Providers of follow-up care in a population-based sample of breast cancer survivors

Employment outcomes in family supporters of patients with early stage breast cancer and their association with patients' health-related quality of life and financial burden

BACKGROUND

Little is known about how cancer impacts the employment status of patients' family supporters, or about associations between patients' health-related quality of life, perceived financial burden, and supporters' employment trajectory.

METHODS

We surveyed patients with early stage breast cancer reported to the Georgia and Los Angeles SEER registries in 2014-15, and their spouse/partner or other family supporters. Patients and supporters were asked about employment impacts of the patient's cancer, and descriptive analyses of supporters' employment trajectories were generated. We measured patients' health-related quality of life (HRQoL) using the PROMIS scale for global health. We measured patients' perceived financial burden attributed to cancer by asking them two questions regarding (i) their financial status since their breast cancer diagnosis and (ii) how much it was impacted by their breast cancer and treatment. Associations between patients' HRQoL, perceived financial burden, and supporters' employment status were assessed using linear mixed model regression analyses.

RESULTS

In total, 2502 patients (68% response rate) and 1203 supporters (70% response rate) responded; 1057 paired patient-supporter dyads were included. Similar proportions of spouse/partner and other family supporters reported missed work and lost employment due to patients' cancer. After adjustment, lower HRQoL and an increased odds of perceived financial burden among patients were associated with changes in other family supporters' employment (both p < 0.05), but not with changes in spouses'/partners' employment. Lower HRQoL was also associated with changes in patients' own employment among patients with both types of supporters (both p < 0.001). An increased odds of perceived financial burden among patients was associated with changes in patients' employment only in those supported by other family members (p < 0.001).

CONCLUSIONS

Both spouse/partner and other family supporters faced adverse employment outcomes due to patients' cancer. This contributes to worse HRQoL and greater perception of financial burden among patients, especially those whose supporter is not a spouse/partner.

Integrated copy number and miRNA expression analysis in triple negative breast cancer of Latin American patients

Triple negative breast cancer (TNBC), a clinically aggressive breast cancer subtype, affects 15–35% of women from Latin America. Using an approach of direct integration of copy number and global miRNA profiling data, performed simultaneously in the same tumor specimens, we identified a panel of 17 miRNAs specifically associated with TNBC of ancestrally characterized patients from Latin America, Brazil. This panel was differentially expressed between the TNBC and non-TNBC subtypes studied (p ≤ 0.05, FDR ≤ 0.25), with their expression levels concordant with the patterns of copy number alterations (CNAs), present mostly frequent at 8q21.3-q24.3, 3q24-29, 6p25.3-p12.2, 1q21.1-q44, 5q11.1-q22.1, 11p13-p11.2, 13q12.11-q14.3, 17q24.2-q25.3 and Xp22.33-p11.21. The combined 17 miRNAs presented a high power (AUC = 0.953 (0.78–0.99);95% CI) in discriminating between the TNBC and non-TNBC subtypes of the patients studied. In addition, the expression of 14 and 15 of the 17miRNAs was significantly associated with tumor subtype when adjusted for tumor stage and grade, respectively. In conclusion, the panel of miRNAs identified demonstrated the impact of CNAs in miRNA expression levels and identified miRNA target genes potentially affected by both CNAs and miRNA deregulation. These targets, involved in critical signaling pathways and biological functions associated specifically with the TNBC transcriptome of Latina patients, can provide biological insights into the observed differences in the TNBC clinical outcome among racial/ethnic groups, taking into consideration their genetic ancestry.

Understanding the engagement of key decision support persons in patient decision making around breast cancer treatment

BACKGROUND

Patients with breast cancer involve multiple decision support persons (DSPs) in treatment decision making, yet little is known about DSP engagement in decision making and its association with patient appraisal of the decision process.

METHODS

Patients newly diagnosed with breast cancer reported to Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries in 2014-2015 were surveyed 7 months after their diagnosis. The individual most involved in each respondent's decision making (the key DSP) was surveyed. DSP engagement was measured across 3 domains: 1) informed about decisions, 2) involved in decisions, and 3) aware of patient preferences. Patient decision appraisal included subjective decision quality (SDQ) and deliberation. This study evaluated bivariate associations with chi-square tests between domains of DSP engagement and independent DSP variables. Analysis of variance and multivariable logistic regression were used to compare domains of DSP engagement with patient decision appraisal.

RESULTS

In all, 2502 patients (68% response rate) and 1203 eligible DSPs (70% response rate) responded. Most DSPs were husbands/partners or daughters, were white, and were college graduates. Husbands/partners were more likely to be more informed, involved, and aware (all P values < .01). English- and Spanish-speaking Latinos had a higher extent of (P = .02) but lower satisfaction with involvement (P < .01). A highly informed DSP was associated with higher odds of patient-reported SDQ (odds ratio, 1.46; 95% confidence interval, 1.03-2.08; P = .03). A highly aware DSP was associated with higher odds of patient-reported deliberation (odds ratio, 1.83; 95% confidence interval, 1.36-2.47; P < .01).

CONCLUSIONS

In this population-based study, informal DSPs were engaged with and positively contributed to patients' treatment decision making. To improve decision quality, future interventions should incorporate DSPs.

Provider Involvement in Care During Initial Cancer Treatment and Patient Preferences for Provider Roles After Initial Treatment

PURPOSE

Patients report strong preferences regarding which provider-oncologist or primary care provider (PCP)-handles their primary care after initial cancer treatment (eg, other cancer screenings, preventive care, comorbidity management). Little is known about associations between provider involvement during initial cancer treatment and patient preferences for provider roles after initial treatment.

METHODS

Women who received a diagnosis of early-stage breast cancer in 2014 to 2015 were identified from the Georgia and Los Angeles County SEER registries and surveyed (N = 2,502; 68% response rate). Women reported the level of their providers' involvement in their care during initial cancer treatment. Associations between level of medical oncologist's participation and PCP's engagement during initial cancer treatment and patient preferences for oncologist led ( v PCP led) other cancer screenings after initial treatment were examined using multivariable logistic regression models.

RESULTS

During their initial cancer treatment, 20% of women reported medical oncologists participated substantially in delivering primary care and 66% reported PCPs were highly engaged in their cancer care. Two-thirds (66%) of women preferred medical oncologists to handle other cancer screenings after initial treatment. Women who reported substantial medical oncologist participation in primary care were more likely (adjusted odds ratio, 1.42; 95% CI, 1.05 to 1.91) and those who reported high PCP engagement in cancer care were less likely (adjusted odds ratio, 0.41; 95% CI, 0.31 to 0.53) to prefer oncologist-led other cancer screenings after initial treatment.

CONCLUSIONS

Providers' involvement during initial cancer treatment may affect patient preferences regarding provision of follow-up primary care. Clarifying provider roles as early as during cancer treatment may help to better delineate their roles throughout survivorship.

Variation in the Types of Providers Participating in Breast Cancer Follow-Up Care: A SEER-Medicare Analysis

BACKGROUND

The current guidelines do not delineate the types of providers that should participate in early breast cancer follow-up care (within 3 years after completion of treatment). This study aimed to describe the types of providers participating in early follow-up care of older breast cancer survivors and to identify factors associated with receipt of follow-up care from different types of providers.

METHODS

Stages 1-3 breast cancer survivors treated from 2000 to 2007 were identified in the Surveillance, Epidemiology and End results Medicare database (n = 44,306). Oncologist (including medical, radiation, and surgical) follow-up and primary care visits were defined using Medicare specialty provider codes and linked American Medical Association (AMA) Masterfile. The types of providers involved in follow-up care were summarized. Stepped regression models identified factors associated with receipt of medical oncology follow-up care and factors associated with receipt of medical oncology care alone versus combination oncology follow-up care.

RESULTS

Oncology follow-up care was provided for 80 % of the patients: 80 % with a medical oncologist, 46 % with a surgeon, and 39 % with a radiation oncologist after radiation treatment. The patients with larger tumor size, positive axillary nodes, estrogen receptor (ER)-positive status, and chemotherapy treatment were more likely to have medical oncology follow-up care than older patients with higher Charlson comorbidity scores who were not receiving axillary care. The only factor associated with increased likelihood of follow-up care with a combination of oncology providers was regular primary care visits (>2 visits/year).

CONCLUSIONS

Substantial variation exists in the types of providers that participate in breast cancer follow-up care. Improved guidance for the types of providers involved and delineation of providers' responsibilities during follow-up care could lead to improved efficiency and quality of care.

Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities

Since the release of the Institute of Medicine report: From cancer patient to cancer survivor: lost in transition, in 2005, there has been a national call in the USA to provide coordinated, comprehensive care for cancer survivors, with an emphasis on the role of primary care. Several models of care have been described, which focus on primary care providers (PCPs) as receiving cancer survivors who are transferred after successful treatment, and who are given specific types of information from oncology-based care (eg, survivorship care plans), and not as active members of the cancer survivorship team. In this Series paper, we assessed survivorship models that have been described in the literature, with a specific focus on strategies that aim to integrate PCPs into the care of cancer survivors across different settings. We offer insights differentiating PCPs' level of expertise in cancer survivorship and how such expertise could be used. We provide recommendations for education, clinical practice, research, and policy initiatives that might advance the integration of PCPs in the care of cancer survivors in diverse clinical settings.

Use of a novel statistical technique to examine the delivery of breast cancer follow-up care by different types of oncology providers

RATIONALE, AIMS AND OBJECTIVES

Frequent follow-up is recommended for the more than 3 million breast cancer survivors living in the USA. Given the multidisciplinary nature of breast cancer treatment, follow-up may be provided by medical oncologists, radiation oncologists, surgeons and primary care providers. This creates the potential for significant redundancy as well as gaps in care. The objective was to examine patterns of breast cancer follow-up provided by different types of oncologists and develop a statistical means of quantifying visit distribution over time.

METHODS

We identified stage I-III breast cancer patients who underwent breast conservation from 2000 to 2006 (n = 12 139) within the SEER-Medicare linked database. Provider type was defined using Medicare specialty provider codes and AMA Masterfile. The coefficient of variation (CV) for time between oncologist follow-up visits was calculated. Ordinal logistic regression assessed factors associated with CV.

RESULTS

Substantial variation in CV was observed. Sixty-seven per cent of patients with low CV (high visit regularity) received follow-up from a single oncologist type, versus 8% with high CV (low visit regularity). The number of oncologist types participating in follow-up had the greatest association with high CV (odds ratio 7.4 [6.7-8.3] and 15.4 [13.6-17.6] for two and three oncologist types).

CONCLUSIONS

Using a novel means of quantifying follow-up visit regularity, we determined that breast cancer patients with dispersed follow-up with more than one oncologist have more disordered care. The CV could be used in electronic medical records to identify cancer survivors with more disordered.

Utility of Clinical Breast Examinations in Detecting Local-Regional Breast Events After Breast-Conservation in Women with a Personal History of High-Risk Breast Cancer

BACKGROUND

Although breast cancer follow-up guidelines emphasize the importance of clinical examinations, prior studies suggest a small fraction of local-regional events occurring after breast conservation are detected by examination alone. Our objective was to examine how local-regional events are detected in a contemporary, national cohort of high-risk breast cancer survivors.

METHODS

A stage-stratified sample of stage II/III breast cancer patients diagnosed in 2006-2007 (n = 11,099) were identified from 1217 facilities within the National Cancer Data Base. Additional data on local-regional and distant breast events, method of event detection, imaging received, and mortality were collected. We further limited the cohort to patients with breast conservation (n = 4854). Summary statistics describe local-regional event rates and detection method.

RESULTS

Local-regional events were detected in 5.5 % (n = 265) of patients. Eighty-three percent were ipsilateral or contralateral in-breast events, and 17 % occurred within ipsilateral lymph nodes. Forty-eight percent of local-regional events were detected on asymptomatic breast imaging, 29 % by patients, and 10 % on clinical examination. Overall, 0.5 % of the 4854 patients had a local-regional event detected on examination. Examinations detected a higher proportion of lymph node events (8/45) compared with in-breast events (18/220). No factors were associated with method of event detection.

DISCUSSION

Clinical examinations, as an adjunct to screening mammography, have a modest effect on local-regional event detection. This contradicts current belief that examinations are a critical adjunct to mammographic screening. These findings can help to streamline follow-up care, potentially improving follow-up efficiency and quality.

Medicaid expansion and access to care among cancer survivors: a baseline overview

PURPOSE

Medicaid expansion under the Affordable Care Act facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Medicaid expansions may provide increased access to care for cancer survivors, a growing population with chronic conditions. We compare access to health care services among cancer survivors living in non-expansion states to those living in expansion states, prior to Medicaid expansion under the Affordable Care Act.

METHODS

We use the 2012 and 2013 Behavioral Risk Factor Surveillance System to estimate multiple logistic regression models to compare inability to see a doctor because of cost, having a personal doctor, and receiving an annual checkup in the past year between cancer survivors who lived in non-expansion states and survivors who lived in expansion states.

RESULTS

Cancer survivors in non-expansion states had statistically significantly lower odds of having a personal doctor (adjusted odds ratio [AOR] 0.76, 95 % confidence interval [CI] 0.63-0.92, p < 0.05) and higher odds of being unable to see a doctor because of cost (AOR 1.14, 95 % CI 0.98-1.31, p < 0.10). Statistically significant differences were not found for annual checkups.

CONCLUSIONS

Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors with limited access to routine care.

IMPLICATIONS FOR CANCER SURVIVORS

Existing disparities in access to care are likely to widen between cancer survivors in Medicaid non-expansion and expansion states.

Oncologists' Perspectives of Their Roles and Responsibilities During Multi-disciplinary Breast Cancer Follow-Up

BACKGROUND

Improving the quality of follow-up provided to the 3 million U.S. breast cancer survivors is a high priority. Current guidelines do not provide guidance regarding who should participate in follow-up or what providers' specific responsibilities should be. Given the multidisciplinary nature of breast cancer care, this results in significant variation and creates the potential for redundancy and/or gaps. Our objective was to provide insight into why different types of oncologists believe their participation in follow-up is necessary.

METHODS

A purposeful sample of breast medical, radiation, and surgical oncologists was identified (n = 35) and in-depth one-on-one interviews were conducted. Data were analyzed using content analysis.

RESULTS

Medical oncologists were driven by a sense of Responsibility for Ongoing Therapy, perceived Strong Patient Relationship, and belief that their systemic approach to follow-up represented a Specific Skillset beneficial to patients. In contrast, surgical and radiation oncologists were selective about which patients they followed, participating when they perceived their Specific Skillset of enhanced local-regional assessments would be valuable. Additionally, they endorsed participating to Ensure Follow-up is Received or not participating to Minimize Redundancy. These individual decisions led to either a Complementary Oncologist Team or Primary Oncologist follow-up approach.

CONCLUSIONS

Oncologists' feel responsible for the cancer-related components of follow-up. Differences amongst oncology specialists' perceived responsibilities influenced decisions to provide ongoing follow-up. Based on these individual decisions, a Complementary Oncologist Team or Primary Oncologist model of care evolves organically. Guidelines that explicitly direct patients into a care model have the potential to significantly improve care quality and efficiency.