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Herbach EL, Curran M, Roberson ML, Carnahan RM, McDowell BD, Wang K, Lizarraga I, Nash SH, Charlton M. Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study. Cancer Causes Control 2024; 35:1017-1031. [PMID: 38546924 DOI: 10.1007/s10552-024-01859-3] [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: 10/24/2023] [Accepted: 01/29/2024] [Indexed: 07/02/2024]
Abstract
PURPOSE To examine racial-ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors. METHODS Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties. RESULTS Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79-0.88), ORAIAN 0.66 (0.54-0.81); known stage: ORBlack 0.87 (0.80-0.94), ORAIAN 0.63 (0.47-0.85); seeing an oncologist: ORBlack 0.75 (0.71-0.79), ORAIAN 0.60 (0.47-0.72); locoregional treatment: ORBlack 0.80 (0.76-0.84), ORAIAN 0.84 (0.68-1.02); systemic therapies: ORBlack 0.90 (0.83-0.98), ORAIAN 0.66 (0.48-0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits. CONCLUSIONS This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial-ethnic disparities in breast cancer care.
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Affiliation(s)
- Emma L Herbach
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Michaela Curran
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Mya L Roberson
- Department of Health Policy and Management, School of Global Public Health, University of North Carolina at Chapel Hill, Gillings, Chapel Hill, NC, USA
| | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Bradley D McDowell
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA
| | - Kai Wang
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Ingrid Lizarraga
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Sarah H Nash
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Mary Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
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Rogers C, Cobb AN, Lloren JIC, Chaudhary LN, Johnson MK, Huang CC, Teshome M, Kong AL, Singh P, Cortina CS. National trends in neoadjuvant chemotherapy utilization in patients with early-stage node-negative triple-negative breast cancer: the impact of the CREATE-X trial. Breast Cancer Res Treat 2024; 203:317-328. [PMID: 37864105 PMCID: PMC10872271 DOI: 10.1007/s10549-023-07114-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/24/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE Neoadjuvant chemotherapy (NAC) for triple-negative breast cancer (TNBC) allows for assessment of tumor pathological response and has survival implications. In 2017, the CREATE-X trial demonstrated survival benefit with adjuvant capecitabine in patients TNBC and residual disease after NAC. We aimed to assess national rates of NAC for cT1-2N0M0 TNBC before and after CREATE-X and examine factors associated with receiving NAC vs adjuvant chemotherapy (AC). METHODS A retrospective cohort study of women with cT1-2N0M0 TNBC diagnosed from 2014 to 2019 in the National Cancer Database (NCDB) was performed. Variables were analyzed via ANOVA, Chi-squared, Fisher Exact tests, and a multivariate linear regression model was created. RESULTS 55,633 women were included: 26.9% received NAC, 52.4% AC, and 20.7% received no chemotherapy (median ages 53, 59, and 71 years, p < 0.01). NAC utilization significantly increased over time: 19.5% in 2014-15 (n = 3,465 of 17,777), 27.1% in 2016-17 (n = 5,140 of 18,985), and 33.6% in 2018-19 (n = 6,337 of 18,871, p < 0.001). On multivariate analysis, increased NAC was associated with younger age (< 50), non-Hispanic white race/ethnicity, lack of comorbidities, cT2 tumors, care at an academic or integrated-network cancer program, and diagnosis post-2017 (p < 0.05 for all). Patients with government-provided insurance were less likely to receive NAC (p < 0.01). Women who traveled > 60 miles for treatment were more likely to receive NAC (p < 0.01). CONCLUSION From 2014 to 2019, NAC utilization increased for patients with cT1-2N0M0 TNBC. Racial, socioeconomic, and access disparities were observed in who received NAC vs AC and warrants interventions to ensure equitable care.
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Affiliation(s)
- Christine Rogers
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Adrienne N Cobb
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Jan I C Lloren
- Zibler School of Public Health, University of Wisconsin at Milwaukee, Milwaukee, WI, USA
| | - Lubna N Chaudhary
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Chiang-Ching Huang
- Zibler School of Public Health, University of Wisconsin at Milwaukee, Milwaukee, WI, USA
| | - Mediget Teshome
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Puneet Singh
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
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Thalji SZ, Cortina CS, Frebault J, Cho Y, Thorgerson A, Bergom CR, Huang CC, Kong AL. Associations Between Hospital Volume and Overall Survival After Surgery in Older Patients with Breast Cancer. Ann Surg Oncol 2023; 30:6462-6470. [PMID: 37314545 DOI: 10.1245/s10434-023-13725-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 05/23/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND High-volume hospitals (HVHs) are associated with improved overall survival (OS) following surgery for breast cancer compared with low-volume hospitals (LVHs). We examined this association in patients age ≥ 80 years and described patient and treatment characteristics associated with HVHs. PATIENTS AND METHODS The National Cancer Database was queried for women age ≥ 80 years who underwent surgery for stage I-III breast cancer between 2005 and 2014. Hospital volume was defined as the average number of cases during the year of the patient's index operation and the year prior. Hospitals were categorized into HVHs and LVHs using penalized cubic spline analysis of OS. A cutoff of ≥ 270 cases/year defined HVHs. RESULTS Among 59,043 patients, 9110 (15%) were treated at HVHs and 49,933 (85%) at LVHs. HVHs were associated with more non-Hispanic Black and Hispanic patients, earlier stage disease (stage I 54.9% vs. 52.6%, p < 0.001), higher rates of breast-conserving surgery (BCS) (68.3% vs. 61.4%, p < 0.001), and adjuvant radiation (37.5% vs. 36.1%, p = 0.004). Improved OS was associated with surgery at a HVH (HR 0.85, CI 0.81-0.88), along with receipt of adjuvant chemotherapy (HR 0.73, CI 0.69-0.77), endocrine therapy (HR 0.70, CI 0.68-0.72), and radiation (HR 0.66, CI 0.64-0.68). CONCLUSIONS Among patients with breast cancer age ≥ 80 years, undergoing surgery at a HVH was associated with improved OS. Patients who completed surgery at HVHs had earlier stage disease and more commonly received adjuvant radiation when appropriate. Processes of care at HVHs should be identified to improve outcomes in all settings.
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Affiliation(s)
- Sam Z Thalji
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Julia Frebault
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA
| | - Youngjoo Cho
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
- Department of Applied Statistics, Konkuk University, Seoul, Republic of Korea
| | - Abigail Thorgerson
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Carmen R Bergom
- Department of Radiation Oncology, Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
- School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Chiang-Ching Huang
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 8701 W, Watertown Plank Road, Milwaukee, WI, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
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Thalji SZ, Cortina CS, Kong AL. ASO Author Reflections: Extending Optimal Care for Breast Cancer to the Elderly Population. Ann Surg Oncol 2023; 30:6471-6472. [PMID: 37368097 DOI: 10.1245/s10434-023-13776-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Sam Z Thalji
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
- Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
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Nattinger AB, Bickell NA, Schymura MJ, Laud P, McGinley EL, Fergestrom N, Pezzin LE. Centralization of Initial Care and Improved Survival of Poor Patients With Breast Cancer. J Clin Oncol 2023; 41:2067-2075. [PMID: 36603178 PMCID: PMC10419674 DOI: 10.1200/jco.22.02012] [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: 09/06/2022] [Revised: 11/03/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Poor women with breast cancer have worse survival than others, and are more likely to undergo surgery in low-volume facilities. We leveraged a natural experiment to study the effectiveness of a policy intervention undertaken by New York (NY) state in 2009 that precluded payment for breast cancer surgery for NY Medicaid beneficiaries treated in facilities performing fewer than 30 breast cancer surgeries annually. METHODS We identified 37,822 women with stage I-III breast cancer during 2004-2008 or 2010-2013 and linked them to NY hospital discharge data. A multivariable difference-in-differences approach compared mortality of Medicaid insured patients with that of commercially or otherwise insured patients unaffected by the policy. RESULTS Women treated during the postpolicy years had slightly lower 5-year overall mortality than those treated prepolicy; the survival gain was significantly larger for Medicaid patients (P = .018). Women enrolled in Medicaid had a greater reduction than others in breast cancer-specific mortality (P = .005), but no greater reduction in other causes of death (P = .50). Adjusted breast cancer mortality among women covered by Medicaid declined from 6.6% to 4.5% postpolicy, while breast cancer mortality among other women fell from 3.9% to 3.8%. A similar effect was not observed among New Jersey Medicaid patients with breast cancer treated during the same years. CONCLUSION A statewide centralization policy discouraging initial care for breast cancer in low-volume facilities was associated with better survival for the Medicaid population targeted. Given these impressive results and those from prior research, other policymakers should consider adopting comparable policies to improve breast cancer outcomes.[Media: see text].
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Affiliation(s)
- Ann B. Nattinger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Nina A. Bickell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Maria J. Schymura
- Bureau of Cancer Epidemiology, New York State Department of Health, Albany, NY
| | - Purushottam Laud
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Emily L. McGinley
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Nicole Fergestrom
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Liliana E. Pezzin
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
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Williams AD, Moo TA. The Impact of Socioeconomic Status and Social Determinants of Health on Disparities in Breast Cancer Incidence, Treatment, and Outcomes. CURRENT BREAST CANCER REPORTS 2023. [DOI: 10.1007/s12609-023-00473-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Minami CA, Jin G, Schonberg MA, Freedman RA, King TA, Mittendorf EA. Variation in Deescalated Axillary Surgical Practices in Older Women with Early-Stage Breast Cancer. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11677-z. [PMID: 35385998 PMCID: PMC9982465 DOI: 10.1245/s10434-022-11677-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/07/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Randomized controlled trials show that certain axillary surgical practices can be safely deescalated in older adults with early-stage breast cancer. Hospital volume is often equated with surgical quality, but it is unclear whether this includes performance of low-value surgeries. We sought to describe how utilization of two low-value axillary surgeries has varied by time and hospital volume. METHODS Women aged ≥ 70 years diagnosed with breast cancer from 2013 to 2016 were identified in the National Cancer Database. The outcomes of interest were sentinel lymph node biopsy (SLNB) in cT1N0 hormone receptor-positive cancer patients and axillary lymph node dissection (ALND) in cT1-2N0 patients undergoing breast-conserving surgery with ≤ 2 pathologically positive nodes. Time trends in procedure use and multivariable regression with restricted cubic splines were performed, adjusting for patient, disease, and hospital factors. RESULTS Overall, 83.4% of 44,779 women eligible for omission of SLNB underwent SLNB and 20.0% of 7216 patients eligible for omission of ALND underwent ALND. SLNB rates did not change significantly over time and remained significantly different by age group (70-74 years: 93.5%; 75-79 years: 89.7%, 80-84 years: 76.7%, ≥ 85 years: 48.9%; p < 0.05). ALND rates decreased over the study period across all age groups included (22.5 to 16.9%, p < 0.001). In restricted cubic splines models, lower hospital volume was associated with higher likelihood of undergoing SLNB and ALND. CONCLUSIONS ALND omission has been more widely adopted than SLNB omission in older adults, but lower hospital volume is associated with higher likelihood of both procedures. Practice-specific deimplementation strategies are needed, especially for lower-volume hospitals.
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Affiliation(s)
- Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Mara A Schonberg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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Dong N, Zhai MD, Chang JF, Wu CH. A self-adaptive approach for white blood cell classification towards point-of-care testing. Appl Soft Comput 2021. [DOI: 10.1016/j.asoc.2021.107709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Nattinger AB, Rademacher N, McGinley EL, Bickell NA, Pezzin LE. Can Regionalization of Care Reduce Socioeconomic Disparities in Breast Cancer Survival? Med Care 2021; 59:77-81. [PMID: 33201083 PMCID: PMC7737859 DOI: 10.1097/mlr.0000000000001456] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Breast cancer patients of low socioeconomic status (SES) have worse survival than more affluent women and are also more likely to undergo surgery in low-volume facilities. Since breast cancer patients treated in high-volume facilities have better survival, regionalizing the care of low SES patients toward high-volume facilities might reduce SES disparities in survival. OBJECTIVE We leverage a natural experiment in New York state to examine whether a policy precluding payment for breast cancer surgery for New York Medicaid beneficiaries undergoing surgery in low-volume facilities led to reduced SES disparities in mortality. RESEARCH DESIGN A multivariable difference-in-differences regression analysis compared mortality of low SES (dual enrollees, Medicare-Medicaid) breast cancer patients to that of wealthier patients exempt from the policy (Medicare only) for time periods before and after the policy implementation. SUBJECTS A total of 14,183 Medicare beneficiaries with breast cancer in 2006-2008 or 2014-2015. MEASURES All-cause mortality at 3 years after diagnosis and Medicaid status, determined by Medicare administrative data. RESULTS Both low SES and Medicare-only patients had better 3-year survival after the policy implementation. However, the decline in mortality was larger in magnitude among the low SES women than others, resulting in a 53% smaller SES survival disparity after the policy after adjustment for age, race, and comorbid illness. CONCLUSION Regionalization of early breast cancer care away from low-volume centers may improve outcomes and reduce SES disparities in survival.
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Affiliation(s)
- Ann B. Nattinger
- Department of Medicine
- Center for Advancing Population Science
- Medical College of Wisconsin, Milwaukee, WI
| | | | - Emily L. McGinley
- Center for Advancing Population Science
- Medical College of Wisconsin, Milwaukee, WI
| | - Nina A. Bickell
- Department of Medicine
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Liliana E. Pezzin
- Department of Medicine
- Medical College of Wisconsin, Milwaukee, WI
- Institute for Health and Equity, Milwaukee, WI
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Baumrucker CC, Spring SR, Cohen BL, Millen JC, Macedo FI, Franceschi D. The Effect of Hospital Volume on Outcomes of Patients with Occult Breast Cancer. Ann Surg Oncol 2020; 28:2128-2135. [PMID: 32914387 DOI: 10.1245/s10434-020-09103-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION With limited data in regards to management, occult breast cancer (OBC) poses a challenging surgical scenario. Current surgical management includes axillary lymphadenectomy (ALND) with or without mastectomy. We sought to investigate the impact of hospital volume on surgical approach and survival outcomes of patients with OBC. METHODS Patients with cT0N+ breast cancer were selected from the National Cancer Data Base (NCDB, 2004-2014). Primary outcome was overall survival (OS), calculated using Kaplan-Meier methods compared according to hospital volume: community cancer center (CC), comprehensive community cancer center (COMP), and academic center (AC). Secondary outcome was the rate of modified radical mastectomy (MRM). RESULTS We identified 574 patients with OBC, 11.1% were treated at a CC, 51.8% at a COMP, and 37.0% at an AC. Patients treated at CC had lower socioeconomic status compared with COMP or AC (23.1%, 14.1%, 19.3%; p = 0.005, respectively). There was no difference in access to radiation therapy (p = 0.888) or neoadjuvant chemotherapy (p = 0.221). Patients treated at CC had worse OS compared with COMP or AC (87.04, 105.29, 108.06 mo, p = 0.026, respectively). There was an increased rate of MRM at CC compared with COMP or AC (54.7%, 41.2%, 30.5%, p = 0.003, respectively). CONCLUSIONS A direct association seems to exist between hospital volume and outcomes of patients with OBC. Patients with OBC treated at AC were more likely to undergo breast-conserving approaches and had better survival than those treated at CC.
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Affiliation(s)
- Camille C Baumrucker
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Samantha R Spring
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Brianna L Cohen
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Janelle-Cheri Millen
- Division of Surgical Oncology, Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Francis I Macedo
- Division of Surgical Oncology, Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Dido Franceschi
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
OBJECTIVE The aim of this study was to determine whether hospital volume was associated with mortality in breast cancer, and what thresholds of case volume impacted survival. BACKGROUND Prior literature has demonstrated improved survival with treatment at high volume centers among less common cancers requiring technically complex surgery. METHODS All adults (18 to 90 years) with stages 0-III unilateral breast cancer diagnosed from 2004 to 2012 were identified from the American College of Surgeons National Cancer Data Base (NCDB). A multivariable Cox proportional hazards model with restricted cubic splines was used to examine the association of annual hospital volume and overall survival, after adjusting for measured covariates. Intergroup comparisons of patient and treatment characteristics were conducted with X and analysis of variance (ANOVA). The log-rank test was used to test survival differences between groups. A multivariable Cox proportional hazards model was used to estimate hazard ratios (HRs) associated with each volume group. RESULTS One million sixty-four thousand two hundred and fifty-one patients met inclusion criteria. The median age of the sample was 60 (interquartile range 50 to 70). Hospitals were categorized into 3 groups using restricted cubic spline analysis: low-volume (<148 cases/year), moderate-volume (148 to 298 cases/year), and high-volume (>298 cases/year). Treatment at high volume centers was associated with an 11% reduction in overall mortality for all patients (HR 0.89); those with stage 0-I, ER+/PR+ or ER+/PR- breast cancers derived the greatest benefit. CONCLUSIONS Treatment at high volume centers is associated with improved survival for breast cancer patients regardless of stage. High case volume could serve as a proxy for the institutional infrastructure required to deliver complex multidisciplinary breast cancer treatment.
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Riba LA, Gruner RA, Fleishman A, James TA. Surgical Risk Factors for the Delayed Initiation of Adjuvant Chemotherapy in Breast Cancer. Ann Surg Oncol 2018; 25:1904-1911. [DOI: 10.1245/s10434-018-6351-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Indexed: 12/25/2022]
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Maschio M, Beghi E, Casazza MML, Colicchio G, Costa C, Banfi P, Quadri S, Aloisi P, Giallonardo AT, Buttinelli C, Pauletto G, Striano S, Salmaggi A, Terenzi R, Daniele O, Crichiutti G, Paladin F, Rossi R, Prato G, Vigevano F, De Simone R, Ricci F, Saladini M, Monti F, Casellato S, Zanoni T, Giannarelli D, Avanzini G, Aguglia U. Patterns of care of brain tumor-related epilepsy. A cohort study done in Italian Epilepsy Center. PLoS One 2017; 12:e0180470. [PMID: 28715490 PMCID: PMC5513411 DOI: 10.1371/journal.pone.0180470] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/15/2017] [Indexed: 01/12/2023] Open
Abstract
Epilepsy is the most common comorbidity in patients with brain tumors. STUDY AIMS To define characteristics of brain tumor-related epilepsy (BTRE) patients and identify patterns of care. Nationwide, multicenter retrospective cohort study. Medical records of BTRE patients seen from 1/1/2010 to 12/31/2011, followed for at least one month were examined. Information included age, sex, tumor type/treatments, epilepsy characteristics, antiepileptic drugs (AEDs). Time to modify first AED due to inefficacy and/or toxicity was assessed with the Kaplan-Meier method and Cox proportional hazard models were used to identify predictors of treatment outcome. Enrolled were 808 patients (447 men, 361 women) from 26 epilepsy centers. Follow-up ranged 1 to 423 months (median 18 months). 732 patients underwent surgery, 483 chemotherapy (CT), 508 radiotherapy. All patients were treated with AEDs. Levetiracetam was the most common drug. 377 patients (46.7%) were still on first drug at end of follow-up, 338 (41.8%) needed treatment modifications (uncontrolled seizures, 229; side effects, 101; poor compliance, 22). Treatment discontinuation for lack of efficacy was associated with younger age, chemotherapy, and center with <20 cases. Treatment discontinuation for side effects was associated with female sex, enzyme-inducing drugs and center with > 20 cases. About one-half of patients with BTRE were on first AED at end of follow-up. Levetiracetam was the most common drug. A non enzyme-inducing AED was followed by a lower risk of drug discontinuation for SE.
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Affiliation(s)
- Marta Maschio
- UOSD di Neurologia, Centro per la Cura dell'Epilessia Tumorale, Istituto Nazionale Tumori Regina Elena, Roma, Italia
| | - Ettore Beghi
- IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milano, Italia
| | | | | | - Cinzia Costa
- Clinica Neurologica, Università degli Studi di Perugia, Ospedale SM Misericordia, Perugia, Italia
| | - Paola Banfi
- Divisione di Neurologia, Ospedale di Circolo, Varese, Italia
| | - Stefano Quadri
- USC di Neurologia Centro Regionale Epilessia ASST Papa Giovanni XXIII, Bergamo, Italia
| | - Paolo Aloisi
- UOC di Neurofisiopatogia, Centro per l'Epilessia, L'Aquila, Italia
| | | | - Carla Buttinelli
- Dipartimento di Neurologia, Università "La Sapienza", Ospedale S. Andrea, Roma, Italia
| | - Giada Pauletto
- SOC di Neurologia, Azienda Ospedaliera Universitaria di Udine, Udine, Italia
| | - Salvatore Striano
- Centro Epilessia, Università degli studi di Napoli "Federico II", Policlinico Federico II, Napoli, Italia
| | | | | | - Ornella Daniele
- Centro per la Diagnosi e Cura dell'Epilessia, UOC Neurologia, Palermo, Italia
| | - Giovanni Crichiutti
- Clinica Pediatrica, Servizio Epilessia Infantile, Azienda Ospedaliera Università di Udine, Udine, Italia
| | - Francesco Paladin
- UOC Neurologia, Centro Epilessie, Ospedale S Giovanni e Paolo, Venezia, Italia
| | | | - Giulia Prato
- Centro Epilessie, U.O. Neuropsichiatria Infantile, Istituto Gaslini, Genova, Italia
| | - Federico Vigevano
- Dipartimento di Neuroscienze, Ospedale Pediatrico Bambin Gesù, Roma, Italia
| | | | - Federica Ricci
- S.C. Neuropsichiatria Infantile, O.I.R.M., A.O. Città della salute e della scienza, Torino, Italia
| | | | - Fabrizio Monti
- Centro per la Diagnosi e Cura delle Epilessie, UOC Neurologia, Trieste, Italia
| | - Susanna Casellato
- Centro per la Diagnosi e Cura delle Epilessie dell' Età Evolutiva, UOC di NPI, AOU, Sassari, Italia
| | - Tiziano Zanoni
- UO Neurologia, Azienda Ospedaliera Integrata-Universitaria, Verona, Italia
| | - Diana Giannarelli
- Unità di Biostatistica, Istituto Nazionale Tumori Regina Elena, Roma, Italia
| | | | - Umberto Aguglia
- Centro Regionale Epilessia, Università Magna Grecia di Catanzaro, Ospedale Riuniti, Reggio Calabria, Italia
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14
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Ajmani GS, James TA, Kantor O, Wang CH, Yao KA. The Impact of Facility Volume on Rates of Pathologic Complete Response to Neoadjuvant Chemotherapy Used in Breast Cancer. Ann Surg Oncol 2017; 24:3157-3166. [DOI: 10.1245/s10434-017-5969-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Indexed: 11/18/2022]
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15
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Powis M, Sutradhar R, Gonzalez A, Enright KA, Taback NA, Booth CM, Trudeau M, Krzyzanowska MK. Establishing achievable benchmarks for quality improvement in systemic therapy for early-stage breast cancer. Cancer 2017; 123:3772-3780. [PMID: 28678343 DOI: 10.1002/cncr.30804] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/14/2017] [Accepted: 05/09/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Setting realistic targets for performance is a consistent challenge in quality improvement. In the current study, the authors used administrative data to define achievable targets for a panel of 15 previously developed quality indicators (QIs) focusing on systemic therapy in patients with early-stage breast cancer. METHODS Deterministically linked administrative databases were used to identify patients with TNM stage I to stage III breast cancer who were diagnosed between 2006 and 2010 in Ontario, Canada. For each individual indicator, data-driven empirical benchmarks were calculated using the pared-mean benchmark approach. Variation in institution-level performance for each indicator was examined through the construction of funnel plots. RESULTS A total of 28,303 patients with early-stage breast cancer were identified, 43% of whom received adjuvant chemotherapy. For the 9 QIs for which receiving the service or outcome was desirable (ie, consultation with a medical oncologist), the benchmark varied from 40.9% to 100%. For the 6 indicators for which not receiving the service or outcome was desirable (ie, incidence of febrile neutropenia), the benchmark varied from 0% to 49.0%. There was substantial variation noted with regard to the number of institutions meeting the target and the amount of interinstitution variation between the QIs. Top performing institutions varied by indicator, with no individual institution meeting the benchmark for all indicators. For the majority of indicators, institution size was not found to be correlated with performance. CONCLUSIONS Data-derived benchmarking can be used to facilitate quality improvement by identifying areas of both good as well as suboptimal performance while defining an achievable target for which to strive. Cancer 2017;123:3772-3780. © 2017 American Cancer Society.
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Affiliation(s)
- Melanie Powis
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Katherine A Enright
- Trillium Health Partners, Mississauga, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nathan A Taback
- Department of Statistical Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | - Maureen Trudeau
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Odette Cancer Centre, Toronto, Ontario, Canada
| | - Monika K Krzyzanowska
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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16
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Yen TWF, Pezzin LE, Li J, Sparapani R, Laud PW, Nattinger AB. Effect of hospital volume on processes of breast cancer care: A National Cancer Data Base study. Cancer 2017; 123:957-966. [PMID: 27861746 DOI: 10.1002/cncr.30413] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/31/2016] [Accepted: 10/03/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation. METHODS Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy). RESULTS Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24). CONCLUSIONS Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Liliana E Pezzin
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jianing Li
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rodney Sparapani
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Purushuttom W Laud
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ann B Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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