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Cunningham JM, Ferraro K, Durfee J, Indovina KA. Social Determinants of Health Impacting the Experience of Young Adults With Cancer at a Single Community Urban Hospital: A Retrospective Cohort Study. J Patient Exp 2024; 11:23743735241255450. [PMID: 38765223 PMCID: PMC11100384 DOI: 10.1177/23743735241255450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024] Open
Abstract
Adolescent and young adult (AYA) cancer patients receive palliative medicine consultation at a late stage and face diagnostic delays. Failure to address social determinants of health (SDOH) and AYA-specific needs can adversely impact patient experience. This retrospective observational cohort study used data from chart review to assess the frequency of SDOH impacting AYA patients and setting of initial diagnosis at a US urban safety-net hospital. The association of SDOH variables with delays in treatment, loss of follow-up, and no-shows was tested using Chi-square and t-tests. One hundred seventy five patient charts were reviewed. Sixty-two percent were diagnosed in acute care settings. Substance use disorders, financial, employment, and insurance issues were associated with delayed treatment, with weak to moderate effect sizes. Mental health diagnoses, substance use disorder, homelessness, and financial burdens were associated with patient no-shows, with moderate to large effect sizes. Twenty-five percent of patients received palliative medicine consultation; 70% of these occurred at end of life. This study demonstrates the impact of SDOH on AYA cancer care and the need for policy allowing for intervention on SDOH.
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Affiliation(s)
- John M Cunningham
- Division of Hospital Medicine, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Kelly Ferraro
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Palliative Medicine, Denver Health and Hospital Authority, Denver, CO, USA
| | - Joshua Durfee
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Kimberly A Indovina
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Palliative Medicine, Denver Health and Hospital Authority, Denver, CO, USA
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Beaulieu-Jones BR, Ha EJ, Fefferman A, Wang J, Chung SH, Tseng JF, Merrill A, Sachs TE, Ko NY, Cassidy MR. Association of Race, Ethnicity, Language, and Insurance with Time to Treatment Initiation Among Women with Breast Cancer at an Urban, Academic, Safety-Net Hospital. Ann Surg Oncol 2024; 31:1608-1614. [PMID: 38017122 DOI: 10.1245/s10434-023-14612-y] [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: 06/23/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Initial treatment for nonmetastatic breast cancer is resection or neoadjuvant systemic therapy, depending on tumor biology and patient factors. Delays in treatment have been shown to impact survival and quality of life. Little has been published on the performance of safety-net hospitals in delivering timely care for all patients. METHODS We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2019 at an academic, safety-net hospital. Time to treatment initiation was calculated for all patients. Consistent with a recently published Committee on Cancer timeliness metric, a treatment delay was defined as time from tissue diagnosis to treatment of greater than 60 days. RESULTS A total of 799 eligible women with stage 1-3 breast cancer met study criteria. Median age was 60 years, 55.7% were non-white, 35.5% were non-English-speaking, 18.9% were Hispanic, and 49.4% were Medicaid/uninsured. Median time to treatment was 41 days (IQR 27-56 days), while 81.1% of patients initiated treatment within 60 days. The frequency of treatment delays did not vary by race, ethnicity, insurance, or language. Diagnosis year was inversely associated with the occurrence of a treatment delay (OR: 0.944, 95% CI 0.893-0.997, p value: 0.039). CONCLUSION At our institution, race, ethnicity, insurance, and language were not associated with treatment delay. Additional research is needed to determine how our safety-net hospital delivered timely care to all patients with breast cancer, as reducing delays in care may be one mechanism by which health systems can mitigate disparities in the treatment of breast cancer.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, USA
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Emily J Ha
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Ann Fefferman
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Judy Wang
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Boston Medical Center, Boston, MA, USA
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jennifer F Tseng
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Andrea Merrill
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Teviah E Sachs
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Naomi Y Ko
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Hematology and Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Michael R Cassidy
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA.
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Mavor ME, Hanna TP, Asai Y, Langley H, Look Hong NJ, Wright FC, Nguyen P, Groome PA. Factors associated with the melanoma diagnostic interval in Ontario, Canada: a population-based study. Br J Cancer 2024; 130:483-495. [PMID: 38102225 PMCID: PMC10844321 DOI: 10.1038/s41416-023-02518-1] [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] [Received: 02/21/2023] [Revised: 11/15/2023] [Accepted: 11/23/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Protracted times to diagnosis of cancer can lead to increased patient anxiety, and in some cases, disease progression and worse outcomes. This study assessed the time to diagnosis for melanoma, and its variability, according to patient-, disease-, and system-level factors. METHODS This is a descriptive, cross-sectional study in Ontario, Canada from 2007-2019. We used administrative health data to measure the diagnostic interval (DI)-and its two subintervals-the primary care subinterval (PCI) and specialist care subinterval (SCI). Multivariable quantile regression was used. RESULTS There were 33,371 melanoma patients. The median DI was 36 days (interquartile range [IQR]: 8-85 days), median PCI 22 days (IQR: 6-54 days), and median SCI 6 days (IQR: 1-42 days). Increasing comorbidity was associated with increasing DI. Residents in the most deprived neighbourhoods and those in rural areas experienced shorter DIs and PCIs, but no differences in SCI. There was substantial variation in the DI and SCI across health regions, but limited differences in the PCI. Finally, patients with a history of non-melanoma skin cancer, and those previously established with a dermatologist experienced significantly longer DI, PCI, and SCI. DISCUSSION This study found variability in the melanoma DI, notably by system-level factors.
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Affiliation(s)
- Meaghan E Mavor
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, ON, Canada.
| | - Timothy P Hanna
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, ON, Canada
- Department of Oncology, Queen's University, Kingston, ON, Canada
- ICES at Queen's University, Kingston, ON, Canada
| | - Yuka Asai
- Division of Dermatology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Hugh Langley
- Department of Oncology, Queen's University, Kingston, ON, Canada
- South East Regional Cancer Program, Kingston, ON, Canada
| | - Nicole J Look Hong
- Surgical Oncology, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Frances C Wright
- Surgical Oncology, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Surgical Oncology Program, Cancer Care Ontario - Ontario Health, Toronto, ON, Canada
| | - Paul Nguyen
- ICES at Queen's University, Kingston, ON, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
- Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen's University, Kingston, ON, Canada
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Gaps in Providers' Knowledge Delays Gastric Cancer Diagnosis. J Gastrointest Surg 2022; 26:750-756. [PMID: 34978028 DOI: 10.1007/s11605-021-05209-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies have suggested that symptomatic cancer patients often experience delays in diagnosis (DD). However, DD of gastric cancer within the USA and etiology of those delays are not understood. Our study quantifies the proportion of gastric cancer patients experiencing DD and contributing barriers of care. METHODS We conducted a single institution retrospective review of 256 gastric cancer patients treated between 2015 and 2020. Patients with an interval from symptom onset to diagnosis of > 90 days were classified as having DD and categorized into one of the following barriers of care: access, provider knowledge/skills, and patient factors. Chi-square tests were used to analyze categorical group differences. Non-pooled t-tests and ANOVA were used to compare differences in group means. RESULTS A total of 59 patients (23%) had DD. Among patients with DD, the mean time from symptom onset to diagnosis was 229 days vs 30 days in the non-delayed group (p < 0.0001). The most common barrier of care was provider knowledge/skills gaps (44%), followed by access (36%) and patient-related factors (20%). Only 5% of patients who experienced delays reported abdominal pain alone, with the remaining 95% of patients reporting more than one symptom including obstruction, gastrointestinal bleeding, or weight loss. CONCLUSION Patients often face lengthy delays in gastric cancer diagnosis which arise from healthcare system factors such as access barriers or gaps in provider knowledge/skills. Understanding concerning alarm symptoms and addressing identified barriers will expedite patient diagnosis and are prime opportunities to improve outcomes for gastric cancer patients.
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Elfgen C, Baumgartner S, Varga Z, Reeve K, Tausch CJ, Bjelic-Radisic V, Fleisch M, Güth U. Diagnostic delay in moderately/poorly differentiated breast cancer types. Eur J Cancer Prev 2022; 31:152-157. [PMID: 33899749 DOI: 10.1097/cej.0000000000000681] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Diagnostic delay of breast cancer related to the false-negative assessment of the healthcare provider leads to tumor progression and might worsen the outcome. Previous studies found some factors associated with provider-related diagnostic delay; however, tumor biology has tended not to be considered. The aim of our study was to find differences in diagnostic delay of poorly differentiated breast cancer types. METHODS Data of 970 patients with newly diagnosed moderately/poorly differentiated (G2/3) breast cancer at the age ≥40 years was retrospectively analyzed regarding breast cancer type, diagnostic delay and its consequence, clinical factors and physician's assessment. Multivariate analysis was used to evaluate associated factors with diagnostic delay. RESULTS We observed a diagnostic delay in 3.8% (n = 37) of all patients. Mean delay time was 128 days, and clinically relevant tumor growth was observed in 43.2% of these cases. Delay was significantly higher in the group of triple-negative breast cancer (9.9% versus 2.7, 5.3 and 1.8% in hormonal receptor (HR)+/human epidermal growth factor receptor 2 (HER2)-, HR-/Her2+ and HR+/Her2+, respectively; P value <0.001). Age, breast density and reason for presentation were not correlated to diagnostic delay. CONCLUSION Patients with triple-negative breast cancer are at higher risk of receiving a false-negative assessment and experiencing a diagnostic delay. Our results emphasize the importance of a detailed consideration of clinical risk factors and provider training and suggest a broad indication for a core needle biopsy.
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Affiliation(s)
- Constanze Elfgen
- Department of Breast Surgery, Breast-Center Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Witten-Herdecke, Witten-Herdecke, Germany
| | | | - Zsuzsanna Varga
- Institute of Pathology and Molecular Pathology, University Hospital of Zurich
| | - Kelly Reeve
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Christoph J Tausch
- Department of Breast Surgery, Breast-Center Zurich, Zurich, Switzerland
- Department of Gynecology and Obstetrics, Landesfrauenklinik Wuppertal, Wuppertal, Germany
| | - Vesna Bjelic-Radisic
- Faculty of Medicine, University of Witten-Herdecke, Witten-Herdecke, Germany
- Department of Gynecology and Obstetrics, Landesfrauenklinik Wuppertal, Wuppertal, Germany
| | - Markus Fleisch
- Faculty of Medicine, University of Witten-Herdecke, Witten-Herdecke, Germany
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Uwe Güth
- Department of Breast Surgery, Breast-Center Zurich, Zurich, Switzerland
- Department of Gynecology and Obstetrics, Landesfrauenklinik Wuppertal, Wuppertal, Germany
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Stey AM, Kanzaria HK, Dudley RA, Bilimoria KY, Knudson MM, Callcut RA. Emergency Department Length of Stay and Mortality in Critically Injured Patients. J Intensive Care Med 2022; 37:278-287. [PMID: 33641512 DOI: 10.1177/0885066621995426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Multicenter data from 2 decades ago demonstrated that critically ill and injured patients spending more than 6 hours in the emergency department (ED) before transfer to the intensive care unit (ICU) had higher mortality rates. A contemporary analysis of ED length of stay in critically injured patients at American College of Surgeons' Trauma Quality Improvement Program (ACS-TQIP) centers was performed to test whether prolonged ED length of stay is still associated with mortality. METHODS This was an observational cohort study of critically injured patients admitted directly to ICU from the ED in ACS-TQIP centers from 2010-2015. Spending more than 6 hours in the ED was defined as prolonged ED length of stay. Patients with prolonged ED length of stay were matched to those with non-prolonged ED length of stay and mortality was compared. MAIN RESULTS A total of 113,097 patients were directly admitted from the ED to the ICU following injury. The median ED length of stay was 167 minutes. Prolonged ED length of stay occurred in 15,279 (13.5%) of patients. Women accounted for 29.4% of patients with prolonged ED length of stay but only 25.8% of patients with non-prolonged ED length of stay, P < 0.0001. Mortality rates were similar after matching-4.5% among patients with prolonged ED length of stay versus 4.2% among matched controls. Multivariable logistic regression of the matched cohorts demonstrated prolonged ED length of stay was not associated with mortality. However, women had higher adjusted mortality compared to men Odds Ratio = 1.41, 95% Confidence Interval 1.28 -1.61, P < 0.0001. CONCLUSION Prolonged ED length of stay is no longer associated with mortality among critically injured patients. Women are more likely to have prolonged ED length of stay and mortality.
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Affiliation(s)
- Anne M Stey
- Northwestern University Feinberg School of Medicine, IL, Chicago
| | - Hemal K Kanzaria
- University of California San Francisco, San Francisco, CA
- Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Karl Y Bilimoria
- Northwestern University Feinberg School of Medicine, IL, Chicago
| | - M Margaret Knudson
- University of California San Francisco, San Francisco, CA
- Zuckerberg San Francisco General Hospital, San Francisco, CA
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Johnsen AT, Flink CE, Winther KP, Markussen ALR, Lund L, Pedersen I, Rix BA, Kehlet KH. Promoting health equity in the health-care system: How can we identify potentially vulnerable patients? Scand J Public Health 2021; 50:903-907. [PMID: 34903121 DOI: 10.1177/14034948211059720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is documented social inequality in cancer. The health-care system may contribute to health equity by targeting interventions to potentially vulnerable patients who may be at risk of not receiving optimal treatment and care. AIM This study aimed to develop and pilot test a tool to identify patients who may need additional support. METHOD The study took place in a department of palliative medicine and in a team for head and neck cancer within an oncology department. The tool to identify potentially vulnerable patients was developed based on literature reviews and interviews with patients and health-care personnel. It was pilot tested in a six-month period, with subsequent interviews with health-care personnel. RESULTS In total, 212 consecutive patients referred to the departments were systematically screened with the tool by health-care personnel. Of these, 74 (35%) patients were considered potentially vulnerable. The most frequently reported sign of vulnerability was 'few supportive relations' (47% of the vulnerable patients). Most health-care personnel found it relevant to focus systematically on these patients. However, some were concerned that using the tool could prove to be stigmatising and were critical of attributing the vulnerability to the individual. CONCLUSIONS Most patients were considered in need of additional support because they lacked a social network or had difficulties communicating with health-care personnel. Applying a tool to identify potentially vulnerable patients was feasible and increased attention to this group of patients. However, the screening procedure was also questioned.
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Affiliation(s)
- Anna Thit Johnsen
- Department of Palliative Medicine, Bispebjerg Hospital, Copenhagen University Hospital, Denmark.,Department of Psychology, University of Southern Denmark, Denmark
| | | | | | | | - Line Lund
- Department of Palliative Medicine, Bispebjerg Hospital, Copenhagen University Hospital, Denmark
| | - Isabella Pedersen
- Department of Palliative Medicine, Bispebjerg Hospital, Copenhagen University Hospital, Denmark
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Ethnic, racial and socioeconomic disparities in breast cancer survival in two Brazilian capitals between 1996 and 2012. Cancer Epidemiol 2021; 75:102048. [PMID: 34700284 DOI: 10.1016/j.canep.2021.102048] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/11/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To study the impact of socio-economic status and ethno-racial strata on excess mortality hazard and net survival of women with breast cancer in two Brazilian state capitals. METHOD We conducted a survival analysis with individual data from population-based cancer registries including women with breast cancer diagnosed between 1996 and 2012 in Aracaju and Curitiba. The main outcomes were the excess mortality hazard (EMH) and net survival. The associations of age, year of diagnosis, disease stage, race/skin colour and socioeconomic status (SES) with the excess mortality hazard and net survival were analysed using multi-level spline regression models, modelled as cubic splines with knots at 1 and 5 years of follow-up. RESULTS A total of 2045 women in Aracaju and 7872 in Curitiba were included in the analyses. The EMH was higher for women with lower SES and for black and brown women in both municipalities. The greatest difference in excess mortality was seen between the most deprived women and the most affluent women in Curitiba, hazard ratio (HR) 1.93 (95%CI 1.63-2.28). For race/skin colour, the greatest ratio was found in Curitiba (HR 1.35, 95%CI 1.09-1.66) for black women compared with white women. The most important socio-economic difference in net survival was seen in Aracaju. Age-standardised net survival at five years was 55.7% for the most deprived women and 67.2% for the most affluent. Net survival at eight years was 48.3% and 61.0%, respectively. Net survival in Curitiba was higher than in Aracaju in all SES groups." CONCLUSION Our findings suggest the presence of contrasting breast cancer survival expectancy in Aracaju and Curitiba, highlighting regional inequalities in access to health care. Lower survival among brown and black women, and those in lower SES groups indicates that early detection, early diagnosis and timely access to treatment must be prioritized to reduce inequalities in outcome among Brazilian women.
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Dinis J, Allam O, Junn A, Park KE, Mozaffari MA, Shah R, Avraham T, Alperovich M. Predictors for Prolonged Drain Use Following Autologous Breast Reconstruction. J Reconstr Microsurg 2021; 38:160-167. [PMID: 34284504 DOI: 10.1055/s-0041-1731765] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical drains are routinely used following autologous reconstruction, but are often cited as the leading cause of peri-operative discomfort. This study defined routine drain use duration and assessed the risk factors for prolonged breast and abdominal drain use during microvascular breast reconstruction, measures which have never previously been defined. METHODS Patients who underwent an abdominal microvascular free flap were included. Demographics, comorbidities, and operation-related characteristics were retrospectively collected in a prospectively maintained database. Statistical analysis utilized chi-square independent t-test, and linear regression analyses. RESULTS One hundred forty-nine patients comprising 233 breast flaps were included. Average breast and abdominal drain duration were 12.9 ± 3.9 and 17.7 ± 8.2 days, respectively. Prolonged breast and abdominal drain duration were defined as drain use beyond the 75th percentile at 14 and 19 days, respectively. Multivariable regression revealed hypertension was associated with an increased breast drain duration by 1.4 days (p = 0.024), axillary dissection with 1.7 days (p = 0.026), African-American race with 3.1 days (p < 0.001), Hispanic race with 1.6 days (p = 0.029), return to the OR with 3.2 days (p = 0.004), and each point increase in BMI with 0.1 days (p = 0.028). For abdominal drains, each point increase in BMI was associated with an increased abdominal drain duration by 0.3 days (p = 0.011), infection with 14.4 days (p < 0.001), and return to the OR with 5.7 days (p = 0.007). CONCLUSION Elevated BMI, hypertension, and axillary dissection increase risk for prolonged breast drain requirement in autologous reconstruction. African-American and Hispanic populations experience prolonged breast drain requirement after controlling for other factors, warranting further study.
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Affiliation(s)
- Jacob Dinis
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Omar Allam
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Alexandra Junn
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Kitae Eric Park
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mohammad Ali Mozaffari
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Rema Shah
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Tomer Avraham
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Alperovich
- Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Connecticut
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Tait SD, Ren Y, Horton CC, Oshima SM, Thomas SM, Wright S, Caesar A, Plichta JK, Hwang ES, Greenup RA, Rosenberger LH, DiLalla GD, Menendez CS, Tolnitch L, Hyslop T, Nelson D, Fayanju OM. Characterizing participants in the North Carolina Breast and Cervical Cancer Control Program: A retrospective review of 90,000 women. Cancer 2021; 127:2515-2524. [PMID: 33826758 DOI: 10.1002/cncr.33473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) provides breast cancer screening services to underserved women to mitigate disparities in access to care. The authors sought to characterize this understudied population. METHODS Women 21 years old or older who underwent their first breast cancer screen through NC BCCCP from 2008 to 2018 were included. Demographic factors associated with the timeline of care and odds of a breast cancer diagnosis were identified with negative binomial and logistic regression, respectively. RESULTS Of the 88,893 women identified, 45.5% were non-Hispanic (NH) White, 30.9% were NH Black, 19.6% were Hispanic, 1.7% were American Indian, and 1.1% were Asian. Breast cancer was diagnosed in 2.5% of the women (n = 2255). Hispanic women were the least likely to be diagnosed with breast cancer (odds ratio vs NH White women, 0.40; 95% confidence interval [CI], 0.34-0.47). Among patients with breast pathology, the median time to diagnosis was 19 days (interquartile range [IQR], 10-33 days), and the time to treatment was 33 days (IQR, 19-54 days). After adjustments, a longer time to diagnosis was significantly associated with age (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) and being NH Black (vs NH White; IRR, 1.17; 95% CI, 1.06-1.29). A longer time to treatment was significantly associated with age (IRR, 1.01; 95% CI, 1.01-1.01), being NH Black (vs NH White; IRR, 1.20; 95% CI, 1.10-1.31), and being Hispanic (vs NH White; IRR, 1.22; 95% CI, 1.05-1.41). CONCLUSIONS NC BCCCP participants with breast cancer received treatment within approximately 1 month of presentation, and this finding aligns with quality care benchmarks. Nevertheless, racial/ethnic disparities in timeliness of care persist, and this suggests opportunities for improvement. LAY SUMMARY This review of approximately 90,000 participants in a breast cancer screening program for uninsured and underinsured women highlights the importance of safety net programs in providing timely care to underserved patients. The authors found that the North Carolina Breast and Cervical Cancer Control Program met timeliness benchmarks from the Centers for Disease Control and Prevention across all racial/ethnic groups. However, non-Hispanic Black women experienced relative delays in the time to diagnosis, and both non-Hispanic Black women and Hispanic women experienced relative delays in the time to treatment. These findings demonstrate how racial/ethnic disparities in the timeliness of care can persist even within a program intended to reduce barriers to access.
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Affiliation(s)
- Sarah D Tait
- Duke University School of Medicine, Durham, North Carolina
| | - Yi Ren
- Duke University School of Medicine, Durham, North Carolina
| | - Cushanta C Horton
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | | | | | - Sherry Wright
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Awanya Caesar
- Lincoln Community Health Center, Durham, North Carolina
| | | | | | | | | | | | | | - Lisa Tolnitch
- Duke University School of Medicine, Durham, North Carolina
| | - Terry Hyslop
- Duke University School of Medicine, Durham, North Carolina
| | - Debi Nelson
- North Carolina Department of Health and Human Services, Raleigh, North Carolina
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Racial Disparities in Time to Treatment Initiation and Outcomes for Early Stage Anal Squamous Cell Carcinoma. Am J Clin Oncol 2021; 43:762-769. [PMID: 32804778 DOI: 10.1097/coc.0000000000000744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although cure rates for early stage anal squamous cell cancer (ASCC) are overall high, there may be racial disparities in receipt of treatment and outcome precluding favorable outcomes across all patient demographics. Therefore, the authors aimed to assess the time to treatment initiation and overall survival (OS) in Black and White patients receiving definitive chemoradiation for early stage ASCC. MATERIALS AND METHODS The authors identified patients diagnosed with early stage (stage I-II) ASCC and treated with chemoradiation diagnosed between 2004 and 2016 in the National Cancer Database. Clinical and treatment variables were compared by race using the χ test, and OS assessed through Cox regression with 1:1 nearest neighbor propensity score matching. RESULTS Among 9331 patients, 90.6% were White. Black patients had longer median time to treatment initiation as compared with White patients (47 vs. 36 d, P<0.001), and on multivariable analysis, the Black race was associated with higher odds of >6 weeks of time to treatment initiation (hazard ratio, 1.78; 95% confidence interval, 1.53-2.08; P<0.001). Furthermore, Black patients had worse OS (5-year survival 71% vs. 77%; P<0.001), which persisted after propensity score matching (P=0.007). CONCLUSIONS Black patients had a longer time to treatment initiation and worse OS as compared with White patients with early stage ASCC treated with chemoradiation. Further research is needed to better elucidate the etiologies of these disparities.
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Emerson MA, Golightly YM, Aiello AE, Reeder-Hayes KE, Tan X, Maduekwe U, Johnson-Thompson M, Olshan AF, Troester MA. Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women. Cancer 2020; 126:4957-4966. [PMID: 32954493 DOI: 10.1002/cncr.33121] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/10/2020] [Accepted: 07/06/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Breast cancer mortality is higher for Black and younger women. This study evaluated 2 possible contributors to disparities-time to treatment and treatment duration-by race and age. METHODS Among 2841 participants with stage I-III disease in the Carolina Breast Cancer Study, we identified groups of women with similar patterns of socioeconomic status (SES), access to care, and tumor characteristics using latent class analysis. We then evaluated latent classes in association with treatment delay (initiation >60 days after diagnosis) and treatment duration (in quartiles by treatment modality). RESULTS Thirty-two percent of younger Black women were in the highest quartile of treatment duration (versus 22% of younger White women). Black women experienced a higher frequency of delayed treatment (adjusted relative frequency difference [RFD], 5.5% [95% CI, 3.2%-7.8%]) and prolonged treatment duration (RFD, 8.8% [95% CI, 5.7%-12.0%]). Low SES was significantly associated with treatment delay among White women (RFD, 3.5% [95% CI, 1.1%-5.9%]), but treatment delay was high at all levels of SES in Black women (eg, 11.7% in high SES Black women compared with 10.6% and 6.7% among low and high SES White women, respectively). Neither SES nor access to care classes were significantly associated with delayed initiation among Black women, but both low SES and more barriers were associated with treatment duration across both groups. CONCLUSIONS Factors that influence treatment timeliness persist throughout the care continuum, with prolonged treatment duration being a sensitive indicator of differences by race, SES, and care barriers.
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Affiliation(s)
- Marc A Emerson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Yvonne M Golightly
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Allison E Aiello
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xianming Tan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ugwuji Maduekwe
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Andrew F Olshan
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Melissa A Troester
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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13
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Stey AM, Byskosh A, Etkin C, Mackersie R, Stein DM, Bilimoria KY, Crandall ML. Describing the density of high-level trauma centers in the 15 largest US cities. Trauma Surg Acute Care Open 2020; 5:e000562. [PMID: 33083559 PMCID: PMC7549441 DOI: 10.1136/tsaco-2020-000562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/02/2020] [Accepted: 09/18/2020] [Indexed: 11/03/2022] Open
Abstract
Background There has been a proliferation of urban high-level trauma centers. The aim of this study was to describe the density of high-level adult trauma centers in the 15 largest cities in the USA and determine whether density was correlated with urban social determinants of health and violence rates. Methods The largest 15 US cities by population were identified. The American College of Surgeons' (ACS) and states' department of health websites were cross-referenced for designated high-level (levels 1 and 2) trauma centers in each city. Trauma centers and associated 20 min drive radius were mapped. High-level trauma centers per square mile and per population were calculated. The distance between high-level trauma centers was calculated. Publicly reported social determinants of health and violence data were tested for correlation with trauma center density. Results Among the 15 largest cities, 14 cities had multiple high-level adult trauma centers. There was a median of one high-level trauma center per every 150 square kilometers with a range of one center per every 39 square kilometers in Philadelphia to one center per596 square kilometers in San Antonio. There was a median of one high-level trauma center per 285 034 people with a range of one center per 175 058 people in Columbus to one center per 870 044 people in San Francisco. The median minimum distance between high-level trauma centers in the 14 cities with multiple centers was 8 kilometers and ranged from 1 kilometer in Houston to 43 kilometers in San Antonio. Social determinants of health, specifically poverty rate and unemployment rate, were highly correlated with violence rates. However, there was no correlation between trauma center density and social determinants of health or violence rates. Discussion High-level trauma centers density is not correlated with social determinants of health or violence rates. Level of evidence VI. Study type Economic/decision.
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Affiliation(s)
- Anne M Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexandria Byskosh
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Caryn Etkin
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert Mackersie
- Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, San Francisco, California, USA
| | - Karl Y Bilimoria
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Marie L Crandall
- Department of Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
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14
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Smith-Graziani D, Lei X, Giordano SH, Zhao H, Karuturi M, Chavez-MacGregor M. Delayed initiation of adjuvant chemotherapy in older women with breast cancer. Cancer Med 2020; 9:6961-6971. [PMID: 32767723 PMCID: PMC7541132 DOI: 10.1002/cam4.3363] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Adjuvant chemotherapy benefits early‐stage breast cancer (BC) patients. Older women receive guideline‐adherent treatment less frequently and experience treatment delays more frequently. We evaluated factors associated with delaying adjuvant chemotherapy and the delays’ survival impact in a large population–based cohort of elderly BC patients. Methods Patients age >66 years diagnosed 2001‐2015 with localized or regional BC were identified in the SEER‐Medicare and Texas Cancer Registry‐Medicare databases. Time from surgery to chemotherapy (TTC) was categorized into four groups: 0‐30, 31‐60, 61‐90, and >90 days. We identified predictors of delays, estimated overall (OS) and BC‐specific (BCSS) survival, and determined the association between TTC and outcome adjusting for other variables. Results Among 28,968 women (median age 71 years), median TTC was 43 days. 10.7% of patients experienced TTC >90 days. Older age, Black or Hispanic race/ethnicity, unmarried status, more comorbidities, hormone receptor‐positivity, mastectomy, Oncotype DX testing, and full state buy‐in were associated with increased risk of delay. Five‐year OS estimates by TTC group were 0.82, 0.81, 0.80, and 0.74, respectively (p<.001). BCSS demonstrated a similar trend (p<.001). Chemotherapy delay was associated with worse OS (HR=1.33, 95%CI 1.25‐1.40) and BCSS (HR=1.39, 95%CI 1.27‐1.53). In subgroup analysis, delayed chemotherapy was associated with worse OS and BCSS among patients with hormone receptor–positive (HR=1.56, 95%CI 0.97‐2.51), HER2‐positive (HR=1.99, 95%CI 1.04‐3.79), and triple‐negative (HR=2.15, 95%CI 1.38‐3.36) tumors. Conclusion Chemotherapy delays are associated with worse survival in older BC patients. Providers should avoid delays and initiate chemotherapy ≤90 days after surgery regardless of patients’ BC subtype or age.
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Affiliation(s)
- Demetria Smith-Graziani
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Meghan Karuturi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariana Chavez-MacGregor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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The use of survivorship care plans by female racial and ethnic minority breast cancer survivors: a systematic review. J Cancer Surviv 2020; 14:806-825. [PMID: 32514908 DOI: 10.1007/s11764-020-00894-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/07/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Racial/ethnic breast cancer survivorship disparities persist as minority breast cancer survivors (MBCSs) report fragmentation in survivorship care, namely in the access and delivery of survivorship care plans (SCPs). To better understand care coordination of MCBS, this review elucidated concerns of female MBCS about their preparation for post-treatment survivorship care, the preferred practices for the delivery of a SCP, and the associated content to improve post-treatment survivorship care understanding. METHODS A systematic search of articles from PubMed, Ovid-Medline, CINAHL databases, and bibliographic reviews included manuscripts using keywords for racial/ethnic minority groups and breast cancer survivorship care coordination terms. Salient themes and article quality were analyzed from the extracted data. RESULTS Fourteen included studies represented 5,854 participants and over 12 racial/ethnic groups. The following themes of post-treatment MBCS were identified from the review: (1) uncertainty about post-treatment survivorship care management is a consequence of sub-optimal patient-provider communication; (2) access to SCPs and related materials are desired, but sporadic; and (3) advancements to the delivery and presentation of SCPs and related materials are desired. CONCLUSIONS Representation of only 14 studies indicates that the MBCSs' perspective post-treatment survivorship care is underrepresented in the literature. Themes from this review support access to, and implementation of, culturally tailored SCP for MBCS. There was multi-ethnic acceptance of SCPs as a tool to help improve care coordination. IMPLICATIONS FOR CANCER SURVIVORS These findings highlight the importance of general education about post-treatment survivorship, post-treatment survivorship needs identification, and the elucidation of gaps in effective SCP delivery among MBCS.
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16
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McCall MK, Connolly M, Nugent B, Conley YP, Bender CM, Rosenzweig MQ. Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:428-440. [PMID: 31392599 PMCID: PMC7245588 DOI: 10.1007/s13187-019-01571-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.
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Affiliation(s)
- Maura K. McCall
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261 USA
| | - Mary Connolly
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261 USA
| | - Bethany Nugent
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261 USA
| | - Yvette P. Conley
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261 USA
| | - Catherine M. Bender
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261 USA
| | - Margaret Q. Rosenzweig
- University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA 15261 USA
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17
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Race and renal cell carcinoma stage at diagnosis: an analysis of the Surveillance, Epidemiology, and End Results data. Eur J Cancer Prev 2019; 28:350-354. [DOI: 10.1097/cej.0000000000000484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Elfgen C, Varga Z, Reeve K, Moskovszky L, Bjelic-Radisic V, Tausch C, Güth U. The impact of distinct triple-negative breast cancer subtypes on misdiagnosis and diagnostic delay. Breast Cancer Res Treat 2019; 177:67-75. [PMID: 31154578 DOI: 10.1007/s10549-019-05298-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 05/25/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Triple-negative breast cancer (TNBC) includes mostly aggressive types of breast cancer with poor prognosis. Due to its growth pattern, misinterpretation in clinical imaging is more frequent than in non-TNBC. As the group of TNBC contains heterogeneous types of tumors, marker expression-based subtypes have recently been established. We analyzed clinical features and false-negative imaging findings that could potentially lead to diagnostic delay within the subtypes. METHODS An exploratory analysis compared the imaging features across the a priori defined subtypes and related these findings to molecular subtype, disease stage, potential diagnostic delay, and patient outcome. RESULTS TNBC cases were categorized into basal-like (BL; 38.6%), mesenchymal-like (ML; 19.9%), luminal androgen receptor (LAR; 28.3%), and immunomodulatory (IM; 13.3%) subtype. In almost every third patient, malignant classification was missed in at least one imaging method. Misclassification in mammogram was more frequent in ML, while benign ultrasound features were reported more often in the BL subtype. Diagnostic delay due to misclassification in imaging led to tumor growth and/or upgrading of the tumor stage in 8.9% of BL tumors, which had the lowest overall survivals. Despite misclassification rate was higher in the ML subtype it showed better outcomes. Misdiagnosis of axillary lymph node metastasis was higher in LAR; however, this subtype showed a higher percentage of affected axillary lymph nodes. CONCLUSION TNBC subtypes have different clinical features, benign appearances, and diagnostic delay, which can lead to tumor stage upgrade. Future clinical studies on TNBC outcomes might consider the confounder of clinical delay in the subtypes.
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Affiliation(s)
- C Elfgen
- Breast-Center Zurich, Seefeldstrasse 214, 8008, Zurich, Switzerland. .,Senology Department, Institute of Gynecology and Obstetrics, University of Witten-Herdecke, Witten, Germany.
| | - Z Varga
- Institute of Pathology and Molecular Pathology, University Hospital of Zurich, Zurich, Switzerland
| | - K Reeve
- Biostatistics Department, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - L Moskovszky
- Institute of Pathology and Molecular Pathology, University Hospital of Zurich, Zurich, Switzerland
| | - V Bjelic-Radisic
- Senology Department, Institute of Gynecology and Obstetrics, University of Witten-Herdecke, Witten, Germany
| | - C Tausch
- Breast-Center Zurich, Seefeldstrasse 214, 8008, Zurich, Switzerland
| | - U Güth
- Breast-Center Zurich, Seefeldstrasse 214, 8008, Zurich, Switzerland
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19
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Torres E, Richman AR, Schreier AM, Vohra N, Verbanac K. An Evaluation of a Rural Community-Based Breast Education and Navigation Program: Highlights and Lessons Learned. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:277-284. [PMID: 29150748 DOI: 10.1007/s13187-017-1298-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Cancer has become the leading cause of death in North Carolina (NC) (North Carolina DHHS, State Center for Health Statistics 2015) and the eastern region of North Carolina (ENC) has experienced greater cancer mortality than the remainder of the state. The Pitt County Breast Wellness Initiative-Education (PCBWI-E) provides culturally tailored breast cancer education and navigation to screening services for uninsured/underinsured women in Pitt and Edgecombe Counties in ENC. PCBWI-E created a network of 23 lay breast health educators, and has educated 735 women on breast health and breast cancer screening guidelines. Navigation services have been provided to 365 women, of which 299 were given breast health assessments, 193 were recommended for a mammogram, and 138 were screened. We have identified five lessons learned to share in the successful implementation of a community-based breast cancer screening intervention: (1) community partnerships are critical for successful community-based cancer screening interventions; (2) assuring access to free or low-cost screening and appropriate follow-up should precede interventions to promote increased use of breast cancer screening; (3) the reduction of system-based barriers is effective in increasing cancer screening; (4) culturally tailored interventions can overcome barriers to screening for diverse racial/ethnic and socioeconomic groups; and (5) multi-component interventions that include multiple community health strategies are effective in increasing screening.
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Affiliation(s)
- Essie Torres
- Department of Health Education and Promotion, East Carolina University, 3202 Carol Belk Building, Greenville, NC, 27858, USA.
| | - Alice R Richman
- Department of Health Education and Promotion, East Carolina University, 3107 Carol Belk Building, Greenville, NC, 27858, USA
| | - Ann M Schreier
- College of Nursing, East Carolina University, Health Sciences Bldg, Greenville, NC, 27834, USA
| | - Nasreen Vohra
- Department of Surgery, Brody School of Medicine, Greenville, NC, 27834, USA
| | - Kathryn Verbanac
- Department of Surgery, Brody School of Medicine, Greenville, NC, 27834, USA
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20
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Wang KY, Malayil Lincoln CM, Chen MM. Radiology Support, Communication, and Alignment Network and Its Role to Promote Health Equity in the Delivery of Radiology Care. J Am Coll Radiol 2019; 16:638-643. [DOI: 10.1016/j.jacr.2018.12.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/22/2018] [Indexed: 12/14/2022]
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21
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Kelley SF, Day GM, DeCourtney CA, Nash SH. Timeliness of Breast Cancer Treatment Within The Alaska Tribal Health System. J Rural Health 2019; 35:216-221. [PMID: 29030951 DOI: 10.1111/jrh.12280] [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: 05/18/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE This study examined the time from breast cancer diagnosis to initiation of treatment among Alaska Native (AN) women. We evaluated the impact of age, cancer stage, and rural/urban residence at diagnosis. METHODS We evaluated characteristics of women recorded in the Alaska Native Tumor Registry who received a first diagnosis of breast cancer between 2009 and 2013. Median time from diagnosis to treatment was assessed. Associations of demographic and clinical characteristics with timely initiation of treatment were evaluated using logistic regression and Cox proportional hazards models. RESULTS Two hundred seventy-eight (278) AN women were diagnosed with invasive breast cancer in years 2009-2013. Mean age at diagnosis was 56.8 years (SD = 13.0). The median time from diagnosis to initiation of treatment was 23 days (P < .05) with most (94.6%, n = 263) meeting the ≤60-day guideline target. Time to treatment was not associated with rural/urban residence, age, or stage at cancer diagnosis. CONCLUSION These findings indicate that most AN women diagnosed with breast cancer within the AN Tribal Health System receive timely treatment after diagnosis.
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Affiliation(s)
- Stacy F Kelley
- Division of Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Gretchen M Day
- Division of Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Christine A DeCourtney
- Division of Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska
| | - Sarah H Nash
- Division of Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska
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22
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Lofters AK, McBride ML, Li D, Whitehead M, Moineddin R, Jiang L, Grunfeld E, Groome PA. Disparities in breast cancer diagnosis for immigrant women in Ontario and BC: results from the CanIMPACT study. BMC Cancer 2019; 19:42. [PMID: 30626375 PMCID: PMC6327524 DOI: 10.1186/s12885-018-5201-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 12/09/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Canada, clinical practice guidelines recommend breast cancer screening, but there are gaps in adherence to recommendations for screening, particularly among certain hard-to-reach populations, that may differ by province. We compared stage of diagnosis, proportion of screen-detected breast cancers, and length of diagnostic interval for immigrant women versus long-term residents of BC and Ontario. METHODS We conducted a retrospective cohort study using linked administrative databases in BC and Ontario. We identified all women residing in either province who were diagnosed with incident invasive breast cancer between 2007 and 2011, and determined who was foreign-born using the Immigration Refugee and Citizenship Canada database. We used descriptive statistics and bivariate analyses to describe the sample and study outcomes. We conducted multivariate analyses (modified Poisson regression and quantile regression) to control for potential confounders. RESULTS There were 14,198 BC women and 46,952 Ontario women included in the study population, of which 11.8 and 11.7% were foreign-born respectively. In both provinces, immigrants and long-term residents had similar primary care access. In both provinces, immigrant women were significantly less likely to have a screen-detected breast cancer (adjusted relative risk 0.88 [0.79-0.96] in BC, 0.88 [0.84-0.93] in Ontario) and had a significantly longer median diagnostic interval (2 [0.2-3.8] days in BC, 5.5 [4.4-6.6] days in Ontario) than long-term residents. Women from East Asia and the Pacific were less likely to have a screen-detected cancer and had a longer diagnostic interval, but were diagnosed at an earlier stage than long-term residents. In Ontario, women from Latin America and the Caribbean and from South Asia were less likely to have a screen-detected cancer, had a longer median diagnostic interval, and were diagnosed at a later stage than long-term residents. These findings were not explained by access to primary care. CONCLUSIONS There are inequalities in breast cancer diagnosis for Canadian immigrant women. We have identified particular immigrant groups (women from Latin America and the Caribbean and from South Asia) that appear to be subject to disparities in the diagnostic process that need to be addressed in order to effectively reduce gaps in care.
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Affiliation(s)
- A. K. Lofters
- Department of Family & Community Medicine, St. Michael’s Hospital, 30 Bond St, Toronto, M5B 1W8 Canada
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Toronto, Canada
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - M. L. McBride
- BC Cancer, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - D. Li
- BC Cancer, Vancouver, Canada
| | | | - R. Moineddin
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - L. Jiang
- ICES, Queen’s University, Kingston, Canada
- Critical Care Services Ontario, Toronto, Ontario Canada
| | - E. Grunfeld
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Ontario Institute for Cancer Research, Toronto, ON Canada
| | - P. A. Groome
- ICES, Queen’s University, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
- Cancer Research Institute, Queen’s University, Kingston, Canada
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23
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Karliner LS, Kaplan C, Livaudais-Toman J, Kerlikowske K. Mammography facilities serving vulnerable women have longer follow-up times. Health Serv Res 2018; 54 Suppl 1:226-233. [PMID: 30394526 PMCID: PMC6341204 DOI: 10.1111/1475-6773.13083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective To investigate mammography facilities’ follow‐up times, population vulnerability, system‐based processes, and association with cancer stage at diagnosis. Data Sources Prospectively collected from San Francisco Mammography Registry (SFMR) 2005‐2011, California Cancer Registry 2005‐2012, SFMR facility survey 2012. Study Design We examined time to biopsy for 17 750 abnormal mammogram results (BI‐RADS 4/5), categorizing eight facilities as short or long follow‐up based on proportion of mammograms with biopsy at 30 days. We examined facility population vulnerability (race/ethnicity, language, education), and system processes. Among women with a cancer diagnosis, we modeled odds of advanced‐stage (≥IIb) cancer diagnosis by facility follow‐up group. Data Extraction Methods Merged SFMR, Cancer Registry and facility survey data. Principal Findings Facilities (N = 4) with short follow‐up completed biopsies by 30 days for 82% of mammograms compared with 62% for facilities with long follow‐up (N = 4) (P < 0.0001). All facilities serving high proportions of vulnerable women were long follow‐up facilities. The long follow‐up facilities had fewer radiologists, longer biopsy appointment wait times, and less communication directly with women. Having the index abnormal mammogram at a long follow‐up facility was associated with higher adjusted odds of advanced‐stage cancer (OR 1.45; 95% CI 1.10‐1.91). Conclusions Providing mammography facilities serving vulnerable women with appropriate resources may decrease disparities in abnormal mammogram follow‐up and cancer diagnosis stage.
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Affiliation(s)
- Leah S Karliner
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, California.,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
| | - Celia Kaplan
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, California.,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
| | - Jennifer Livaudais-Toman
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, California.,Multiethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
| | - Karla Kerlikowske
- General Internal Medicine Section, San Francisco Veteran Affairs Medical Center, San Francisco, California.,Departments of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
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24
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Green AK, Aviki EM, Matsoukas K, Patil S, Korenstein D, Blinder V. Racial disparities in chemotherapy administration for early-stage breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat 2018; 172:247-263. [PMID: 30094552 DOI: 10.1007/s10549-018-4909-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/02/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE We conducted a systematic review and meta-analysis to measure the extent to which race is associated with delayed initiation or receipt of inadequate chemotherapy among women with early-stage breast cancer. METHODS We performed a systematic search of all articles published from January 1987 until June 2017 within four databases: PubMed/Medline, EMBASE, CINAHL, and Cochrane CENTRAL. Eligible studies were US-based and examined the influence of race on chemotherapy delays, cessation, or dose reductions among women with stage I, II, or III breast cancer. Data were pooled using a random effects model. RESULTS A total of twelve studies were included in the quantitative analysis. Blacks were significantly more likely than whites to have delays to initiation of adjuvant therapy of 90 days or more (OR 1.41, 95% CI 1.06-1.87; X² = 31.05, p < 0.00001; I² = 90%). There was no significant association between race and chemotherapy dosing. Due to overlap between studies assessing the relationship between race and completion of chemotherapy, we conducted two separate analyses. Black patients were significantly more likely to discontinue chemotherapy, however, this was no longer statistically significant when larger numbers of patients with more advanced (stage III) breast cancer were included. CONCLUSIONS These results suggest that black breast cancer patients experience clinically relevant delays in the initiation of adjuvant chemotherapy more often than white patients, which may in part explain the increased mortality observed among black patients.
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Affiliation(s)
- Angela K Green
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Emeline M Aviki
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | | | - Sujata Patil
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Deborah Korenstein
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Victoria Blinder
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
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Rangel-Méndez JA, Novelo-Tec JF, Sánchez-Cruz JF, Cedillo-Rivera R, Moo-Puc RE. Healthcare delay in breast cancer patients: a case study in a low-density population region from Mexico. Future Oncol 2018; 14:2067-2082. [DOI: 10.2217/fon-2017-0713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To describe delay intervals, their impact on clinical stage and initiation of first oncologic treatment, and evaluate associated factors in breast cancer patients in Yucatan, Mexico, a low-density population region. Patients & methods: A retrospective analysis was done of 92 medical records, and bivariate and multivariate models applied to identify associations between healthcare delay and several factors. Results: System delay accounted for most of the delay (median: 86 days; 61% of delay). Socioeconomic status and delivery to tertiary-care hospital predicted delay. Clinical stage determined initiation of first oncologic treatment. Conclusion: Delay in treatment was largely due to system delay. Only a few variables explained this delay. Clinical stage had the strongest effect on initiation of first oncologic treatment.
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Affiliation(s)
- Jorge Aarón Rangel-Méndez
- Unidad de Investigación Médica Yucatán, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional “Ignacio García Téllez”, Instituto Mexicano del Seguro Social, Calle 41 No. 439, Col. Industrial, Mérida, Yucatán 97150, México
| | - José Feliciano Novelo-Tec
- Unidad de Medicina Familiar número 58, Delegación Estatal Yucatán, Instituto Mexicano del Seguro Social, Calle 42 999 X 127 A Y 131, Serapio Rendón II, Mérida, Yucatán 97285, México
| | - Juan Francisco Sánchez-Cruz
- Coordinación de Investigación, Delegación Estatal Yucatán, Instituto Mexicano del Seguro Social, Calle 41 No. 439, Col. Industrial, Mérida, Yucatán 97150, México
| | - Roberto Cedillo-Rivera
- Unidad Interinstitucional de Investigación Clínica y Epidemiológica, Facultad de Medicina, Universidad Autónoma de Yucatán, Avenida Itzáes No. 498 x 86 Y 59A, Centro, Mérida, Yucatán 97000, México
| | - Rosa Esther Moo-Puc
- Unidad de Investigación Médica Yucatán, Unidad Médica de Alta Especialidad, Hospital de Especialidades del Centro Médico Nacional “Ignacio García Téllez”, Instituto Mexicano del Seguro Social, Calle 41 No. 439, Col. Industrial, Mérida, Yucatán 97150, México
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26
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Moore JX, Akinyemiju T, Bartolucci A, Wang HE, Waterbor J, Griffin R. Mediating Effects of Frailty Indicators on the Risk of Sepsis After Cancer. J Intensive Care Med 2018; 35:708-719. [PMID: 29862879 DOI: 10.1177/0885066618779941] [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] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cancer survivors are at increased risk of sepsis, possibly attributed to weakened physiologic conditions. The aims of this study were to examine the mediation effect of indicators of frailty on the association between cancer survivorship and sepsis incidence and whether these differences varied by race. METHODS We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort from years 2003 to 2012. We categorized frailty as the presence of ≥2 frailty components (weakness, exhaustion, and low physical activity). We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer. We examined the mediation effect of frailty on the association between cancer survivorship and sepsis incidence using Cox regression. We repeated analysis stratified by race. RESULTS Among 28 062 eligible participants, 2773 (9.88%) were cancer survivors and 25 289 (90.03%) were no cancer history participants. Among a total 1315 sepsis cases, cancer survivors were more likely to develop sepsis (12.66% vs 3.81%, P < .01) when compared to participants with no cancer history (hazard ratios: 2.62, 95% confidence interval: 2.31-2.98, P < .01). The mediation effects of frailty on the log-hazard scale were very small: weakness (0.57%), exhaustion (0.31%), low physical activity (0.20%), frailty (0.75%), and total number of frailty indicators (0.69%). Similar results were observed when stratified by race. CONCLUSION Cancer survivors had more than a 2-fold increased risk of sepsis, and indicators of frailty contributed to less than 1% of this disparity.
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Affiliation(s)
- Justin Xavier Moore
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Tomi Akinyemiju
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Epidemiology, University of Kentucky, Lexington, KY, USA
| | - Alfred Bartolucci
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Henry E Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - John Waterbor
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Moore JX, Akinyemiju T, Bartolucci A, Wang HE, Waterbor J, Griffin R. A prospective study of cancer survivors and risk of sepsis within the REGARDS cohort. Cancer Epidemiol 2018; 55:30-38. [PMID: 29763753 DOI: 10.1016/j.canep.2018.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hospitalized cancer patients are nearly 10 times more likely to develop sepsis when compared to patients with no cancer history. We compared the risk of sepsis between cancer survivors and no cancer history participants, and examined whether race was an effect modifier. METHODS We performed a prospective analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer, excluding non-melanoma skin cancer. We defined sepsis as hospitalization for a serious infection with ≥2 systemic inflammatory response syndrome criteria. We performed Cox proportional hazard models to examine the risk of sepsis after cancer (adjusted for sociodemographics, health behaviors, and comorbidities), and stratified by race. RESULTS Among 29,693 eligible participants, 2959 (9.97%) were cancer survivors, and 26,734 (90.03%) were no cancer history participants. Among 1393 sepsis events, the risk of sepsis was higher for cancer survivors (adjusted HR: 2.61, 95% CI: 2.29-2.98) when compared to no cancer history participants. Risk of sepsis after cancer survivorship was similar for Black and White participants (p value for race and cancer interaction = 0.63). CONCLUSION In this prospective cohort of community-dwelling adults we observed that cancer survivors had more than a 2.5-fold increased risk of sepsis. Public health efforts should attempt to mitigate sepsis risk by awareness and appropriate treatment (e.g., antibiotic administration) to cancer survivors with suspected infection regardless of the number of years since cancer remission.
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Affiliation(s)
- Justin Xavier Moore
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States; Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis School of Medicine, St Louis, MO, United States.
| | - Tomi Akinyemiju
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States; Department of Epidemiology, University of Kentucky, Lexington, KY, United States
| | - Alfred Bartolucci
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Henry E Wang
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - John Waterbor
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, United States
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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.
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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.
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29
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Leal IM, Kao LS, Karanjawala B, Escamilla RJ, Ko TC, Millas SG. Understanding Patients' Experiences of Diagnosis and Treatment of Advanced Colorectal Cancer in a Safety-Net Hospital System: A Qualitative Study. Dis Colon Rectum 2018. [PMID: 29521833 DOI: 10.1097/dcr.0000000000000967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Greater understanding of barriers to screening of colorectal cancer among lower socioeconomic, particularly Hispanic, patients is needed to improve disparities in care. OBJECTIVE This study aimed to explore patients' perceptions and experiences of care seeking for colorectal cancer to identify barriers to early diagnosis and treatment. DESIGN This explorative qualitative study was conducted as a focused ethnography of patients diagnosed with advanced-stage colorectal cancer. SETTINGS This study was conducted at an urban safety-net hospital. PARTICIPANTS Thirty lower-income, primarily minority, patients diagnosed with stage III and IV colorectal cancer without prior colorectal cancer screening were selected. MAIN OUTCOME MEASURES The primary outcomes measured were participants' perceptions and experiences of colorectal cancer and barriers they faced in seeking diagnosis and treatment RESULTS:: Data analysis yielded 4 themes consistently influencing participants' decisions to seek diagnosis and treatment: 1) limited resources for accessing care (structural barriers, including economic, health care and health educational resources); 2) (mis)understanding of symptoms by patients; misdiagnosis of symptoms, by physicians; 3) beliefs about illness and health, such as relying on faith, or self-care when symptoms developed; and 4) reactions to illness, including maintenance of masculinity, confusing interactions with physicians, embarrassment, and fear. These 4 themes describe factors on the structural, health care system, provider and patient level, that interact to make engaging in prevention foreign among this population, thus limiting early detection and treatment of colorectal cancer. LIMITATIONS This study was limited by selection bias and the lack of generalizability. CONCLUSION Improving screening rates among lower-income populations requires addressing barriers across the multiple levels, structural, personal, health care system, that patients encounter in seeking care for colorectal cancer. Acknowledging the complex, multilevel influences impacting patient health care choices and behaviors allows for the development of culturally tailored interventions, and educational, financial, and community resources to decrease disparities in cancer screening and care and improve outcomes for these at-risk patients. See Video Abstract at http://links.lww.com/DCR/A473.
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Affiliation(s)
- Isabel M Leal
- Department of General Surgery, The University of Texas Health Science Center, Houston, Texas.,Department of Psychological, Health and Learning Sciences, University of Houston, Houston, Texas
| | - Lillian S Kao
- Department of General Surgery, The University of Texas Health Science Center, Houston, Texas.,Center for Surgical Trials and Evidence-based Practice, The University of Texas Health Science Center, Houston, Texas
| | - Burzeen Karanjawala
- Department of General Surgery, The University of Texas Health Science Center, Houston, Texas
| | - Richard J Escamilla
- Department of General Surgery, The University of Texas Health Science Center, Houston, Texas
| | - Tien C Ko
- Department of General Surgery, The University of Texas Health Science Center, Houston, Texas
| | - Stefanos G Millas
- Department of General Surgery, The University of Texas Health Science Center, Houston, Texas
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Foy KC, Fisher JL, Lustberg MB, Gray DM, DeGraffinreid CR, Paskett ED. Disparities in breast cancer tumor characteristics, treatment, time to treatment, and survival probability among African American and white women. NPJ Breast Cancer 2018; 4:7. [PMID: 29582015 PMCID: PMC5861087 DOI: 10.1038/s41523-018-0059-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 02/09/2018] [Accepted: 02/20/2018] [Indexed: 01/28/2023] Open
Abstract
African American (AA) women have a 42% higher breast cancer death rate compared to white women despite recent advancements in management of the disease. We examined racial differences in clinical and tumor characteristics, treatment and survival in patients diagnosed with breast cancer between 2005 and 2014 at a single institution, the James Cancer Hospital, and who were included in the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Cancer Registry in Columbus OH. Statistical analyses included likelihood ratio chi-square tests for differences in proportions, as well as univariate and multivariate Cox proportional hazards regressions to examine associations between race and overall and progression-free survival probabilities. AA women made up 10.2% (469 of 4593) the sample. Average time to onset of treatment after diagnosis was almost two times longer in AA women compared to white women (62.0 days vs 35.5 days, p < 0.0001). AA women were more likely to report past or current tobacco use, experience delays in treatment, have triple negative and late stage breast cancer, and were less likely to receive surgery, especially mastectomy and reconstruction following mastectomy. After adjustment for confounding factors (age, grade, and surgery), overall survival probability was significantly associated with race (HR = 1.33; 95% CI 1.03–1.72). These findings highlight the need for efforts focused on screening and receipt of prompt treatment among AA women diagnosed with breast cancer. African Americans with breast cancer wait longer to get treated and then live shorter than white women, a US cancer center’s records show. Electra Paskett and her colleagues from Ohio State University in Columbus examined racial differences in tumor characteristics and patient outcomes among the 4,593 women treated for breast cancer at their institution’s affiliated hospitals between 2005 and 2014. They found that the time between diagnosis and treatment onset was longer for African Americans — 62 days compared to 35.5 days for white women. African Americans were also more likely to have harder-to-treat forms of disease and they were less likely to undergo surgery. Even accounting for many of these factors, African American women still had worse outcomes, as measured by survival probability. The findings highlight the need address racial disparities in breast cancer treatment.
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Affiliation(s)
- Kevin Chu Foy
- 1College of Nursing, The Ohio State University, Columbus, USA.,2Comprehensive Cancer Center, The Ohio State University, Columbus, USA
| | - James L Fisher
- 3Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA.,4Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, USA
| | - Maryam B Lustberg
- 2Comprehensive Cancer Center, The Ohio State University, Columbus, USA.,5Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, USA.,6Stefanie Spielman Comprehensive Breast Center, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Darrell M Gray
- 2Comprehensive Cancer Center, The Ohio State University, Columbus, USA.,7Division of Gastroenterology, Hepatology & Nutrition, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, USA
| | | | - Electra D Paskett
- 2Comprehensive Cancer Center, The Ohio State University, Columbus, USA.,3Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, USA.,4Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, USA.,8Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, USA
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31
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Impact of Delayed Time to Advanced Imaging on Missed Appointments Across Different Demographic and Socioeconomic Factors. J Am Coll Radiol 2018; 15:713-720. [PMID: 29503152 DOI: 10.1016/j.jacr.2018.01.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/11/2018] [Accepted: 01/21/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. METHODS An institutional review board-approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. RESULTS A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. CONCLUSIONS Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.
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Vijayasiri G, Molina Y, Chukwudozie IB, Tejeda S, Pauls HA, Rauscher GH, Campbell RT, Warnecke RB. Racial Disparities in Breast Cancer Survival: The Mediating Effects of Macro-Social Context and Social Network Factors. JOURNAL OF HEALTH DISPARITIES RESEARCH AND PRACTICE 2018; 11:6. [PMID: 34026339 PMCID: PMC8136761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This study attempts to clarify the associations between macro-social and social network factors and the continuing racial disparities in breast cancer survival. The study improves on prior methodologies by using a neighborhood disadvantage measure that assesses both economic and social disadvantage and an ego-network measurement tool that assesses key social network characteristics. Our population-based sample included 786 breast cancer patients (nHWhite=388; nHBlack=398) diagnosed during 2005-2008 in Chicago, IL. The data included census-derived macro-social context, self-reported social network, self-reported demographic and medically abstracted health measures. Mortality data from the National Death Index (NDI) were used to determine 5-year survival. Based on our findings, neighborhood concentrated disadvantage was negatively associated with survival among nHBlack and nHWhite breast cancer patients. In unadjusted models, social network size, network density, practical support, and financial support were positively associated with 5-year survival. However, in adjusted models only practical support was associated with 5-year survival. Our findings suggested that the association between network size and breast cancer survival is sensitive to scaling of the network measure, which helps to explain inconsistencies in past findings. Social networks of nHWhites and nHBlacks differed in size, social support dimensions, network density, and geographic proximity. Among social factors, residence in disadvantaged neighborhoods and unmet practical support explained some of the racial disparity in survival. Differences in late stage diagnosis and comorbidities between nHWhites and nHBlacks also explained some of the racial disparity in survival. Our findings highlight the relevance of social factors, both macro and inter-personal in the racial disparity in breast cancer survival. Findings suggest that reduced survival of nHBlack women is in part due to low social network resources and residence in socially and economically deprived neighborhoods. To improve survival among breast cancer patients social policies need to continue improving health care access as well as racially patterned social and economic disadvantage.
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Affiliation(s)
- Ganga Vijayasiri
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Rd, Chicago, IL, 60608
| | - Yamile Molina
- School of Public Health, University of Illinois at Chicago, 1603 West Taylor Street, Chicago, IL, 60612
| | - Ifeanyi Beverly Chukwudozie
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Rd, Chicago, IL, 60608
| | - Silvia Tejeda
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Rd, Chicago, IL, 60608
| | - Heather A. Pauls
- College of Nursing, University of Illinois at Chicago, 845 S. Damen Ave, Chicago, IL 60612
| | - Garth H Rauscher
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Rd, Chicago, IL, 60608
- School of Public Health, University of Illinois at Chicago, 1603 West Taylor Street, Chicago, IL, 60612
| | - Richard T. Campbell
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Rd, Chicago, IL, 60608
| | - Richard B. Warnecke
- Institute for Health Research and Policy, University of Illinois at Chicago, 1747 West Roosevelt Rd, Chicago, IL, 60608
- School of Public Health, University of Illinois at Chicago, 1603 West Taylor Street, Chicago, IL, 60612
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Jemal A, Robbins AS, Lin CC, Flanders WD, DeSantis CE, Ward EM, Freedman RA. Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013. J Clin Oncol 2018; 36:14-24. [DOI: 10.1200/jco.2017.73.7932] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer. Patients and Methods Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs). Results We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor–positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor–negative disease, although the HRs were substantially smaller. Conclusion Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.
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Affiliation(s)
- Ahmedin Jemal
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
| | - Anthony S. Robbins
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
| | - Chun Chieh Lin
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
| | - W. Dana Flanders
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
| | - Carol E. DeSantis
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
| | - Elizabeth M. Ward
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
| | - Rachel A. Freedman
- Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA
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Durham DD, Robinson WR, Lee SS, Wheeler SB, Reeder-Hayes KE, Bowling JM, Olshan AF, Henderson LM. Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography. Cancer Epidemiol Biomarkers Prev 2017; 25:1474-1482. [PMID: 27803069 DOI: 10.1158/1055-9965.epi-16-0148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 08/10/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Insurance may lengthen or inhibit time to follow-up after positive screening mammography. We assessed the association between insurance status and time to initial diagnostic follow-up after a positive screening mammogram. METHODS Using 1995-2010 data from a North Carolina population-based registry of breast imaging and cancer outcomes, we identified women with a positive screening mammogram. We compared receipt of follow-up within 60 days of screening using logistic regression and evaluated time to follow-up initiation using Cox proportional hazards regression. RESULTS Among 43,026 women included in the study, 73% were <65 years and 27% were 65+ years. Median time until initial diagnostic follow-up was similar by age group and insurance status. In the adjusted model for women <65, uninsured women experienced a longer time to initiation of diagnostic follow-up [HR, 0.47; 95% confidence interval (CI), 0.25-0.89] versus women with private insurance. There were increased odds of these uninsured women not meeting the Centers for Disease Control and Prevention guideline for follow-up within 60 days (OR, 1.59; 95% CI, 1.31-1.94). Among women ages 65+, women with private insurance experienced a faster time to follow-up (adjusted HR, 2.09; 95% CI, 1.27-3.44) than women with Medicare and private insurance. Approximately 10% of women had no follow-up by 365 days. CONCLUSIONS We found differences in time to initial diagnostic follow-up after a positive screening mammogram by insurance status and age group. Uninsured women younger than 65 years at a positive screening event had delayed follow-up. IMPACT Replication of these findings and examination of their clinical significance warrant additional investigation. Cancer Epidemiol Biomarkers Prev; 25(11); 1474-82. ©2016 AACR.
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Affiliation(s)
- Danielle D Durham
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina
| | - Whitney R Robinson
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina
| | - Sheila S Lee
- Department of Radiology, UNC School of Medicine, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.,Department of Health Policy and Management, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.,Division of Hematology/Oncology, UNC School of Medicine, Chapel Hill, North Carolina
| | - J Michael Bowling
- Department of Health Behavior, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrew F Olshan
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina
| | - Louise M Henderson
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina. .,Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.,Department of Radiology, UNC School of Medicine, Chapel Hill, North Carolina
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Khanna S, Kim KN, Qureshi MM, Agarwal A, Parikh D, Ko NY, Rand AE, Hirsch AE. Impact of patient demographics, tumor characteristics, and treatment type on treatment delay throughout breast cancer care at a diverse academic medical center. Int J Womens Health 2017; 9:887-896. [PMID: 29255374 PMCID: PMC5723124 DOI: 10.2147/ijwh.s150064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose and objective The aim of this study was to examine the impact of patient demographics, tumor characteristics, and treatment type on time to treatment (TTT) in patients with breast cancer treated at a safety net medical center with a diverse patient population. Patients and methods A total of 1,130 patients were diagnosed and treated for breast cancer between 2004 and 2014 at our institution. We retrospectively collected data on patient age at diagnosis, race/ethnicity, primary language spoken, marital status, insurance coverage, American Joint Committee on Cancer (AJCC) stage, hormone receptor status, and treatment dates. TTT was determined from the date of breast cancer biopsy to treatment start date. Nonparametric Mann-Whitney U-test (or Kruskal-Wallis test when appropriate) and multivariable quantile regression models were employed to assess for significant differences in TTT associated with each factor. Results Longer median TTT was noted for Black (P=0.002) and single (P=0.002) patients. AJCC stage IV patients had shorter TTT (27.5 days) compared to earlier AJCC patients (36, 35, 37, 37 days for stage 0, I, II, III, respectively), P=0.028. Age, primary language spoken, insurance coverage, and hormone receptor status had no significant impact on TTT. On multivariate analysis, race/ethnicity remained the only significant factor with Black reporting longer TTT, P=0.025. However, race was not a significant factor for time from first to second treatment. More Black patients were noted to be single (P<0.0001) and received chemotherapy as first treatment (P=0.008) compared to White, Hispanic, or other race/ethnicity patients. Conclusion In this retrospective analysis, Black patients had longer TTT, were more likely to receive chemotherapy as first treatment, and have a single marital status. These patient factors will help identify vulnerable patients and guide further research to understand the barriers to care and the impact of treatment delays on outcomes.
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Affiliation(s)
- Shivani Khanna
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
| | - Kristine N Kim
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
| | - Muhammad M Qureshi
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
| | - Ankit Agarwal
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
| | - Divya Parikh
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
| | - Naomi Y Ko
- Department of Hematology Oncology, Boston Medical Center, Boston MA, USA
| | - Alexander E Rand
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
| | - Ariel E Hirsch
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine
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Glover M, Daye D, Khalilzadeh O, Pianykh O, Rosenthal DI, Brink JA, Flores EJ. Socioeconomic and Demographic Predictors of Missed Opportunities to Provide Advanced Imaging Services. J Am Coll Radiol 2017; 14:1403-1411. [DOI: 10.1016/j.jacr.2017.05.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 01/02/2023]
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Abstract
PURPOSE/OBJECTIVES To examine predictors of perceived access to care and reported barriers to care of patients with cancer actively seeking treatment.
. DESIGN Retrospective secondary data analysis.
. SETTING U.S. Medical Expenditure Panel Survey, a national survey with questions about healthcare coverage and access.
. SAMPLE 1,170 adults with cancer actively seeking treatment.
. METHODS A retrospective analysis of data. Bivariate tests for significant association between individual characteristics and low perceived access to care were conducted using a chi-square test.
. MAIN RESEARCH VARIABLES The dependent variable was perceived access to care. The independent variables included sex, age, race, poverty status, education level, marital status, cancer site, comorbidities, and insurance status.
. FINDINGS Those with Medicaid insurance or no health insurance had significantly lower perceived access to care compared to those with Medicare. Institutional barriers to treatment, such as financial or insurance, were the most common reported barriers.
. CONCLUSIONS Most adults with cancer reported adequate access to medical care and medications, but a small yet vulnerable population expressed difficulties in accessing treatment.
. IMPLICATIONS FOR NURSING To effectively advocate for vulnerable populations with Medicaid or no insurance, nurses may require specialized knowledge beyond the scope of general oncology nursing.
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He X, Ye F, Zhao B, Tang H, Wang J, Xiao X, Xie X. Risk factors for delay of adjuvant chemotherapy in non-metastatic breast cancer patients: A systematic review and meta-analysis involving 186982 patients. PLoS One 2017; 12:e0173862. [PMID: 28301555 PMCID: PMC5354309 DOI: 10.1371/journal.pone.0173862] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/28/2017] [Indexed: 01/11/2023] Open
Abstract
Purpose Delay performance of adjuvant chemotherapy (AC) after surgery has been presented to affect survival of breast cancer patients adversely, but the risk factors for delay in initiation remain controversial. Therefore, we conducted this systematic review of the literature and meta-analysis aiming at identifying the risk factors for delay of adjuvant chemotherapy (DAC) in non-metastatic breast cancer patients. Methods The search was performed on PubMed, Embase, Chinese National Knowledge Infrastructure and Wanfang Database from inception up to July 2016. DAC was defined as receiving AC beyond 8-week after surgery. Data were combined and analyzed using random-effects model or fixed-effects model for risk factors considered by at least 3 studies. Heterogeneity was analyzed with meta-regression analysis of year of publication and sample size. Publication bias was studied with Egger’s test. Results A total of 12 observational studies including 186982 non-metastatic breast cancer patients were eligible and 12 risk factors were analyzed. Combined results demonstrated that black race (vs white; OR, 1.18; 95% CI, 1.01–1.39), rural residents (vs urban; OR, 1.60; 95% CI, 1.27–2.03) and receiving mastectomy (vs breast conserving surgery; OR, 1.35; 95% CI, 1.00–1.83) were significantly associated with DAC, while married patients (vs single; OR, 0.58; 95% CI, 0.38–0.89) was less likely to have a delay in initiation. No significant impact from year of publication or sample size on the heterogeneity across studies was found, and no potential publication bias existed among the included studies. Conclusions Risk factors associated with DAC included black race, rural residents, receiving mastectomy and single status. Identifying of these risk factors could further help decisions making in clinical practice.
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Affiliation(s)
- Xiaofang He
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Fen Ye
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Bingcheng Zhao
- Department of Anesthesiology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hailin Tang
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jin Wang
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xiangsheng Xiao
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xiaoming Xie
- Department of Breast Oncology, Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
- * E-mail:
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Montagna G, Schneeberger AR, Rossi L, Bianchi Micheli G, Meani F, Imperiali M, Spitale A, Pagani O. Can we make a portrait of women with inoperable locally advanced breast cancer? Breast 2017; 33:83-90. [PMID: 28288387 DOI: 10.1016/j.breast.2017.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Delay between clinical presentation and treatment of breast cancer (BC) can significantly impact mortality. We aimed at drawing a picture of women with locally advanced breast cancer (LABC) treated at our Breast Unit and at investigating factors associated with treatment delay. MATERIAL AND METHODS A retrospective descriptive analysis, using a specific 28-item semi-structured questionnaire, was conducted in 67 patients diagnosed with T4 BC. RESULTS Nearly a third of our patients had at least one known predisposing factor for LABC. 42% of patients did not perform routine medical breast checks, 49% reported indifference as the first feeling and 47% waited at least 3 months before seeking medical attention. The reasons for diagnostic delay were different in the various age groups. Doctor's delay in making the right diagnosis occurred in 60% of younger patients (≤40 years, n = 5), whereas among women aged 41-69years (n = 34) 50% suffered from psychiatric comorbidities. In patients ≥70 years (n = 28) social factors such as isolation, being widowed and living in a retirement home were present in most of the cases. Delay in seeking medical care was also associated with increasing age. Across all age groups, coping factors such as denial and indifference were also associated with an increase in the odds of delayed presentation, as opposed to fear. CONCLUSIONS Factors possibly explaining late medical consultation seem to differ according to age. Psychological factors are crucial in patients' delay whereas age and social factors are relevant in doctors' and system's delay.
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Affiliation(s)
- Giacomo Montagna
- Department of Obstetrics and Gynecology, Ente Ospedaliero Cantonale, Lugano, Switzerland; Breast Unit of Southern Switzerland (CSSI), Lugano, Switzerland.
| | - Andres R Schneeberger
- Psychiatric University Hospital (UPK), University Basel, Basel, Switzerland; Psychiatric Services Grisons (PDGR), Chur, Switzerland; Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences (AECOM), New York, NY, USA
| | - Lorenzo Rossi
- Breast Unit of Southern Switzerland (CSSI), Lugano, Switzerland; Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland
| | | | - Francesco Meani
- Department of Obstetrics and Gynecology, Ente Ospedaliero Cantonale, Lugano, Switzerland; Breast Unit of Southern Switzerland (CSSI), Lugano, Switzerland
| | - Mauro Imperiali
- Department of Laboratory Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Olivia Pagani
- Breast Unit of Southern Switzerland (CSSI), Lugano, Switzerland; Oncology Institute of Southern Switzerland (IOSI), Bellinzona, Switzerland
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Louis CJ, Clark JR, Hillemeier MM, Camacho F, Yao N, Anderson RT. The Effects of Hospital Characteristics on Delays in Breast Cancer Diagnosis in Appalachian Communities: A Population-Based Study. J Rural Health 2017; 34 Suppl 1:s91-s103. [PMID: 28102909 DOI: 10.1111/jrh.12226] [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: 03/18/2016] [Revised: 08/26/2016] [Accepted: 10/27/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE Despite being generally accepted that delays in diagnosing breast cancer are of prognostic and psychological concern, the influence of hospital characteristics on such delays remains poorly understood, especially in rural and underserved areas. However, hospital characteristics have been tied to greater efficiency and warrant further investigation as they may have implications for breast cancer care in these areas. METHODS Study data were derived from the Kentucky, North Carolina, Ohio, and Pennsylvania state central cancer registries (2006-2008). We then linked Medicare enrollment files and claims data (2005-2009), the Area Resource File (2006-2008), and the American Hospital Association Annual Survey of Hospitals (2007) to create an integrated data set. Hierarchical linear modeling was used to regress the natural log of breast cancer diagnosis delay on a number of hospital-level, demographic, and clinical characteristics. FINDINGS The baseline study sample consisted of 4,547 breast cancer patients enrolled in Medicare that lived in Appalachian counties at the time of diagnosis. We found that hospitals with for-profit ownership (P < .01) had shorter diagnosis delays than their counterparts. Estimates for comprehensive oncology services, system membership and size were not statistically significant at conventional levels. CONCLUSIONS Some structural characteristics of hospitals (eg, for-profit ownership) in the Appalachian region are associated with having shorter delays in diagnosing breast cancer. Researchers and practitioners must go beyond examining patient-level demographic and tumor characteristics to better understand the drivers of timely cancer diagnosis, especially in rural and underserved areas.
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Affiliation(s)
- Christopher J Louis
- Department of Health Law, Policy and Management, Boston University, Boston, Massachusetts
| | - Jonathan R Clark
- College of Business, The University of Texas at San Antonio, San Antonio, Texas
| | - Marianne M Hillemeier
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania
| | - Fabian Camacho
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Nengliang Yao
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Roger T Anderson
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
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Understanding racial differences in health-related quality of life in a population-based cohort of breast cancer survivors. Breast Cancer Res Treat 2016; 159:535-43. [PMID: 27585477 DOI: 10.1007/s10549-016-3965-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Although racial disparities in health-related quality of life (HRQOL) among women with breast cancer (BC) are well documented, less is known about HRQOL changes over time among women of different races. Our objective was to assess racial differences in HRQOL during active treatment and survivorship phases of BC care. METHODS We used data from the third phase of the Carolina Breast Cancer Study (CBCS-III). CBCS-III enrolled 3000 women in North Carolina aged 20-74 years diagnosed with BC between 2008 and 2013. HRQOL assessments occurred 5 and 25 months post diagnosis, representing distinct phases of care. HRQOL measures included the Functional Assessment of Cancer Therapy for BC and Functional Assessment of Chronic Illness Therapy for Spiritual Well-Being. Analysis of covariance models were employed to assess racial differences in changes in HRQOL. RESULTS The cohort included 2142 Non-Hispanic White (n = 1105) and Black women (n = 1037) who completed both HRQOL assessments. During active treatment, Whites reported physical and functional scores 2-2.5 points higher than Blacks (p < 0.0001). Spiritual HRQOL was 2.1 points higher for Blacks (p < 0.0001). During survivorship, differences persisted. After adjusting for demographic, socioeconomic, tumor, and treatment characteristics, physical and functional HRQOL gaps narrowed, but spiritual HRQOL gaps widened. CONCLUSIONS Racial differences in physical and functional HRQOL during active treatment and survivorship may be largely mediated by socioeconomic factors. However, our results suggest that among Black women, spiritual HRQOL is well supported throughout the BC care continuum. These results inform opportunities for improving the quality and equity of supportive services for women with BC.
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Ko NY, Snyder FR, Raich PC, Paskett ED, Dudley D, Lee JH, Levine PH, Freund KM. Racial and ethnic differences in patient navigation: Results from the Patient Navigation Research Program. Cancer 2016; 122:2715-22. [PMID: 27227342 PMCID: PMC4992408 DOI: 10.1002/cncr.30109] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/14/2016] [Accepted: 04/04/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patient navigation was developed to address barriers to timely care and reduce cancer disparities. The current study explored navigation and racial and ethnic differences in time to the diagnostic resolution of a cancer screening abnormality. METHODS The authors conducted an analysis of the multisite Patient Navigation Research Program. Participants with an abnormal cancer screening test were allocated to either navigation or control. The unadjusted median time to resolution was calculated for each racial and ethnic group by navigation and control. Multivariable Cox proportional hazards models were fit, adjusting for sex, age, cancer abnormality type, and health insurance and stratifying by center of care. RESULTS Among a sample of 7514 participants, 29% were non-Hispanic white, 43% were Hispanic, and 28% were black. In the control group, black individuals were found to have a longer median time to diagnostic resolution (108 days) compared with non-Hispanic white individuals (65 days) or Hispanic individuals (68 days) (P<.0001). In the navigated groups, black individuals had a reduction in the median time to diagnostic resolution (97 days) (P<.0001). In the multivariable models, among controls, black race was found to be associated with an increased delay to diagnostic resolution (hazard ratio, 0.77; 95% confidence interval, 0.69-0.84) compared with non-Hispanic white individuals, which was reduced in the navigated arm (hazard ratio, 0.85; 95% confidence interval, 0.77-0.94). CONCLUSIONS Patient navigation appears to have the greatest impact among black patients, who had the greatest delays in care. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2715-2722. © 2016 American Cancer Society.
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Affiliation(s)
- Naomi Y Ko
- Section of Hematology Oncology, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Boston, MA 02118, (617) 638-8036 phone, (617) 638-8096 fax
| | - Frederick R Snyder
- NOVA Research Company, 801 Roeder Road, Suite 700, Silver Spring, MD 20910
| | - Peter C Raich
- Denver Health, Denver, Colorado; and University of Colorado Denver, Aurora, Colorado, 94 High Meadow Dr., Dillon, CO 80435, (970)468-4763
| | - Electra D. Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, 1590 North High Street, Columbus, OH 43201, (614) 293-3917 phone, (614) 293-5611 fax
| | - Donald Dudley
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA 22908, (434) 243-6790
| | - Ji-Hyun Lee
- University of New Mexico Comprehensive Cancer Center, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, New Mexico 87131-0001, Phone: 505-272-3718
| | - Paul H. Levine
- The George Washington University School of Public Health; and Health Services; and The George Washington Cancer Institute, 950 New Hampshire Ave. NW 5th Floor, Washington, DC 20052, (202) 994-5330
| | - Karen M Freund
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, 35 Kneeland Street, Boston, Massachusetts 02111
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Licqurish S, Phillipson L, Chiang P, Walker J, Walter F, Emery J. Cancer beliefs in ethnic minority populations: a review and meta-synthesis of qualitative studies. Eur J Cancer Care (Engl) 2016; 26. [PMID: 27515153 DOI: 10.1111/ecc.12556] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2016] [Indexed: 11/29/2022]
Abstract
People from ethnic minorities often experience poorer cancer outcomes, possibly due to later presentation to healthcare and later diagnosis. We aimed to identify common cancer beliefs in minority populations in developed countries, which can affect symptom appraisal and help seeking for symptomatic cancer. Our systematic review found 15 relevant qualitative studies, located in the United Kingdom (six), United States (five), Australia (two) and Canada (two) of African, African-American, Asian, Arabic, Hispanic and Latino minority groups. We conducted a meta-synthesis that found specific emotional reactions to cancer, knowledge and beliefs and interactions with healthcare services as contributing factors in help seeking for a cancer diagnosis. These findings may be useful to inform the development of interventions to facilitate cancer diagnosis in minority populations.
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Affiliation(s)
- S Licqurish
- Department of General Practice, University of Melbourne, Carlton, Vic., Australia
| | - L Phillipson
- Centre for Health Initiatives, University of Wollongong, Wollongong, NSW, Australia
| | - P Chiang
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia
| | - J Walker
- Department of General Practice, University of Melbourne, Carlton, Vic., Australia
| | - F Walter
- Department of Public Health and Primary Care, Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - J Emery
- Department of General Practice, University of Melbourne, Carlton, Vic., Australia
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Yao N, Wang J, Cai Y, Yuan J, Wang H, Gong J, Anderson R, Sun X. Patterns of cancer screening, incidence and treatment disparities in China: protocol for a population-based study. BMJ Open 2016; 6:e012028. [PMID: 27491672 PMCID: PMC4985820 DOI: 10.1136/bmjopen-2016-012028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Cancer has become the leading cause of death in China. Several knowledge gaps exist with respect to the patterns of cancer care and disparities in China. Chinese healthcare researchers do not have access to cancer research data of high quality. Only cancer incidence and mortality rates have been analysed in China while the patterns of cancer screening and treatment and disparities have not been rigorously examined. Potential disparities in cancer care by socioeconomic status have not been analysed in the previous literature. Population-based estimates of cancer care costs remain unexamined in China. This project will depict the pattern of cancer screening, incidence and treatment in Shandong province and enhance our understanding of causes of disparities in cancer control. METHODS AND ANALYSIS We will create the first linked database of cancer registry and health insurance claims in China. We obtained cancer registry data on breast, gastrointestinal and lung cancer incidence from 2011 to 2014 and their health insurance claims information from 6 cities/counties of 10.63 million population and validated it with hospital discharge data. A 1600 participant survey will be administered to collect additional information of patients' socioeconomic status, employment and cancer care costs. Frequency analysis, spatial data exploratory analysis, multivariate logistic regression with instrumental variable, generalised linear regression and subgroup analysis will be used to analyse the following: the receipt of cancer screening, stage at diagnosis, guideline-concordant treatment and cancer care costs. Patient characteristics, tumour features, hospital characteristics, patient comorbidities and county-level descriptors will be used as covariates in the multivariate analysis. ETHICS AND DISSEMINATION The Institutional Review Board of the School of Public Health of Shandong University approved this study (20140201). Data compiled from this project will be made available to all Chinese healthcare researchers. Study results will be disseminated through peer-reviewed publications and presentations at national and international meetings.
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Affiliation(s)
- Nengliang Yao
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Jialin Wang
- Shandong Provincial Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Yuanchu Cai
- Center for Health Management and Policy (Key Laboratory of Health Economics and Policy, National Health and Family Planning Commission), Shandong University, Jinan, China
| | - Jing Yuan
- School of Public Health and Management, Binzhou Medical University, Yantai, China
| | - Haipeng Wang
- Center for Health Management and Policy (Key Laboratory of Health Economics and Policy, National Health and Family Planning Commission), Shandong University, Jinan, China
| | - Jiyong Gong
- Shandong Provincial Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, China
| | - Roger Anderson
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Xiaojie Sun
- Center for Health Management and Policy (Key Laboratory of Health Economics and Policy, National Health and Family Planning Commission), Shandong University, Jinan, China
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Wieder R, Shafiq B, Adam N. African American Race is an Independent Risk Factor in Survival from Initially Diagnosed Localized Breast Cancer. J Cancer 2016; 7:1587-1598. [PMID: 27698895 PMCID: PMC5039379 DOI: 10.7150/jca.16012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 06/04/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND: African American race negatively impacts survival from localized breast cancer but co-variable factors confound the impact. METHODS: Data sets were analyzed from the Surveillance, Epidemiology and End Results (SEER) directories from 1973 to 2011 consisting of patients with designated diagnosis of breast adenocarcinoma, race as White or Caucasian, Black or African American, Asian, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, age, stage I, II or III, grade 1, 2 or 3, estrogen receptor or progesterone receptor positive or negative, marital status as single, married, separated, divorced or widowed and laterality as right or left. The Cox Proportional Hazards Regression model was used to determine hazard ratios for survival. Chi square test was applied to determine the interdependence of variables found significant in the multivariable Cox Proportional Hazards Regression analysis. Cells with stratified data of patients with identical characteristics except African American or Caucasian race were compared. RESULTS: Age, stage, grade, ER and PR status and marital status significantly co-varied with race and with each other. Stratifications by single co-variables demonstrated worse hazard ratios for survival for African Americans. Stratification by three and four co-variables demonstrated worse hazard ratios for survival for African Americans in most subgroupings with sufficient numbers of values. Differences in some subgroupings containing poor prognostic co-variables did not reach significance, suggesting that race effects may be partly overcome by additional poor prognostic indicators. CONCLUSIONS: African American race is a poor prognostic indicator for survival from breast cancer independent of 6 associated co-variables with prognostic significance.
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Affiliation(s)
- Robert Wieder
- 1. Department of Medicine, Rutgers New Jersey Medical School and the New Jersey Medical School Cancer Center, Rutgers Biomedical and Health Sciences
| | - Basit Shafiq
- 2. Rutgers Institute for Data Science, Learning, and Applications and the Center for Information Management, Integration, and Connectivity, Rutgers Newark
| | - Nabil Adam
- 2. Rutgers Institute for Data Science, Learning, and Applications and the Center for Information Management, Integration, and Connectivity, Rutgers Newark
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Halpern MT, Schrag D. Effects of state-level medicaid policies and patient characteristics on time to breast cancer surgery among medicaid beneficiaries. Breast Cancer Res Treat 2016; 158:573-81. [PMID: 27422241 DOI: 10.1007/s10549-016-3879-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 06/18/2016] [Indexed: 11/25/2022]
Abstract
Medicaid beneficiaries with cancer are less likely to receive timely and high-quality care. This study examined whether differences in state-level Medicaid policies affect delays in time to surgery (TTS) among women diagnosed with breast cancer. Using 2006-2008 Medicaid data, we identified women aged 18-64 enrolled in Medicaid diagnosed with breast cancer. Analyses examined associations of state-specific Medicaid surgery reimbursements, Medicaid eligibility recertification period (annually vs. shorter) and required patient copayment on time from breast cancer diagnosis to receipt of breast surgery. Patients receiving neoadjuvant therapy were excluded. Separate multivariable regression analyses controlling for patient demographic characteristics and clustering by state were performed for breast conserving surgery (BCS), inpatient mastectomy, and outpatient mastectomy. The study included 7542 Medicaid beneficiaries with breast cancer: 3272 received BCS, 2156 outpatient mastectomy, and 2115 inpatient mastectomy. Higher Medicaid reimbursements for BCS were associated with decreased time from diagnosis to surgery. A 12-month (vs. <12 month) Medicaid eligibility recertification period was associated with decreased TTS for BCS and outpatient mastectomy. Black Medicaid beneficiaries (compared with non-Hispanic White beneficiaries) were more likely to experience delays for all three types of surgery, while Hispanic beneficiaries were more likely to experience delays only for outpatient mastectomy. State-level Medicaid policies and patient characteristics can affect receipt of timely surgery among Medicaid beneficiaries with breast cancer. As delays in surgery can increase morbidity and mortality, changes to state Medicaid policies and health system programs are needed to improve access to care for this vulnerable population.
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Affiliation(s)
- Michael T Halpern
- RTI International, Washington, DC, USA.
- Health Services Administration and Policy, Temple University College of Public Health, 1301 Cecil B. Moore Ave. # 533, Philadelphia, PA, 19122, USA.
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Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:916-20. [PMID: 27166865 DOI: 10.1097/acm.0000000000001232] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Critical examination of "health disparities" is gaining consideration in medical schools across the United States, often as elective curricula that supplement required education. However, there is disconnect between discussions of race and disparities in these curricula and in core science courses. Specifically, required preclinical science lecturers often operationalize race as a biological concept, framing racialized disparities as inherent in bodies. A three- and five-month sampling of lecture slides at the authors' medical school demonstrated that race was almost always presented as a biological risk factor.This presentation of race as an essential component of epidemiology, risk, diagnosis, and treatment without social context is problematic, as a broad body of literature supports that race is not a robust biological category. The authors opine that current preclinical medical curricula inaccurately employ race as a definitive medical category without context, which may perpetuate misunderstanding of race as a bioscientific datum, increase bias among student-doctors, and ultimately contribute to worse patient outcomes.At the authors' institution, students approached the medical school administration with a letter addressing the current use of race, urging reform. The administration was receptive to proposals for further analysis of race in medical education and created a taskforce to examine curricular reform. Curricular changes were made as part of the construction of a longitudinal race-in-medicine curriculum. The authors seek to use their initiatives and this article to spark critical discussion on how to use teaching of race to work against racial inequality in health care.
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Affiliation(s)
- Jennifer Tsai
- J. Tsai is a second-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. L. Ucik is a third-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. N. Baldwin is a third-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. C. Hasslinger is a third-year medical student, Warren Alpert Medical School of Brown University, Providence, Rhode Island. P. George is associate professor of family medicine and associate professor of medical science, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Monzavi-Karbassi B, Siegel ER, Medarametla S, Makhoul I, Kieber-Emmons T. Breast cancer survival disparity between African American and Caucasian women in Arkansas: A race-by-grade analysis. Oncol Lett 2016; 12:1337-1342. [PMID: 27446434 PMCID: PMC4950488 DOI: 10.3892/ol.2016.4804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 05/19/2016] [Indexed: 01/25/2023] Open
Abstract
Despite progress in breast cancer treatment, disparity persists in survival time between African American (AA) and Caucasian women in the US. Tumor stage and tumor grade are the major prognostic factors that define tumor aggressiveness and contribute to racial disparity between AA and Caucasian women. Studying the interaction of race with tumor grade or stage may provide further insights into the role of intrinsic biological aggressiveness in disecting the AA-Caucasian survival disparity. Therefore, the current study was performed to evaluate the interaction of race with tumor grade and stage at diagnosis regarding survival in a cohort of patients treated at the Winthrop P. Rockefeller Cancer Institute of the University of Arkansas for Medical Sciences (Little Rock, AR, USA). The cohort included 1,077 patients, 208 (19.3%) AA and 869 (80.7%) Caucasian, diagnosed with breast cancer between January 1997 and December 2005. Kaplan-Meier survival plots were generated and Cox regressions were performed to analyze the associations of race with breast cancer-specific survival time. Over a mean follow-up time of 1.5 years, AA women displayed increased mortality risk due to breast cancer-specific causes [hazard ratio (HR), 1.74; 95% confidence interval (CI), 1.23–2.46]. The magnitude of racial disparity varied strongly with tumor grade (race-x-grade interaction; P<0.001). No significant interaction was observed between race and tumor stage or race and age at diagnosis. Among women diagnosed with grade I tumors, the race disparity in survival time after controlling for tumor stage and age was strong (HR, 9.07; 95% CI, 2.11–38.95), but no significant AA-Caucasian disparity was observed among women with higher-grade tumors. The data suggest that, when diagnosed with grade I breast cancer, AA may experience poorer survival outcomes compared with Caucasian patients, regardless of tumor stage or age. The findings potentially provide significant clinical and public health implications and justify further investigation.
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Affiliation(s)
- Behjatolah Monzavi-Karbassi
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Eric R Siegel
- Division of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Srikanth Medarametla
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Issam Makhoul
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; Division of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - Thomas Kieber-Emmons
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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The Challenge of Improving Breast Cancer Care Coordination in Safety-net Hospitals: Barriers, Facilitators, and Opportunities. Med Care 2016; 54:147-54. [PMID: 26565530 DOI: 10.1097/mlr.0000000000000458] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Minority breast cancer patients tend to have higher rates of adjuvant treatment underuse. We implemented a web-based intervention that closes referral loops between surgeons and oncologists at inner-city safety-net hospitals serving high volumes of minority breast cancer patients to assist these hospitals and improve care coordination. RESEARCH DESIGN Following intervention implementation, we conducted interviews with key personnel to improve our understanding of the implementation process and to identify barriers, facilitators, and opportunities for improvement. We used the constant comparative method of analysis to code interview transcripts and identify common themes regarding intervention implementation. SUBJECTS We interviewed 64 administrative and clinical key informants from 10 inner-city safety-net hospitals with high volumes of minority breast cancer patients. RESULTS We found substantial barriers to implementing an intervention designed to support care coordination efforts, despite initial feedback that the intervention itself was both easy to use and in line with organizational goals. We also characterized facilitators and challenges of breast cancer care coordination in the safety-net environment, as well as opportunities to improve intervention design to support increased quality of breast cancer care. CONCLUSIONS Coordination of care for women with breast cancer is extremely important, but safety-net hospitals face considerable resource constraints from lack of time, support, and information systems. As safety-net hospital networks grow across numerous care sites, the challenge of care coordination will likely increase, highlighting the importance of interventions that can be successfully implemented and used to promote better care.
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Breast cancer survival in African-American women by hormone receptor subtypes. Breast Cancer Res Treat 2015; 153:211-8. [PMID: 26250393 DOI: 10.1007/s10549-015-3528-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 08/01/2015] [Indexed: 12/31/2022]
Abstract
Breast cancer accounts for over 200,000 annual cases among women in the United States, and is the second leading cause of cancer-related deaths. However, few studies have investigated the association between breast cancer subtype and survival among African-American women. We analyzed cancer-related deaths among African-American women using data obtained from the SEER database linked to the 2000 U.S. census data. We examined distribution of baseline socio-demographic and clinical characteristics by breast cancer subtypes and used Cox proportional hazard models to determine associations between breast cancer subtypes and cancer-related mortality, adjusting for age, socio-economic status, stage at diagnosis, and treatment. Among 19,836 female breast cancer cases, 54.4% were diagnosed with the HER2-/HR+ subtype, with the majority of those cases occurring among women ages 55 and older. However, after adjusting for age, stage, and treatment type (surgery, radiation, or no radiation and/or cancer-directed surgery), TNBC (HR 2.34; 95% CI 1.95-2.81) and HER2+/HR- (HR 1.39, 95% CI 1.08-1.79) cases had significantly higher hazards of cancer-related deaths compared with HER2+/HR+ cases. Adjusting for socio-economic status did not significantly alter these associations. African-American women with TNBC were more likely to have a cancer-related death than African-American women with other breast cancer subtypes. This association remained after adjustments for age, stage, treatment, and socio-economic status. Further studies are needed to identify subtype-specific risk and prognostic factors aimed at better informing prevention efforts for all women.
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