Socioeconomic status and breast cancer treatment

Disparities in PI3K/mTOR inhibitor use, toxicities, and outcomes among patients with metastatic breast cancer

PURPOSE

Novel agents such as PI3K and mTOR inhibitors (PI3K/mTORi) have expanded treatment options in metastatic breast cancer (MBC). Nevertheless, mortality rates remain disproportionately high for Black patients and patients with lower socioeconomic status. Furthermore, clinical trials for these novel agents lacked diversity, so their toxicity profile in minority populations is uncertain.

METHODS

We conducted a retrospective analysis of EHR-derived data from the Flatiron Health Database for patients with HR+, HER2- MBC. Multivariable logistic regression was used to evaluate factors associated with PI3K/mTORi use and toxicity outcomes.

RESULTS

A total of 9169 patients with MBC were included in our analysis, of which 1780 (19.4%) received a PI3K/mTORi. We estimated the conditional total effect of insurance through Medicaid, and found lower odds of use of PI3K/mTORi among patients on Medicaid compared to those with commercial insurance (OR 0.73, 95% CI 0.54-0.99, p = 0.049). Odds of PI3K/mTORi use were higher for patients treated at an academic center (OR 1.28, CI 1.06-1.55, p = 0.01). Modeled as a controlled direct effect, Black/African American (Black/AA) race had no impact on odds of PI3K/mTOR use. Black/AA patients had twice the odds of developing hyperglycemia on PI3K/mTORi compared to White patients (OR 2.02, CI 1.24-3.39, p < 0.01).

CONCLUSION

This analysis of real-world data suggests that the use of PI3K/mTORi is influenced by socioeconomic factors. We also found racial disparities in toxicity outcomes, with Black/AA patients having twice the risk of hyperglycemia. Our findings call for greater efforts to ensure access to novel treatments and improve their tolerability in diverse populations.

Associations between subjective social status and predictors of interest in genetic testing among women diagnosed with breast cancer at a young age

PURPOSE

Genetic testing for gene mutations which elevate risk for breast cancer is particularly important for women diagnosed at a young age. Differences remain in access and utilization to testing across social groups, and research on the predictors of interest in genetic testing for women diagnosed at a young age is limited.

METHODS

We examined the relationships between subjective social status (SSS) and variables previously identified as possible predictors of genetic testing, including genome sequencing knowledge, genetic worry, cancer worry, health consciousness, decision-making preferences, genetic self-efficacy, genetic-related beliefs, and subjective numeracy, among a cohort of women who were diagnosed with breast cancer at a young age.

RESULTS

In this sample (n = 1,076), those who had higher SSS had significantly higher knowledge about the limitations of genome sequencing (Odds Ratio (OR) = 1.11; 95% CI = 1.01-1.21) and significantly higher informational norms (OR = 1.93; 95% CI = 1.19-3.14) than those with lower SSS. Similarly, education (OR = 2.75; 95% CI = 1.79-4.22), health status (OR = 2.18; 95% CI = 1.44-3.31) were significant predictors among higher SSS women compared to lower SSS women in our multivariate analysis. Lower SSS women with low self-reported income (OR = 0.13; 95% CI = 0.08-0.20) had lower odds of genetic testing interest. Our results are consistent with some prior research utilizing proxy indicators for socioeconomic status, but our research adds the importance of using a multidimensional indicator such as SSS to examine cancer and genetic testing predictor outcomes.

CONCLUSION

To develop interventions to improve genetic knowledge, researchers should consider the social status and contexts of women diagnosed with breast cancer at a young age (or before 40 years old) to ensure equity in the distribution of genetic testing benefits.

Factors and Beliefs Affecting Women Diagnosed With Breast Cancer to Initiate Cancer Treatment: A Systematic Review

BACKGROUND

Initiating treatment within the optimal time is critical for women with breast cancer. A delay in cancer treatment initiation can result in increased morbidity and mortality and decreased overall survival.

OBJECTIVE

This systematic review aims to investigate the literature for the factors and beliefs affecting women diagnosed with breast cancer with regard to initiating cancer treatment.

METHODS

The PubMed, CINAHL, and PsycINFO databases were searched using the terms of breast cancer, initiating or seeking treatment, and beliefs. The Johns Hopkins Evidence-Based Practice Research Evidence Appraisal Tool was used to evaluate the included articles.

RESULTS

Sixteen articles were included in this review. The addressed factors were classified as (1) patient-related factors, (2) disease-related factors, (3) provider-related factors, and (4) system-related factors. The identified beliefs were cultural beliefs and perceived barriers to initiating treatment.

CONCLUSION

Although the literature reported multiple factors and beliefs that impact the time of initiating treatment among women with breast cancer, more research is needed to fully understand the beliefs influencing treatment initiation. It is essential to address and screen the factors and beliefs identified for women diagnosed with breast cancer to enhance treatment initiation early and prevent any possible delay. Interventions can be developed to overcome the factors and beliefs that may lead to late treatment initiation. Advocacy for new policies should be in action to reduce the disparities associated with treatment initiation among women with breast cancer.

Predictors of stool deoxyribonucleic acid test use in the United States: Implications for outreach to under-resourced populations

OBJECTIVE

Although colorectal cancer screening (CRCS) is a public health priority, uptake is suboptimal in under-resourced groups. Noninvasive modalities, including stool deoxyribonucleic acid (sDNA) testing, may mitigate economic, geographic, cultural, or impairment-related barriers to CRCS. We assessed use of sDNA testing and other CRCS modalities in U.S. residents, comparing subgroups defined by several social determinants of health (SDOH).

METHODS

A nationally representative sample of community-dwelling respondents aged 50-75 years self-reported use of CRCS modalities in the 2020 Behavioral Risk Factor Surveillance System Survey. Statistical analyses assessed up-to-date screening status and choice of modality in the recommended screening interval.

RESULTS

Of 179,833 sampled respondents, 60.8% reported colonoscopy, 5.7% sDNA testing, 5.5% another modality. The rate of up-to-date screening was 72.0% overall and negatively associated with Hispanic ethnicity (63.6%), lower educational and annual income levels (e.g.,

CONCLUSIONS

Under-resourced persons were more likely than better-resourced persons to access sDNA testing, possibly offsetting screening barriers in some groups. Findings suggest opportunities to increase CRCS with heightened communication about sDNA testing to those who may experience difficulty accessing other modalities.

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Key Words

• Behavioral Risk Factor Surveillance System
• Cancer screening
• Colonoscopy
• Colorectal cancer
• Colorectal cancer screening
• Health disparities
• Social determinants of health
• Stool deoxyribonucleic acid

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MESH Headings

• Humans
• Male
• Middle Aged
• Female
• Aged
• United States
• Feces/chemistry
• Colorectal Neoplasms/diagnosis
• Early Detection of Cancer/statistics & numerical data
• Behavioral Risk Factor Surveillance System
• DNA/analysis
• Colonoscopy/statistics & numerical data
• Mass Screening/statistics & numerical data
• Social Determinants of Health

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Affiliation(s)

Kathleen A Fairman Midwestern University College of Pharmacy, Glendale Campus, 19555 North 59(th) Avenue, Glendale, AZ 85308, United States of America.
Sarah T Lira Veterinary Pharmacy Resident, University of Illinois Urbana-Champaign, At the time the research was conducted, Dr. Lira was a PharmD student at the Midwestern University College of Pharmacy, Glendale Campus., 1008 West Hazelwood Drive, Urbana, IL 61802, United States of America.

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Simultaneous integrated boost intensity-modulated radiotherapy post breast-conserving surgery: clinical efficacy, adverse effects, and cosmetic outcomes in breast cancer patients

BACKGROUND

Simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) is an innovative technique delivering a higher dose to the tumor bed while irradiating the entire breast. This study aims to assess the clinical outcomes, adverse effects, and cosmetic results of SIB-IMRT following breast-conserving surgery in breast cancer patients.

METHODS

We conducted a retrospective analysis of 308 patients with stage 0-III breast cancer who underwent breast-conserving surgery and SIB-IMRT from January 2016 to December 2020. The prescribed doses included 1.85 Gy/27 fractions to the whole breast and 2.22 Gy/27 fractions or 2.20 Gy/27 fractions to the tumor bed. Primary endpoints included overall survival (OS), local-regional control (LRC), distant metastasis-free survival (DMFS), acute and late toxicities, and cosmetic outcomes.

RESULTS

The median follow-up time was 36 months. The 3-year OS, LRC, and DMFS rates were 100%, 99.6%, and 99.2%, respectively. Five patients (1.8%) experienced local recurrence or distant metastasis, and one patient succumbed to distant metastasis. The most common acute toxicity was grade 1-2 skin reactions (91.6%). The most common late toxicity was grade 0-1 skin and subcutaneous tissue reactions (96.7%). Five patients (1.8%) developed grade 1-2 upper limb lymphedema, and three patients (1.1%) had grade 1 radiation pneumonitis. Among the 262 patients evaluated for cosmetic outcomes at least 2 years post-radiotherapy, 96.9% achieved excellent or good results, while 3.1% had fair or poor outcomes.

CONCLUSIONS

SIB-IMRT after breast-conserving surgery in breast cancer patients demonstrated excellent clinical efficacy, mild acute and late toxicities, and satisfactory cosmetic outcomes in our study. SIB-IMRT appears to be a feasible and effective option for breast cancer patients suitable for breast-conserving surgery.

Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study

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.

A scoping review of racial, ethnic, socioeconomic, and geographic disparities in the outcomes of older adults with cancer

INTRODUCTION

Cancer health disparities are widespread. Nevertheless, the disparities in outcomes among diverse survivors of cancer ages 65 years and older ("older") have not been systematically evaluated.

METHODS

We conducted a scoping review of original research articles published between January 2016 and September 2023 and indexed in Medline (Ovid), Embase, Scopus, and CINAHL databases. We included studies evaluating racial, ethnic, socioeconomic disadvantaged, geographic, sexual and gender, and/or persons with disabilities disparities in treatment, survivorship, and mortality among older survivors of cancer. We excluded studies with no a priori aims related to a health disparity, review articles, conference proceedings, meeting abstracts, studies with unclear methodologies, and articles in which the disparity group was examined only as an analytic covariate. Two reviewers independently extracted data following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines.

RESULTS

After searching and removing duplicates, 2573 unique citations remained and after screening 59 articles met the inclusion criteria. Many investigated more than one health disparity, and most focused on racial and ethnic (n = 44) or socioeconomic (n = 25) disparities; only 10 studies described geographic disparities, and none evaluated disparities in persons with disabilities or due to sexual and gender identity. Research investigating disparities in outcomes among diverse older survivors of cancer is increasing gradually-68% of eligible articles were published between 2020 and 2023. Most studies focused on the treatment phase of care (n = 28) and mortality (n = 26), with 16 examined disparities in survivorship, symptoms, or quality of life. Most research was descriptive and lacked analyses of potential underlying mechanisms contributing to the reported disparities.

CONCLUSION

Little research has evaluated the effect of strategies to reduce health disparities among older patients with cancer. This lack of evidence perpetuates cancer inequities and leaves the cancer care system ill equipped to address the unique needs of the rapidly growing and increasingly diverse older adult cancer population.

Preexisting Diabetes and Breast Cancer Treatment Among Low-Income Women

IMPORTANCE

Diabetes is associated with poorer prognosis of patients with breast cancer. The association between diabetes and adjuvant therapies for breast cancer remains uncertain.

OBJECTIVE

To comprehensively examine the associations of preexisting diabetes with radiotherapy, chemotherapy, and endocrine therapy in low-income women with breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included women younger than 65 years diagnosed with nonmetastatic breast cancer from 2007 through 2015, followed up through 2016, continuously enrolled in Medicaid, and identified from the linked Missouri Cancer Registry and Medicaid claims data set. Data were analyzed from January 2022 to October 2023.

EXPOSURE

Preexisting diabetes.

MAIN OUTCOMES AND MEASURES

Logistic regression was used to estimate odds ratios (ORs) of utilization (yes/no), timely initiation (≤90 days postsurgery), and completion of radiotherapy and chemotherapy, as well as adherence (medication possession ratio ≥80%) and persistence (<90-consecutive day gap) of endocrine therapy in the first year of treatment for women with diabetes compared with women without diabetes. Analyses were adjusted for sociodemographic and tumor factors.

RESULTS

Among 3704 women undergoing definitive surgery, the mean (SD) age was 51.4 (8.6) years, 1038 (28.1%) were non-Hispanic Black, 2598 (70.1%) were non-Hispanic White, 765 (20.7%) had a diabetes history, 2369 (64.0%) received radiotherapy, 2237 (60.4%) had chemotherapy, and 2505 (67.6%) took endocrine therapy. Compared with women without diabetes, women with diabetes were less likely to utilize radiotherapy (OR, 0.67; 95% CI, 0.53-0.86), receive chemotherapy (OR, 0.67; 95% CI, 0.48-0.93), complete chemotherapy (OR, 0.71; 95% CI, 0.50-0.99), and be adherent to endocrine therapy (OR, 0.71; 95% CI, 0.56-0.91). There were no significant associations of diabetes with utilization (OR, 0.95; 95% CI, 0.71-1.28) and persistence (OR, 1.09; 95% CI, 0.88-1.36) of endocrine therapy, timely initiation of radiotherapy (OR, 1.09; 95% CI, 0.86-1.38) and chemotherapy (OR, 1.09; 95% CI, 0.77-1.55), or completion of radiotherapy (OR, 1.25; 95% CI, 0.91-1.71).

CONCLUSIONS AND RELEVANCE

In this cohort study, preexisting diabetes was associated with subpar adjuvant therapies for breast cancer among low-income women. Improving diabetes management during cancer treatment is particularly important for low-income women with breast cancer who may have been disproportionately affected by diabetes and are likely to experience disparities in cancer treatment and outcomes.

Toward a comprehensive life-cycle carcinogenic impact assessment: A statistical regression approach based on cancer burden

The current approach to life cycle carcinogenic impact assessment (LCCA) is hindered by its static and linear characteristics. This situation prevents the accurate prediction of the incidence, associated damage, and potential economic burden of cancer. This study explores a highly comprehensive pathway for LCCA assessment. It uses the impacts of Tracheal, bronchus, and lung (TBL) predicted by the LCCA of China's coal power industry through a screened statistical regression model as the research target. The latest global burden of disease estimates is utilized to quantify the health damage from TBL incidence, whereas an approach combining the actual cost of health and human capital is applied to further assess the economic burden of TBL. Findings indicate that the traditional and static LCCA method, which relies on animal toxicity data, can lead to underestimations in actual LCCA. The interaction among spatiotemporal meteorological factors, epidemiological cancer disease burden, and socioeconomic behaviors allows exhibits nonlinearity due to the changes in the combined toxicity of mixed key substances. Following the active implementation of ultralow emission and energy-saving transformations in China's coal power industry, the national percentage of TBL cancer incidence caused by pollutants from the coal power industry decreased from 25.2 % in 2004 to 11.5 % in 2020. Results indicate that the established dynamic LCCA model based on temporal and spatial climate, socioeconomic, and epidemiological cancer data can be feasibly employed for the accurate impact evaluation and mitigation of carcinogens in practical applications.

Role of patient characteristics in adherence to first-line treatment guidelines in breast, lung and prostate cancer: insights from the Nordic healthcare system

OBJECTIVES

This study investigates the influence of socioeconomic status, health literacy, and numeracy on treatment decisions and the occurrence of adverse events in patients with breast, lung, and prostate cancer within a Nordic healthcare setting.

DESIGN

A follow-up to a cross-sectional, mixed-methods, single-centre study.

SETTING

A Nordic, tertiary cancer clinic.

PARTICIPANTS

A total of 244 participants with breast, lung and prostate cancer were initially identified, of which 138 first-line treatment participants were eligible for this study. First-line treatment participants (n=138) surpassed the expected cases (n=108).

INTERVENTIONS

Not applicable as this was an observational study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The study's primary endpoint was the rate of guideline adherence. The secondary endpoint involved assessing treatment toxicity in the form of adverse events.

RESULTS

Guideline-adherent treatment was observed in 114 (82.6%) cases. First-line treatment selection appeared uninfluenced by participants' education, occupation, income or self-reported health literacy. A minority (3.6%) experienced difficulties following treatment instructions, primarily with oral cancer medications.

CONCLUSIONS

The findings indicated lesser cancer health disparities regarding guideline adherence and treatment toxicity within the Nordic healthcare framework. A causal connection may not be established; however, the findings contribute to discourse on equitable cancer health provision.

Breast cancer mortality among ultra-orthodox and non-ultra-orthodox Israeli women: A retrospective cohort study

Background

Breast cancer is the leading cause of cancer death in Israeli women. Previous studies found socioeconomic status and other risk factors impact breast cancer outcomes. The ultra-orthodox community is characterized by a longer life expectancy, lower rates of mammography performance, higher fertility rates and other sociodemographic variables that may be related to breast cancer mortality. This study examined disparities in breast cancer mortality between ultra-Orthodox and non-ultra-Orthodox Israeli women.

Methods

This retrospective cohort study for breast cancer mortality included the all Jewish Israeli citizens women born between 1940 and 1960 and lived in communities with over 20,000 residents (n = 628,617). Data was collected from various sources, monitoring a period of 31 years; for each participants, their sociodemographic characteristics were compiled from the population registry, the tax authority, the education registry, and the Central Bureau of Statistics (CBS). Variables included religiosity, age, marital status, children, origin, education, and income. Multivariable Cox models evaluated predictors of mortality.

Results

Of the 628,617 women in the study, 29,611 were ultra-Orthodox. Ultra-Orthodox women had higher marriage rates, more children, and lower secular education and income. Mortality was 108.8/100,000 overall, lower among ultra-Orthodox (83.4/100,000) than non-ultra-Orthodox women (110.1/100,000) despite their risk factors. Using a multivariate model to evaluate the association between ultra-Orthodoxy and breast cancer mortality, the study found higher breast cancer mortality rate among non-ultra-Orthodox women compared to ultra-Orthodox women (HR = 1.491; 99% CI = 1.232, 1.804). Associations with sociodemographic variables were different for each group.

Conclusions

Although ultra-Orthodox women have socioeconomic risk factors, breast cancer mortality was lower than non-ultra-Orthodox women. Further research on potential cultural and religious factors influencing mortality is warranted. These findings highlight the importance of evaluating predictors within specific populations.

Revolutionizing the battle against locally advanced breast cancer: A comprehensive insight into neoadjuvant radiotherapy

Breast cancer (BC) constitutes one of the most pervasive malignancies affecting the female population. Despite progressive improvements in diagnostic and therapeutic technologies, leading to an increased detection of early stage BCs, locally advanced breast cancer (LABC) persists as a significant clinical challenge. Owing to its poor overall survival (OS) rate, elevated recurrence rate, and high potential for distant metastasis, LABC prominently impacts the comprehensive efficacy of BC treatments. Radiotherapy, encompassing preoperative, intraoperative, and postoperative modalities, is acknowledged as an effective strategy for mitigating BC metastasis and enhancing survival rates among patients. Nevertheless, the domain of preoperative neoadjuvant radiotherapy (NART) remains conspicuously underexplored in clinical studies. Available research suggests that NART can induce tumor volume reduction, provoke fibrotic changes in tumor and adjacent normal tissues, thereby mitigating intraoperative cancer propagation and enhancing the quality of life for LABC patients. This manuscript seeks to provide a review of contemporary research pertaining to LABC and its preoperative radiotherapy.

Axillary management in breast cancer after neoadjuvant chemotherapy in the modern era: A national cancer database analysis

BACKGROUND

Axillary management for node-positive breast cancer continues to evolve. Data further supporting targeted axillary dissection after neoadjuvant chemotherapy was published in 2016 and may have induced changes in practice.

METHODS

Patients included in the National Cancer Database from 2014 to 2017 with clinical T1 to T4 and node-positive disease who underwent neoadjuvant chemotherapy before surgical axillary management were evaluated. Patients were divided into the following 3 groups: selective axillary dissection, minimal axillary dissection, and maximal axillary dissection, according to surgical axillary management and pathological node status.

RESULTS

Patients who underwent selective axillary dissection were younger (52.4 years ± 12.4, P < .0001) compared to maximal axillary dissection (55.1 ± 12.7) and minimal axillary dissection (54.6 ± 12.7). Patients with higher clinical stage more frequently underwent maximal axillary dissection, and those with lower tumor grade more frequently underwent minimal axillary dissection (P < .0001). Community cancer programs were more likely to perform maximal axillary dissection compared to all other types of programs and had the slowest rate of adoption of selective axillary dissection. Integrated Network Cancer Programs had the lowest proportion of maximal axillary dissection performed and the highest proportion of selective axillary dissection. Uninsured patients were more likely to receive maximal axillary dissection, and those with private insurance were more likely to undergo selective axillary dissection (P < .0001). Selective axillary dissection rates increased from 29.8% of procedures in 2016 to 41.5% in 2017, and MaxAD rates decreased from 62.4% in 2016 to 47.9% in 2017.

CONCLUSION

Utilization of selective axillary dissection has increased since 2016; however, discrepancies in surgical axillary management after neoadjuvant chemotherapy still exist.

Timing to Surgery and Lymph Node Upstaging in Gastric Cancer: An NCDB Analysis

BACKGROUND

Prior studies have shown tumor specificity on the impact of longer time interval from diagnosis to surgery, however in gastric cancer (GC) this remains unclear. We aimed to determine if a longer time interval from diagnosis to surgery had an impact on lymph node (LN) upstaging and overall survival (OS) outcomes among patients with clinically node negative (cN0) GC.

PATIENTS AND METHODS

Patients diagnosed with cN0 GC undergoing surgery between 2004-2018 were identified in the National Cancer Database (NCDB) and divided into intervals between time of diagnosis and surgery [short interval (SI): ≥ 4 days to < 8 weeks and long interval (LI): ≥ 8 weeks]. Multivariable regression analysis evaluated the independent impact of surgical timing on LN upstaging and a Cox proportional hazards analysis and Kaplan-Meier curves evaluated survival outcomes.

RESULTS

Of 1824 patients with cN0 GC, 71.8% had a SI to surgery and 28.1% had a LI to surgery. LN upstaging was seen more often in the SI group when compared to LI group (82% versus 76%, p = 0.004). LI to surgery showed to be an independent factor protective against LN upstaging [adjusted odds ratio = 0.62, 95% CI: (0.39-0.99)]. Multivariate Cox regression analysis indicated that time to surgery was not associated with a difference in overall survival [hazard ratio (HR) = 0.91, 95% CI: (0.71-1.17)], however uncontrolled Kaplan-Meier curves showed OS difference between the SI and LI to surgery groups (p = 0.037).

CONCLUSION

Timing to surgery was not a predictor of LN upstaging or overall survival, suggesting that additional medical optimization in preparation for surgery and careful preoperative staging may be appropriate in patients with node negative early stage GC without affecting outcomes.

Disparity in treatment patterns among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia: an analysis of patient and contextual factors

This study characterizes the patterns and timing of CLL treatment and, to our knowledge, is the first to identify social vulnerability factors associated with CLL treatment receipt in the Medicare population. A total of 3508 Medicare beneficiaries diagnosed with CLL from 2017 to 2019 were identified. We reported the proportion of individuals who received CLL treatment and the time until the first CLL treatment receipt after the first observed claim with a CLL diagnosis. Logistic regression and time-to-event models provided adjusted odds ratios and hazard ratios associated with baseline individual-level and county-level factors. Sixteen percent of individuals received CLL treatment, and the median follow-up time was 540 d. The median time to receipt of CLL treatment was 61 d. Older age and residence in a county ranked high in social vulnerability (as defined by minority status and language) were negatively associated with treatment receipt and time to treatment receipt.

Risk of contralateral breast cancer among Asian/Pacific Islander women in the United States

PURPOSE

While breast cancer studies often aggregate Asian/Pacific Islander (API) women, as a single group or exclude them, this population is heterogeneous in terms of genetic background, environmental exposures, and health-related behaviors, potentially resulting in different cancer outcomes. Our purpose was to evaluate risks of contralateral breast cancer (CBC) among subgroups of API women with breast cancer.

METHODS

We conducted a retrospective cohort study of women ages 18 + years diagnosed with stage I-III breast cancer between 2000 and 2016 in the Surveillance, Epidemiology and End Results registries. API subgroups included Chinese, Japanese, Filipina, Native Hawaiian, Korean, Vietnamese, Indian/Pakistani, and other API women. Asynchronous CBC was defined as breast cancer diagnosed in the opposite breast 12 + months after first primary unilateral breast cancer. Multivariable-adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were estimated and stratified by API subgroups.

RESULTS

From a cohort of 44,362 API women with breast cancer, 25% were Filipina, 18% were Chinese, 14% were Japanese, and 8% were Indian/Pakistani. API women as an aggregate group had increased risk of CBC (SHR 1.15, 95% CI 1.08-1.22) compared to NHW women, among whom Chinese (SHR 1.23, 95% CI 1.08-1.40), Filipina (SHR 1.37, 95% CI 1.23-1.52), and Native Hawaiian (SHR 1.69, 95% CI 1.37-2.08) women had greater risks.

CONCLUSION

Aggregating or excluding API patients from breast cancer studies ignores their heterogeneous health outcomes. To advance cancer health equity among API women, future research should examine inequities within the API population to design interventions that can adequately address their unique differences.

Predictors and benefits of multiagent chemotherapy for pancreatic adenocarcinoma: Timing matters

INTRODUCTION

Adjuvant (A) multiagent chemotherapy (MC) is the standard of care for patients with pancreatic adenocarcinoma (PDAC). Tolerating MC following a morbid operation may be difficult, thus neoadjuvant (NA) treatment is preferable. This study examined how the timing of chemotherapy was related to the regimen given and ultimately the overall survival (OS).

METHODS

The National Cancer Database was queried from 2006 to 2017 for nonmetastatic PDAC patients who underwent surgical resection and received MC or single-agent chemotherapy (SC) pre- or postresection. Predictors of receiving MC were determined using multivariable logistic regression. Five-year OS was evaluated using the Kaplan-Meier and Cox proportional hazards model.

RESULTS

A total of 12,440 patients (NA SC, n = 663; NA MC, n = 2313; A SC, n = 6152; A MC, n = 3312) were included. MC utilization increased from 2006-2010 to 2011-2017 (33.1%-49.7%; odds ratio [OR]: 0.59; p < 0.001). Younger age, fewer comorbidities, higher clinical stage, and larger tumor size were all associated with receipt of MC (all p < 0.001), but NA treatment was the greatest predictor (OR 5.18; 95% confidence interval [CI]: 4.63-5.80; p < 0.001). MC was associated with increased median 5-year OS (26.0 vs. 23.9 months; hazard ratio [HR]: 0.92; 95% CI: 0.88-0.96) and NA MC was associated with the highest survival (28.2 months) compared to NA SC (23.3 months), A SC (24.0 months), and A MC (24.6 months; p < 0.001).

CONCLUSION

Use and timing of MC contribute to OS in PDAC with an improved 5-year OS compared to SC. The greatest predictor of receiving MC was being given as NA therapy and the greatest survival benefit was the NA MC subgroup. Randomized studies evaluating the timing of effective MC in PDAC are needed.

Satisfaction with Care and Attention to Age-Specific Concerns by Race and Ethnicity in a National Sample of Young Women with Breast Cancer

Purpose: In light of disparities in breast cancer care and outcomes, we explored whether attention to fertility, genetic, and emotional health concerns, as well as satisfaction with care, differs by race/ethnicity among young breast cancer patients. Methods: The Young and Strong Study was a cluster randomized trial of an intervention for patients and providers at 54 U.S. oncology practices enrolling women diagnosed with breast cancer at ≤45 years of age. Provider attention to fertility, genetics, and emotional health was evaluated by medical record review. The proportions of patients with attention to these concerns were compared by race/ethnicity (Hispanic, non-Hispanic Black [NHB], Asian, non-Hispanic White [NHW], or multiracial/other). Satisfaction with care was assessed with the Patient Satisfaction Questionnaire-18 (PSQ-18) at 3 months, with median scores for each of 7 PSQ-18 subscales (general satisfaction, interpersonal manner, communication, financial, time spent with doctor, accessibility, and technical quality) compared by race/ethnicity. Results: Among 465 patients, median age at diagnosis was 40; 6% were Hispanic, 11% NHB, 4% were Asian, 75% NHW, and 3% multiracial/other. Provider attention to genetics, emotional health, and fertility did not differ by race/ethnicity. Median PSQ-18 scores did not differ by race/ethnicity, with median subscale scores ranging from 3.0 to 4.5 across groups, indicating high levels of satisfaction. Conclusion: Satisfaction with care and provider attention to age-specific concerns were similar across racial/ethnic groups among young patients enrolled in an educational and supportive care intervention study. These data suggest that high-quality, equitable care is feasible. Further care delivery research is warranted in more diverse patient and practice settings. Clinical Trial Registration number: NCT01647607.

Global Stage Distribution of Breast Cancer at Diagnosis: A Systematic Review and Meta-Analysis

Importance

Stage at diagnosis is a key prognostic factor for cancer survival.

Objective

To assess the global distribution of breast cancer stage by country, age group, calendar period, and socioeconomic status using population-based data.

Data Sources

A systematic search of MEDLINE and Web of Science databases and registry websites and gray literature was conducted for articles or reports published between January 1, 2000, and June 20, 2022.

Study Selection

Reports on stage at diagnosis for individuals with primary breast cancer (C50) from a population-based cancer registry were included.

Data Extraction and Synthesis

Study characteristics and results of eligible studies were independently extracted by 2 pairs of reviewers (J.D.B.F., A.D.A., A.M., R.S., and F.G.). Stage-specific proportions were extracted and cancer registry data quality and risk of bias were assessed. National pooled estimates were calculated for subnational or annual data sets using a hierarchical rule of the most relevant and high-quality data to avoid duplicates.

Main Outcomes and Measures

The proportion of women with breast cancer by (TNM Classification of Malignant Tumors or the Surveillance, Epidemiology, and End Results Program [SEER]) stage group.

Results

Data were available for 2.4 million women with breast cancer from 81 countries. Globally, the proportion of cases with distant metastatic breast cancer at diagnosis was high in sub-Saharan Africa, ranging from 5.6% to 30.6% and low in North America ranging from 0.0% to 6.0%. The proportion of patients diagnosed with distant metastatic disease decreased over the past 2 decades from around 3.8% to 35.8% (early 2000s) to 3.2% to 11.6% (2015 onwards), yet stabilization or slight increases were also observed. Older age and lower socioeconomic status had the largest proportion of cases diagnosed with distant metastatic stage ranging from 2.0% to 15.7% among the younger to 4.1% to 33.9% among the oldest age group, and from 1.7% to 8.3% in the least disadvantaged groups to 2.8% to 11.4% in the most disadvantaged groups.

Conclusions and Relevance

Effective policy and interventions have resulted in decreased proportions of women diagnosed with metastatic breast cancer at diagnosis in high-income countries, yet inequality persists, which needs to be addressed through increased awareness of breast cancer symptoms and early detection. Improving global coverage and quality of population-based cancer registries, including the collection of standardized stage data, is key to monitoring progress.

Discordant Breast and Axillary Pathologic Response to Neoadjuvant Chemotherapy

INTRODUCTION

Neoadjuvant chemotherapy (NAC) for breast cancer has the advantage of determining in vivo response to treatment, enabling more conservative surgery, and facilitating the understanding of tumor biology. Pathologic complete response (pCR) after NAC is a predictor of improved overall survival. However, some patients demonstrate a discordant response to NAC between the breast and axillary nodes. This study was designed to identify factors that correlate to achieving a breast pCR without an axillary node pCR following NAC and explore the potential clinical implications.

METHODS

The National Cancer Database was used to identify patients diagnosed with clinical T1-4, N1-3 breast cancer between 2004 and 2017. Patients underwent NAC followed surgical resection of the breast cancer and axillary node surgery. Multivariable analyses were used to identify clinical and pathologic factors associated with discordant pathologic response.

RESULTS

In total, 13,934 patients met the inclusion criteria. Of these, 4292 (30.8%) patients demonstrated a breast pCR without a corresponding axillary pCR on final pathology. After adjusting for covariates, factors associated with higher discordance between axillary response in our cohort of breast pCR patients included older age (≥ 54), treatment at a community facility, T1 tumors, HR-positive, HER2 negative, low-grade tumors, and cN2/3 disease.

CONCLUSIONS

Discordance between breast and axillary pCR is not infrequent and may be related to a number of patient-related factors and tumor characteristics impacting nodal response to NAC. Further investigation into differing responses to NAC is warranted to better understand the mechanism of this phenomenon and to determine how these findings may influence treatment.

The Military Health System: Minimizing Disparities in Breast Cancer Treatment

BACKGROUND

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population.

METHODS

A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs.

RESULTS

Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004).

CONCLUSIONS

There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.

Effects of socioeconomic status and race on survival and treatment in metastatic breast cancer

Race and socioeconomic factors affect outcomes in breast cancer. We aimed to assess the effect of race and neighborhood socioeconomic status (SES) on overall survival and treatment patterns in patients with metastatic breast cancer (MBC). This is a retrospective cohort study involving patients (N = 1246) with distant breast cancer metastases diagnosed at UPMC Magee Women's Breast Cancer Clinic from 2000-2017. Overall survival and treatment patterns were compared between races (Blacks and whites) and SES groups (defined using Area Deprivation Index). Low SES, but not tumor characteristics, was associated with Black race (P < 0.001) in the study population. Low SES (Median [Interquartile Range, IQR] survival 2.3[2.2-2.5] years vs high SES 2.7[2.5-3.1] years, P = 0.01) and Black race (Median [IQR] survival 1.8[1.3-2.3] years, vs white 2.5[2.3-2.7] years P = 0.008) separately were associated with worse overall survival in patients with MBC. In the Cox Proportional Hazard model with SES, race, age, subtype, number of metastases, visceral metastasis, and year of diagnosis as covariates, low SES (Hazard ratio 1.19[1.04-1.35], P = 0.01), but not Black race (Hazard ratio 1.19[0.96-1.49], P = 0.12), independently predicted overall survival in MBC. Moreover, patients from low SES neighborhoods and Black race received fewer lines of chemotherapy than high SES and whites. In conclusion, low neighborhood SES is associated with worse outcomes in patients with MBC. Poor outcomes in Black patients with MBC, at least in part is driven by socioeconomic factors. Future studies should delineate the interplay between neighborhood SES, race, and their effects on tumor biology in MBC.

Social Determinants of Health in Imaging-based Cancer Screening: A Case-based Primer with Strategies for Care Improvement

Health disparities, preventable differences in the burden of disease and disease outcomes often experienced by socially disadvantaged populations, can be found in nearly all areas of radiology, including emergency radiology, neuroradiology, nuclear medicine, image-guided interventions, and imaging-based cancer screening. Disparities in imaging-based cancer screening are especially noteworthy given the far-reaching population health impact. The social determinants of health (SDoH) play an important role in disparities in cancer screening and outcomes. Through improved understanding of how SDoH can drive differences in health outcomes in radiology, radiologists can effectively provide patient-centered, high-quality, and equitable care. Radiologists and radiology practices can become active partners in efforts to assist patients along their imaging journey and overcome existing barriers to equitable cancer screening care for traditionally marginalized populations. As radiology exists at the intersection of diagnostic imaging, image-guided diagnostic intervention, and image-guided treatment, radiologists are uniquely positioned to design these strategies. Cost-effective and socially conscious strategies that address barriers to equitable care can improve both public health and equitable health outcomes. Potential strategies include championing supportive health policy, reducing out-of-pocket costs, increasing price transparency, improving education and outreach efforts, ensuring that appropriate language translation services are available, providing individualized assistance with appointment scheduling, and offering transportation assistance and childcare. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Identification of Populations at Risk for "Choosing Un-Wisely": A SEER Population-Based Study

BACKGROUND

Since 2016, the Choosing Wisely campaign has recommended against routine axillary surgery in elderly patients with early stage, hormone receptor positive (ER+) breast cancer. The objective was to evaluate factors associated with axillary surgery in breast cancer patients meeting criteria for sentinel lymph node biopsy (SLNB) omission and identify potential disparities.

METHODS

Female patients age ≥70 years with cT1-2N0M0, ER+, HER2-negative breast cancer diagnosed after publication of the Choosing Wisely recommendations, between 2016 and 2019, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patient demographics and tumor characteristics associated with axillary surgery were analyzed.

RESULTS

Of the 31 756 patients meeting omission criteria, 25 771 (81.2%) underwent axillary surgery. Hispanic ethnicity, median household income between $35,000 and $70,000, treatment in rural areas, poor differentiation, lobular and mixed lobular with ductal histology, T2 tumors, radiation therapy, and systemic therapy were factors associated with receiving axillary surgery on multivariable analysis. In the axillary surgery cohort, a median of 2 (IQR = 2) nodes were examined and 529 (2.1%) patients were found to have 1 or more positive lymph nodes.

DISCUSSION

Among elderly patients meeting Choosing Wisely criteria for SLNB omission, particular racial, ethnic, socioeconomic, and geographic populations may be at increased risk for potential over treatment. Identification of these factors provides specific opportunities for education and implementation of de-escalation of unnecessary procedures.

Socioeconomic status and lifestyle patterns in the most common cancer types-community-based research

INTRODUCTION

As the global burden of chronic cancer increases, its correlation to lifestyle, socioeconomic status (SES) and health equity becomes more important. The aim of the present study was to provide a snapshot of the socioeconomic and lifestyle patterns for different cancer types in patients at a Nordic tertiary cancer clinic.

MATERIALS AND METHODS

In a descriptive observational study, questionnaires addressed highest-attained educational level, occupational level, economy, relationship status, exposures, and lifestyle habits. The questionnaire was distributed to all cancer patients attending the cancer clinic. Treating physicians added further information about the cancer disease, including primary origin, pathology report, TNM-classification and stage.

RESULTS

Patients with lung cancer had the lowest SES, and patients with gastrointestinal (GI) cancer, other cancer types and prostate cancer had the second, third and fourth lowest SES, respectively. However, breast cancer patients had the highest SES. Lifestyle and exposure patterns differed among the major cancer types. Lung cancer patients reported the highest proportion of unfavourable lifestyle and exposure patterns, and patients with GI cancer, prostate cancer and other cancer types had the second, third and fourth highest proportion of unfavourable lifestyle and exposure patterns, respectively. The most favourable exposure and lifestyle patterns were observed in breast cancer patients.

CONCLUSIONS

The present study indicated significant socioeconomic and lifestyle differences among cancer types at a Nordic cancer centre, with differences in lifestyle being more prominent than socioeconomic differences.

Proximity to Radiotherapy Center, Population, Average Income, and Health Insurance Status as Predictors of Cancer Mortality at the County Level in the United States

PURPOSE

Sufficient radiotherapy (RT) capacity is essential to delivery of high-quality cancer care. However, despite sufficient capacity, universal access is not always possible in high-income countries because of factors beyond the commonly used parameter of machines per million people. This study assesses the barriers to RT in a high-income country and how these affect cancer mortality.

METHODS

This cross-sectional study used US county-level data obtained from Center for Disease Control and Prevention and the International Atomic Energy Agency Directory of Radiotherapy Centres. RT facilities in the United States were mapped using Geographic Information Systems software. Univariate analysis was used to identify whether distance to a RT center or various socioeconomic factors were predictive of all-cancer mortality-to-incidence ratio (MIR). Significant variables (P ≤ .05) on univariate analysis were included in a step-wise backward elimination method of multiple regression analysis.

RESULTS

Thirty-one percent of US counties have at least one RT facility and 8.3% have five or more. The median linear distance from a county's centroid to the nearest RT center was 36 km, and the median county all-cancer MIR was 0.37. The amount of RT centers, linear accelerators, and brachytherapy units per 1 million people were associated with all-cancer MIR (P < .05). Greater distance to RT facilities, lower county population, lower average income per county, and higher proportion of patients without health insurance were associated with increased all-cancer MIR (R-squared, 0.2113; F, 94.22; P < .001).

CONCLUSION

This analysis used unique high-quality data sets to identify significant barriers to RT access that correspond to higher cancer mortality at the county level. Geographic access, personal income, and insurance status all contribute to these concerning disparities. Efforts to address these barriers are needed.

Geospatial Associations between Female Breast Cancer Mortality Rates and Environmental Socioeconomic Indicators for North Carolina

In North Carolina, over 6000 women will be diagnosed with breast cancer yearly, and over 1000 will die. It is well known that environmental conditions contribute greatly to health outcomes, and many of these factors include a geographic component. Using death data records from 2003-2019 extracted from North Carolina Vital Statistics Dataverse, a spatial database was developed to map and analyze female breast cancer mortality rates at the ZIP code scale in North Carolina. Thirty-nine hot spots and thirty cold spots of age-adjusted death rates were identified using the Getis-Ord analysis. Two-tailed t-tests were run between each cohort for environmental socioeconomic-related factors associated with breast cancer progression and mortality. The median age and household income of individuals who resided in ZIP codes with the highest breast cancer mortality were significantly lower than those who lived in ZIP codes with lower breast cancer mortality. The poverty rate, percentage of SNAP benefits, and the percentage of minorities were all significantly higher (p < 0.05, p < 0.001, and p < 0.001) in ZIP codes with high breast cancer rates. High-quality (ZIP code) granular cancer data were developed for which detailed analysis can be performed for future studies.

Differences in survivorship care experiences among older breast cancer survivors by clinical cancer characteristics, race/ethnicity, and socioeconomic factors: A SEER-CAHPS study

PURPOSE

To determine if disparities exist in survivorship care experiences among older breast cancer survivors by breast cancer characteristics, race/ethnicity, and socioeconomic factors.

METHODS

A total of 19,017 female breast cancer survivors (≥ 65 at post-diagnosis survey) contributed data via SEER-CAHPS data linkage (2000-2019). Analyses included overall and stratified multivariable linear regression to estimate beta (β) coefficients and standard errors (SE) to identify relationships between clinical cancer characteristics and survivorship care experiences.

RESULTS

Minority survivors were mostly non-Hispanic (NH)-Black (8.1%) or NH-Asian (6.5%). Survivors were 76.3 years (SD = 7.14) at CAHPS survey and were 6.10 years (SD = 3.51) post-diagnosis on average. Survivors with regional breast cancer vs. localized at diagnosis (β = 1.00, SE = 0.46, p = 0.03) or treated with chemotherapy vs. no chemotherapy/unknown (β = 1.05, SE = 0.48, p = 0.03) reported higher mean scores for Getting Needed Care. Results were similar for Overall Care Ratings (β = 0.87, SE = 0.38, p = 0.02) among women treated with chemotherapy. Conversely, women diagnosed with distant breast cancer vs. localized reported lower mean scores for Physician Communication (β = - 1.94, SE = 0.92, p = 0.03). Race/ethnicity, education, and area-level poverty significantly modified several associations between stage, estrogen receptor status, treatments, and various CAHPS outcomes.

CONCLUSION

These study findings can be used to inform survivorship care providers treating women diagnosed with more advanced stage and aggressive disease. The disparities we observed among minority groups and by socioeconomic status should be further evaluated in future research as these interactions could impact long-term outcomes, including survival.

Social determinants of health and CDK4/6 inhibitor use and outcomes among patients with metastatic breast cancer

BACKGROUND

Survival outcomes in metastatic breast cancer (MBC) have improved due to novel agents such as CDK4/6 inhibitors (CDK4/6i). Nevertheless, Black patients and patients with lower socioeconomic status (SES) continue to bear a disproportionate mortality burden.

METHODS

We conducted a retrospective analysis of EHR-derived data from the Flatiron Health Database (FHD). A dataset was constructed to include Black/African-American (Black/AA) and White patients with hormone receptor (HR)-positive, HER2-negative MBC. Outcomes included CDK4/6i use (overall and first-line), and rates of leukopenia, dose reduction, and time on treatment for first-line CDK4/6i. Multivariable logistic regression was used to evaluate factors associated with use and outcomes.

RESULTS

A total of 6802 patients with MBC were included, of which 5187 (76.3%) received CDK4/6i. Of those, 3186 (61.4%) received CDK4/6i first-line. Overall, 86.7% of patients were categorized as White and 13.3% as Black/AA; 22.4% were > 75 years old; 12.6% were treated at an academic site; 3.3% had Medicaid insurance. In addition to advanced age and poorer performance status, lower use of CDK4/6i was associated with Black/AA vs White race (72.9% vs 76.8%; OR 0.83, 95% CI 0.70-0.99, p = 0.04) and Medicaid vs commercial insurance (69.6% vs 77.4%; OR: 0.68, 95% CI 0.49-0.95, p = 0.02). Odds of CDK4/6i use were twofold higher for patients treated at an academic center (p < 0.001). Rates of CDK4/6i-induced leukopenia and dose reductions did not differ significantly by race, insurance type, or treatment site. Time on CDK4/6i was significantly lower among Medicaid patients (395 days) than patients with commercial insurance (558 days) or Medicare (643 days) (p = 0.03).

CONCLUSION

This analysis of real-world data suggests that Black race and lower SES are associated with decreased CDK4/6i use. However, among patients treated with CDK4/6i, subsequent toxicity outcomes are similar. Efforts to ensure access to these life-prolonging medications are warranted.

Patient reported symptom burden amongst immigrant and Canadian long-term resident women undergoing breast cancer surgery

PURPOSE

Immigrants are susceptible to marginalization due to social isolation, economic disadvantage and systemic bias. Our goal was to compare symptom burden between immigrant and long-term resident women undergoing breast cancer surgery in Ontario, Canada.

METHODS

A population-level retrospective cohort-study using administrative databases was conducted. Women who underwent surgery for newly diagnosed breast cancer and were treated at regional cancer centers between 2010 and 2016 were included. The primary outcome was a moderate or severe (≥ 4) symptom score on the Edmonton Symptom Assessment System Scale (ESAS).

RESULTS

There were 12,250 (87.2%) long-term Canadian residents and 1,806(12.8%) immigrants. Immigrants were younger (mean age 53 vs. 61 years); had a higher proportion residing in a lowest income quintile neighbourhood (22.2% vs 15.4%); were less often on a primary-care physician roster (83.7% vs. 90.4%); and were less often diagnosed with Stage I/II disease (80.9% vs. 84.6%) (all p < 0.01). The proportion of women with scores ≥ 4 was significantly higher amongst immigrant women for 7/9 symptom categories; with the largest differences for depression (24.9% vs. 20.2%, p < 0.01) and pain (28.0% vs. 22.4%, p < 0.01). On multivariable regression analysis, immigration status was associated with scores ≥ 4 for pain (OR 1.13, 95% CI 1.02-1.23). There was an association between moderate/severe pain and region of origin, but not length of stay in Canada or immigration class.

CONCLUSIONS

This is the first study comparing symptom burden amongst immigrant and non-immigrant women with breast cancer at a population-level. Immigrant women with breast cancer undergoing surgery were found to have a higher burden of pain.

"There's not enough studies": Views of black breast and ovarian cancer patients on research participation

BACKGROUND

Black breast and ovarian cancer patients are underrepresented in clinical cancer trials disproportionate to the prevalence of these cancers in Black females. Historically, lower enrollment has been attributed to individualized factors, including medical mistrust, but more recently structural factors, including systemic racism, have received additional scrutiny. We interviewed Black women with a personal or family history of breast and ovarian cancer to understand their views and experiences related to research participation.

METHODS

Qualitative interviews were conducted via telephone or video conference and transcribed verbatim. Transcripts were qualitatively analyzed for iterative themes related to the offer and participation in cancer clinical trials and research studies, impact on cancer care, and recommendations to increase enrollment of Black patients.

RESULTS

Sixty-one Black women completed an interview. Participants expressed that Black women are underrepresented in cancer research, and that this negatively impacted their own care. Many cited past historical abuses, including the Tuskegee syphilis trial, as a potential factor for lower enrollment but suggested that lower enrollment was better understood in the context of the entirety of their healthcare experiences, including present-day examples of patient mistreatment or dismissal. Participants suggested that proactive community engagement, transparency, and increased representation of Black research team members were strategies likely to foster trust and bolster research participation.

CONCLUSION(S)

Medical mistrust is only a partial factor in the lower participation of Black patients in cancer research. Researchers should implement the strategies identified by our participants to promote diverse enrollment and ensure that Black patients are included in future therapeutic advances.

Relationship between Health Inequalities and Breast Cancer Survival in Mexican Women

OBJECTIVE

We aimed to analyze the relationship between the survival of patients with breast cancer and health inequalities.

METHODS

A retrospective cohort study of women with stage III breast cancer according to public healthcare was conducted. Groups were stratified according to the course of treatment and the presence of chronic disease other than cancer. Survival functions were estimated by using the Kaplan-Meier estimator, while the Cox proportional hazards model was employed for prognostic assessment.

RESULTS

The study was performed on 964 breast cancer patients. One hundred and seventy-six patients (18.23%) died during the follow-up period and 788 (81.77%) were alive at the end of the follow-up period. Education, marital status, personal history of prior biopsies, and socioeconomic status (SES) were found to be linked with survival. However, only SES exceeded the baseline risk of mortality when the treatment cycle was interrupted (full treatment: unadjusted 4.683, p = 0.001; adjusted 4.888 p = 0.001, partial treatment: unadjusted 1.973, p = 0.012; adjusted 4.185, p = 0.001). The same effect was observed when stratifying by the presence of chronic disease other than cancer (with chronic disease adjusted HR = 4.948, p = 0.001; unadjusted HR = 3.303, p = 0.001; without chronic disease adjusted HR = 4.850, p = 0.001; unadjusted HR = 5.121, p = 0.001).

CONCLUSION

Since lower SES was linked with a worse prognosis, strategies to promote preventive medicine, particularly breast cancer screening programs and prompt diagnosis, are needed.

Current Situation of Diagnosis and Treatment of HER2-Positive Metastatic Breast Cancer Patients in China: A Nationwide Cross-Sectional Survey of Doctors

BACKGROUND

The Advanced Breast Cancer Alliance conducted a nationwide investigation to understand the current situation of the diagnosis and treatment of human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) patients.

METHODS

In 2019, electronic questionnaires including basic information about respondents, characteristics of patients, and the present status of diagnosis and treatment were sent to 495 doctors from 203 medical centers covering 28 provinces.

RESULTS

The factors that influenced treatment plans included the disease process, the performance status, and the economic status of patients. Regimens and response to neoadjuvant/adjuvant chemotherapy were important factors in the decision of the first-line treatment. Overall, 54% of doctors retained trastuzumab and replaced chemotherapy drugs in second-line treatment regimens for patients with progression-free survival (PFS) ≥ 6 months in the first-line setting, while 52% of participants chose pyrotinib plus capecitabine for patients with PFS < 6 months. Economic factors played an important role in doctors' decision-making and the varying treatment options for respondents in first-tier, second-tier, and other cities.

CONCLUSIONS

This large-scale survey regarding the diagnosis and treatment of HER2-positive MBC patients revealed that clinical decisions made by Chinese doctors followed the guidelines, but their choices were constrained by economic factors.

Patterns of better breast cancer care in countries with higher human development index and healthcare expenditure: Insights from GLOBOCAN 2020

Background

The huge burden of breast cancer (BC) necessitates the profound and accurate knowledge of the most recent cancer epidemiology and quality of care provided. We aimed to evaluate BC epidemiology and quality of care and examine the effects of socioeconomic development and healthcare expenditure on disparities in BC care.

Methods

The results from the GLOBOCAN 2020 study were utilized to extract data on female BC, including incidence and mortality numbers, crude rates, and age-standardized rates [age-standardized incidence rates (ASIRs) and age-standardized mortality rates (ASMRs)]. The mortality-to-incidence ratio (MIR) was calculated for different locations and socioeconomic stratifications to examine disparities in BC care, with higher values reflecting poor quality of care and vice versa. In both descriptive and analytic approaches, the human development index (HDI) and the proportion of current healthcare expenditure (CHE) to gross domestic product (CHE/GDP%) were used to evaluate the values of MIR.

Results

Globally, 2,261,419 (95% uncertainty interval (UI): 2,244,260-2,278,710) new cases of female BC were diagnosed in 2020, with a crude rate of 58.5/100,000 population, and caused 684,996 (675,493-694,633) deaths, with a crude rate of 17.7. The WHO region with the highest BC ASIR (69.7) was Europe, and the WHO region with the highest ASMR (19.1) was Africa. The very high HDI category had the highest BC ASIR (75.6), and low HDI areas had the highest ASMR (20.1). The overall calculated value of female BC MIR in 2020 was 0.30, with Africa having the highest value (0.48) and the low HDI category (0.53). A strong statistically significant inverse correlation was observed between the MIR and HDI values for countries/territories (Pearson's coefficient = -0.850, p-value < 0.001). A significant moderate inverse correlation was observed between the MIR and CHE/GDP values (Pearson's coefficient = -0.431, p-value < 0.001).

Conclusions

This study highlighted that MIR of BC was higher in less developed areas and less wealthy countries. MIR as an indicator of the quality of care showed that locations with higher healthcare expenditure had better BC care. More focused interventions in developing regions and in those with limited resources are needed to alleviate the burden of BC and resolve disparities in BC care.

Socioeconomic Disparities in Neoadjuvant Chemotherapy for Early-Stage Breast Cancer

Background

Neoadjuvant chemotherapy (NCT) is often used for patients with early-stage breast cancer. Disparities in the use of NCT based on clinical, demographic, and socioeconomic factors have not been evaluated.

Methods

Data from the National Cancer Database was analyzed for patients with T1-2, N0-1 breast cancer from 2006 to 2015. Univariate and multivariate analysis determined which factors predicted for the receipt of NCT.

Results

We found 159 946 eligible patients. Factors associated with receipt of NCT included T2 vs. T1 disease, N1 vs. N0, and treatment at an academic facility. Race itself was not significant; however, a higher level of education amongst Black populations correlated with the receipt of NCT.

Discussion

Clinical factors are the greatest determinants for receipt of NCT in early-stage breast cancer. Disparities exist that cannot be explained by race alone; socioeconomic and demographic factors are important. Cancer care should be evaluated in the context of the intersectionality of these health determinants.

Clinical-Epidemiological Profile and Health-Related Quality of Life of Women with Breast Cancer During Chemotherapy Treatment: Observational Study

Introduction: Breast cancer may affect different profiles of women worldwide. In addition, chemotherapy to treat breast neoplasms directly affects health-related quality of life. Objective: To describe the clinical-epidemiological profile and to compare the general and specific health-related quality of life of women with breast cancer during chemotherapy. Method: In an observational and prospective study, 140 women with breast cancer in northeastern Brazil were evaluated in the intermediate cycle and at the end of chemotherapy. Quality of life was assessed using a general instrument (EORTC-QLQ-C30) and a specific module (EORTC-QLQ-BR23). Data were compared with a paired non-parametric test, with a significance level of 5%. Results: Regarding the clinical-epidemiological profile, the median age was 50 years, 82.9% were black or mixed-race, and 95% lived in Sergipe, Brazil. In addition, 50.7% had no occupation, the median family income was one minimum wage, as well as the median of education was eight years of study and only 40.7% have completed high school. Considering the data from the C30 and BR23 questionnaires, it was observed that most items and scales worsened at the end of chemotherapy when compared to the intermediate cycle. Among the items and scales with significant differences, most had moderate or high effect sizes. Conclusion: It is possible to conclude that the clinical-epidemiological profile was unfavorable and chemotherapy reduced several aspects of the health-related quality of life of women with breast cancer.

Alcohol Consumption Is a Modifiable Risk Factor for Breast Cancer: Are Women Aware of This Relationship?

AIMS

Despite alcohol consumption being a dose-dependent risk factor for breast cancer, a recent study conducted in the UK found <20% of women attending breast screening programmes were aware of this relationship and proposed proper information campaigns need to be conducted. We aimed to investigate the awareness of this relationship among a related sample of Italian women to evaluate whether similar information campaigns should also be conducted in Italy.

METHODS

The questionnaire used by the UK study was translated into Italian, slightly modified for the Italian context, validated and submitted to a sample of Italian women.

RESULTS

Overall 507 women were interviewed. Among them, 160 were classified as breast cancer screening attenders (SG), 44 as symptomatic breast clinic attenders (CAG) and 303 as non-screening group (NSG). Alcohol was correctly identified as a risk factor for breast cancer by 16.9, 11.4 and 14.9% of participants of SG, CAG and NSG, respectively without differences between the three groups. Despite the methodological differences, the rates of participants who correctly identified alcohol as a risk factor among women attending breast screening programmes were surprisingly similar between the study conducted in UK (15.7%) and the present study (16.9%).

CONCLUSION

The results of the present study confirm the limited awareness of the relationship between alcohol consumption and risk of developing breast cancer among women and suggest the urgent need to conduct proper awareness-raising campaigns to counter this in the Italian female population.

Racial and ethnic disparities in the refusal of surgical treatment in women 40 years and older with breast cancer in the USA between 2010 and 2017

PURPOSE

Although surgical resection is the main modality of treatment for breast cancer, some patients elect to refuse the recommended surgery. We assessed racial and ethnic differences in women 40 years and older who received or refused to receive surgical treatment for breast cancer in the USA and whether racial disparities in mortality were affected by their differences in the prevalence of refusal for surgical treatment.

METHODS

We studied 277,127 women with breast cancer using the Surveillance, Epidemiology, and End Results (SEER) data and performed multivariable logistic regressions to investigate the association between surgery status of breast cancer and race/ethnicity. Additionally, we performed Cox regression analyses to determine the predictors of mortality outcomes.

RESULTS

Of 277,127 patients with breast cancer, 1468 (0.53%) refused to receive the recommended surgical treatment in our cohort. Non-Hispanic Black women were 112% more likely to refuse the recommended surgical treatment for breast cancer compared to their non-Hispanic White counterparts [adjusted odds ratio: 2.12, 95% confidence interval (CI) 1.82-2.47]. Women who underwent breast-conserving surgery [hazards ratio (HR) 0.15, 95% CI 0.13-0.16] and mastectomy (HR 0.21, 95% CI 0.18-0.23) had lower hazard ratios of mortality as compared to women who refused the recommended treatment after adjusting for covariates.

CONCLUSION

Race/ethnicity was associated with refusal for the recommended surgery, especially among non-Hispanic Black women. Also, surgery refusal was associated with a higher risk of all-cause and breast cancer-related mortality. These disparities stress the need to tailor interventions aimed at raising awareness of the importance of following physician recommendations among minorities.

Breast-conserving surgery versus mastectomy for older women with triple-negative breast cancer: population-based study

Purpose: To assess whether the poor prognosis of triple-negative breast cancer (TNBC) necessitates a more aggressive surgical approach. Methods: We examined the association of: breast-conserving surgery (BCS); BCS plus radiotherapy; mastectomy; and mastectomy plus radiotherapy with overall and breast cancer-specific survival of stage I-III TNBC patients aged 66 years and older. We used unweighted and inverse probability of treatment weighted Cox proportional hazards regression and the Fine and Gray sub-distribution model. Results: Among 4333 women, individuals who were selected for BCS, mastectomy or mastectomy plus radiotherapy had lower adjusted overall and breast cancer-specific survival compared with women who had BCS plus radiotherapy. Conclusion: In this population-based study, women with TNBC treated with BCS plus radiotherapy have a better prognosis than those treated with BCS, mastectomy or mastectomy plus radiotherapy. Given the poor prognosis of TNBC and selection bias inherent in observational studies, these findings should be confirmed in further studies such as randomized clinical trials.

Long-Term Outcomes among Adolescent and Young Adult Survivors of Acute Leukemia: A Surveillance, Epidemiology, and End Results Analysis

BACKGROUND

There is a growing population of adolescent and young adult (AYA, age 15-39 years) acute leukemia survivors in whom long-term mortality outcomes are largely unknown.

METHODS

The current study utilized the Surveillance, Epidemiology, and End Results (SEER) registry to assess long-term outcomes of AYA acute leukemia 5-year survivors. The impact of diagnosis age, sex, race/ethnicity, socioeconomic status, and decade of diagnosis on long-term survival were assessed utilizing an accelerated failure time model.

RESULTS

A total of 1,938 AYA acute lymphoblastic leukemia (ALL) and 2,350 AYA acute myeloid leukemia (AML) survivors diagnosed between 1980 and 2009 were included with a median follow-up of 12.3 and 12.7 years, respectively. Ten-year survival for ALL and AML survivors was 87% and 89%, respectively, and 99% for the general population. Survival for AYA leukemia survivors remained below that of the age-adjusted general population at up to 30 years of follow-up. Primary cancer mortality was the most common cause of death in early survivorship with noncancer causes of death becoming more prevalent in later decades of follow-up. Male AML survivors had significantly worse survival than females (survival time ratio: 0.61, 95% confidence interval: 0.45-0.82).

CONCLUSIONS

AYA leukemia survivors have higher mortality rates than the general population that persist for decades after diagnosis.

IMPACT

While there have been improvements in late mortality, long-term survival for AYA leukemia survivors remains below that of the general population. Studies investigating risk factors for mortality and disparities in late effects among long-term AYA leukemia survivors are needed.

Sociodemographic disparities in molecular testing for breast cancer

PURPOSE

Molecular testing is a critical component of breast cancer care used to identify the presence of estrogen and/or progesterone receptors (jointly hormone receptors-HRs) and the expression of human epidermal growth factor 2 (HER2) on a tumor. Our objective was to characterize trends and predictors of lack of molecular testing among female breast cancer patients overall and by sociodemographic characteristics.

METHODS

We examined data on female breast cancer patients diagnosed between 2010 and 2016 from Surveillance Epidemiology and End Results-18. Joinpoint regression analyses assessed annual percent change (APC) in lack of ER, PR, or HER2 testing. Multivariable, multilevel logistic regression models identified factors associated with lack of molecular testing.

RESULTS

A nominally lower proportion of rural patients did not receive molecular testing (e.g., 1.8% in rural vs. 2.3% in urban for HER2). For all tests, a higher proportion of Hispanic and non-Hispanic Black women were not tested. Across all characteristics, improvement in testing was noted, although disparities among groups remained. For example, lack of HER2 testing improved from 3.2 to 1.7% in White patients (APC = - 10.05) but was consistently higher in Black patients 3.9 to 2.3% (APC = - 8.21). Multivariable, multilevel models showed that older, non-Hispanic Black, and unpartnered women were at greater odds of not receiving molecular testing.

CONCLUSIONS

While lack of molecular testing of breast cancer patients is relatively rare, racial/ethnic, insurance status, and age-related disparities have been identified. To reduce testing and downstream treatment and outcome disparities, it is imperative for all breast cancer patients to receive molecular testing.

The French Early Breast Cancer Cohort (FRESH): A Resource for Breast Cancer Research and Evaluations of Oncology Practices Based on the French National Healthcare System Database (SNDS)

Simple Summary

Because of an important disparity of care pathways and quality of care among women diagnosed with an early-stage breast cancer, we aimed to create a unique cohort of patients including all French women aged 18 years or over, treated by surgery and registered in the general health insurance coverage plan. After aggregating and annotating medico-administrative data on 235,368 early breast cancer patients, we open up perspectives for research on adverse effects, morbidity, mortality, the monitoring of care consumption, or medical-economic studies. We describe data sources, inclusion, and exclusion criteria, basic descriptive analyses, and longitudinal trends over time.

Abstract

Background: Breast cancer (BC) is the most frequent cancer and the leading cause of cancer-related death in women. The French National Cancer Institute has created a national cancer cohort to promote cancer research and improve our understanding of cancer using the National Health Data System (SNDS) and amalgamating all cancer sites. So far, no detailed separate data are available for early BC. Objectives: To describe the creation of the French Early Breast Cancer Cohort (FRESH). Methods: All French women aged 18 years or over, with early-stage BC newly diagnosed between 1 January 2011 and 31 December 2017, treated by surgery, and registered in the general health insurance coverage plan were included in the cohort. Patients with suspected locoregional or distant metastases at diagnosis were excluded. BC treatments (surgery, chemotherapy, targeted therapy, radiotherapy, and endocrine therapy), and diagnostic procedures (biopsy, cytology, and imaging) were extracted from hospital discharge reports, outpatient care notes, or pharmacy drug delivery data. The BC subtype was inferred from the treatments received. Results: We included 235,368 patients with early BC in the cohort (median age: 60 years). The BC subtype distribution was as follows: luminal (80.2%), triple-negative (TNBC, 9.5%); HER2⁺ (10.3%), or unidentifiable (n = 44,388, 18.9% of the cohort). Most patients underwent radiotherapy (n = 200,685, 85.3%) and endocrine therapy (n = 165,655, 70.4%), and 38.3% (n = 90,252) received chemotherapy. Treatments and care pathways are described. Conclusions: The FRESH Cohort is an unprecedented population-based resource facilitating future large-scale real-life studies aiming to improve care pathways and quality of care for BC patients.

Racial Disparities in Survival of Breast Cancer Patients After Surgery

Introduction

The racial disparities of opportunity to receive the appropriate intervention and lower insurance coverage may result in survival disparities in different races. This study aims to provide a perspective on racial disparities in the survival of breast cancer patients after surgery.

Methods

Through data from the Surveillance, Epidemiology, and End Results (SEER) program, this study estimated the survival of breast cancer patients of different races from 1998 to 2017. Inverse probability weighting (IPW) was utilized to adjust the imbalanced clinicopathological features of patients of different races.

Results

This study analyzed 214,965 breast cancer patients after surgery. Among them, 130,746 patients received BCS, and the remaining 84,219 breast cancer patients underwent mastectomy. Although Asian or Pacific Islander (API) patients after surgery showed higher survival benefit than that of white patients in the primary data, after adjusting for age at diagnosis, luminal subtype, grade, T stage, and N stage in different races, white individuals had the longest period of survival was higher than that of the minority groups in BCS group [breast cancer-specific survival (BCSS): HR_Whitevs.API = 0.402, HR_{Whitevs.Black} = 0.132; P < 0.001; overall survival (OS): HR_Whitevs.API = 0.689, HR_{Whitevs.Black} = 0.254; all P < 0.001] and mastectomy group (BCSS: HR_Whitevs.API = 0.325, HR_{Whitevs.Black} = 0.128; P < 0.001; OS: HR_Whitevs.API = 0.481, HR_{Whitevs.Black} = 0.206; all P < 0.001)

Conclusions

We first identified that the survival benefit of the minority group after surgery was lower than that of white individuals, regardless of tumor chrematistics and surgery types.

Socioeconomic status and its relation with breast cancer recurrence and survival in young women in the Netherlands

BACKGROUND

Associations between socioeconomic status (SES) and breast cancer survival are most pronounced in young patients. We further investigated the relation between SES, subsequent recurrent events and mortality in breast cancer patients < 40 years. Using detailed data on all recurrences that occur between date of diagnosis of the primary tumor and last observation, we provide a unique insight in the prognosis of young breast cancer patients according to SES.

METHODS

All women < 40 years diagnosed with primary operated stage I-III breast cancer in 2005 were selected from the nationwide population-based Netherlands Cancer Registry. Data on all recurrences within 10 years from primary tumor diagnosis were collected directly from patient files. Recurrence patterns and absolute risks of recurrence, contralateral breast cancer (CBC) and mortality - accounting for competing risks - were analysed according to SES. Relationships between SES, recurrence patterns and excess mortality were estimated using a multivariable joint model, wherein the association between recurrent events and excess mortality (expected mortality derived from the general population) was included.

RESULTS

We included 525 patients. The 10-year recurrence risk was lowest in high SES (18.1%), highest in low SES (29.8%). Death and CBC as first events were rare. In high, medium and low SES 13.2%, 15.3% and 19.1% died following a recurrence. Low SES patients had shorter median time intervals between diagnosis, first recurrence and 10-year mortality (2.6 and 2.7 years, respectively) compared to high SES (3.5 and 3.3 years, respectively). In multivariable joint modeling, high SES was significantly related to lower recurrence rates over 10-year follow-up, compared to low SES. A strong association between the recurrent event process and excess mortality was found.

CONCLUSIONS

High SES is associated with lower recurrence risks, less subsequent events and better prognosis after recurrence over 10 years than low SES. Breast cancer risk factors, adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association.

The Role of Safety-Net Hospitals in Reducing Disparities in Breast Cancer Care

Advances in breast cancer screening and systemic therapies have been credited with profound improvements in breast cancer outcomes; indeed, 5-year relative survival rate approaches 91% in the USA (U.S. National Institutes of Health NCI. SEER Training Modules, Breast). While breast cancer mortality has been declining, oncologic outcomes have not improved equally among all races and ethnicities. Many factors have been implicated in breast cancer disparities; chief among them is limited access to care which contributes to lower rates of timely screening mammography and, once diagnosed with breast cancer, lower rates of receipt of guideline concordant care (Wu, Lund, Kimmick GG et al. in J Clin Oncol 30(2):142-150, 2012). Hospitals with a safety-net mission, such as the essential hospitals, historically have been dedicated to providing high-quality care to all populations and have eagerly embraced the role of caring for the most vulnerable and working to eliminate health disparities. In this article, we review landmark articles that have evaluated the role safety-net hospitals have played in providing equitable breast cancer care including to those patients who face significant social and economic challenges.

Boys Don't Cry: Examining Sex Disparities in Behavioral Oncology Referral Rates for AYA Cancer Patients

Psychosocial distress is highly prevalent in cancer patients, approaching rates around 40% across various cancer sites according to multicenter studies. As such, distress screening procedures have been developed and implemented to identify and respond to cancer patients' psychosocial distress and concerns. However, many cancer patients continue to report unmet psychosocial needs suggesting gaps in connecting patients with psychosocial services. Presently, there is a paucity of research examining sex-based disparities in referral rates to behavioral oncology services, particularly for adolescent and young adult (AYA) cancer patients. Informed by gender role conflict and empirical literature documenting disparities in cancer care and treatment based on a variety of sociocultural variables, this study aimed to examine the presence of sex disparities in referral rates to behavioral oncology services for AYA cancer patients. Data for this study consisted of 1,700 AYA cancer patients (age 18–39) who completed a distress screening at a large cancer center of a teaching hospital in the Midwestern United. Results indicated that patient sex significantly predicted the odds of behavioral oncology referral (γ₅₀ = −0.95, Odds ratio = 2.60, p < 0.001). This finding indicates that female AYA cancer patients are 2.5 times more likely to be referred to behavioral oncology services compared to male AYA cancer patients after controlling for psychosocial distress and emotional, family, and practical problems. Additionally, we found that emotional problems significantly moderated the odds of referral for males and females (γ₆₀ = 0.37, Odds ratio = 1.44, p < 0.001), however the odds of referral for males who endorsed emotional problems were lower than males who did not endorse emotional problems. This contrasted with female AYA cancer patients where the endorsement of emotional problems increased the odds of referral to behavioral oncology services. Findings are discussed with particular focus on how to enhance equitable care and reduce sex and other sociocultural-based disparities in AYA psychosocial oncology.

Utilization of neoadjuvant chemotherapy in high-risk, node-negative early breast cancer

BACKGROUND

Controversy exists regarding the optimal sequence of chemotherapy among women with operable node-negative breast cancers with high-risk tumor biology. We evaluated national patterns of neoadjuvant chemotherapy (NACT) use among women with early-stage HER2+, triple-negative (TNBC), and high-risk hormone receptor-positive (HR+) invasive breast cancers.

METHODS

Women ≥18 years with cT1-2/cN0 HER2+, TNBC, or high recurrence risk score (≥31) HR+ invasive breast cancers who received chemotherapy were identified in the National Cancer Database (2010-2016). Cochran-Armitage and logistic regression examined temporal trends and likelihood of undergoing NACT versus adjuvant chemotherapy based on patient age and molecular subtype.

RESULTS

Overall, 96,622 patients met study criteria; 25% received NACT and 75% underwent surgery first, with comparable 5-year estimates of overall survival (0.90, 95% CI 0.892-0.905 vs 0.91, 95% CI 0.907-0.913). During the study period, utilization of NACT increased from 14% to 36% and varied according to molecular subtype (year*molecular subtype p < 0.001, p-corrected < 0.001). Women with HER2+ (OR 4.17, 95% CI 3.70-4.60, p < 0.001, p-corrected < 0.001) and TNBC (OR 3.81, 95% CI 3.38-4.31, p < 0.001, p-corrected < 0.001) were more likely to receive NACT over time, without a change in use among those with HR+ disease (OR 1.58, 95% CI 0.88-2.87, p = 0.13, p-corrected = 0.17).

CONCLUSION

Among women with early-stage triple-negative and HER2+ breast cancers, utilization of NACT increased over time, a trend that correlates with previously reported improved rates of pCR and options post-neoadjuvant treatment with residual disease. Future research is needed to better understand multidisciplinary decisions for NACT and implications for breast cancer patients.