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McLeod M, Leung K, Pramesh CS, Kingham P, Mutebi M, Torode J, Ilbawi A, Chakowa J, Sullivan R, Aggarwal A. Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals. BJS Open 2024; 8:zrae009. [PMID: 38513280 PMCID: PMC10957165 DOI: 10.1093/bjsopen/zrae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups. METHODS A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level. RESULTS A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data. CONCLUSION Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.
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Affiliation(s)
- Megan McLeod
- Department of Health Policy, London School of Economics and Political Science, London, UK
- Department of Otolaryngology—Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kari Leung
- Department of Oncology, Guy’s & St Thomas’ NHS Trust, London, UK
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Julie Torode
- Institute of Cancer Policy, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Andre Ilbawi
- Department of Universal Health Coverage, World Health Organization, Geneva, Switzerland
| | | | - Richard Sullivan
- Institute of Cancer Policy, Global Oncology Group, Centre for Cancer, Society & Public Health, King’s College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Ellsworth DL, Turner CE, Ellsworth RE. A Review of the Hereditary Component of Triple Negative Breast Cancer: High- and Moderate-Penetrance Breast Cancer Genes, Low-Penetrance Loci, and the Role of Nontraditional Genetic Elements. JOURNAL OF ONCOLOGY 2019; 2019:4382606. [PMID: 31379942 PMCID: PMC6652078 DOI: 10.1155/2019/4382606] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/23/2019] [Indexed: 12/31/2022]
Abstract
Triple negative breast cancer (TNBC), representing 10-15% of breast tumors diagnosed each year, is a clinically defined subtype of breast cancer associated with poor prognosis. The higher incidence of TNBC in certain populations such as young women and/or women of African ancestry and a unique pathological phenotype shared between TNBC and BRCA1-deficient tumors suggest that TNBC may be inherited through germline mutations. In this article, we describe genes and genetic elements, beyond BRCA1 and BRCA2, which have been associated with increased risk of TNBC. Multigene panel testing has identified high- and moderate-penetrance cancer predisposition genes associated with increased risk for TNBC. Development of large-scale genome-wide SNP assays coupled with genome-wide association studies (GWAS) has led to the discovery of low-penetrance TNBC-associated loci. Next-generation sequencing has identified variants in noncoding RNAs, viral integration sites, and genes in underexplored regions of the human genome that may contribute to the genetic underpinnings of TNBC. Advances in our understanding of the genetics of TNBC are driving improvements in risk assessment and patient management.
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Affiliation(s)
| | - Clesson E. Turner
- Murtha Cancer Center/Research Program, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rachel E. Ellsworth
- Murtha Cancer Center/Research Program, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
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Abstract
Motivated by personalized decision making, given observational data [Formula: see text] involving features [Formula: see text], assigned treatments or prescriptions [Formula: see text], and outcomes [Formula: see text], we propose a tree-based algorithm called optimal prescriptive tree (OPT) that uses either constant or linear models in the leaves of the tree to predict the counterfactuals and assign optimal treatments to new samples. We propose an objective function that balances optimality and accuracy. OPTs are interpretable and highly scalable, accommodate multiple treatments, and provide high-quality prescriptions. We report results involving synthetic and real data that show that OPTs either outperform or are comparable with several state-of-the-art methods. Given their combination of interpretability, scalability, generalizability, and performance, OPTs are an attractive alternative for personalized decision making in a variety of areas, such as online advertising and personalized medicine.
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Affiliation(s)
- Dimitris Bertsimas
- Sloan School of Management and Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139
| | - Jack Dunn
- Sloan School of Management and Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139
| | - Nishanth Mundru
- Sloan School of Management and Operations Research Center, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139
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4
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Surgeon-associated variation in breast cancer staging with sentinel node biopsy. Surgery 2018; 164:680-686. [DOI: 10.1016/j.surg.2018.06.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/25/2018] [Accepted: 06/12/2018] [Indexed: 11/23/2022]
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Fischer C, Lingsma H, Klazinga N, Hardwick R, Cromwell D, Steyerberg E, Groene O. Volume-outcome revisited: The effect of hospital and surgeon volumes on multiple outcome measures in oesophago-gastric cancer surgery. PLoS One 2017; 12:e0183955. [PMID: 29073140 PMCID: PMC5658198 DOI: 10.1371/journal.pone.0183955] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
Background Most studies showing a volume outcome effect in resection surgery for oesophago-gastric cancer were conducted before the centralisation of clinical services. This study evaluated the relation between hospital- and surgeon volume and different risk-adjusted outcomes after oesophago-gastric (OG) cancer surgery in England between 2011 and 2013. Methods In data from the National Oesophago-Gastric Cancer Audit from the UK, multivariable random-effects logistic regression models were used to quantify the effect of surgeon and hospital volume on three outcomes: 30-day and 90-day mortality and anastomotic leakage. The models included patient risk factors to adjust for differences in case-mix among hospitals and surgeons. The between-cluster heterogeneity was estimated with the median odds ratio (MOR). Results The study included patients treated at 42 hospitals and 329 surgeons. The median (interquartile range) of the annual hospital and surgeon volumes were 110 patients (82 to 137) and 13 patients (8 to 19), respectively. The overall rates for 30-day and 90-day mortality were 2.3% and 4.4% respectively, and the anastomotic leakage was 6.3%. Higher hospital volume was associated with lower 30-day mortality (OR: 0.94; 95% CI: 0.91–0.98) and lower anastomotic leakage rates (OR: 0.96; 95% CI: 0.93–0.98) but not 90-day mortality. Higher surgeon volume was only associated with lower anastomotic leakage rates (OR: 0.81; 95% CI: 0.72–0.92). Hospital volume explained a part of the between-hospital variation in 30-day mortality whereas surgeon volume explained part of the between-hospital variation in anastomotic leakage. Conclusions In the setting of centralized O-G cancer surgery in England, we could still observe an effect of volume on short-term outcomes. However, the effect is inconsistent, depending on the type of outcome measure under consideration, and much smaller than in previous studies. Efforts to centralise O-G cancer services further should carefully address the effects of both hospital and surgeon volume on the range of outcome measures that are relevant to patients.
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Affiliation(s)
- Claudia Fischer
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Hester Lingsma
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Niek Klazinga
- Amsterdam Medical Center, Department of Public Health, Amsterdam, The Netherlands
| | - Richard Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ewout Steyerberg
- Erasmus MC, Department of Public Health, Rotterdam, The Netherlands
| | - Oliver Groene
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
- OptiMedis AG, Hamburg, Germany
- * E-mail:
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Abstract
PURPOSE Hospital factors along with various patient and surgeon factors are considered to affect the prognosis of colorectal cancer. Hospital volume is well known, but little is known regarding other hospital factors. METHODS We reviewed data on 853 patients with stage IV colorectal cancer who underwent elective palliative primary tumor resection between January 2006 and December 2007. To detect the hospital factors that could influence the prognosis of incurable colorectal cancer, the relationships between patient/hospital factors and overall survival were analyzed. Among hospital factors, hospital type (Group A: university hospital or cancer center; Group B: community hospital), hospital volume, and number of colorectal surgeons were examined. RESULTS In univariate analysis, Group A hospitals showed significantly better prognosis than Group B hospitals (p = 0.034), while hospital volume and number of colorectal surgeons were not associated with overall survival. After adjustment for patient factors in multivariate analysis, hospital type was significantly associated with overall survival (hazard ratio: 1.31; 95 % confidence interval: 1.05-1.63; p = 0.016). However, there was no significant difference in short-term outcomes between hospital types. CONCLUSIONS Hospital type was identified as a hospital factor that possibly affects the prognosis of stage IV colorectal cancer patients.
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van Putten M, Verhoeven RHA, van Sandick JW, Plukker JTM, Lemmens VEPP, Wijnhoven BPL, Nieuwenhuijzen GAP. Hospital of diagnosis and probability of having surgical treatment for resectable gastric cancer. Br J Surg 2015; 103:233-41. [DOI: 10.1002/bjs.10054] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/22/2015] [Accepted: 10/16/2015] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Gastric cancer surgery is increasingly being centralized in the Netherlands, whereas the diagnosis is often made in hospitals where gastric cancer surgery is not performed. The aim of this study was to assess whether hospital of diagnosis affects the probability of undergoing surgery and its impact on overall survival.
Methods
All patients with potentially curable gastric cancer according to stage (cT1/1b–4a, cN0–2, cM0) diagnosed between 2005 and 2013 were selected from the Netherlands Cancer Registry. Multilevel logistic regression was used to examine the probability of undergoing surgery according to hospital of diagnosis. The effect of variation in probability of undergoing surgery among hospitals of diagnosis on overall survival during the intervals 2005–2009 and 2010–2013 was examined by using Cox regression analysis.
Results
A total of 5620 patients with potentially curable gastric cancer, diagnosed in 91 hospitals, were included. The proportion of patients who underwent surgery ranged from 53·1 to 83·9 per cent according to hospital of diagnosis (P < 0·001); after multivariable adjustment for patient and tumour characteristics it ranged from 57·0 to 78·2 per cent (P < 0·001). Multivariable Cox regression showed that patients diagnosed between 2010 and 2013 in hospitals with a low probability of patients undergoing curative treatment had worse overall survival (hazard ratio 1·21; P < 0·001).
Conclusion
The large variation in probability of receiving surgery for gastric cancer between hospitals of diagnosis and its impact on overall survival indicates that gastric cancer decision-making is suboptimal.
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Affiliation(s)
- M van Putten
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
| | - R H A Verhoeven
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
| | - J W van Sandick
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J T M Plukker
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - V E P P Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Eindhoven, The Netherlands
- Department of Public Health, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Pellet AC, Erten MZ, James TA. Value analysis of postoperative staging imaging for asymptomatic, early-stage breast cancer: implications of clinical variation on utility and cost. Am J Surg 2015; 211:1084-8. [PMID: 26545344 DOI: 10.1016/j.amjsurg.2015.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/23/2015] [Accepted: 08/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Routine staging imaging for early-stage breast cancer is not recommended. Despite this, there is clinical practice variation with imaging studies obtained for asymptomatic patients with a positive sentinel node (SN+). We characterize the utility, cost, and clinical implications of imaging studies obtained in asymptomatic SN+ patients. METHODS A retrospective review was performed of asymptomatic, clinically node-negative patients who were found to have a positive sentinel node after surgery. The type of imaging, subsequent tests/interventions, frequency of additional malignancy detected, and costs were recorded. RESULTS From April 2009 to April 2013, a total of 50 of 113 (44%) asymptomatic patients underwent staging imaging for a positive sentinel node; 11 (22%) patients had at least 1 subsequent imaging study or diagnostic intervention. No instance of metastatic breast cancer was identified, with a total cost of imaging calculated at $116,905. CONCLUSIONS Staging imaging for asymptomatic SN+ breast cancer demonstrates clinical variation. These tests were associated with low utility, increased costs, and frequent false positives leading to subsequent testing/intervention. Evidence-based standardization may help increase quality by decreasing unnecessary variation and cost.
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Affiliation(s)
- Andrew C Pellet
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA
| | - Mujde Z Erten
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA
| | - Ted A James
- Department of Surgery, University of Vermont, 89 Beaumont Avenue, Given Building, Burlington, VT, 05405, USA.
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Rummel S, Hueman MT, Costantino N, Shriver CD, Ellsworth RE. Tumour location within the breast: Does tumour site have prognostic ability? Ecancermedicalscience 2015; 9:552. [PMID: 26284116 PMCID: PMC4531129 DOI: 10.3332/ecancer.2015.552] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Indexed: 11/06/2022] Open
Abstract
Introduction Tumour location within the breast varies with the highest frequency in the upper outer quadrant (UOQ) and lowest frequency in the lower inner quadrant (LIQ). Whether tumour location is prognostic is unclear. To determine whether tumour location is prognostic, associations between tumour site and clinicopathological characteristics were evaluated. Materials and Methods All patients enrolled in the Clinical Breast Care Project whose tumour site—UOQ, upper inner quadrant (UIQ), central, LIQ, lower outer quadrant (LOQ)—was determined by a single, dedicated breast pathologist were included in this study. Patients with multicentric disease (n = 122) or tumours spanning multiple quadrants (n = 381) were excluded from further analysis. Clinicopathological characteristics were analysed using chi-square tests for univariate analysis with multivariate analysis performed using principal components analysis (PCA) and multiple logistic regression. Significance was defined as P < 0.05. Results Of the 980 patients with defined tumour location, 30 had bilateral disease. Tumour location in the UOQ (51.5%) was significantly higher than in the UIQ (15.6%), LOQ (14.2%), central (10.6%), or LIQ (8.1%). Tumours in the central quadrant were significantly more likely to have higher tumour stage (P = 0.003) and size (P < 0.001), metastatic lymph nodes (P < 0.001), and mortality (P = 0.011). After multivariate analysis, only tumour size and lymph node status remained significantly associated with survival. Conclusions Evaluation of tumour location as a prognostic factor revealed that although tumours in the central region are associated with less favourable outcome, these associations are not independent of location but rather driven by larger tumour size. Tumours in the central region are more difficult to detect mammographically, resulting in larger tumour size at diagnosis and thus less favourable prognosis. Together, these data demonstrate that tumour location is not an independent prognostic factor.
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Affiliation(s)
- Seth Rummel
- Clinical Breast Care Project, Windber Research Institute, Windber, Pennsylvania 15963, USA
| | - Matthew T Hueman
- Clinical Breast Care Project, Murtha Cancer Centre, Walter Reed National Military Medical Centre, Bethesda, Maryland 20889, USA
| | - Nick Costantino
- Clinical Breast Care Project, Windber Research Institute, Windber, Pennsylvania 15963, USA
| | - Craig D Shriver
- Clinical Breast Care Project, Murtha Cancer Centre, Walter Reed National Military Medical Centre, Bethesda, Maryland 20889, USA
| | - Rachel E Ellsworth
- Clinical Breast Care Project, Murtha Cancer Centre, Walter Reed National Military Medical Centre, Bethesda, Maryland 20889, USA
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Hospital center effect for laparoscopic colectomy among elderly stage I-III colon cancer patients. Ann Surg 2014; 259:924-9. [PMID: 23817508 DOI: 10.1097/sla.0b013e31829d0468] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate hospital-level variation in short-term laparoscopic colectomy outcomes among stage I-III elderly colon cancer patients. BACKGROUND Surgical outcomes are associated with patient and surgeon characteristics. If outcomes are also impacted by the hospital where the surgery occurs, there is a hospital center effect (HCE). METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare data was used to identify stage I-III colon cancer patients treated with laparoscopic colectomies. Multilevel regressions were utilized to study potential HCE for length of stay (LOS), 30-day rehospitalization, and in-hospital mortality, adjusting for patient, surgeon, and hospital-level characteristics. To quantify HCE, we calculated the median instantaneous rate ratio (MIRR) for LOS and median odds ratio (MOR) for in-hospital mortality and 30-day rehospitalization. Sensitivity analyses were conducted for high volume/medical school affiliated hospitals and colorectal surgeons. RESULTS The multilevel analyses based on 4617 patients from 465 hospitals documented statistically significant HCEs for LOS (MIRR = 1.35; P < 0.001) and in-hospital mortality (MOR = 1.69; P = 0.032), but no HCE for 30-day rehospitalization. Sensitivity analyses confirmed our findings. HCE was significant for LOS in all sensitivity analyses and was significant for in-hospital mortality for high volume/medical school affiliated hospitals. CONCLUSIONS HCE exists for LOS and in-hospital mortality of laparoscopic colectomy, which suggests that the choice of hospital affects outcomes independently of other confounding variables. Reducing the variation in outcomes associated with HCE may improve the quality of cancer care.
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Molecular alterations associated with breast cancer mortality. PLoS One 2012; 7:e46814. [PMID: 23056464 PMCID: PMC3464216 DOI: 10.1371/journal.pone.0046814] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 09/05/2012] [Indexed: 11/19/2022] Open
Abstract
Background Breast cancer is a heterogeneous disease and patients with similar pathologies and treatments may have different clinical outcomes. Identification of molecular alterations associated with disease outcome may improve risk assessment and treatments for aggressive breast cancer. Methods Allelic imbalance (AI) data was generated for 122 invasive breast tumors with known clinical outcome. Levels and patterns of AI were compared between patients who died of disease (DOD) and those with ≥5 years disease-free survival (DFS) using Student t-test and chi-square analysis with a significance value of P<0.05. Results Levels of AI were significantly higher in tumors from the 31 DOD patients (28.6%) compared to the 91 DFS patients (20.1%). AI at chromosomes 7q31, 8p22, 13q14, 17p13.3, 17p13.1 and 22q12.3 was associated with DOD while AI at 16q22–q24 was associated with DFS. After multivariate analysis, AI at chromosome 8p22 remained an independent predictor of breast cancer mortality. The frequency of AI at chromosome 13q14 was significantly higher in patients who died ≥5 years compared to those who died <5 years from diagnosis. Conclusion Tumors from DOD compared to DFS patients are marked by increased genomic instability and AI at chromosome 8p22 is significantly associated with breast cancer morality, independent of other clinicopathological factors. AI at chromosome 13q14 was associated with late (>5-years post-diagnosis) mortality but not with death from disease within five years, suggesting that patients with short- and long-term mortality may have distinct genetic diseases.
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Garibaldi JM, Zhou SM, Wang XY, John RI, Ellis IO. Incorporation of expert variability into breast cancer treatment recommendation in designing clinical protocol guided fuzzy rule system models. J Biomed Inform 2012; 45:447-59. [PMID: 22265814 DOI: 10.1016/j.jbi.2011.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 12/14/2011] [Accepted: 12/25/2011] [Indexed: 11/28/2022]
Affiliation(s)
- Jonathan M Garibaldi
- Intelligent Modelling and Analysis Research Group, School of Computer Science, University of Nottingham, Nottingham NG8 1BB, United Kingdom
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13
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Raising the Bar for Breast Health Care in the United States. Womens Health Issues 2012; 22:e129-33. [DOI: 10.1016/j.whi.2011.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 08/23/2011] [Accepted: 08/23/2011] [Indexed: 11/30/2022]
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Structural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients. Breast Cancer Res Treat 2012; 133:333-45. [PMID: 22270934 DOI: 10.1007/s10549-012-1955-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 01/09/2012] [Indexed: 10/14/2022]
Abstract
Observed racial/ethnic disparities in the process and outcomes of breast cancer care may be explained, in part, by structural/organizational characteristics of health care systems. We examined the role of surgical facility characteristics and distance to care in explaining racial/ethnic variation in timing of initiation of guideline-recommended radiation therapy (RT) after breast conserving surgery (BCS). We used Surveillance Epidemiology and End Results-Medicare data to identify women ages 65 and older diagnosed with stages I-III breast cancer and treated with BCS in 1994-2002. We used stepwise multivariate logistic regression to examine the interactive effects of race/ethnicity and facility profit status, teaching status, size, and institutional affiliations, and distance to nearest RT on timing of RT initiation, controlling for known covariates. Among 38,574 eligible women who received BCS, 39% received RT within 2 months, 52% received RT within 6 months, and 57% received RT within 12 months post-diagnosis, with significant variation by race/ethnicity. In multivariate models, women attending smaller surgical facilities and those with on-site radiation had higher odds of RT at each time interval, and women attending governmental facilities had lower odds of RT at each time interval (P < 0.05). Increasing distance between patients' residence and nearest RT provider was associated with lower overall odds of RT, particularly among Hispanic women (P < 0.05). In fully adjusted models including race-by-distance interaction terms, racial/ethnic disparities disappeared in RT initiation within 6 and 12 months. Racial/ethnic disparities in timing of RT for breast cancer can be partially explained by structural/organizational health system characteristics. Identifying modifiable system-level factors associated with quality cancer care may help us target policy interventions that can reduce disparities in outcomes.
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Ellsworth RE, Decewicz DJ, Shriver CD, Ellsworth DL. Breast cancer in the personal genomics era. Curr Genomics 2010; 11:146-61. [PMID: 21037853 PMCID: PMC2878980 DOI: 10.2174/138920210791110951] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 01/24/2010] [Accepted: 01/26/2010] [Indexed: 11/22/2022] Open
Abstract
Breast cancer is a heterogeneous disease with a complex etiology that develops from different cellular lineages, progresses along multiple molecular pathways, and demonstrates wide variability in response to treatment. The "standard of care" approach to breast cancer treatment in which all patients receive similar interventions is rapidly being replaced by personalized medicine, based on molecular characteristics of individual patients. Both inherited and somatic genomic variation is providing useful information for customizing treatment regimens for breast cancer to maximize efficacy and minimize adverse side effects. In this article, we review (1) hereditary breast cancer and current use of inherited susceptibility genes in patient management; (2) the potential of newly-identified breast cancer-susceptibility variants for improving risk assessment; (3) advantages and disadvantages of direct-to-consumer testing; (4) molecular characterization of sporadic breast cancer through immunohistochemistry and gene expression profiling and opportunities for personalized prognostics; and (5) pharmacogenomic influences on the effectiveness of current breast cancer treatments. Molecular genomics has the potential to revolutionize clinical practice and improve the lives of women with breast cancer.
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Affiliation(s)
- Rachel E. Ellsworth
- Clinical Breast Care Project, Henry M. Jackson Foundation for the Advancement of Military Medicine, Windber, PA, USA
| | - David J. Decewicz
- Clinical Breast Care Project, Walter Reed Army Medical Center, Washington, DC, USA
| | - Craig D. Shriver
- Clinical Breast Care Project, Windber Research Institute, Windber, PA, USA
| | - Darrell L. Ellsworth
- Clinical Breast Care Project, Walter Reed Army Medical Center, Washington, DC, USA
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Abstract
The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.
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Gort M, Otter R, Plukker JTM, Broekhuis M, Klazinga NS. Actionable indicators for short and long term outcomes in rectal cancer. Eur J Cancer 2010; 46:1808-14. [PMID: 20335020 DOI: 10.1016/j.ejca.2010.02.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/19/2010] [Accepted: 02/24/2010] [Indexed: 01/07/2023]
Abstract
AIM OF THE STUDY Although patient and tumour characteristics are the most important determinants for outcomes in rectal cancer care, actionable factors for improving these are still unclear. Therefore, the purpose of this study was to assess the impact of surgeon and hospital factors which can actually be influenced to improve on postoperative complications, disease-free survival (DFS) and relative survival (RS) in rectal cancer. METHODS For 819 curatively operated rectal cancer patients, staged I-III and diagnosed between 2001 and 2005, data were derived from the population-based Cancer Registry of the Comprehensive Cancer Centre North East and supplemented by medical record examination. (Multilevel) Logistic regression analysis was performed to examine the influence of relevant factors on postoperative complications and time from diagnosis to first treatment. Besides, Cox regression analysis for DFS and relative survival analysis was performed. RESULTS Postoperative complications were dependent on type of surgery (p=0.024) and hospital volume (p=0.029). DFS was mainly influenced by stage (p<0.001) and time to treatment (p=0.018). Actionable indicators related to RS were type of surgery (p=0.011) and time to treatment (p=0.048). Time to treatment was found to be related to co-morbidity (p=0.007), preoperative radiotherapy (p=0.003) and referral for operation (p=0.048). Nevertheless, 18.2% unexplained variation in time to treatment remained on hospital level. CONCLUSIONS We conclude that optimal outcomes for rectal cancer care can be achieved by focusing on early detection and timely diagnosis, as well as adequate choice and timeliness of treatment in hospitals with optimal logistics for rectal cancer patients.
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Affiliation(s)
- Marjan Gort
- Comprehensive Cancer Centre North East, Groningen, The Netherlands.
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Ellsworth RE, Hooke JA, Shriver CD, Ellsworth DL. Genomic heterogeneity of breast tumor pathogenesis. Clin Med Oncol 2009; 3:77-85. [PMID: 20689613 PMCID: PMC2872596 DOI: 10.4137/cmo.s2946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pathological grade is a useful prognostic factor for stratifying breast cancer patients into favorable (low-grade, well-differentiated tumors) and less favorable (high-grade, poorly-differentiated tumors) outcome groups. Under the current system of tumor grading, however, a large proportion of tumors are characterized as intermediate-grade, making determination of optimal treatments difficult. In an effort to increase objectivity in the pathological assessment of tumor grade, differences in chromosomal alterations and gene expression patterns have been characterized in low-grade, intermediate-grade, and high-grade disease. In this review, we outline molecular data supporting a linear model of progression from low-grade to high-grade carcinomas, as well as contradicting genetic data suggesting that low-grade and high-grade tumors develop independently. While debate regarding specific pathways of development continues, molecular data suggest that intermediate-grade tumors do not comprise an independent disease subtype, but represent clinical and molecular hybrids between low-grade and high-grade tumors. Finally, we discuss the clinical implications associated with different pathways of development, including a new clinical test to assign grade and guide treatment options.
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Affiliation(s)
- Rachel E Ellsworth
- Clinical Breast Care Project, Henry M. Jackson Foundation for the Advancement of Military Medicine, 620 Seventh Street, Windber, PA, 15963, USA
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Bates T, Kearins O, Monypenny I, Lagord C, Lawrence G. Clinical outcome data for symptomatic breast cancer: the Breast Cancer Clinical Outcome Measures (BCCOM) Project. Br J Cancer 2009; 101:395-402. [PMID: 19603016 PMCID: PMC2720241 DOI: 10.1038/sj.bjc.6605155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Data collection for screen-detected breast cancer in the United Kingdom is fully funded, which has led to improvements in clinical practice. However, data on symptomatic cancer are deficient, and the aim of this project was to monitor the current practice. Methods: A data set was designed together with surrogate outcome measures to reflect best practice. Data from cancer registries initially required the consent of clinicians, but in the third year anonymised data were available. Results: The quality of data improved, but this varied by region and only a third of the cases were validated by clinicians. Regional variations in mastectomy rates were identified, and one-third of patients who underwent conservative surgery for the treatment invasive breast cancer were not recorded as receiving radiotherapy. Conclusion: National data are essential to ensure that all patients receive appropriate treatment for breast cancer, but variations still exist in the United Kingdom and further improvement in data capture is required.
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Affiliation(s)
- T Bates
- The Breast Unit, William Harvey Hospital, Ashford, Kent. TN24 OLZ, UK
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Orr J, Kelley J, Dizon D, Escobar P, Fleming E, Gemignani M, Hetzel D, Hoskins W, Kieback D, Kilgore L, LaPolla J, Lewin S, Lucci J, Markman M, Pothuri B, Powell CB, Tejada-Berges T. Society of gynecologic oncologists position paper: breast cancer care. Gynecol Oncol 2008; 110:7-12. [PMID: 18589209 DOI: 10.1016/j.ygyno.2008.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 04/04/2008] [Indexed: 10/21/2022]
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