1
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Peckham ME, Shah LM, Meeks HD, Fraser A, Galvao C, Safazadeh G, Hutchins TA, Anzai Y, Fritz JM, Kean J, Carlos RC. Disparities in Provider Ordering Practices of Image-Guided Interventions and Surgery for Patients With Low Back Pain: A Cohort Study. J Am Coll Radiol 2024; 21:1010-1023. [PMID: 38369043 DOI: 10.1016/j.jacr.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To assess individual- and neighborhood-level sociodemographic factors associating with providers' ordering of nonpharmacologic treatments for patients with low back pain (LBP), specifically physical therapy, image-guided interventions, and lumbar surgery. METHODS Our cohort included all patients diagnosed with LBP from 2000 to 2017 in a statewide database of all hospitals and ambulatory surgical facilities within Utah. We compared sociodemographic and clinical characteristics of (1) patients with LBP who received any treatment with those who received none and (2) patients with LBP who received invasive LBP treatments with those who only received noninvasive LBP treatments using the Student's t test, Wilcoxon's rank-sum tests, and Pearson's χ2 tests, as applicable, and two separate multivariate logistic regression models: (1) to determine whether sociodemographic characteristics were risk factors for receiving any LBP treatments and (2) risk factors for receiving invasive LBP treatments. RESULTS Individuals in the most disadvantaged neighborhoods were less likely to receive any nonpharmacologic treatment orders (odds ratio [OR] 0.74 for most disadvantaged, P < .001) and received fewer invasive therapies (0.92, P = .018). Individual-level characteristics correlating with lower rates of treatment orders were female sex, Native Hawaiian or other Pacific Islander race (OR 0.50, P < .001), Hispanic ethnicity (OR 0.77, P < .001), single or unmarried status (OR 0.69, P < .001), and no insurance or self-pay (OR 0.07, P < .001). CONCLUSION Neighborhood and individual sociodemographic variables associated with treatment orders for LBP with Area Deprivation Index, sex, race or ethnicity, insurance, and marital status associating with receipt of any treatment, as well as more invasive image-guided interventions and surgery.
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Affiliation(s)
- Miriam E Peckham
- Assistant Professor, Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah.
| | - Lubdha M Shah
- Professor, Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Huong D Meeks
- Assistant Professor, Department of Pediatrics, Critical Care Division, University of Utah Spencer F. Eccles School of Medicine, Salt Lake City, Utah
| | - Alison Fraser
- Senior Database Manager, Utah Population Database, Pedigree and Population Resource, Salt Lake City, Utah
| | - Carlos Galvao
- Database Analyst, Utah Population Database, Salt Lake City, Utah
| | - Ghazaleh Safazadeh
- Research Associate, Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Troy A Hutchins
- Associate Professor, Vice Chair of Clinical Operations, Department of Radiology at University of Utah, Salt Lake City, Utah
| | - Yoshimi Anzai
- Professor, Vice Chair for Quality and Safety, Department of Radiology at University of Utah School of Medicine, Salt Lake City, Utah
| | - Julie M Fritz
- Professor, Department of Physical Therapy & Athletic Training, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Jacob Kean
- Associate Professor, Department of Population Health Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Ruth C Carlos
- Professor, Department of Radiology, University of Michigan, Ann Arbor, Michigan; and Editor-in-Chief of the JACR
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Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation. Ann Surg 2024; 279:246-257. [PMID: 37450703 PMCID: PMC10787813 DOI: 10.1097/sla.0000000000005994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health. BACKGROUND Studies focused on single or binary composite outcomes may not detect health disparities. METHODS Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO). RESULTS Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases. CONCLUSIONS DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.
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Affiliation(s)
- Michael A. Jacobs
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
| | - Susanne Schmidt
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and
Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh
Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh,
Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel
Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The
University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University
of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of
Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- UT Health Physicians Business Intelligence and Data
Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of
Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Paula K. Shireman
- Department of Surgery, University of Texas Health San
Antonio, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and
Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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3
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Wang DR, Li J, Parikh RV, Ziaeian B, Aksoy O, Jackson NJ, Hsu JJ. Racial/Ethnic Disparities in Outcomes After Percutaneous Coronary Intervention. Am J Cardiol 2023; 205:120-125. [PMID: 37597486 DOI: 10.1016/j.amjcard.2023.07.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 08/21/2023]
Abstract
Asian American/Pacific Islanders (AAPIs) and Hispanics are growing minority United States populations, but are poorly represented in the cardiovascular literature. This study examines guideline adherence and outcomes in AAPIs and Hispanics compared with non-Hispanic Whites (NHWs) in a quaternary care center after inpatient percutaneous coronary intervention (PCI). The primary end points were inpatient post-PCI bleed, heart failure, cardiogenic shock, and all-cause mortality, whereas the secondary end point was the prescription rate of post-PCI guideline-directed medical therapy including aspirin, statins, P2Y12 receptor blockers, and cardiopulmonary rehabilitation. Intergroup differences were assessed through analysis of variance or two-way chi-square tests, and the association of race with binary outcomes was examined through logistic regression with NHW as the reference group. Compared with NHW, AAPIs, and Hispanics had higher odds of diabetes mellitus, and AAPIs had higher odds of hypertension and being on dialysis. Hispanics had higher odds of post-PCI mortality versus NHW, both in acute coronary syndrome (odds ratio [OR] 2.04, p = 0.03) and elective PCI (OR 2.51, p = 0.04). AAPI also trended toward higher mortality than NHW in both categories. AAPIs were found to have higher odds of statin prescription (OR 1.91, p = 0.04). Hispanics had lower odds of ticagrelor prescription versus NHW (OR 0.65, p = 0.04), and AAPIs trended toward such. No differences were found for cardiopulmonary rehabilitation prescriptions in groups. This study suggests that despite quality improvement efforts, disparities remain in postprocedural outcomes in minority groups in comparison with NHW.
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Affiliation(s)
- Daniel R Wang
- Divisions of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California.
| | - Joshua Li
- Divisions of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Rushi V Parikh
- Divisions of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Boback Ziaeian
- Divisions of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Olcay Aksoy
- Divisions of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Nicholas J Jackson
- Divisions of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Jeffrey J Hsu
- Divisions of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare, Los Angeles, California
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4
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Schmidt S, Kim J, Jacobs MA, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Independent Associations of Neighborhood Deprivation and Patient-level Social Determinants of Health with Textbook Outcomes after Inpatient Surgery. ANNALS OF SURGERY OPEN 2023; 4:e237. [PMID: 37588414 PMCID: PMC10427124 DOI: 10.1097/as9.0000000000000237] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Objective Assess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO). Summary Background Data Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods Three healthcare system cohort study using National Surgical Quality Improvement Program (2013-2019) linked with ADI risk-adjusted for frailty, case status and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, Emergency Department/Observation Stays and readmissions). Results Cohort (34,251 cases) mean age 58.3 [SD=16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI>85, and 81.8% TO. Racial and ethnic minorities, non-Private insurance, and ADI>85 patients had increased odds of urgent/emergent surgeries (aORs range: 1.17-2.83, all P<.001). Non-Hispanic Black patients, ADI>85 and non-Private insurances had lower TO odds (aORs range: 0.55-0.93, all P<.04), but ADI>85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR=0.51, P<.001). ADI>85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (CI=7.2%-12.6%) for urgent/emergent cases, 7.0% (CI=4.6%-9.3%) for Medicaid, and 1.6% (CI=0.2%-3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI≤85-elective) to highest-risk (Black-Medicaid-ADI>85-urgent/emergent) was 29.8% for very frail patients. Conclusion Multi-level SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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5
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Jacobs MA, Kim J, Tetley JC, Schmidt S, Brimhall BB, Mika V, Wang CP, Manuel LS, Damien P, Shireman PK. Cost of Failure to Achieve Textbook Outcomes: Association of Insurance Type with Outcomes and Cumulative Cost for Inpatient Surgery. J Am Coll Surg 2023; 236:352-364. [PMID: 36648264 DOI: 10.1097/xcs.0000000000000468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Surgical outcome/cost analyses typically focus on single outcomes and do not include encounters beyond the index hospitalization. STUDY DESIGN This cohort study used NSQIP (2013-2019) data with electronic health record and cost data risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status, and operative stress assessing cumulative costs of failure to achieve textbook outcomes defined as absence of 30-day Clavien-Dindo level III and IV complications, emergency department visits/observation stays (EDOS), and readmissions across insurance types (private, Medicare, Medicaid, uninsured). Return costs were defined as costs of all 30-day emergency department visits/observation stays and readmissions. RESULTS Cases were performed on patients (private 1,506; Medicare 1,218; Medicaid 1,420; uninsured 2,178) with a mean age 52.3 years (SD 14.7) and 47.5% male. Medicaid and uninsured patients had higher odds of presenting with preoperative acute serious conditions (adjusted odds ratios 1.89 and 1.81, respectively) and undergoing urgent/emergent surgeries (adjusted odds ratios 2.23 and 3.02, respectively) vs private. Medicaid and uninsured patients had lower odds of textbook outcomes (adjusted odds ratios 0.53 and 0.78, respectively) and higher odds of emergency department visits/observation stays and readmissions vs private. Not achieving textbook outcomes was associated with a greater than 95.1% increase in cumulative costs. Medicaid patients had a relative increase of 23.1% in cumulative costs vs private, which was 18.2% after adjusting for urgent/emergent cases. Return costs were 37.5% and 65.8% higher for Medicaid and uninsured patients, respectively, vs private. CONCUSIONS Higher costs for Medicaid patients were partially driven by increased presentation acuity (increased rates/odds of preoperative acute serious conditions and urgent/emergent surgeries) and higher rates of multiple emergency department visits/observation stays and readmission occurrences. Decreasing surgical costs/improving outcomes should focus on reducing urgent/emergent surgeries and improving postoperative care coordination, especially for Medicaid and uninsured populations.
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Affiliation(s)
- Michael A Jacobs
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Jeongsoo Kim
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Jasmine C Tetley
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
| | - Susanne Schmidt
- Department of Population Health Sciences (Schmidt, Wang), University of Texas Health San Antonio, San Antonio, TX
| | - Bradley B Brimhall
- Department of Pathology and Laboratory Medicine (Brimhall), University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
| | - Virginia Mika
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
| | - Chen-Pin Wang
- Department of Population Health Sciences (Schmidt, Wang), University of Texas Health San Antonio, San Antonio, TX
| | - Laura S Manuel
- Business Intelligence and Data Analytics, University of Texas Health Physicians (Manuel), University of Texas Health San Antonio, San Antonio, TX
| | - Paul Damien
- Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX (Damien)
| | - Paula K Shireman
- From the Department of Surgery (Jacobs, Kim, Tetley, Shireman), University of Texas Health San Antonio, San Antonio, TX
- University Health, San Antonio, TX (Brimhall, Mika, Shireman)
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX (Shireman)
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Caston NE, Williams CP, Wan C, Ye S, Pywell C, Ingram SA, Azuero A, Sussell J, Patel S, Arend R, Rocque GB. Associations between geography, decision‐making style, and interest in cancer clinical trial participation. Cancer 2022; 128:3977-3984. [DOI: 10.1002/cncr.34455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Nicole E. Caston
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Courtney P. Williams
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Clara Wan
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Star Ye
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Cameron Pywell
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Stacey A. Ingram
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Andres Azuero
- Department of Family, Community, and Health Systems University of Alabama at Birmingham School of Nursing Birmingham Alabama USA
| | | | | | - Rebecca Arend
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Gabrielle B. Rocque
- Department of Medicine, Division of Hematology and Oncology University of Alabama at Birmingham Birmingham Alabama USA
- O'Neal Comprehensive Cancer Center Birmingham Alabama USA
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7
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Sutton AL, Obeng-Gyasi S, Hines AL. Leveling Up: Examining the Impact of Neighborhood Social Vulnerability on Comorbid Cardiovascular and Cancer Mortality. JACC CardioOncol 2022; 4:338-340. [PMID: 36213349 PMCID: PMC9537065 DOI: 10.1016/j.jaccao.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Arnethea L. Sutton
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Anika L. Hines
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
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Kim G, Pastoriza JM, Qin J, Lin J, Karagiannis GS, Condeelis JS, Yothers G, Anderson S, Julian T, Entenberg D, Rohan TE, Xue X, Sparano JA, Oktay MH. Racial disparity in distant recurrence-free survival in patients with localized breast cancer: A pooled analysis of National Surgical Adjuvant Breast and Bowel Project trials. Cancer 2022; 128:2728-2735. [PMID: 35578919 DOI: 10.1002/cncr.34241] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Black race is associated with worse outcome in patients with breast cancer. The distant relapse-free survival (DRFS) between Black and White women with localized breast cancer who participated in National Cancer Institute-sponsored clinical trial was evaluated. METHODS Pooled data were analyzed from 8 National Surgical Adjuvant Breast and Bowel Project (NSABP) trials including 9702 women with localized breast cancer treated with adjuvant chemotherapy (AC, n = 7485) or neoadjuvant chemotherapy (NAC, n = 2217), who self-reported as Black (n = 1070) or White (n = 8632) race. The association between race and DRFS was analyzed using log-rank tests and multivariate Cox regression. RESULTS After adjustment for covariates including age, tumor size, nodal status, body mass index and taxane use, and treatment (AC vs NAC), Black race was associated with an inferior DRFS in estrogen receptor-positive (ER+; hazard ratio [HR], 1.24; 95% CI, 1.05-1.46; P = .01), but not in ER- disease (HR, 0.97; 95% CI, 0.83-1.14; P = .73), and significant interaction between race and ER status was observed (P = .03). There was no racial disparity in DRFS among patients with pathologic complete response (pCR) (log-rank P = .8). For patients without pCR, Black race was associated with worse DRFS in ER+ (HR, 1.67; 95% CI, 1.14-2.45; P = .01), but not in ER- disease (HR, 0.91; 95% CI, 0.65-1.28; P = .59). CONCLUSIONS Black race was associated with significantly inferior DRFS in ER+ localized breast cancer treated with AC or NAC, but not in ER- disease. In the NAC group, racial disparity was also observed in patients with residual ER+ breast cancer at surgery, but not in those who had pCR. LAY SUMMARY Black women with breast cancer have worse outcomes compared with White women. We investigated if this held true in the context of clinical trials that provide controlled treatment setting. Black women with cancer expressing estrogen receptors (ERs) had worse outcome than White women. If breast cancers did not express ERs, there was no racial disparity in outcome. We also observed racial disparity in women who received chemotherapy before their cancer was removed, but only if they had cancer expressing ERs and residual disease on completion of treatment. If the cancer disappeared with presurgical chemotherapy, there was no racial disparity.
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Affiliation(s)
- Gina Kim
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
- Department of Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Jessica M Pastoriza
- Department of Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Jiyue Qin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Juan Lin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - George S Karagiannis
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
- Gruss-Lipper Biophotonics Center, Albert Einstein College of Medicine/Montefiore Medical center, Bronx, New York
- Integrated Imaging Program, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - John S Condeelis
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
- Gruss-Lipper Biophotonics Center, Albert Einstein College of Medicine/Montefiore Medical center, Bronx, New York
- Integrated Imaging Program, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Greg Yothers
- Department of Biostatistics, Graduate School of Public, Health at University of Pittsburgh, Pittsburgh, Pennsylvania
- NRG Oncology, Philadelphia, Pennsylvania
| | - Stewart Anderson
- Department of Biostatistics, Graduate School of Public, Health at University of Pittsburgh, Pittsburgh, Pennsylvania
- NRG Oncology, Philadelphia, Pennsylvania
| | - Thomas Julian
- NRG Oncology, Philadelphia, Pennsylvania
- Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - David Entenberg
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
- Gruss-Lipper Biophotonics Center, Albert Einstein College of Medicine/Montefiore Medical center, Bronx, New York
- Integrated Imaging Program, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Thomas E Rohan
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Xiaonan Xue
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Joseph A Sparano
- Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York
| | - Maja H Oktay
- Department of Anatomy and Structural Biology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
- Gruss-Lipper Biophotonics Center, Albert Einstein College of Medicine/Montefiore Medical center, Bronx, New York
- Integrated Imaging Program, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
- Department of Pathology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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9
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Obeng-Gyasi S, Coles CE, Jones J, Sacks R, Lightowlers S, Bliss JM, Brunt AM, Haviland JS, Kirby AM, Kalinsky K. When the World Throws You a Curve Ball: Lessons Learned in Breast Cancer Management. Am Soc Clin Oncol Educ Book 2021; 41:1-11. [PMID: 33956493 DOI: 10.1200/edbk_320691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the care of patients with operable breast cancer, there has been a shift toward increasing use of neoadjuvant therapy. There are benefits to neoadjuvant therapy, such as monitoring for response, as well as an increased rate of breast conservation and reduction of potential morbidity associated with breast surgery, including axillary management. Among patients with highly proliferative tumors, such as HER2-positive or triple-negative breast cancer, those with residual disease are at higher risk of recurrence, which informs the recommended systemic therapy in the adjuvant setting. For instance, in patients with residual disease after neoadjuvant chemotherapy and HER2-targeted therapy, there is a role for adjuvant trastuzumab emtansine for those with residual disease at the time of surgery. The same holds true regarding the role of adjuvant capecitabine in patients with residual disease after neoadjuvant chemotherapy. With the added complexities of treating patients in the era of the COVID-19 outbreak, additional considerations are critical, including initiation of surgery within an appropriate time from completion of neoadjuvant therapy. National consensus guidelines on time to surgery must be developed to improve measurement and comparison across systems. In addition, there is emerging radiation treatment management research addressing a number of factors, including hypofractionation, role of proton beam therapy, safe omission of radiotherapy, and preoperative radiotherapy with or without drug combination. In this article, the multidisciplinary approach of treating patients with operable breast cancer is highlighted, with updates and future considerations described.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Jade Jones
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Ruth Sacks
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sara Lightowlers
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - A Murray Brunt
- School of Medicine, University of Keele, Keele, United Kingdom
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Anna M Kirby
- Department of Radiotherapy, Royal Marsden National Health Service Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Kevin Kalinsky
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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Obeng-Gyasi S, O'Neill A, Zhao F, Kircher SM, Lava TR, Wagner LI, Miller KD, Sparano JDA, Sledge GW, Carlos RC. Impact of insurance and neighborhood socioeconomic status on clinical outcomes in therapeutic clinical trials for breast cancer. Cancer Med 2020; 10:45-52. [PMID: 33264502 PMCID: PMC7826479 DOI: 10.1002/cam4.3542] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/16/2020] [Accepted: 09/26/2020] [Indexed: 02/05/2023] Open
Abstract
The objective of this study was to evaluate the impact of insurance and neighborhood SES (nSES) on chemotherapy completion and overall mortality among participants in breast cancer clinical trials. The data sources for this study were two adjuvant breast cancer trials (ECOG E1199 and E5103) collectively including 9790 women. Insurance status at trial registration was categorized into private, government (Medicaid, Medicare, and other government type insurance), and self‐pay. An Agency for Healthcare Research Quality (AHRQ) nSES index was calculated using residential zip codes linked to county level data on occupation, income, poverty, wealth, education, and crowding. Logistic regression and Cox Proportional Hazard models estimated odds ratios (OR) for chemotherapy treatment completion and hazard ratios (HR) for mortality, respectively, for insurance status and nSES. The models adjusted for: race, age, tumor size, nodal status, hormone receptor status, and primary surgery. The majority of patients had private insurance at trial registration: E1199: 85.6% (4154/4854) and E5103: 82.4% (3987/4836); median SES index was 53.8 (range: 41.8‐66.8) and 54.1 (range: 44.5‐66.1), respectively. Patients with government insurance were less likely to complete chemotherapy treatment (E1199 OR (95%CI): 0.73 (0.57‐0.94); E5103 0.76 (0.64‐0.91)) and had an increased risk of death (E1199 HR (95%CI): 1.44 (1.22‐1.70); E5103 1.29 (1.06‐1.58)) compared to the privately insured patients. There was no association between nSES and chemotherapy completion or overall mortality. Patients with government insurance at trial registration appeared to face barriers in chemotherapy completion and had a higher overall mortality compared to their privately insured counterparts.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anne O'Neill
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Fengmin Zhao
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Sheetal M Kircher
- Northwestern University, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
| | - Timisina R Lava
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lynne I Wagner
- Department of Social Sciences & Health Policy, Wake Forest School of Medicine; Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Kathy D Miller
- Indiana University School of Medicine
- Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Joseph DA Sparano
- Montefiore Medical Center, Albert Einstein College of Medicine, Albert Einstein Cancer Center, Bronx, NY, USA
| | | | - Ruth C Carlos
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA
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