Surgical Leadership and Standardization of Multidisciplinary Breast Cancer Care

Temporal Trends in Treatment and Outcomes of Endometrial Carcinoma in the United States, 2005-2020

Endometrial cancer has continued to see a rising incidence in the US over the years. The main aim of this study was to assess current trends in patients' characteristics and outcomes of treatment for endometrial carcinoma over 16 years. A dataset from the National Cancer Database (NCDB) for patients diagnosed with endometrial carcinoma from 2005 to 2020 was used in this retrospective, case series study. The main outcomes and measures of interest included tumor characteristics, hospitalization, treatments, mortality, and overall survival. Then, 569,817 patients who were diagnosed with endometrial carcinoma were included in this study. The mean (SD) age at diagnosis was 62.7 (11.6) years, but 66,184 patients (11.6%) were younger than 50 years, indicating that more patients are getting diagnosed at younger ages. Of the patients studied, 37,079 (6.3%) were Hispanic, 52,801 (9.3%) were non-Hispanic Black, 432,058 (75.8%) were non-Hispanic White, and 48,879 (8.6%) were other non-Hispanic. Patients in the 4th period from 2017 to 2020 were diagnosed more with stage IV (7.1% vs. 5.2% vs. 5.4% vs. 5.9%; p < 0.001) disease compared with those in the other three periods. More patients with severe comorbidities (Charlson Comorbidity Index score of three) were seen in period 4 compared to the first three periods (3.9% vs. ≤1.9%). Systemic chemotherapy use (14.1% vs. 17.7% vs. 20.4% vs. 21.1%; p < 0.001) and immunotherapy (0.01% vs. 0.01% vs. 0.2% vs. 1.1%; p < 0.001) significantly increased from period 1 to 4. The use of laparotomy decreased significantly from 42.1% in period 2 to 16.7% in period 4, while robotic surgery usage significantly increased from 41.5% in period 2 to 64.3% in period 4. The 30-day and 90-day mortality decreased from 0.6% in period 1 to 0.2% in period 4 and 1.4% in period 1 to 0.6% in period 4, respectively. Over the period studied, we found increased use of immunotherapy, chemotherapy, and minimally invasive surgery for the management of endometrial cancer. Overall, the time interval from cancer diagnosis to final surgery increased by about 6 days. The improvements observed in the outcomes examined can probably be associated with the treatment trends observed.

Uptake of Breast Cancer Clinical Trials at Minority Serving Cancer Centers

BACKGROUND

Most minorities receive cancer care at minority-serving hospitals (MSHs) that have been associated with disparate treatment between Black and White patients.

OBJECTIVE

Our aim was to examine the uptake of clinical trials that have changed axillary management in breast cancer patients at MSH and non-MSH cancer centers.

METHODS

The National Cancer Database was used to identify patients eligible for the American College of Surgeons Oncology Group Z0011 and Z1071 trials, and mastectomy patients fulfilling the European AMAROS trial. Uptake of trial results (omission of axillary lymph node dissection) was analyzed between patients treated at MSHs and non-MSHs and adjusted for patient, tumor, and facility factors. MSHs were defined as the top decile of hospitals according to the proportion of Black and Hispanic patients treated.

RESULTS

Of 7167 patients eligible for Z0011, 4546 for Z0171, and 9433 for AMAROS from 2015 to 2016, clinical trial uptake was seen in 1195 (74.6%) MSH and 4056 (72.9%) non-MSH patients (p = 0.173) for Z0011, 588 (41.9%) MSH and 1366 (43.5%) non-MSH patients for Z1071 (p = 0.302), and 272 (11.7%) MSH and 996 (14.0%) non-MSH patients (p = 0.005) for AMAROS. On adjusted analyses, MSH status was not significant for uptake of any of the three trials. Black race, socioeconomic status, and insurance were not associated with clinical trial uptake.

CONCLUSION

The uptake of three landmark clinical trials of axillary management in breast cancer was not different at MSH and non-MSH centers despite adjustment for social determinants of health. At the Commission on Cancer-accredited centers in this analysis, MSH status did not affect the uptake of evidence-based care.

How Ineffective Interprofessional Collaboration Affects Delivery of Breast Reconstruction to Breast Cancer Patients: A Qualitative Study

BACKGROUND

Despite the benefits of breast reconstruction (BR), health care professionals do not consistently integrate it as an option in the treatment of breast cancer patients. Interprofessional collaboration (IPC) amongst professionals may facilitate the elaboration of comprehensive oncological treatment plans. As the application of IPC in the delivery of BR has not yet been studied, we undertook a qualitative study to explore the perceptions of physicians and administrators on IPC in breast cancer care and how these impact BR delivery.

METHODS

Interviews were conducted with 30 participants (22 physicians and 8 administrators). Physician interviews focused on their personal beliefs and values regarding BR, while administrator interviews explored their institutional treatment regimens as well as the availability of a BR program. Our thematic analysis was informed by the Canadian Interprofessional Health Collaborative (CIHC) competency framework.

RESULTS

IPC challenges were thought by participants to affect the delivery of BR. At the physician level, a lack of role clarity as well as the absence of an explicitly established leader negatively influence collaboration in BR delivery. In addition, varying views on the usefulness of BR and on the role of plastic surgeons in breast oncological teams discourage positive collaboration, rendering the delivery of BR more difficult.

CONCLUSIONS

The delivery of BR is overall impaired due to a lack of effective IPC. IPC could be improved through clarifying physician roles, establishing clear leadership, and aligning viewpoints on quality oncological care in collaborative teams; ultimately, this may promote equitable BR delivery for breast cancer patients.

The changing surgical treatment of breast cancer in the United States: The tipping point

The surgical management of breast cancer began to change in the middle of the last decade. The use of unilateral mastectomy decreased while the rate of contralateral prophylactic mastectomy for unilateral cancer increased sixfold from 1998 to 2011. The use of immediate breast reconstruction increased from 30% in 2005 to 45% in 2012. Four changes came together in the middle of the last decade to cause this paradigm shift in the surgical management of early breast cancer. (a) Breast MRI would be available in nearly 75% of breast imaging centers. (b) Genetic counseling would become a standard of care for patients with potential hereditary breast cancer. (c) In 2006, the FDA would approve the use of silicone-gel implants. (d) Nipple-sparing mastectomy would become a standard of care in the treatment of early breast cancer.

Regional Variation in Performance for Commission on Cancer Breast Quality Measures and Impact on Overall Survival

BACKGROUND

Adherence to quality measures has become an important indicator of cancer center performance for high-quality cancer care. We examined regional variation in performance for Commission on Cancer breast quality measures and its impact on overall survival (OS) for those measures that have been shown to impact OS.

METHODS

Six breast quality measures were analyzed using the National Cancer Data Base from 2014 to 2015, and a multivariable model was used to assess performance for each measure by region. Kaplan-Meier and Cox proportional hazard models were used to examine OS between high- and low-performing centers from 2007 to 2012.

RESULTS

Overall, 305,391 women had surgery at 1322 institutions in nine US regions; 90.8% underwent needle biopsy (range 86.0-92.6% between regions, p < 0.01), 69.8% had breast-conserving surgery (BCS) for stage 0-II cancer (60.9-79.3%, p < 0.01), 85.2% aged < 70 years had radiation therapy (RT) after BCS (79.6-90.8%, p < 0.01), 78.3% of women with four or more positive nodes had post-mastectomy RT (70.9-84.5%, p < 0.01), 90.9% with hormone receptor (HR)-positive stage IB-III cancer had hormone therapy (83.7-95.1%, p < 0.01), and 89.4% aged < 70 years with HR-negative stage IB-III cancer had chemotherapy (87.6-91.4%, p < 0.01). Multivariate analyses adjusted for patient and facility factors found that region was the only consistent predictor of non-compliance across measures. With median 65-month follow-up, there was no difference in OS between high- and low-performing centers for the three measures that have been shown to impact OS.

CONCLUSIONS

There is significant regional variation in performance on the breast quality measures but this variation did not impact OS. Targeted efforts in certain areas of the country may help improve performance on these measures.

Treatment experiences of Latinas after diagnosis of breast cancer

BACKGROUND

The authors examined racial/ethnic differences in patient perspectives regarding their breast cancer treatment experiences.

METHODS

A weighted random sample of women newly diagnosed with breast cancer between 2013 and 2015 in Los Angeles County and Georgia were sent surveys 2 months after undergoing surgery (5080 women; 70% response rate). The analytic sample was limited to patients residing in Los Angeles County (2397 women).

RESULTS

The pattern of visits with different specialists before surgery was found to be similar across racial/ethnic groups. Low acculturated Latinas (Latinas-LA) were less likely to report high clinician communication quality for both surgeons and medical oncologists (<69% vs >72% for all other groups; P<.05). The percentage of patients who reported high satisfaction regarding how physicians worked together was similar across racial/ethnic groups. Latinas-LA were more likely to have a low autonomy decision style (48% vs 24%-50% for all other groups; P<.001) and were more likely to report receiving too much information versus other ethnic groups (20% vs <16% for other groups; P<.001). Patients who reported a low autonomy decision style were more likely to rate the amount of information they received for the surgery decision as "too much" (16% vs 9%; P<.001).

CONCLUSIONS

There appears to be moderate disparity in breast cancer treatment communication and decision-making experiences reported by Latinas-LA versus other groups. The approach to treatment decision making by Latinas-LA represents an important challenge to health care providers. Initiatives are needed to improve patient engagement in decision making and increase clinician awareness of these challenges in this patient population. Cancer 2017;123:3022-30. © 2017 American Cancer Society.

Effect of Multidisciplinary Case Conferences on Physician Decision Making: Breast Diagnostic Rounds

Purpose: To evaluate the utility of multidisciplinary case conferences (MCCs) on physician decision making in benign and malignant breast disease management.

Methods:  Patients with interesting or challenging diagnostic or management issues were discussed at biweekly diagnostic breast MCCs. Prior to discussion, a clinical summary and intended management plan prior to the MCC was presented. For each case, diagnostic images/histopathology were centrally reviewed after which group discussion achieved a management consensus which was documented prospectively. Initial management plans were compared to the post-MCC consensus. A change in a management plan was defined as a consensus plan different from the pre-MCC plan or no definite plan prior to the MCC.

Results:  From November 2014 to December 2015, 76 patients (43 malignant and 33 benign diagnoses) were discussed in 19 MCCs. All cases presented resulted in a consensus management recommendation. Thirty-one case discussions (41%) resulted in a changed management plan (20 malignant and 11 benign diagnoses). Management changes included avoidance of immediate surgery (9% of cases), change in the type of surgery (5%), non-invasive investigation to invasive/surgical intervention (7%), and detection of a new suspicious lesion (1%).

Conclusion: MCCs had a substantial impact on physician decision making. Management plans changed in 41% of cases presented, the majority due to new/clarified diagnostic information. Presentation of cases at MCCs should be encouraged, especially for challenging diagnostic or management issues regarding malignant or benign breast diagnoses.

Comparing cancer detection rates of patients undergoing short term follow-up vs routine follow-up after benign breast biopsies, is follow-up needed?

PURPOSE

To compare cancer rates after benign breast biopsies between patients with short term imaging follow-up (STFU) and those with routine follow-up (RFU).

MATERIALS & METHODS

Retrospective review of benign stereotactic, US or DCE-MRI breast biopsies.

RESULTS

Of 580 lesions, 192 (33%) had STFU, and 388 (67%) had RFU. For US and mammographic detected lesions, there is no difference in cancer rates between the STFU (1 cancer, n=148) and the RFU group (0 cancer, n=365) (p=0.29). There were 2 cancers in the STFU group versus 0 in the RFU DCE-MRI group (p=0.54).

CONCLUSION

Our results support RFU after benign ultrasound and stereotactic breast biopsies.

Patterns of multidisciplinary care in the management of non-metastatic invasive breast cancer in the United States Medicare patient

PURPOSE

Multidisciplinary care (MDC) in managing breast cancer is resource-intensive and growing in prevalence anecdotally, although care patterns are poorly characterized. We sought to determine MDC patterns and effects on care in the United States Medicare patient.

METHODS

Patients diagnosed with non-metastatic invasive breast cancer from 1992-2009 were reviewed using the Survival, Epidemiology, and End Results (SEER)-Medicare linked dataset. MDC was defined as a post-diagnosis, preoperative visit with a surgical, medical, and radiation oncologist. Same-day MDC (MDCSD) was the MDC subset having all three visits on one date.

RESULTS

Among 88,865 patients, MDC was utilized in 2.9 %, with 14.1 % of these having MDCSD. MDC use did not vary by stage, but MDC patients were more likely to be younger, black, receive lumpectomy, have fewer nodes examined, and receive radiotherapy. MDCSD patients were more likely than non-MDC patients to be black, receive mastectomy, and receive radiotherapy. MDC and MDCSD use increased over time and varied by geographic region, with rural patients less likely to receive MDC (OR 0.54 [95 % CI 0.45-0.65]) and MDCSD (OR 0.32 [95 % CI 0.19-0.54]). Radiotherapy after breast conserving surgery, used in 86.2 % of non-MDC patients, was administered to 90.2 % of MDC (p < 0.001) and 92.6 % of MDC(SD) (p = 0.096) patients. Post-mastectomy radiotherapy was administered in 52.0 % of non-MDC patients, 63.8 % of MDC (p = 0.050), and 89.1 % of MDC(SD) (p = 0.011) patients after propensity score adjustment.

CONCLUSION

While increasing, few Medicare patients undergo MDC and MDCSD is rare. MDC may improve quality and MDCSD should be considered for patient convenience. While not yet widespread, efforts should integrate MDC and MDCSD across the U.S.

Quality measurement in breast cancer

Variation in the quality of breast care affects outcomes. Objective measurement tools are central to this effort. Most quality measures are process measures. Application of these improves quality. Many national organizations are promoting them for purposes ranging from feedback to providers to public reporting and directing payment. Surgeons should evaluate their own practices and should be involved in local, regional and national efforts to assess and improve breast care.