 10.1007/s10549-018-5036-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Prior research demonstrates racial disparities in breast cancer treatment. Disparities are commonly attributed to more advanced stage at presentation or aggressive tumor biology. We seek to evaluate if racial disparities persist in the treatment of stage 1 breast cancer patients who by definition are not delayed in presentation. METHODS We selected stage 1 breast cases in the National Cancer Data Base. Patients were divided into two cohorts based on race and included White and Black patients. We also performed a subgroup analysis of patients with private insurance for comparison to determine if private insurance diminished the racial disparities noted. We analyzed differences in time to treatments by race. RESULTS Our analysis included 546,351 patients of which 494,784 (90.6%) were White non-Hispanic and 51,567 (9.4%) were Black non-Hispanic. Black women had significantly longer times to first treatment (35.5 days vs 28.1 days), surgery (36.6 days vs 28.8 days), chemotherapy (88.1 days vs 75.4 days), radiation (131.3 days vs 99.1 days), and endocrine therapy (152.1 days vs 126.5 days) than White women. When patients with private insurance were analyzed the difference in time to surgery decreased by 1.2 days but racial differences remained statistically significant. CONCLUSIONS Despite selecting for early-stage breast cancer, racial disparities between White and Black women in time to all forms of breast cancer treatment persist. These disparities while likely not oncologically significant do suggest institutional barriers for obtaining care faced by women of color which may not be addressed with improving access to mammography alone.
Collapse
|
355
|
Illei PB, Wong W, Wu N, Chu L, Gupta R, Schulze K, Gubens MA. ALK Testing Trends and Patterns Among Community Practices in the United States. JCO Precis Oncol 2018; 2:1-11. [DOI: 10.1200/po.18.00159] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Purpose Targeted therapy of ALK in patients with metastatic nonsquamous non–small-cell lung cancer (NSCLC) and ALK rearrangements improves outcomes compared with chemotherapy. This study assessed real-world ALK testing patterns among community practices in the United States in patients with advanced (stage IIIB or IV) NSCLC. Methods Patients age ≥ 18 years with two or more visits within the Flatiron Health electronic health record–derived database after January 2011 and diagnosed with stage IIIB or IV NSCLC through May 2017 were included in this analysis. Logistic regression was used to examine the association between demographic and clinical characteristics and testing for ALK rearrangements. Results Of 31,483 patients analyzed from the database, 16,726 patients (53.1%) were tested for ALK rearrangements. ALK testing rates were 66.9% and 18.5% in patients with nonsquamous and squamous histology, respectively. Average ALK testing rates increased over time from 32.4% in 2011 to 62.1% in 2016. Fluorescent in situ hybridization was the most common ALK testing method. Agreement between fluorescent in situ hybridization and other assays ranged from 94.1% to 97.9%. Median (interquartile range) time from laboratory receipt of sample to first ALK test result was 7 (7) days; median time from advanced diagnosis to first ALK test result was 25 (29) days. Patients who were older, male, had a history of smoking, lived in non-Western US regions, and who had recurrent disease or squamous histology were less likely to be tested for ALK. Patients with Medicaid and Medicare insurance were less likely to be tested than patients with commercial insurance. Overall, 21.5% of patients initiated therapy (20.4% chemotherapy) before receiving test results. Conclusion ALK testing rates have increased over time. However, certain subgroups of patients are less likely to be tested, suggesting that additional education on molecular testing is warranted.
Collapse
Affiliation(s)
- Peter B. Illei
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| | - William Wong
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| | - Ning Wu
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| | - Laura Chu
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| | - Ravindra Gupta
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| | - Katja Schulze
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| | - Matthew A. Gubens
- Peter B. Illei, Johns Hopkins University School of Medicine, Baltimore, MD; William Wong, Laura Chu, Ravindra Gupta, and Katja Schulze, Genentech, South San Francisco; Matthew A. Gubens, University of California, San Francisco, CA; and Ning Wu, PRO Unlimited, Boca Raton, FL
| |
Collapse
|
356
|
Davies J, Reyes-Rivera I, Pattipaka T, Skirboll S, Ugiliweneza B, Woo S, Boakye M, Abrey L, Garcia J, Burton E. Survival in elderly glioblastoma patients treated with bevacizumab-based regimens in the United States. Neurooncol Pract 2018; 5:251-261. [PMID: 31385957 PMCID: PMC6655482 DOI: 10.1093/nop/npy001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The efficacy of bevacizumab (BEV) in elderly patients with glioblastoma remains unclear. We evaluated the effect of BEV on survival in this patient population using the Survival, Epidemiology, and End Results (SEER)-Medicare database. METHODS This retrospective, cohort study analyzed SEER-Medicare data for patients (aged ≥66 years) diagnosed with glioblastoma from 2006 to 2011. Two cohorts were constructed: one comprised patients who had received BEV (BEV cohort); the other comprised patients who had received any anticancer treatment other than BEV (NBEV cohort). The primary analysis used a multivariate Cox proportional hazards model to compare overall survival in the BEV and NBEV cohorts with initiation of BEV as a time-dependent variable, adjusting for potential confounders (age, gender, Charlson comorbidity index, region, race, radiotherapy after initial surgery, and diagnosis of coronary artery disease). Sensitivity analyses were conducted using landmark survival, propensity score modeling, and the impact of poor Karnofsky Performance Status. RESULTS We identified 2603 patients (BEV, n = 597; NBEV, n = 2006). In the BEV cohort, most patients were Caucasian males and were younger with fewer comorbidities and more initial resections. In the primary analysis, the BEV cohort showed a lower risk of death compared with the NBEV cohort (hazard ratio, 0.80; 95% confidence interval, 0.72-0.89; P < .01). The survival benefit of BEV appeared independent of the number of temozolomide cycles or frontline treatment with radiotherapy and temozolomide. CONCLUSION BEV exposure was associated with a lower risk of death, providing evidence that there might be a potential benefit of BEV in elderly patients with glioblastoma.
Collapse
Affiliation(s)
| | | | | | | | | | - Shiao Woo
- University of Louisville School of Medicine and James Graham Brown Cancer Center, Louisville, Kentucky, USA (S.W.)
| | - Maxwell Boakye
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | | | | | - Eric Burton
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| |
Collapse
|
357
|
Mazor AM, Mateo AM, Demora L, Sigurdson ER, Handorf E, Daly JM, Aggon AA, Anderson PR, Weiss SE, Bleicher RJ. Breast conservation versus mastectomy in patients with T3 breast cancers (> 5 cm): an analysis of 37,268 patients from the National Cancer Database. Breast Cancer Res Treat 2018; 173:301-311. [PMID: 30343456 DOI: 10.1007/s10549-018-5007-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/09/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Breast conservation therapy (BCT) is standard for T1-T2 tumors, but early trials excluded breast cancers > 5 cm. This study was performed to assess patterns and outcomes of BCT for T3 tumors. METHODS We reviewed the National Cancer Database (NCDB) for noninflammatory breast cancers > 5 cm, between 2004 and 2011 who underwent BCT or mastectomy (Mtx) with nodal evaluation. Patients with skin or chest wall involvement were excluded. Patients having clinical T3 tumors were analyzed to determine outcomes based upon presentation, with those having pathologic T3 tumors, subsequently assessed, irrespective of presentation. Overall survival (OS) was analyzed using multivariable Cox proportional hazards models, with adjusted survival curves estimated using inverse probability weighting. RESULTS After exclusions, 37,268 patients remained. Median age and tumor size for BCT versus Mtx were 53 versus 54 years (p < 0.001) and 6.0 versus 6.7 cm (p < 0.001), respectively. Predictors of BCT included age, race, location, facility type, year of diagnosis, tumor size, grade, histology, nodes examined and positive, and administration of chemotherapy and radiotherapy. OS was similar between Mtx and BCT (p = 0.36). This held true when neoadjuvant chemotherapy patients were excluded (p = 0.39). BCT percentages declined over time (p < 0.001), while tumor sizes remained the same (p = 0.77). Median follow-up was 51.4 months. CONCLUSIONS OS for patients with T3 breast cancers is similar whether patients received Mtx or BCT, confirming that tumor size should not be an absolute BCT exclusion. Declining use of BCT for tumors > 5 cm in younger patients may be accounted for by recent trends toward mastectomy.
Collapse
Affiliation(s)
- Anna M Mazor
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Room C-308, Philadelphia, PA, 19111, USA
| | - Alina M Mateo
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Room C-308, Philadelphia, PA, 19111, USA
| | - Lyudmila Demora
- Department of Biostatistics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Room C-308, Philadelphia, PA, 19111, USA
| | - Elizabeth Handorf
- Department of Biostatistics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - John M Daly
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Room C-308, Philadelphia, PA, 19111, USA
| | - Allison A Aggon
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Room C-308, Philadelphia, PA, 19111, USA
| | - Penny R Anderson
- Departments of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Stephanie E Weiss
- Departments of Radiation Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Room C-308, Philadelphia, PA, 19111, USA.
| |
Collapse
|
358
|
Abstract
BACKGROUND Even small delays in the treatment of breast cancer are a frequently expressed concern of patients. Knowledge about this subject is important for clinicians to counsel patients appropriately and realistically, while also optimizing care. Although data and quality measures regarding time to chemotherapy and radiotherapy have been present for some time, data regarding surgical care are more recent and no standard exists. This review was written to discuss our current knowledge about the relationship of treatment times to outcomes. METHODS The published medical literature addressing delays and optimal times to treatment was reviewed in the context of our current time-dependent standards for chemotherapy and radiotherapy. The surgical literature and the lack of a time-dependent surgical standard also were discussed, suggesting a possible standard. RESULTS Risk factors for delay are numerous, and tumor doubling times are both difficult to determine and unhelpful to assess the impact of longer treatment times on outcomes. Evaluation components also have a time cost and are inextricable from the patient's workup. Although the published literature has lack of uniformity, optimal times to each modality are strongly suggested by emerging data, supporting the current quality measures. Times to surgery, chemotherapy, and radiotherapy all have a measurable impact on outcomes, including disease-free survival, disease-specific survival, and overall survival. CONCLUSIONS Delays have less of an impact than often thought but have a measurable impact on outcomes. Optimal times from diagnosis are < 90 days for surgery, < 120 days for chemotherapy, and, where chemotherapy is administered, < 365 days for radiotherapy.
Collapse
Affiliation(s)
- Richard J Bleicher
- Department of Surgical Oncology, Room C-308, Fox Chase Cancer Center, Philadelphia, PA, USA.
| |
Collapse
|
359
|
Does breast cancer growth rate really depend on tumor subtype? Measurement of tumor doubling time using serial ultrasonography between diagnosis and surgery. Breast Cancer 2018; 26:206-214. [PMID: 30259332 DOI: 10.1007/s12282-018-0914-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Breast cancer growth is generally expected to differ between tumor subtypes. We aimed to evaluate tumor doubling time (DT) using ultrasonography and verify whether each tumor subtype has a unique DT. METHODS This retrospective study included 265 patients with invasive breast cancer who received serial ultrasonography between diagnosis and surgery. Tumor diameters were measured in three directions and DTs were calculated according to an exponential growth model using the volume change during serial ultrasonography. We investigated the relationships between DT, tumor subtype, and histopathological factors. RESULTS Volumes did not change in 95 (36%) of 265 tumors and increased in 170 (64%) tumors during serial ultrasonography (mean interval, 56.9 days). The mean volume increases of all tumors and volume-increased tumors were 22.1% and 34.5%, respectively. Triple-negative tumors had greater volume increases (40% vs. 20%, p = 0.001) and shorter DT (124 vs. 185 days, p = 0.027) than estrogen receptor (ER)+/human epidermal growth factor receptor 2 (HER2)- tumors. Volume-increased tumors had higher Ki-67 indices than those of volume-stable tumors in ER+/HER2- (p = 0.002) and ER+/HER2+ tumors (p = 0.011) and higher histological grades in all tumors except triple-negative tumors (p < 0.001). Triple-negative tumors with DTs < 90 days (short-DT) showed higher Ki-67 indices than those with DTs > 90 days (long-DT) (p = 0.008). In ER+/HER2- tumors, histological grades were higher for short-DT than for long-DT tumors (p = 0.022). CONCLUSION Differences in tumor DT depending on breast cancer subtype, Ki-67 index, and histological grade were confirmed using serial ultrasonography even during preoperative short interval.
Collapse
|
360
|
Di Girolamo C, Walters S, Gildea C, Benitez Majano S, Rachet B, Morris M. Can we assess Cancer Waiting Time targets with cancer survival? A population-based study of individually linked data from the National Cancer Waiting Times monitoring dataset in England, 2009-2013. PLoS One 2018; 13:e0201288. [PMID: 30133466 PMCID: PMC6104918 DOI: 10.1371/journal.pone.0201288] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/12/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cancer Waiting Time targets have been integrated into successive cancer strategies as indicators of cancer care quality in England. These targets are reported in national statistics for all cancers combined, but there is mixed evidence of their benefits and it is unclear if meeting Cancer Waiting Time targets, as currently defined and published, is associated with improved survival for individual patients, and thus if survival is a good metric for judging the utility of the targets. METHODS AND FINDINGS We used individually-linked data from the National Cancer Waiting Times Monitoring Dataset (CWT), the cancer registry and other routinely collected datasets. The study population consisted of all adult patients diagnosed in England (2009-2013) with colorectal (164,890), lung (171,208) or ovarian (24,545) cancer, of whom 82%, 76%, and 77%, respectively, had a CWT matching record. The main outcome was one-year net survival for all matched patients by target attainment ('met/not met'). The time to each type of treatment for the 31-day and 62-day targets was estimated using multivariable analyses, adjusting for age, sex, tumour stage and deprivation. The two-week wait (TWW) from GP referral to specialist consultation and 31-day target from decision to treat to start of treatment were met for more than 95% of patients, but the 62-day target from GP referral to start of treatment was missed more often. There was little evidence of an association between meeting the TWW target and one-year net survival, but for the 31-day and 62-day targets, survival was worse for those for whom the targets were met (e.g. colorectal cancer: survival 89.1% (95%CI 88.9-89.4) for patients with 31-day target met, 96.9% (95%CI 96.1-91.7) for patients for whom it was not met). Time-to-treatment analyses showed that treatments recorded as palliative were given earlier in time, than treatments with potentially curative intent. There are possible limitations in the accuracy of the categorisation of treatment variables which do not allow for fully distinguishing, for example, between curative and palliative intent; and it is difficult in these data to assess the appropriateness of treatment by stage. These limitations in the nature of the data do not affect the survival estimates found, but do mean that it is not possible to separate those patients for whom the times between referral, decision to treat and start of treatment could actually have an impact on the clinical outcomes. This means that the use of these survival measures to evaluate the targets would be misleading. CONCLUSIONS Based on these individually-linked data, and for the cancers we looked at, we did not find that Cancer Waiting Time targets being met translates into improved one-year survival. Patients may benefit psychologically from limited waits which encourage timely treatment, but one-year survival is not a useful measure for evaluating Trust performance with regards to Cancer Waiting Time targets, which are not currently stratified by stage or treatment type. As such, the current composition of the data means target compliance needs further evaluation before being used for the assessment of clinical outcomes.
Collapse
Affiliation(s)
- Chiara Di Girolamo
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Medical and Surgical Sciences, Alma Mater Studorium–University of Bologna, Bologna, Italy
| | - Sarah Walters
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Carolynn Gildea
- National Cancer Registration and Analysis Service, Public Health England, Vulcan House Steel, Sheffield, United Kingdom
| | - Sara Benitez Majano
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Bernard Rachet
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Melanie Morris
- Cancer Survival Group, Faculty of Epidemiology and Population Health, Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
361
|
Amraoui J, Pouliquen C, Fraisse J, Dubourdieu J, Rey Dit Guzer S, Leclerc G, de Forges H, Jarlier M, Gutowski M, Bleuse JP, Janiszewski C, Diaz J, Cuvillon P. Effects of a Hypnosis Session Before General Anesthesia on Postoperative Outcomes in Patients Who Underwent Minor Breast Cancer Surgery: The HYPNOSEIN Randomized Clinical Trial. JAMA Netw Open 2018; 1:e181164. [PMID: 30646110 PMCID: PMC6324272 DOI: 10.1001/jamanetworkopen.2018.1164] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Hypnosis is now widespread in medical practice and is emerging as an alternative technique for pain management and anxiety. However, its effects on postoperative outcomes remain unclear. OBJECTIVE To evaluate the efficacy of a preoperative hypnosis session for reducing postoperative breast pain in patients who underwent minor breast cancer surgery. DESIGN, SETTING, AND PARTICIPANTS The HYPNOSEIN prospective randomized clinical trial was conducted from October 7, 2014, to April 5, 2016. In this multicenter study in France, 150 women scheduled for minor breast cancer surgery were randomized between control and hypnosis arms, and 148 (71 control and 77 hypnosis) were included in the intent-to-treat analysis. INTERVENTION On the day of surgery, eligible patients were randomly assigned (1:1) to the control arm or the hypnosis arm. Patients (but not the care teams) were blinded to the arm to which they were assigned. A 15-minute hypnosis session before general anesthesia in the operating room was performed in the hypnosis arm. MAIN OUTCOMES AND MEASURES The primary end point was breast pain reduction (by 2 on a visual analog scale), assessed immediately before discharge from the postanesthesia care unit (PACU). Secondary end points were nausea/vomiting, fatigue, comfort/well-being, anxiety, and PACU length of stay, assessed at different times until postoperative day 30. RESULTS The median patient age was 57 years (range, 33-79 years) in the control arm and 53 years (range, 20-84 years) in the hypnosis arm. Baseline characteristics were similar in the 2 arms. The median duration of the hypnosis session was 6 minutes (range, 2-15 minutes). The use of intraoperative opioids and hypnotics was lower in the hypnosis arm. The mean (SD) breast pain score (range, 0-10) was 1.75 (1.59) in the control arm vs 2.63 (1.62) in the hypnosis arm (P = .004). At PACU discharge and with longer follow-up, no statistically significant difference in breast pain was reported. Fatigue was significantly lower in the hypnosis arm on the evening of surgery (mean [SD] score, 3.81 [2.15] in the control arm vs 2.99 [2.56] in the hypnosis arm; P = .03). The median PACU length of stay was 60 minutes (range, 20-290 minutes) in the control arm vs 46 minutes (range, 5-100 minutes) in the hypnosis arm (P = .002). Exploratory analyses according to patient perception of whether she received hypnosis showed significantly lower fatigue scores in the perceived hypnosis subgroup on the evening of surgery (mean [SD], 4.13 [2.26] for no perceived hypnosis vs 2.97 [2.42] for perceived hypnosis; P = .01). Anxiety was also significantly lower on the evening of surgery in the perceived hypnosis subgroup (mean [SD], 0.75 [1.64] for perceived hypnosis vs 1.67 [2.29] for no perceived hypnosis; P = .03). CONCLUSIONS AND RELEVANCE The results of this study do not support a benefit of hypnosis on postoperative breast pain in women undergoing minor breast cancer surgery. However, other outcomes seem to be improved, which needs to be confirmed by further studies. TRIAL REGISTRATION EudraCT Identifier: 2014-A00681-46 and ClinicalTrials.gov Identifier: NCT03253159.
Collapse
Affiliation(s)
- Jibba Amraoui
- Department of Anesthesia, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Camille Pouliquen
- Department of Anesthesia, Paoli Calmette Institute, Marseille, France
| | - Julien Fraisse
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Jacques Dubourdieu
- Department of Anesthesia, Centre Hospitalier Universitaire Montpellier, University of Montpellier, Montpellier, France
| | - Sophie Rey Dit Guzer
- Department of Anesthesia, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Gilles Leclerc
- Department of Anesthesia, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Hélène de Forges
- Department of Clinical Research, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Marta Jarlier
- Biometrics Unit, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Marian Gutowski
- Department of Surgical Oncology, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Jean-Pierre Bleuse
- Department of Clinical Research, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Chloé Janiszewski
- Department of Clinical Research, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Jésus Diaz
- Department of Anesthesia, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
| | - Philippe Cuvillon
- Department of Anesthesia, Montpellier Cancer Institute (ICM), University of Montpellier, Montpellier, France
- Department of Anesthesia, Centre Hospitalier Universitaire Nîmes, University of Montpellier, Nîmes, France
| |
Collapse
|
362
|
Joshi SS, Handorf ER, Smaldone MC, Geynisman DM. What can the National Cancer Database tell us about disparities in advanced bladder cancer outcomes? Transl Androl Urol 2018; 7:732-735. [PMID: 30211063 PMCID: PMC6127539 DOI: 10.21037/tau.2018.06.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Shreyas S Joshi
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elizabeth R Handorf
- Department of Bioinformatics and Biostatistics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Marc C Smaldone
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Daniel M Geynisman
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| |
Collapse
|
363
|
Jabo B, Lin AC, Aljehani MA, Ji L, Morgan JW, Selleck MJ, Kim HY, Lum SS. Impact of Breast Reconstruction on Time to Definitive Surgical Treatment, Adjuvant Therapy, and Breast Cancer Outcomes. Ann Surg Oncol 2018; 25:3096-3105. [DOI: 10.1245/s10434-018-6663-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 12/11/2022]
|
364
|
Patel SA, Ng M, Nardello SM, Ruth K, Bleicher RJ. Immediate breast reconstruction for women having inflammatory breast cancer in the United States. Cancer Med 2018; 7:2887-2902. [PMID: 29761885 PMCID: PMC6051180 DOI: 10.1002/cam4.1546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/10/2018] [Accepted: 03/15/2018] [Indexed: 01/07/2023] Open
Abstract
Inflammatory breast cancer (IBC) is an aggressive malignancy having a poor prognosis. Traditionally, reconstruction is not offered due to concerns about treatment delay, margin positivity, recurrence, and poor long-term survival. There is a paucity of literature, however, evaluating whether immediate breast reconstruction (IBR) is associated with greater mortality in patients with IBC. A population-based study was conducted via the SEER-Medicare-linked database (1991-2009). Female patients greater than 65 years were reviewed who had mastectomy and reconstruction claims for nonmetastatic IBC. Competing risk and Cox regression were used to assess whether IBR was associated with higher breast cancer-specific mortality (BCSM) or overall mortality (OM). Among 552 936 patients, 1472 (median age 74 years) were diagnosed with IBC and had a mastectomy. Forty-four patients (3%) underwent IBR. Younger age, a lower Charlson comorbidity score, and a greater median income were predictors of IBR use. Tumor grade, hormone receptor status, and lymph node status were independent predictors of adjusted OM and BCSM. There was no difference by IBR status in BCSM or covariate-adjusted BCSM (sHR 1.04; CI 0.71-1.54; P = .83 and sHR 1.13; CI 0.84-1.93; P = .58, respectively). Cumulative incidence of OM was lower among IR patients (P = .013), and IR did not influence the cumulative incidence of BCSM (P = .91). IBR was not associated with increased overall and BCSM mortality. Although further study of IBR in the IBC setting may be of value, these data suggest that IBC should not be considered an absolute contraindication to IBR.
Collapse
Affiliation(s)
- Sameer A. Patel
- Department of Surgical OncologyFox Chase Cancer CenterPhiladelphiaPAUSA
| | - Marilyn Ng
- Division Plastic, Reconstructive and Hand SurgeryDepartment of SurgeryNorthwell Health‐Staten Island University HospitalStaten IslandNYUSA
| | | | - Karen Ruth
- Department of BiostatisticsFox Chase Cancer CenterPhiladelphiaPAUSA
| | | |
Collapse
|
365
|
Fonseca V, Brito M. Starting hormone therapy immediately after histological diagnosis of breast cancer. Breast J 2018; 24:693-694. [DOI: 10.1111/tbj.12995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Vasco Fonseca
- Centro Hospitalar de Lisboa Ocidental; Lisboa Portugal
| | | |
Collapse
|
366
|
|
367
|
Curtis GL, Lawrenz JM, George J, Styron JF, Scott J, Shah C, Shepard DR, Rubin B, Nystrom LM, Mesko NW. Adult soft tissue sarcoma and time to treatment initiation: An analysis of the National Cancer Database. J Surg Oncol 2018; 117:1776-1785. [DOI: 10.1002/jso.25095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 04/16/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Gannon L. Curtis
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | | | - Jaiben George
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Joe F. Styron
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Jacob Scott
- Taussig Cancer Institute; Cleveland Clinic; Cleveland Ohio
| | - Chirag Shah
- Taussig Cancer Institute; Cleveland Clinic; Cleveland Ohio
| | | | - Brian Rubin
- Department of Pathology; Cleveland Clinic; Cleveland Ohio
| | - Lukas M. Nystrom
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Nathan W. Mesko
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| |
Collapse
|
368
|
Sardar M, Shaikh N, Malik SU, Anwer F, Lee P, Sharon D, Eng MH. Possible Predictive Factors for In-hospital Cardiac Arrest in Patients with Cancer: A Retrospective Single Center Study. Cureus 2018; 10:e2828. [PMID: 30131921 PMCID: PMC6101448 DOI: 10.7759/cureus.2828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/18/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Despite cancer being the second most common cause of death in the United States, more people are living longer after the diagnosis of cancer than before. Healthcare workers will be treating an increasing number of patients with cancer. Various studies have identified predictors of cardiac arrest in the general population, however, none have been done to identify such factors in cancer patients who form a more vulnerable group with lower survival rate following cardiac arrest. METHODS We retrospectively analysed charts of all patients with active cancer who experienced in-hospital cardiac arrest (IHCA) and underwent cardio-pulmonary resuscitation (CPR) from January 2015 to December 2017 at our hospital (n=44, group A). We compared this group to 44 consecutive patients with active cancer admitted to the oncology unit who did not experience cardiac arrest (n=44, group B). We excluded patients in remission. RESULTS Both the groups were comparable in terms of age (69 ± 14 vs 68 ± 15, p=0.776) and gender distribution (50% vs 56% males, p=0.521). Prevalence of coronary artery disease (CAD) (25% vs 11%, p=0.097), hypertension (68% vs 66%, p=0.821), hyperlipidaemia (34% in both groups, p=1.000), tobacco abuse (18% vs 27%, p=0.308), and diabetes mellitus (34% vs 23%, p=0.237) was not significantly different between the two groups. Group with cardiac arrest had significantly higher alanine aminotransferase (100 U/L ± 150 vs 47 U/L ± 87, p=0.043), alkaline phosphatase (288 U/L ± 512 vs 118 U/L ± 80, p=0.032), creatinine (1.8 mg/dl ± 1.74 vs 1.1 mg/dl ± 0.76, p=0.023), international normalised ratio (INR) (2.1 ± 1.5 vs 1.2 ± 0.5, p=0.005), and lower estimated -glomerular filtration rate (43 mL/min/1.73m2 ± 17 vs 51 mL/min/1.73m2 ± 15, p=0.022) on admission. Group A also had significantly higher incidence of sepsis during the hospital course as compared to group B (30% vs 2%, p<0.001). In group A, 11.4% survived to discharge as compared to 95.5% in group B. Significantly higher number of patients in group B were taking chemotherapy (77.27% vs 34.09%, p=0.000046) and radiation therapy (65.9% vs 22.72%, p=0.000046) as compared to group A. CONCLUSION Cancer patients who experienced IHCA had worse renal and hepatic function; they were frequently diagnosed with sepsis and had similar cardiovascular risk factors as compared to cancer patients who did not experience cardiac arrest. Furthermore, a higher number of patients with active cancer who did not experience cardiac arrest were on chemotherapy, immunotherapy or radiation therapy.
Collapse
Affiliation(s)
- Muhammad Sardar
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
| | - Nasreen Shaikh
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, USA
| | | | - Faiz Anwer
- Hematology and Oncology, University of Arizona, Tucson, USA
| | - Patrick Lee
- Hematology Oncology, Monmouth Medical Center, Long Branch, USA
| | - David Sharon
- Hematology Oncology, Monmouth Medical Center, Long Branch, USA
| | - Margaret Hh Eng
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
| |
Collapse
|
369
|
Han X, Zhao J, Ruddy KJ, Lin CC, Sineshaw HM, Jemal A. The impact of dependent coverage expansion under the Affordable Care Act on time to breast cancer treatment among young women. PLoS One 2018; 13:e0198771. [PMID: 29897976 PMCID: PMC5999229 DOI: 10.1371/journal.pone.0198771] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/24/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Breast cancer in young women tends to be more aggressive, but timely treatment may not be always available, particularly to those without health insurance. We aim to examine whether the dependent coverage expansion under the Affordable Care Act (ACA-DCE) implemented in 2010 was associated with changes in time to treatment among women diagnosed with early stage breast cancer. METHODS A total of 7,176 patients diagnosed with early stage breast cancer in 2007-2009 (pre-ACA) and 2011-2013 (post-ACA) were identified from the National Cancer Database. A quasi-experimental design difference-in-differences (DD) approach was used, with patients aged 19-25 (targeted by the policy) considered as the intervention group, and patients aged 26-34 years (not affected by the policy) as the control group. Changes in the following treatment outcomes were examined: time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, and time from adjuvant chemotherapy to radiation. RESULTS Compared with the control group of patients aged 26-34, young patients aged 19-25 experienced a statistically nonsignificant decrease of 2.7 percentage points (95% CI [-1.2, 6.5]) in the uninsured rate. This did not translate into more reduction in delays to surgery (DD = 2.7 days, 95% CI [-3.2, 8.3]), chemotherapy (DD = -1.0 days, 95% CI [-7.2, 5.2]) or radiation (DD = 5.3 days, 95% CI [-15.6, 26.3]) in the younger cohort than the older cohort. CONCLUSIONS AND RELEVANCE No significant changes in time to treatment were found among young women diagnosed with early stage breast cancer after the implementation of the ACA-DCE. Future studies examining impacts of health care policy reform on breast cancer care are warranted to include patients from low-income families and to consider effects from Medicaid expansion.
Collapse
Affiliation(s)
- Xuesong Han
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
- * E-mail:
| | - Jingxuan Zhao
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Kathryn J. Ruddy
- Department of Oncology, Mayo Clinic, Rochester, MN, United States of America
| | - Chun Chieh Lin
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
| | - Helmneh M. Sineshaw
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, United States of America
- Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| |
Collapse
|
370
|
Kim U, Donley G, Koroukian S, Rose J. Balancing the goals of improving health care quality with out-of-pocket costs in breast cancer patients. JOURNAL OF HOSPITAL MANAGEMENT AND HEALTH POLICY 2018; 2:23. [PMID: 35464493 PMCID: PMC9033056 DOI: 10.21037/jhmhp.2018.05.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Uriel Kim
- Case Western Reserve University School of Medicine, Center for Community Health Integration, Cleveland, Ohio, USA
| | - Gwendolyn Donley
- Case Western Reserve University School of Medicine, Population and Quantitative Health Sciences, Cleveland, Ohio, USA
| | - Siran Koroukian
- Case Western Reserve University School of Medicine, Population and Quantitative Health Sciences, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Johnie Rose
- Case Western Reserve University School of Medicine, Center for Community Health Integration, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| |
Collapse
|
371
|
Larson KE, Grobmyer SR, Karafa M, Pratt D. Time to treatment and survival in triple negative breast cancer patients receiving trimodality treatment in the United States. Cancer Treat Res Commun 2018; 16:32-37. [PMID: 31299000 DOI: 10.1016/j.ctarc.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/25/2018] [Accepted: 04/03/2018] [Indexed: 06/10/2023]
Abstract
BACKGROUND Time from diagnosis to treatment for breast cancer patients has been linked to outcomes. Our goal was to assess the relationship between survival, time to first treatment (TFT), and time to treatment completion (TTC) in Stage I-III triple negative breast cancer (TNBC) receiving trimodality therapy (surgery, chemotherapy, and radiation). METHODS National Cancer Database (NCDB) was queried for TNBC patients diagnosed with Stage I-III disease from 2010 to 2011 who received all treatments (surgery, chemotherapy, radiation) within 18 months of diagnosis. Multivariate analysis controlled for age, stage, operation, neoadjuvant chemotherapy (NAC), and comorbidities. RESULTS 17,717 women were included. Most had early stage disease (34.1% Stage 1; 48.2% Stage 2) treated with lumpectomy (69.2%) and adjuvant chemotherapy (63.3%). During follow-up (2.8 ± 1.1 years), mortality was 11.4%. TFT was 34.8 days for NAC and 35.6 days for surgery. Multivariate analysis demonstrated no mortality difference when considering TFT in 30 day (p = 0.43) or 6 week (p = 0.91) intervals. When separating into NAC or surgery first, there remained no mortality difference when considering TFT in 30 day (NAC p = 0.96, surgery p = 0.26) or 6 week (NAC p = 0.91, surgery p = 0.91) intervals. Overall, TTC was 9.0 ± 1.8 months. When dividing patients into tertiles by TTC, multivariate analysis demonstrated no survival difference between groups (p = 0.9). There was also no mortality difference for each 30 day increased TTC (p = 0.40). CONCLUSIONS In Stage I-III TNBC patients receiving trimodality therapy, TFT (NAC or surgery) and TTC do not impact short-term survival if TTC is <18 months.
Collapse
Affiliation(s)
- K E Larson
- Department of General Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH, USA; Department of Surgery, Division of Breast Surgery, University of Kansas Health System, Kansas City, KS, USA
| | - S R Grobmyer
- Department of General Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH, USA
| | - M Karafa
- Department of Quantitate Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - D Pratt
- Department of General Surgery, Division of Breast Services, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
372
|
Bachand J, Soulos PR, Herrin J, Pollack CE, Xu X, Ma X, Gross CP. Physician peer group characteristics and timeliness of breast cancer surgery. Breast Cancer Res Treat 2018; 170:657-665. [PMID: 29693229 DOI: 10.1007/s10549-018-4789-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/13/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Little is known about how the structure of interdisciplinary groups of physicians affects the timeliness of breast cancer surgery their patients receive. We used social network methods to examine variation in surgical delay across physician peer groups and the association of this delay with group characteristics. METHODS We used linked Surveillance, Epidemiology, and End Results-Medicare data to construct physician peer groups based on shared breast cancer patients. We used hierarchical generalized linear models to examine the association of three group characteristics, patient racial composition, provider density (the ratio of potential vs. actual connections between physicians), and provider transitivity (clustering of providers within groups), with delayed surgery. RESULTS The study sample included 8338 women with breast cancer in 157 physician peer groups. Surgical delay varied widely across physician peer groups (interquartile range 28.2-50.0%). For every 10% increase in the percentage of black patients in a peer group, there was a 41% increase in the odds of delayed surgery for women in that peer group regardless of a patient's own race [odds ratio (OR) 1.41, 95% confidence interval (CI) 1.15-1.73]. Women in physician peer groups with the highest provider density were less likely to receive delayed surgery than those in physician peer groups with the lowest provider density (OR 0.65, 95% CI 0.44-0.98). We did not find an association between provider transitivity and delayed surgery. CONCLUSIONS The likelihood of surgical delay varied substantially across physician peer groups and was associated with provider density and patient racial composition.
Collapse
Affiliation(s)
- Jacqueline Bachand
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT, 06520, USA
| | - Jeph Herrin
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA.,Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Health Research & Educational Trust, Chicago, IL, USA
| | - Craig E Pollack
- Johns Hopkins School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Xiao Xu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA.,Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA.,Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale School of Medicine, New Haven, CT, USA. .,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT, 06520, USA.
| |
Collapse
|
373
|
Larson KE, Grobmyer SR, Valente SA. Evaluation of recurrence patterns and survival in modern series of young women with breast cancer. Breast J 2018; 24:749-754. [PMID: 29687541 DOI: 10.1111/tbj.13041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/10/2017] [Accepted: 10/04/2017] [Indexed: 01/12/2023]
Abstract
The data on oncologic outcomes in young women with breast cancer (BC) are dated as it relates to recurrences and mortality. Our goal was to assess these outcomes in a modern series of young women with BC. A retrospective chart review identified women ≤40 years old with stage I-III BC diagnosed from 2006 to 2013 at our institution. Demographics, tumor biology, type of operation, recurrence, and survival were analyzed. Overall, 322 women were identified. Most had ER+(70%) infiltrating ductal tumors (88%) with low stage (42% T1; 41% T2; 56% N0). Follow-up was 4.2 years with 5.6% local-regional recurrence (LRR), 15.2% metastatic recurrence (MR), and 8% mortality. There was no survival difference based on demographics, tumor biology, or type of operation. T3 tumors (P < .001) and node positivity (P < .001) were associated with worse disease-free survival. In this modern series of young women with BC, stage rather than tumor biology or surgical choice has more effect on recurrence-free survival. MR was more common than LRR, with most MR occurring within the first 2 years after surgery.
Collapse
Affiliation(s)
- Kelsey E Larson
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen R Grobmyer
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie A Valente
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
374
|
Eriksson L, Bergh J, Humphreys K, Wärnberg F, Törnberg S, Czene K. Time from breast cancer diagnosis to therapeutic surgery and breast cancer prognosis: A population-based cohort study. Int J Cancer 2018; 143:1093-1104. [PMID: 29603736 DOI: 10.1002/ijc.31411] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/07/2018] [Accepted: 03/22/2018] [Indexed: 11/12/2022]
Abstract
Theoretically, time from breast cancer diagnosis to therapeutic surgery should affect survival. However, it is unclear whether this holds true in a modern healthcare setting in which breast cancer surgery is carried out within weeks to months of diagnosis. This is a population- and register-based study of all women diagnosed with invasive breast cancer in the Stockholm-Gotland healthcare region in Sweden, 2001-2008, and who were initially operated. Follow-up of vital status ended 2014. 7,017 women were included in analysis. Our main outcome was overall survival. Main analyses were carried out using Cox proportional hazards models. We adjusted for likely confounders and stratified on mode of detection, tumor size and lymph node metastasis. We found that a longer interval between date of morphological diagnosis and therapeutic surgery was associated with a poorer prognosis. Assuming a linear association, the hazard rate of death from all causes increased by 1.011 (95% CI 1.006-1.017) per day. Comparing, for example, surgery 6 weeks after diagnosis to surgery 3 weeks after diagnosis, thereby confers a 1.26-fold increased hazard rate. The increase in hazard rate associated with surgical delay was strongest in women with largest tumors. Whilst there was a clear association between delays and survival in women without lymph node metastasis, the association may be attenuated in subgroups with increasing number of lymph node metastases. We found no evidence of an interaction between time to surgery and mode of detection. In conclusion, unwarranted delays to primary treatment of breast cancer should be avoided.
Collapse
Affiliation(s)
- Louise Eriksson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 171 77, Sweden.,Department of Oncology-Pathology, Cancer Center Karolinska, Department of Oncology, Radiumhemmet, Karolinska Institutet and Karolinska University Hospital, Stockholm, 17176, Sweden
| | - Jonas Bergh
- Department of Oncology-Pathology, Cancer Center Karolinska, Department of Oncology, Radiumhemmet, Karolinska Institutet and Karolinska University Hospital, Stockholm, 17176, Sweden
| | - Keith Humphreys
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 171 77, Sweden
| | - Fredrik Wärnberg
- Department of Surgical Sciences, Uppsala University, Uppsala, 751 85, Sweden.,Department of Surgery, Uppsala Academic Hospital, Uppsala, 751 85, Sweden
| | - Sven Törnberg
- Department of Cancer Screening, Stockholm-Gotland Regional Cancer Centre, Stockholm, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 171 77, Sweden
| |
Collapse
|
375
|
Perlow HK, Ramey SJ, Silver B, Kwon D, Chinea FM, Samuels SE, Samuels MA, Elsayyad N, Yechieli R. Assessment of Oropharyngeal and Laryngeal Cancer Treatment Delay in a Private and Safety Net Hospital System. Otolaryngol Head Neck Surg 2018; 159:484-493. [DOI: 10.1177/0194599818768795] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To examine the impact of treatment setting and demographic factors on oropharyngeal and laryngeal cancer time to treatment initiation (TTI). Study Design Retrospective case series. Setting Safety net hospital and adjacent private academic hospital. Subjects and Methods Demographic, staging, and treatment details were retrospectively collected for 239 patients treated from January 1, 2014, to June 30, 2016. TTI was defined as days between diagnostic biopsy and initiation of curative treatment (defined as first day of radiotherapy [RT], surgery, or chemotherapy). Results On multivariable analysis, safety net hospital treatment (vs private academic hospital treatment), initial diagnosis at outside hospital, and oropharyngeal cancer (vs laryngeal cancer) were all associated with increased TTI. Surgical treatment, severe comorbidity, and both N1 and N2 status were associated with decreased TTI. Conclusion Safety net hospital treatment was associated with increased TTI. No differences in TTI were found when language spoken and socioeconomic status were examined in the overall cohort.
Collapse
Affiliation(s)
- Haley K. Perlow
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Stephen J. Ramey
- Department of Radiation Oncology, Jackson Memorial Hospital, Miami, Florida, USA
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Ben Silver
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Felix M. Chinea
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Stuart E. Samuels
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Michael A. Samuels
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Nagy Elsayyad
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| | - Raphael Yechieli
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
- Department of Radiation Oncology, University of Miami, Florida, USA
| |
Collapse
|
376
|
Evaluation of waiting times for breast cancer diagnosis and surgical treatment. Clin Transl Oncol 2018; 20:1345-1352. [DOI: 10.1007/s12094-018-1867-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/26/2018] [Indexed: 02/01/2023]
|
377
|
Ramey SJ, Asher D, Kwon D, Ahmed AA, Wolfson AH, Yechieli R, Portelance L. Delays in definitive cervical cancer treatment: An analysis of disparities and overall survival impact. Gynecol Oncol 2018; 149:53-62. [PMID: 29605051 DOI: 10.1016/j.ygyno.2017.12.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/03/2017] [Accepted: 12/07/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Delays in time to treatment initiation (TTI) with definitive radiation therapy (RT) or chemotherapy and RT (CRT) for cervical cancer could lead to poorer outcomes. This study investigates disparities in TTI and the impact of TTI on overall survival (OS). METHODS Adult women with non-metastatic cervical squamous cell carcinoma diagnosed between 2004 and 2014, treated with definitive RT or CRT, and reported to the National Cancer Database were included. TTI was defined as days from diagnosis to start of RT or CRT. The impact of TTI on OS in patients treated with concurrent CRT which included brachytherapy was then assessed. RESULTS Overall, 14,924 patients were included (84.7% CRT, 15.3% RT). TTI was significantly longer for Non-Hispanic Black (NHB) (RR, 1.14; 95% CI, 1.11 to 1.18) and Hispanic women (RR, 1.19; 95% CI, 1.15 to 1.24) compared to Non-Hispanic White (NHW) women. Expected TTI (eTTI) for NHW, NHB, and Hispanic women were 38.1, 45.2, and 49.4days. eTTI rose from 36.2days in 2004 to 44.3days by 2014. Intensity-modulated radiation therapy (IMRT) was associated with increased eTTI of 46.5days versus 40.0days for non-IMRT. Longer TTI was not associated with inferior OS in patients treated with concurrent CRT. CONCLUSIONS Delays in starting RT/CRT for cervical cancer increased from 2004 to 2014. Delays disproportionately affect NHB and Hispanic women. However, increased TTI was not associated with increased mortality for women receiving CRT. Further study of TTI's impact on other endpoints is warranted to determine if TTI represents an important quality indicator.
Collapse
Affiliation(s)
- Stephen J Ramey
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - David Asher
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Shared Resource, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Awad A Ahmed
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Aaron H Wolfson
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Raphael Yechieli
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Lorraine Portelance
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, FL, United States.
| |
Collapse
|
378
|
Impact of Insurance Coverage on Outcomes in Primary Breast Sarcoma. Sarcoma 2018; 2018:4626174. [PMID: 29736143 PMCID: PMC5875066 DOI: 10.1155/2018/4626174] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/06/2017] [Accepted: 12/17/2017] [Indexed: 11/17/2022] Open
Abstract
Private insurance is associated with better outcomes in multiple common cancers. We hypothesized that insurance status would significantly impact outcomes in primary breast sarcoma (PBS) due to the additional challenges of diagnosing and coordinating specialized care for a rare cancer. Using the National Cancer Database, we identified adult females diagnosed with PBS between 2004 and 2013. The influence of insurance status on overall survival (OS) was evaluated using the Kaplan-Meier estimator with log-rank tests and Cox proportional hazard models. Among a cohort of 607 patients, 67 (11.0%) had Medicaid, 217 (35.7%) had Medicare, and 323 (53.2%) had private insurance. Compared to privately insured patients, Medicaid patients were more likely to present with larger tumors and have their first surgical procedure further after diagnosis. Treatment was similar between patients with comparable disease stage. In multivariate analysis, Medicaid (hazard ratio (HR), 2.47; 95% confidence interval (CI), 1.62-3.77; p < 0.001) and Medicare (HR, 1.68; 95% CI, 1.10-2.57; p=0.017) were independently associated with worse OS. Medicaid insurance coverage negatively impacted survival compared to private insurance more in breast sarcoma than in breast carcinoma (interaction p < 0.001). In conclusion, patients with Medicaid insurance present with later stage disease and have worse overall survival than privately insured patients with PBS. Worse outcomes for Medicaid patients are exacerbated in this rare cancer.
Collapse
|
379
|
The National Surgical Quality Improvement Program 30-Day Challenge: Microsurgical Breast Reconstruction Outcomes Reporting Reliability. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1643. [PMID: 29707443 PMCID: PMC5908495 DOI: 10.1097/gox.0000000000001643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 11/29/2017] [Indexed: 12/04/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The aim was to assess reliability of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) 30-day perioperative outcomes and complications for immediate, free-tissue transfer breast reconstruction by direct comparisons with our 30-day and overall institutional data, and assessing those that occur after 30 days. Methods: Data were retrieved for consecutive immediate, free-tissue transfer breast reconstruction patients from a single-institution database (2010–2015) and the ACS-NSQIP (2011–2014). Multiple logistic regressions were performed to compare adjusted outcomes between the 2 datasets. Results: For institutional versus ACS-NSQIP outcomes, there were no significant differences in surgical-site infection (SSI; 30-day, 3.6% versus 4.1%, P = 0.818; overall, 5.3% versus 4.1%, P = 0.198), wound disruption (WD; 30-day, 1.3% versus 1.5%, P = 0.526; overall, 2.3% versus 1.5%, P = 0.560), or unplanned readmission (URA; 30-day, 2.3% versus 3.3%, P = 0.714; overall, 4.6% versus 3.3%, P = 0.061). However, the ACS-NSQIP reported a significantly higher unplanned reoperation (URO) rate (30-day, 3.6% versus 9.5%, P < 0.001; overall, 5.3% versus 9.5%, P = 0.025). Institutional complications consisted of 5.3% SSI, 2.3% WD, 5.3% URO, and 4.6% URA, of which 25.0% SSI, 28.6% WD, 12.5% URO, and 7.1% URA occurred at 30–60 days, and 6.3% SSI, 14.3% WD, 18.8% URO, and 42.9% URA occurred after 60 days. Conclusion: For immediate, free-tissue breast reconstruction, the ACS-NSQIP may be reliable for monitoring and comparing SSI, WD, URO, and URA rates. However, clinicians may find it useful to understand limitations of the ACS-NSQIP for complications and risk factors, as it may underreport complications occurring beyond 30 days.
Collapse
|
380
|
Yadav S, Jinna S, Pereira-Rodrigues O, Reeves A, Campian S, Sufka A, Zakalik D. Impact of preoperativeBRCA1/2testing on surgical decision making in patients with newly diagnosed breast cancer. Breast J 2018; 24:541-548. [DOI: 10.1111/tbj.13007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 07/30/2017] [Accepted: 08/03/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Siddhartha Yadav
- Hematology-Oncology Fellowship Program; Mayo Clinic; Rochester MN USA
| | - Sruthi Jinna
- Department of Internal Medicine; Beaumont Health; Royal Oak MI USA
| | | | - Ashley Reeves
- Nancy and James Grosfeld Cancer Genetics Center; Beaumont Cancer Institute; Beaumont Health; Royal Oak MI USA
| | - Sarah Campian
- Nancy and James Grosfeld Cancer Genetics Center; Beaumont Cancer Institute; Beaumont Health; Royal Oak MI USA
| | - Amy Sufka
- Nancy and James Grosfeld Cancer Genetics Center; Beaumont Cancer Institute; Beaumont Health; Royal Oak MI USA
| | - Dana Zakalik
- Nancy and James Grosfeld Cancer Genetics Center; Beaumont Cancer Institute; Beaumont Health; Royal Oak MI USA
- Oakland University William Beaumont School of Medicine; Rochester MI USA
| |
Collapse
|
381
|
Wharam JF, Zhang F, Lu CY, Wagner AK, Nekhlyudov L, Earle CC, Soumerai SB, Ross-Degnan D. Breast Cancer Diagnosis and Treatment After High-Deductible Insurance Enrollment. J Clin Oncol 2018; 36:1121-1127. [PMID: 29489428 DOI: 10.1200/jco.2017.75.2501] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose High-deductible health plans (HDHPs) require substantial out-of-pocket spending and might delay crucial health services. Breast cancer treatment delays of as little as 2 months are associated with adverse outcomes. Methods We used a controlled prepost design with survival analysis to assess timing of breast cancer care events among 273,499 women age 25 to 64 years without evidence of breast cancer before inclusion. Women were included if continuously enrolled for 1 year in a low-deductible ($0 to $500) plan followed by up to 4 years in a HDHP (at least $1,000 deductible) after an employer-mandated switch. Study inclusion was on a rolling basis, and members were followed between 2003 and 2012. The comparison group comprised 2.4 million contemporaneously matched women whose employers offered only low-deductible plans. Measures were times to first diagnostic breast imaging (diagnostic mammogram, breast ultrasound, or breast magnetic resonance imaging), breast biopsy, incident early-stage breast cancer diagnosis, and breast cancer chemotherapy. Outcomes were analyzed by using Cox models and adjusted for age-group, morbidity score, poverty level, US region, index date, and employer size. Results After the index date, HDHP members experienced delays in receipt of diagnostic imaging (adjusted hazard ratio [aHR], 0.95; 95% CI, 0.94 to 0.96), biopsy (aHR, 0.92; 95% CI, 0.89 to 0.95), early-stage breast cancer diagnosis (aHR, 0.83; 0.78 to 0.90), and chemotherapy initiation (aHR, 0.79; 95% CI, 0.72 to 0.86) compared with the control group. Conclusion Women switched to HDHPs experienced delays in diagnostic breast imaging, breast biopsy, early-stage breast cancer diagnosis, and chemotherapy initiation. Additional research should determine whether such delays cause adverse health outcomes, and policymakers should consider selectively reducing out-of-pocket costs for key breast cancer services.
Collapse
Affiliation(s)
- J Frank Wharam
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Fang Zhang
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Christine Y Lu
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Anita K Wagner
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Larissa Nekhlyudov
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Craig C Earle
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Stephen B Soumerai
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Dennis Ross-Degnan
- J. Frank Wharam, Fang Zhang, Christine Y. Lu, Anita K. Wagner, Stephen B. Soumerai, and Dennis Ross-Degnan, Harvard Medical School and Harvard Pilgrim Health Care Institute; Larissa Nekhlyudov, Dana-Farber Cancer Institute; Boston, MA; and Craig C. Earle, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| |
Collapse
|
382
|
Tan Y, Li X, Chen H, Hu Y, Jiang M, Fu J, Yuan Y, Ding K. Hormone receptor status may impact the survival benefit of surgery in stage iv breast cancer: a population-based study. Oncotarget 2018; 7:70991-71000. [PMID: 27542240 PMCID: PMC5342604 DOI: 10.18632/oncotarget.11235] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 05/29/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction The role of surgery in stage IV breast cancer is controversial. We used the Surveillance, Epidemiology, and End Results database to explore the impact of surgery on the survival of patients with stage IV breast cancer. Methods In total, 10,441 eligible stage IV breast cancer patients from 2004 to 2008 were included. They were divided into four groups as follows: R0 group (patients who underwent primary site and distant metastatic site resection), primary site resection group, metastases resection group, and no resection group. Results The four groups achieved a median survival time (MST) of 51, 43, 31 and 21 months, respectively, P < 0.001. The Cox proportional hazards model showed that the R0 group, primary resection group and metastases resection group had a good survival benefit, with hazard ratios of 0.558 (95% CI, 0.471-0.661), 0.566 (95% CI, 0.557-0.625) and 0.782 (95% CI, 0.693-0.883), respectively. In the hormone receptor (HR)-positive population, the R0 group (MST = 66 m, 5-year OS = 54.1%) gained an additional survival benefit compared with the primary resection group (MST = 52 m; 5-year OS = 44.9%; P < 0.001). The metastases resection group (MST = 38 m; 5-year OS = 31.7%) survived longer than the no resection group (MST = 28 m; 5-year OS = 22.0%; P < 0.001). In the HR-negative population, the R0 group and primary resection group had a similar survival (P = 0.691), and the metastases resection group had a similar outcome to that of the no resection group (P = 0.526). Conclusion Patients who underwent surgery for stage IV breast cancer showed better overall survival than the no resection group. Cytoreductive surgery could provide a survival benefit in HR+ stage IV breast cancer; however, in the HR- population, extreme caution should be exercised when considering surgery.
Collapse
Affiliation(s)
- Yinuo Tan
- Department of Surgical Oncology, 2nd Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China.,Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Xiaofen Li
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Haiyan Chen
- Department of Surgical Oncology, 2nd Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China.,Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Yeting Hu
- Department of Surgical Oncology, 2nd Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China.,Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Mengjie Jiang
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China.,Department of Medical Oncology, 2nd Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Jianfei Fu
- Department of Oncology, Jinhua Central Hospital, Jinhua, P.R. China
| | - Ying Yuan
- Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China.,Department of Medical Oncology, 2nd Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Kefeng Ding
- Department of Surgical Oncology, 2nd Hospital of Zhejiang University School of Medicine, Hangzhou, P.R. China.,Cancer Institute, Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Hangzhou, Zhejiang Province, China, and The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| |
Collapse
|
383
|
Phipps C, Lee YS, Ying H, Nagarajan C, Grigoropoulos N, Chen Y, Tang T, Goh AZ, Ghosh A, Ng HJ, Gopalakrishnan S, Loh Y, Lim ST, Hwang W, Tan D, Goh YT. The impact of time from diagnosis to treatment in diffuse large B-cell lymphoma. Leuk Lymphoma 2018; 59:2336-2341. [DOI: 10.1080/10428194.2017.1422863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Colin Phipps
- Department of Haematology, Singapore General Hospital, Singapore
- Academic Medicine Programme, DUKE-NUS Graduate Medical School, Singapore
| | - Yuh Shan Lee
- Department of Haematology, Singapore General Hospital, Singapore
| | - Hao Ying
- Health Services Research Unit, Division of Medicine, Singapore General Hospital, Singapore
| | | | | | - Yunxin Chen
- Department of Haematology, Singapore General Hospital, Singapore
| | - Tiffany Tang
- Division of Medical Oncology, National Cancer Centre, Singapore
| | - Alan Z. Goh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Aditi Ghosh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
- Academic Medicine Programme, DUKE-NUS Graduate Medical School, Singapore
| | | | - Yvonne Loh
- Department of Haematology, Singapore General Hospital, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre, Singapore
| | - William Hwang
- Department of Haematology, Singapore General Hospital, Singapore
- Academic Medicine Programme, DUKE-NUS Graduate Medical School, Singapore
| | - Daryl Tan
- Department of Haematology, Singapore General Hospital, Singapore
| | - Yeow Tee Goh
- Department of Haematology, Singapore General Hospital, Singapore
- Academic Medicine Programme, DUKE-NUS Graduate Medical School, Singapore
| |
Collapse
|
384
|
Pederson HJ, Hussain N, Noss R, Yanda C, O'Rourke C, Eng C, Grobmyer SR. Impact of an embedded genetic counselor on breast cancer treatment. Breast Cancer Res Treat 2018; 169:43-46. [PMID: 29349711 DOI: 10.1007/s10549-017-4643-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND We predicted that embedding a genetic counselor within our breast practice would improve identification of high-risk individuals, timeliness of care, and appropriateness of surgical decision making. The aim of this study is to compare cancer care between 2012 and 2014, prior to embedding a genetic counselor in the breast center and following the intervention, respectively. METHODS A retrospective review of patients diagnosed with breast cancer in 2012 (n = 471) and 2014 (n = 440) was performed to assess patterns of medical genetics referral, compliance with referral, genetic testing findings, and impact on treatment. RESULTS Between 2012 and 2014, patients were 49% more likely to be referred to genetics, 66% more likely to follow through with their genetic counseling appointment, experienced a 73% reduction in wait times to genetic counseling visits and 69% more likely to have genetic testing results prior to surgery. Notably, while the number of genetic mutations identified was in the expected range over both time periods (9% of those tested in 2012 vs. 6.6% of those tested in 2014), there was a 31% reduction in time to treatment in 2014 vs. 2012. CONCLUSION Awareness of germline genetic mutations is critical in surgical decision making for newly diagnosed breast cancer patients. Having an experienced genetics specialist on site in a busy surgical breast clinic allows for timely access to genetic counseling and testing, and may have influenced time to treatment in our institution.
Collapse
Affiliation(s)
- Holly J Pederson
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave./A80, Cleveland, OH, 44195, USA. .,Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA. .,Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA. .,Department of Genetics and Genome Sciences, Cleveland Clinic, Cleveland, OH, USA. .,CASE Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA.
| | - Najaah Hussain
- CASE Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ryan Noss
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Genetics and Genome Sciences, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Courtney Yanda
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave./A80, Cleveland, OH, 44195, USA.,Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Colin O'Rourke
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Charis Eng
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Genetics and Genome Sciences, Cleveland Clinic, Cleveland, OH, USA.,CASE Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen R Grobmyer
- Division of Breast Services, Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave./A80, Cleveland, OH, 44195, USA.,Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Surgery, Cleveland Clinic, Cleveland, OH, USA.,Department of Genetics and Genome Sciences, Cleveland Clinic, Cleveland, OH, USA.,CASE Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
385
|
Xia L, Taylor BL, Pulido JE, Guzzo TJ. Impact of surgical waiting time on survival in patients with upper tract urothelial carcinoma: A national cancer database study. Urol Oncol 2018; 36:10.e15-10.e22. [DOI: 10.1016/j.urolonc.2017.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/20/2017] [Accepted: 09/14/2017] [Indexed: 12/20/2022]
|
386
|
Mariella M, Kimbrough CW, Mcmasters KM, Ajkay N. Longer Time Intervals from Diagnosis to Surgical Treatment in Breast Cancer: Associated Factors and Survival Impact. Am Surg 2018. [DOI: 10.1177/000313481808400124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Time interval (TI) from breast cancer diagnosis to definitive surgery is increasing, but the impact on outcomes is not well understood. TI longer than 30 days is associated with a greater chance of delay of chemotherapy, which may impact survival. We sought to identify factors associated with longer TI and the influence on outcome measures. Methods: We examined TI for stage 0-III breast cancer patients treated between 2006 and 2015 at a university-based cancer center. Univariate and multivariate analyses were used to study factors associated with TI <30, 30 to 60, and >60 days. Kaplan–Meier plots were used to examine the effect of different TI on overall survival, disease-specific survival, and recurrence-free survival. Results: 1589 patients were included with a median follow-up of 47 months. Median TI was 32 days. Median TI increased in patients from 2011 to 2015 compared with those from 2006 to 2010 (35 vs 30 days, P < 0.001). On multivariate analysis, mastectomy (with or without reconstruction), MRI use, and increasing age were independent predictors of TI >30 days. There were no significant differences in overall survival, disease-specific survival, or recurrence-free survival. There was no association between TI >30 days and a subsequent delay >60 days to adjuvant chemotherapy (OR 1.04, 95% CI 0.72–1.52). Conclusions: TI has increased in the last five years. Patient characteristics, tumor biology, and stage do not influence TI, whereas age, mastectomy, and MRI use were all associated with longer TI. Longer TI does not appear to significantly delay adjuvant chemotherapy or influence short-term outcomes.
Collapse
Affiliation(s)
- Margaret Mariella
- The Hiram C. Polk, Jr. MD, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Charles W. Kimbrough
- The Hiram C. Polk, Jr. MD, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kelly M. Mcmasters
- The Hiram C. Polk, Jr. MD, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Nicolas Ajkay
- The Hiram C. Polk, Jr. MD, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| |
Collapse
|
387
|
Conic RZ, Cabrera CI, Khorana AA, Gastman BR. Determination of the impact of melanoma surgical timing on survival using the National Cancer Database. J Am Acad Dermatol 2018; 78:40-46.e7. [PMID: 29054718 PMCID: PMC6053055 DOI: 10.1016/j.jaad.2017.08.039] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/09/2017] [Accepted: 08/16/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND The ideal timing for melanoma treatment, predominantly surgery, remains undetermined. Patient concern for receiving immediate treatment often exceeds surgeon or hospital availability, requiring establishment of a safe window for melanoma surgery. OBJECTIVE To assess the impact of time to definitive melanoma surgery on overall survival. METHODS Patients with stage I to III cutaneous melanoma and with available time to definitive surgery and overall survival were identified by using the National Cancer Database (N = 153,218). The t test and chi-square test were used to compare variables. Cox regression was used for multivariate analysis. RESULTS In a multivariate analysis of patients in all stages who were treated between 90 and 119 days after biopsy (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.01-1.18) and more than 119 days (HR, 1.12; 95% CI, 1.02-1.22) had a higher risk for mortality compared with those treated within 30 days of biopsy. In a subgroup analysis of stage I, higher mortality risk was found in patients treated within 30 to 59 days (HR, 1.05; 95% CI, 1.01-1.1), 60 to 89 days (HR, 1.16; 95% CI, 1.07-1.25), 90 to 119 days (HR, 1.29; 95% CI, 1.12-1.48), and more than 119 days after biopsy (HR, 1.41; 95% CI, 1.21-1.65). Surgical timing did not affect survival in stages II and III. LIMITATIONS Melanoma-specific survival was not available. CONCLUSION Expeditious treatment of stage I melanoma is associated with improved outcomes.
Collapse
Affiliation(s)
- Ruzica Z Conic
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Claudia I Cabrera
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alok A Khorana
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Brian R Gastman
- Department of Dermatology and Plastic Surgery, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
388
|
Esposito AC, Crawford J, Sigurdson ER, Handorf EA, Hayes SB, Boraas M, Bleicher RJ. Omission of radiotherapy after breast conservation surgery in the postneoadjuvant setting. J Surg Res 2017; 221:49-57. [PMID: 29229152 DOI: 10.1016/j.jss.2017.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 08/01/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Breast conservation therapy (BCT) consists of breast conservation surgery (BCS) and radiotherapy (RT). Neoadjuvant chemotherapy (NACT) can downstage tumors, broadening BCS eligibility in patients requiring mastectomy. However, tumor downstaging does not obviate need for RT. This study evaluated factors that predict RT omission after NACT and BCS. METHODS The National Cancer Database was queried for women with unilateral, clinical stage II-III breast cancer, treated with NACT and BCS between 2008 and 2012. Patients not receiving RT after NACT and BCS were identified. A subgroup analysis was performed eliminating patients for whom RT was recommended but not received. RESULTS Among 10,220 patients meeting study eligibility, 974 (9.53%) did not receive RT after BCS. Predictors of RT omission included older age, insurance status, facility type, facility region, more recent year of diagnosis, receptor status unknown, human epidermal growth factor receptor 2 status positive or unknown, and positive margins. Factors increasing the likelihood of RT receipt included cN3 disease, receptor positivity, and primary downstaging. Race, Hispanicity, education, income, comorbidities, rural versus urban setting, histology, grade, and nodal stage change were not associated with RT omission. When excluding the 314 patients for whom RT was recommended but not received, age, Medicaid insurance, facility type, facility region, receptor status unknown, human epidermal growth factor receptor 2 status unknown, and positive margins were predictors of RT omission. CONCLUSIONS Race, comorbidities, and socioeconomic status were not predictors of RT omission. It remains unclear whether omission of RT in some cases is due to lack of physician knowledge. Further efforts are needed to ensure that physicians and patients recognize that RT is a vital and required part of BCT, even after NACT.
Collapse
Affiliation(s)
- Andrew C Esposito
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - James Crawford
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elin R Sigurdson
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elizabeth A Handorf
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Shelly B Hayes
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Marcia Boraas
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard J Bleicher
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
| |
Collapse
|
389
|
Isheden G, Humphreys K. Modelling breast cancer tumour growth for a stable disease population. Stat Methods Med Res 2017; 28:681-702. [DOI: 10.1177/0962280217734583] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Statistical models of breast cancer tumour progression have been used to further our knowledge of the natural history of breast cancer, to evaluate mammography screening in terms of mortality, to estimate overdiagnosis, and to estimate the impact of lead-time bias when comparing survival times between screen detected cancers and cancers found outside of screening programs. Multi-state Markov models have been widely used, but several research groups have proposed other modelling frameworks based on specifying an underlying biological continuous tumour growth process. These continuous models offer some advantages over multi-state models and have been used, for example, to quantify screening sensitivity in terms of mammographic density, and to quantify the effect of body size covariates on tumour growth and time to symptomatic detection. As of yet, however, the continuous tumour growth models are not sufficiently developed and require extensive computing to obtain parameter estimates. In this article, we provide a detailed description of the underlying assumptions of the continuous tumour growth model, derive new theoretical results for the model, and show how these results may help the development of this modelling framework. In illustrating the approach, we develop a model for mammography screening sensitivity, using a sample of 1901 post-menopausal women diagnosed with invasive breast cancer.
Collapse
Affiliation(s)
- Gabriel Isheden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Keith Humphreys
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| |
Collapse
|
390
|
Irwin KE, Park ER, Shin JA, Fields LE, Jacobs JM, Greer JA, Taylor JB, Taghian AG, Freudenreich O, Ryan DP, Pirl WF. Predictors of Disruptions in Breast Cancer Care for Individuals with Schizophrenia. Oncologist 2017; 22:1374-1382. [PMID: 28559411 PMCID: PMC5679818 DOI: 10.1634/theoncologist.2016-0489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/12/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with schizophrenia experience markedly increased breast cancer mortality, yet reasons for this disparity are poorly understood. We sought to characterize disruptions in breast cancer care for patients with schizophrenia and identify modifiable predictors of those disruptions. MATERIALS AND METHODS We performed a medical record review of 95 patients with schizophrenia and breast cancer treated at an academic cancer center between 1993 and 2015. We defined cancer care disruptions as processes that interfere with guideline-concordant cancer care, including delays to diagnosis or treatment, deviations from stage-appropriate treatment, and interruptions in treatment. We hypothesized that lack of psychiatric treatment at cancer diagnosis would be associated with care disruptions. RESULTS Half of patients with schizophrenia experienced at least one breast cancer care disruption. Deviations in stage-appropriate treatment were associated with breast cancer recurrence at 5 years (p = .045). Patients without a documented psychiatrist experienced more delays (p = .016), without documented antipsychotic medication experienced more deviations (p = .007), and with psychiatric hospitalizations after cancer diagnosis experienced more interruptions (p < .0001). Independent of stage, age, and documented primary care physician, lack of documented antipsychotic medication (odds ratio [OR] = 4.97, 95% confidence interval [CI] = 1.90, 12.98) and psychiatric care (OR = 4.56, 95% CI = 1.37, 15.15) predicted cancer care disruptions. CONCLUSION Disruptions in breast cancer care are common for patients with schizophrenia and are associated with adverse outcomes, including cancer recurrence. Access to psychiatric treatment at cancer diagnosis may protect against critical disruptions in cancer care for this underserved population. IMPLICATIONS FOR PRACTICE Disruptions in breast cancer care are common for patients with schizophrenia, yet access to mental health treatment is rarely integrated into cancer care. When oncologists documented a treating psychiatrist and antipsychotic medication, patients had fewer disruptions in breast cancer care after adjusting for age, cancer stage, and access to primary care. Addressing psychiatric comorbidity at breast cancer diagnosis may increase the likelihood that patients with schizophrenia receive timely, stage-appropriate cancer treatment. Comanagement of schizophrenia and breast cancer at cancer diagnosis may be one key strategy to decrease inequities in cancer treatment and improve cancer survival in this underserved population.
Collapse
Affiliation(s)
- Kelly E Irwin
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Schizophrenia Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Elyse R Park
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer A Shin
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren E Fields
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jamie M Jacobs
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Oliver Freudenreich
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Schizophrenia Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William F Pirl
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
391
|
McKevitt E, Dingee C, Warburton R, Pao J, Brown C, Wilson C, Kuusk U. Coordination of radiologic and clinical care reduces the wait time to breast cancer diagnosis. Curr Oncol 2017; 24:e388-e393. [PMID: 29089809 PMCID: PMC5659163 DOI: 10.3747/co.24.3767] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND In 2009, a Rapid Access Breast Clinic (rabc) was opened at our urban hospital. Compared with the traditional system (ts), the navigated care through the clinic was associated with a significantly shorter time to surgical consultation. Since 2009, many radiology facilities have introduced facilitated-care pathways for patients with breast pathology. Our objective was to determine if that change in diagnostic imaging pathways had eliminated the advantage in time to care previously shown for the rabc. METHODS All patients seen in the rabc and the office-based ts in November-December 2012 were included in the analysis. A retrospective chart review tabulated demographic, surgeon, pathology, and radiologic data, including time intervals to care for all patients. The results were compared with data from 2009. RESULTS In 2012, time from presentation to surgical consultation was less for the rabc group than for the ts group (36 days vs. 73 days, p < 0.001) for both malignant (31 days vs. 55 days, p = 0.008) and benign diagnoses (43 days vs. 79 days, p < 0.001). Comparing the 2012 results with results from 2009, a decline in mean wait time was observed for the ts group (86 days vs. 73 days, p = 0.02). Compared with patients having investigations in the ts, rabc patients with cancer were more likely to undergo surgery within 60 days of presentation (33% vs. 15%, p = 0.04). CONCLUSIONS The coordination of radiology and clinical care reduces wait times for diagnosis and surgery in breast cancer. To achieve recommended targets, we recommend implementation of more systematic coordination of care for a breast cancer diagnosis and of navigation to surgeons for patients needing surgical care.
Collapse
Affiliation(s)
- E.C. McKevitt
- Department of Surgery, Providence Health Care
- Department of Surgery, University of British Columbia
| | - C.K. Dingee
- Department of Surgery, Providence Health Care
- Department of Surgery, University of British Columbia
| | - R. Warburton
- Department of Surgery, Providence Health Care
- Department of Surgery, University of British Columbia
| | - J.S. Pao
- Department of Surgery, Providence Health Care
- Department of Surgery, University of British Columbia
| | - C.J. Brown
- Department of Surgery, Providence Health Care
- Department of Surgery, University of British Columbia
| | - C. Wilson
- Department of Radiology, BC Cancer Agency; and
- Department of Radiology, University of British Columbia, Vancouver, BC
| | - U. Kuusk
- Department of Surgery, Providence Health Care
- Department of Surgery, University of British Columbia
| |
Collapse
|
392
|
Buckley EJ, Zahnd WE, Rea DJ, Mellinger JD, Ganai S. Impact of rural-urban status on survival after mastectomy without reconstruction versus mastectomy with reconstruction. Am J Surg 2017; 214:645-650. [DOI: 10.1016/j.amjsurg.2017.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/08/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
|
393
|
Stamatovic L, Vasovic S, Trifunovic J, Boskov N, Gajic Z, Parezanovic A, Icevic M, Cirkovic A, Milic N. Factors influencing time to seeking medical advice and onset of treatment in women who are diagnosed with breast cancer in Serbia. Psychooncology 2017; 27:576-582. [PMID: 28857314 DOI: 10.1002/pon.4551] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Streamlining the diagnosis is a key factor in improving the treatment outcomes for breast cancer. The aim of this study was to determine factors influencing time to seeking medical advice and treatment onset in women who are diagnosed with breast cancer in Serbia. METHODS The study was a multicenter, cross-sectional national survey, performed at 10 oncology centers in Serbia. Time intervals spent throughout the complex diagnostic pathway were evaluated using a validated questionnaire administered to women with breast cancer (n = 800). Total interval (TI) was determined using predefined time scales, including one referring to patient interval (PI), and several related to health care system interval (SI). RESULTS Mean PI, SI, and TI were 4.5, 9.2, and 12.9 weeks, respectively; 20% of patients had a PI>12 weeks. Based on the multivariate regression model, longer PI was associated with perceived lack of time and personal disregard or trivialization of detected symptoms and signs. Women who were supported by family members or friends and had at least a secondary level education tended to have a shorter PI. Longer PI was correlated with a longer SI, while regular self-examination, having been diagnosed by an oncologist, and living in a major city were associated with shorter SI. CONCLUSIONS Several factors, related to psychological, demographic, behavioral, and health system characteristics, determined both the time to seeking medical advice and treatment onset for breast cancer. These findings support review and refining of national strategies and policies to promote early detection, diagnosis, and treatment of breast cancer.
Collapse
Affiliation(s)
- L Stamatovic
- Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - S Vasovic
- Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
| | - J Trifunovic
- Oncology Institute of Vojvodina, Novi Sad, Serbia
| | - N Boskov
- General Hospital Zrenjanin, Zrenjanin, Serbia
| | - Z Gajic
- General Hospital Kruševac, Kruševac, Serbia
| | | | | | - A Cirkovic
- Institute for Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia
| | - N Milic
- Institute for Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia.,Department for Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
394
|
Kuo K, Caughey AB. Optimal timing of delivery for women with breast cancer, according to cancer stage and hormone status: a decision-analytic model. J Matern Fetal Neonatal Med 2017; 32:419-428. [PMID: 28954567 DOI: 10.1080/14767058.2017.1381900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To compare strategies for the timing of delivery in women with breast cancer and known cancer stage or hormone receptor subtype, and to determine the optimal gestational age for induction in regards to maternal-fetal outcomes. STUDY DESIGN A decision-analytic model was designed comparing eight different strategies for scheduled delivery at 30, 31, 32, 33, 34, 35, 36, and 37 weeks gestation. Optimal breast cancer treatment was assumed to be delayed until after delivery. Baseline estimates of the stage- and subtype-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate sensitivity analyses and Monte Carlo simulations were performed to test the robustness of our model. RESULTS For women with stage I-II breast cancer, delivery at 36 weeks yielded the highest number of overall quality-adjusted life years (QALYs), while maternal QALYs were maximized with delivery at 34 weeks. For stage III and IV disease, maternal QALYs were maximized at 31 and 30 weeks, respectively. For women with estrogen or progesterone receptor-positive, human epidermal receptor-2 negative breast cancer, both maternal QALYs and overall QALYs were maximized with delivery at 36 weeks. More aggressive biological phenotypes were similarly associated with optimal delivery at decreasing gestational age. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decreases in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest. CONCLUSIONS For women with breast cancer diagnosed during pregnancy, decisions regarding timing of delivery should take into consideration both cancer stage and hormone receptor subtype.
Collapse
Affiliation(s)
- Kelly Kuo
- a Department of Obstetrics and Gynecology , Oregon Health & Science University , Portland , OR , USA
| | - Aaron B Caughey
- a Department of Obstetrics and Gynecology , Oregon Health & Science University , Portland , OR , USA
| |
Collapse
|
395
|
Losk K, Freedman RA, Lin NU, Golshan M, Pochebit SM, Lester SC, Natsuhara K, Camuso K, King TA, Bunnell CA. Implementation of Surgeon-Initiated Gene Expression Profile Testing (Onco type DX) Among Patients With Early-Stage Breast Cancer to Reduce Delays in Chemotherapy Initiation. J Oncol Pract 2017; 13:e815-e820. [PMID: 28858535 DOI: 10.1200/jop.2017.023788] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Delays to adjuvant chemotherapy initiation in breast cancer may adversely affect clinical outcomes and patient satisfaction. We previously identified an association between genomic testing (Onco type DX) and delayed chemotherapy initiation. We sought to reduce the interval between surgery and adjuvant chemotherapy initiation by developing standardized criteria and workflows for Onco type DX testing. METHODS Criteria for surgeon-initiated reflex Onco type DX testing, workflows for communication between surgeons and medical oncologists, and a streamlined process for receiving and processing Onco type DX requests in pathology were established by multidisciplinary consensus. Criteria for surgeon-initiated testing included patients ≤ 65 years old with T1cN0 (grade 2 or 3), T2N0 (grade 1 or 2), or T1/T2N1 (grade 1 or 2) breast cancer on final surgical pathology. Medical oncologists could elect to initiate Onco type testing for cases falling outside the criteria. We then examined 720 consecutive patients with breast cancer who underwent Onco type DX testing postoperatively between January 1, 2014 and November 28, 2016 and measured intervals between date of surgery, Onco type DX order date, result received date, and chemotherapy initiation date (if applicable) before and after intervention implementation. RESULTS The introduction of standardized criteria and workflows reduced time between surgery and Onco type DX ordering, and time from surgery to receipt of result, by 7.3 days ( P < .001) and 6.3 days ( P < .001), respectively. The mean number of days between surgery and initiation of chemotherapy was also reduced by 6.4 days ( P = .004). CONCLUSION Developing consensus on Onco type DX testing criteria and implementing streamlined workflows has led to clinically significant reductions in wait times to chemotherapy decision making and initiation.
Collapse
Affiliation(s)
- Katya Losk
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Rachel A Freedman
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Nancy U Lin
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Mehra Golshan
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Stephen M Pochebit
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Susan C Lester
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Kelsey Natsuhara
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Kristen Camuso
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Tari A King
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| | - Craig A Bunnell
- Dana-Farber Cancer Institute; Dana-Farber/Brigham and Women's Cancer Center; Brigham and Women's Hospital; and Harvard Medical School, Boston, MA
| |
Collapse
|
396
|
Murphy AE, Hussain L, Ho C, Dunki-Jacobs E, Lee D, Tameron A, Huelsman K, Rice C, Wexelman BA. Preoperative Panel Testing for Hereditary Cancer Syndromes Does Not Significantly Impact Time to Surgery for Newly Diagnosed Breast Cancer Patients Compared with BRCA1/2 Testing. Ann Surg Oncol 2017; 24:3055-3059. [DOI: 10.1245/s10434-017-5957-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Indexed: 11/18/2022]
|
397
|
van Maaren MC, Bretveld RW, Jobsen JJ, Veenstra RK, Groothuis-Oudshoorn CG, Struikmans H, Maduro JH, Strobbe LJ, Poortmans PM, Siesling S. The influence of timing of radiation therapy following breast-conserving surgery on 10-year disease-free survival. Br J Cancer 2017; 117:179-188. [PMID: 28588320 PMCID: PMC5520509 DOI: 10.1038/bjc.2017.159] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/28/2017] [Accepted: 05/11/2017] [Indexed: 11/13/2022] Open
Abstract
Background: The Dutch guidelines advise to start radiation therapy (RT) within 5 weeks following breast-conserving surgery (BCS). However, much controversy exists regarding timing of RT. This study investigated its effect on 10-year disease-free survival (DFS) in a Dutch population-based cohort. Methods: All women diagnosed with primary invasive stage I-IIIA breast cancer in 2003 treated with BCS+RT were included. Two populations were studied. Population 1 excluded patients receiving chemotherapy before RT. Analyses were stratified for use of adjuvant systemic therapy (AST). Population 2 included patients treated with chemotherapy, and compared chemotherapy before (BCS-chemotherapy-RT) and after RT (BCS-RT-chemotherapy). DFS was estimated using multivariable Cox regression. Locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS) and overall survival (OS) were secondary outcomes. Results: Population 1 (n=2759) showed better DFS and DMFS for a time interval of >55 than a time interval of <42 days. Patients treated with AST showed higher DFS for >55 days (hazards ratio (HR) 0.60 (95% confidence interval (CI): 0.38–0.94)) and 42–55 days (HR 0.64 (95% CI: 0.45–0.91)) than <42 days. Results were similar for DMFS, while timing did not affect LRRFS and OS. For patients without AST, timing was not associated with DFS, DMFS and LLRFS, but 10-year OS was significantly lower for 42–55 and >55 days compared to <42 days. In population 2 (n=1120), timing did not affect survival in BCS-chemotherapy-RT. In BCS-RT-chemotherapy, DMFS was higher for >55 than <42 days. Conclusions: Starting RT shortly after BCS seems not to be associated with a better long-term outcome. The common position that RT should start as soon as possible following surgery in order to increase treatment efficacy can be questioned.
Collapse
Affiliation(s)
- Marissa C van Maaren
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, Utrecht 3501 DB, The Netherlands.,Department of Health Technology &Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
| | - Reini W Bretveld
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, Utrecht 3501 DB, The Netherlands
| | - Jan J Jobsen
- Department of Radiation Oncology, Medical Spectrum Twente, PO Box 217, Enschede 7500 AE, The Netherlands
| | - Renske K Veenstra
- Department of Operations, Medical Research Data Management B.V., PO Box 90, Deventer 7400 AB, The Netherlands
| | - Catharina Gm Groothuis-Oudshoorn
- Department of Health Technology &Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
| | - Hendrik Struikmans
- Department of Radiation Oncology, Haaglanden Medical Center, PO Box 432, The Hague 2501 CK, The Netherlands.,Department of Radiation Oncology, Leiden University Medical Center, PO Box 9600, Leiden 2300 RC, The Netherlands
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, PO Box 30001, Groningen 9700 RB, The Netherlands
| | - Luc Ja Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, PO Box 9015, Nijmegen 6500 GS, The Netherlands
| | - Philip Mp Poortmans
- Department of Radiation Oncology, Institut Curie, 26 Rue d'Ulm, Paris 75005, France
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, Utrecht 3501 DB, The Netherlands.,Department of Health Technology &Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, PO Box 50000, Enschede 7500 KA, The Netherlands
| |
Collapse
|
398
|
Xie Y, Lv X, Luo C, Hu K, Gou Q, Xie K, Zheng H. Surgery of the primary tumor improves survival in women with stage IV breast cancer in Southwest China: A retrospective analysis. Medicine (Baltimore) 2017; 96:e7048. [PMID: 28562563 PMCID: PMC5459728 DOI: 10.1097/md.0000000000007048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 05/02/2017] [Accepted: 05/06/2017] [Indexed: 02/05/2023] Open
Abstract
The International Consensus Guidelines for advanced breast cancer (ABC) considers that the surgery of the primary tumor for stage IV breast cancer patients does not usually improve the survival. However, studies have showed that resection of the primary tumor may benefit these patients. The correlation between surgery and survival remains unclear.The impact of surgery and other clinical factors on overall survival (OS) of stage IV patients is investigated in West China Hospital. Female patients diagnosed with stage IV breast cancer between 1999 and 2014 were included (N = 223). Univariate and multivariate analysis assessed the association between surgery and OS.One hundred seventy-seven (79.4%) underwent surgery for the primary tumor, and 46 (20.6%) had no surgery. No significant differences were observed in age at diagnosis, T-stage, N-stage, histological grade, molecular subtype, hormone receptor (HR), and number of metastatic sites between 2 groups. Patients in the surgery group had dramatically longer OS (45.6 vs 21.3 months, log-rank P < .001). In univariate analysis, survival was associated with surgical treatment, residence, tumor size, lymph node, HR status, hormonal therapy, and radiotherapy. In multivariate analysis, surgery was an independent prognostic factor for OS [hazard ratio (HR), 0.569; 95% confidence interval (CI) 0.329-0.984, P = .044]. Additional independent prognostic factors were hormonal therapy (HR, 0.490; 95% CI 0.300-0.800) and radiotherapy (HR, 0.490; 95% CI 0.293-0.819). In addition, a favorable impact of surgery was observed by subgroup analysis.Our study showed that surgery of the primary breast tumor has a positive impact on OS in with stage IV breast cancer patients.
Collapse
Affiliation(s)
- Yuxin Xie
- Cancer Center
- Laboratory of Molecular Diagnosis of Cancer, State Key Laboratory of Biotherapy, National Collaborative Innovation Center for Biotherapy
| | - Xingxing Lv
- Cancer Center
- Laboratory of Molecular Diagnosis of Cancer, State Key Laboratory of Biotherapy, National Collaborative Innovation Center for Biotherapy
| | - Chuanxu Luo
- Cancer Center
- Laboratory of Molecular Diagnosis of Cancer, State Key Laboratory of Biotherapy, National Collaborative Innovation Center for Biotherapy
| | - Kejia Hu
- Cancer Center
- Laboratory of Molecular Diagnosis of Cancer, State Key Laboratory of Biotherapy, National Collaborative Innovation Center for Biotherapy
| | - Qiheng Gou
- State Key Laboratory of Biotherapy/Collaborative Innovation Center of Biotherapy, West China Hospital, Sichuan University, Chengdu
| | - Keqi Xie
- Departments of Anesthesiology, Mianyang Central Hospital, Mianyang, Sichuan, China
| | - Hong Zheng
- Cancer Center
- Laboratory of Molecular Diagnosis of Cancer, State Key Laboratory of Biotherapy, National Collaborative Innovation Center for Biotherapy
| |
Collapse
|
399
|
Zarcos-Pedrinaci I, Fernández-López A, Téllez T, Rivas-Ruiz F, Rueda A A, Suarez-Varela MMM, Briones E, Baré M, Escobar A, Sarasqueta C, de Larrea NF, Aguirre U, Quintana JM, Redondo M. Factors that influence treatment delay in patients with colorectal cancer. Oncotarget 2017; 8:36728-36742. [PMID: 27888636 PMCID: PMC5482692 DOI: 10.18632/oncotarget.13574] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 11/12/2016] [Indexed: 01/07/2023] Open
Abstract
A prospective study was performed of patients diagnosed with colorectal cancer (CRC), distinguishing between colonic and rectal location, to determine the factors that may provoke a delay in the first treatment (DFT) provided.2749 patients diagnosed with CRC were studied. The study population was recruited between June 2010 and December 2012. DFT is defined as time elapsed between diagnosis and first treatment exceeding 30 days.Excessive treatment delay was recorded in 65.5% of the cases, and was more prevalent among rectal cancer patients. Independent predictor variables of DFT in colon cancer patients were a low level of education, small tumour, ex-smoker, asymptomatic at diagnosis and following the application of screening. Among rectal cancer patients, the corresponding factors were primary school education and being asymptomatic.We conclude that treatment delay in CRC patients is affected not only by clinicopathological factors, but also by sociocultural ones. Greater attention should be paid by the healthcare provider to social groups with less formal education, in order to optimise treatment attention.
Collapse
Affiliation(s)
- Irene Zarcos-Pedrinaci
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | | | - Teresa Téllez
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Francisco Rivas-Ruiz
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Rueda A
- Servicio de Oncología Médica, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - María Manuela Morales Suarez-Varela
- Unit of Public Health, Hygiene and Environmental Health, Department of Preventive Medicine and Public Health, Food Science, Toxicology and Legal Medicine, University of Valencia, CIBER-Epidemiology and Public Health (CIBERESP), Valencia, Spain
| | - Eduardo Briones
- Public Health Unit, Distrito Sanitario Sevilla, Consorcio de Investigación Biomédica de Epidemiología y Salud Pública, Madrid, Spain
| | - Marisa Baré
- Clinical Epidemiology and Cancer Screening, Corporació Sanitària Parc Taulí, Sabadell, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Antonio Escobar
- Research Unit, Hospital Universitario Basurto, Bilbao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Cristina Sarasqueta
- Research Unit, Donostia University Hospital, San Sebastián, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Nerea Fernández de Larrea
- Area of Environmental Epidemiology and Cancer, National Epidemiology Centre, Instituto de Salud Carlos III, Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública, CIBERESP), Madrid, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Urko Aguirre
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - José María Quintana
- Research Unit, Hospital Galdakao-Usansolo, Galdakao, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| | - Maximino Redondo
- Research Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas – REDISSEC, Spain
| |
Collapse
|
400
|
O'Neil DS, Keating NL, Dusengimana JMV, Hategekimana V, Umwizera A, Mpunga T, Shulman LN, Pace LE. Quality of Breast Cancer Treatment at a Rural Cancer Center in Rwanda. J Glob Oncol 2017; 4:1-11. [PMID: 30241207 PMCID: PMC6180813 DOI: 10.1200/jgo.2016.008672] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE As breast cancer incidence and mortality rise in sub-Saharan Africa, it is critical to identify strategies for delivery of high-quality breast cancer care in settings with limited resources and few oncology specialists. We investigated the quality of treatments received by a cohort of patients with breast cancer at Butaro Cancer Center of Excellence (BCCOE), Rwanda's first public cancer center. PATIENTS AND METHODS We reviewed medical records of all female patients diagnosed with invasive breast cancer at BCCOE between July 2012 and December 2013. We evaluated the provision of chemotherapy, endocrine therapy, surgery, and chemotherapy dose densities. We also applied modified international quality metrics and estimated overall survival using interval-censored analysis. RESULTS Among 150 patients, 28 presented with early-stage, 64 with locally advanced, and 53 with metastatic disease. Among potentially curable patients (ie, those with early-stage or locally advanced disease), 74% received at least four cycles of chemotherapy and 63% received surgery. Among hormone receptor-positive patients, 83% received endocrine therapy within 1 year of diagnosis. Fifty-seven percent of potentially curable patients completed surgery and chemotherapy and initiated endocrine therapy if indicated within 1 year of biopsy. Radiotherapy was not available. At the end of follow-up, 62% of potentially curable patients were alive, 24% were dead, and 14% were lost to follow-up. CONCLUSION Appropriate delivery of chemotherapy and endocrine therapy for breast cancer is possible in rural sub-Saharan African even without oncologists based on site. Performing timely surgery and ensuring treatment completion were key challenges after the opening of BCCOE. Further investigation should examine persistent quality gaps and the relationship between treatment quality and survival.
Collapse
Affiliation(s)
- Daniel S O'Neil
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Nancy L Keating
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Jean Marie V Dusengimana
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Vedaste Hategekimana
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Aline Umwizera
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Tharcisse Mpunga
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lawrence N Shulman
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lydia E Pace
- Daniel S. O'Neil, Columbia University Medical Center, New York, NY; Nancy L. Keating and Lydia E. Pace, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Jean Marie V. Dusengimana, Partners in Health/Inshuti Mu Buzima, Rwinkwavu; Vedaste Hategekimana, Aline Umwizera, and Tharcisse Mpunga, Ministry of Health, Kigali, Rwanda; Lawrence N. Shulman, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|