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Mootz AR, Ozcan BB, Polat DS, Acevedo Z, Xi Y, Unni N, Nwachukwu C, Dogan BE. A Tale of Two Hospitals: Effect of Access to Care Through a Safety Net Hospital on Adjuvant Therapy, Imaging Compliance and 5-Year Survival Rates Compared to the University Hospital Served by the Same Breast Cancer Clinical Teams. Acad Radiol 2024:S1076-6332(24)00052-7. [PMID: 38365491 DOI: 10.1016/j.acra.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/18/2024]
Abstract
RATIONALE AND OBJECTIVES To compare rates of guideline-concordant care, imaging surveillance, recurrence and survival outcomes between a safety-net (SNH) and tertiary-care University Hospital (UH) served by the same breast cancer clinical teams. MATERIALS AND METHODS 647 women with newly diagnosed breast cancer treated in affiliated SNH and UH between 11.1.2014 and 3.31.2017 were reviewed. Patient demographics, completion of guideline-concordant adjuvant chemotherapy, radiation and hormonal therapy were recorded. Two multivariable logistic regression models were performed to investigate the effect of hospital and race on cancer stage. Kaplan-Meier log-rank and Cox-regression were used to analyze five-year recurrence-free (RFS) and overall survival (OS) between hospitals and races, (p < 0.05 significant). RESULTS Patients in SNH were younger (mean SNH 53.2 vs UH 57.9, p < 0.001) and had higher rates of cT3/T4 disease (SNH 19% vs UH 5.5%, p < 0.001). Patients in the UH had higher rates of bilateral mastectomy (SNH 17.6% vs UH 40.1% p < 0.001) while there was no difference in the positive surgical margin rate (SNH 5.0% vs UH 7.6%, p = 0.20), completion of adjuvant radiation (SNH 96.9% vs UH 98.7%, p = 0.2) and endocrine therapy (SNH 60.8% vs UH 66.2%, p = 0.20). SNH patients were less compliant with mammography surveillance (SNH 64.1% vs UH 75.1%, p = 0.02) and adjuvant chemotherapy (SNH 79.1% vs UH 96.3%, p < 0.01). RFS was lower in the SNH (SNH 54 months vs UH 57 months, HR 1.90, 95% CI: 1.18-3.94, p = 0.01) while OS was not significantly different (SNH 90.5% vs UH 94.2%, HR 1.78, 95% CI: 0.97-3.26, p = 0.06). CONCLUSION In patients experiencing health care disparities, having access to guideline-concordant care through SNH resulted in non-inferior OS to those in tertiary-care UH.
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Affiliation(s)
- Ann R Mootz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA.
| | - B Bersu Ozcan
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Dogan S Polat
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Zachary Acevedo
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Nisha Unni
- Department of Internal Medicine, Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chika Nwachukwu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California, USA
| | - Basak E Dogan
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
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2
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Dell'Aquila K, Vadlamani A, Maldjian T, Fineberg S, Eligulashvili A, Chung J, Adam R, Hodges L, Hou W, Makower D, Duong TQ. Machine learning prediction of pathological complete response and overall survival of breast cancer patients in an underserved inner-city population. Breast Cancer Res 2024; 26:7. [PMID: 38200586 PMCID: PMC10782738 DOI: 10.1186/s13058-023-01762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Generalizability of predictive models for pathological complete response (pCR) and overall survival (OS) in breast cancer patients requires diverse datasets. This study employed four machine learning models to predict pCR and OS up to 7.5 years using data from a diverse and underserved inner-city population. METHODS Demographics, staging, tumor subtypes, income, insurance status, and data from radiology reports were obtained from 475 breast cancer patients on neoadjuvant chemotherapy in an inner-city health system (01/01/2012 to 12/31/2021). Logistic regression, Neural Network, Random Forest, and Gradient Boosted Regression models were used to predict outcomes (pCR and OS) with fivefold cross validation. RESULTS pCR was not associated with age, race, ethnicity, tumor staging, Nottingham grade, income, and insurance status (p > 0.05). ER-/HER2+ showed the highest pCR rate, followed by triple negative, ER+/HER2+, and ER+/HER2- (all p < 0.05), tumor size (p < 0.003) and background parenchymal enhancement (BPE) (p < 0.01). Machine learning models ranked ER+/HER2-, ER-/HER2+, tumor size, and BPE as top predictors of pCR (AUC = 0.74-0.76). OS was associated with race, pCR status, tumor subtype, and insurance status (p < 0.05), but not ethnicity and incomes (p > 0.05). Machine learning models ranked tumor stage, pCR, nodal stage, and triple-negative subtype as top predictors of OS (AUC = 0.83-0.85). When grouping race and ethnicity by tumor subtypes, neither OS nor pCR were different due to race and ethnicity for each tumor subtype (p > 0.05). CONCLUSION Tumor subtypes and imaging characteristics were top predictors of pCR in our inner-city population. Insurance status, race, tumor subtypes and pCR were associated with OS. Machine learning models accurately predicted pCR and OS.
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Affiliation(s)
- Kevin Dell'Aquila
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Abhinav Vadlamani
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Takouhie Maldjian
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Susan Fineberg
- Department of Pathology, Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Anna Eligulashvili
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Julie Chung
- Department of Oncology, Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard Adam
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Laura Hodges
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Wei Hou
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Della Makower
- Department of Oncology, Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Tim Q Duong
- Department of Radiology, Montefiore Health System and Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA.
- Center for Health Data Innovation, Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY, USA.
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3
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Chen JC, Stover DG, Ballinger TJ, Bazan JG, Schneider BP, Andersen BL, Carson WE, Obeng-Gyasi S. Racial Disparities in Breast Cancer: from Detection to Treatment. Curr Oncol Rep 2024; 26:10-20. [PMID: 38100011 DOI: 10.1007/s11912-023-01472-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 02/12/2024]
Abstract
PURPOSE OF REVIEW Update on current racial disparities in the detection and treatment of breast cancer. RECENT FINDINGS Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.
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Affiliation(s)
- J C Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Daniel G Stover
- Department of Internal Medicine, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Tarah J Ballinger
- Department of Internal Medicine, Indiana University, Indianapolis, IN, USA
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Bryan P Schneider
- Department of Internal Medicine, Indiana University, Indianapolis, IN, USA
| | | | - William E Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA.
- The Ohio State University, N924 Doan Hall, 410 West 10th, Columbus, OH, 43210, USA.
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Wieder R, Adam N. Racial Disparities in Breast Cancer Treatments and Adverse Events in the SEER-Medicare Data. Cancers (Basel) 2023; 15:4333. [PMID: 37686609 PMCID: PMC10486612 DOI: 10.3390/cancers15174333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Despite lower incidence rates, African American (AA) patients have shorter survival from breast cancer (BC) than white (W) patients. Multiple factors contribute to decreased survival, including screening disparities, later presentation, and access to care. Disparities in adverse events (AEs) may contribute to delayed or incomplete treatment, earlier recurrence, and shortened survival. Here, we analyzed the SEER-Medicare dataset, which captures claims from a variety of venues, in order to determine whether the cancer care venues affect treatment and associated adverse events. We investigated a study population whose claims are included in the Outpatient files, consisting of hospital and healthcare facility venues, and a study population from the National Claims History (NCH) files, consisting of claims from physicians, office practices, and other non-institutional providers. We demonstrated statistically and substantively significant venue-specific differences in treatment rates, drugs administered, and AEs from treatments between AA and W patients. We showed that AA patients in the NCH dataset received lower rates of treatment, but patients in the Outpatient dataset received higher rates of treatment than W patients. The rates of recorded AEs per treatment were higher in the NCH setting than in the Outpatient setting in all patients. AEs were consistently higher in AA patients than in W patients. AA patients had higher comorbidity indices and were younger than W patients, but these variables did not appear to play roles in the AE differences. The frequency of specific anticancer drugs administered in cancer- and venue-specific circumstances and their associated AEs varied between AA and W patients. The higher AE rates were due to slightly higher frequencies in the administration of drugs with higher associated AE rates in AA patients than in W patients. Our investigations demonstrate significant differences in treatment rates and associated AEs between AA and W patients with BC, depending on the venues of care, likely contributing to differences in outcomes.
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Affiliation(s)
- Robert Wieder
- Rutgers New Jersey Medical School and the Cancer Institute of New Jersey, 185 South Orange Avenue, MSB F671, Newark, NJ 07103, USA
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5
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Hu X, Kaplan CM, Martin MY, Walker MS, Stepanski E, Schwartzberg LS, Vidal GA, Graetz I. Race Differences in Patient-Reported Symptoms during Chemotherapy among Women with Early-Stage Hormone Receptor-Positive Breast Cancer. Cancer Epidemiol Biomarkers Prev 2023; 32:167-174. [PMID: 36166516 PMCID: PMC9905215 DOI: 10.1158/1055-9965.epi-22-0692] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Symptom burden differences may contribute to racial disparities in breast cancer survival. We compared symptom changes from before to during chemotherapy among women with breast cancer. METHODS This observational study followed a cohort of Black and White women diagnosed with Stage I-III, hormone receptor-positive breast cancer from a large cancer center in 2007 to 2015, and reported symptoms before and during chemotherapy. We identified patients who experienced a one-standard deviation (SD) increase in symptom burden after starting chemotherapy using four validated composite scores (General Physical Symptoms, Treatment Side Effects, Acute Distress, and Despair). Kitagawa-Blinder-Oaxaca decomposition was used to quantify race differences in symptom changes explained by baseline characteristics (sociodemographic, baseline scores, cancer stage) and first-line chemotherapy regimens. RESULTS Among 1,273 patients, Black women (n = 405, 31.8%) were more likely to report one-SD increase in General Physical Symptoms (55.6% vs. 48.2%, P = 0.015), Treatment Side Effects (74.0% vs. 63.4%, P < 0.001), and Acute Distress (27.4% vs. 20.0%, P = 0.010) than White women. Baseline characteristics and first-line chemotherapy regimens explained a large and significant proportion of the difference in Acute Distress changes (93.7%, P = 0.001), but not General Physical Symptoms (25.7%, P = 0.25) or Treatment Side Effects (16.4%, P = 0.28). CONCLUSIONS Black women with early-stage breast cancer were more likely to experience significant increases in physical and psychological symptom burden during chemotherapy. Most of the difference in physical symptom changes remained unexplained by baseline characteristics, which suggests inadequate symptom management among Black women. IMPACT Future studies should identify strategies to improve symptom management among Black women and reduce differences in symptom burden. See related commentary by Rosenzweig and Mazanec, p. 157.
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Affiliation(s)
- Xin Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Cameron M Kaplan
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Los Angeles, California
| | - Michelle Y Martin
- Center for Innovation in Health Equity Research, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | | | - Gregory A Vidal
- West Cancer Center and Research Institute, Germantown, Tennessee.,School of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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6
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Yang F, Liu G, Mao F, Zheng YC. Re: Pathologic complete responses, long-term outcomes, and recurrence patterns in HER2-low vs. HER2-zero breast cancer after neoadjuvant chemotherapy: Several issues about HER2 expression and neoadjuvant chemotherapy in breast cancer. Eur J Cancer 2023; 180:184-185. [PMID: 36581473 DOI: 10.1016/j.ejca.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/28/2022]
Affiliation(s)
- Fan Yang
- Department of Liver Surgery, Peking Union Medical College Hospital, China; Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guanmo Liu
- Department of Breast Surgery, Peking Union Medical College Hospital, China; Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Feng Mao
- Department of Breast Surgery, Peking Union Medical College Hospital, China; Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yong-Chang Zheng
- Department of Liver Surgery, Peking Union Medical College Hospital, China; Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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7
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Relation T, Obeng-Gyasi S, Bhattacharyya O, Li Y, Eskander MF, Tsung A, Oppong BA. Racial Differences in Response to Neoadjuvant Chemotherapy: Impact on Breast and Axillary Surgical Management. Ann Surg Oncol 2021; 28:6489-6497. [PMID: 33586065 PMCID: PMC8491425 DOI: 10.1245/s10434-021-09657-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC), an increasingly used method for breast cancer patients, has the potential to downstage patient tumors and thereby have an impact on surgical options for treatment of the breast and axilla. Previous studies have identified racial disparities in tumor heterogeneity, nodal recurrence, and NAC completion. This report compares the effects of NAC response among non-Hispanic white women and black women in relation to surgical treatment of the breast and axilla. METHODS A retrospective review of 85,303 women with stages 1 to 3 breast cancer in the National Cancer Database who received NAC between 1 January 2010 and 31 December 2016 was conducted. Differences in sociodemographic and clinical variables between black patients and white patients with breast cancer were tested. RESULTS The study identified 68,880 non-Hispanic white and 16,423 non-Hispanic black women who received NAC. The average age at diagnosis was 54.8 years for the white women versus 52.5 years for the black women. A higher proportion of black women had stage 3 disease, more poorly differentiated tumors, and triple-negative subtype. The black women had lower rates of complete pathologic response, more breast-conservation surgery, and higher rates of axillary lymph node dissection, but fewer sentinel lymph node biopsies. Axillary management for the women who were downstaged showed more use of axillary lymph node dissection for black women compared with sentinel lymph node biopsy. CONCLUSIONS The black patients were younger at diagnosis, had more advanced disease, and were more likely to have breast-conservation surgery. De-escalating axillary surgery is being adopted increasingly but used disproportionately for white women.
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Affiliation(s)
- Theresa Relation
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Yaming Li
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Mariam F Eskander
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Bridget A Oppong
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA.
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Ho Y, Harris A, Wesolowski M, Refaat T, Small W, Thomas TO. Impact of Race and Health Insurance Status on Response to Neoadjuvant Chemotherapy for Breast Cancer Patients. Cureus 2021; 13:e16127. [PMID: 34367759 PMCID: PMC8330506 DOI: 10.7759/cureus.16127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 11/05/2022] Open
Abstract
We evaluated how race, insurance status, and other sociodemographic, tumor, and treatment variables influenced the response to neoadjuvant chemotherapy (NAC) in breast cancer. We performed an IRB-approved retrospective review of 298 breast cancer patients treated with NAC from 2006-2018 at our institution. Univariable and multivariable binary logistic regression analyses were performed to estimate the effects of race, insurance status, and other variables on outcomes. Outcomes of interest included pathologic complete response (pCR), partial response (pPR), and any response (pCR or pPR). Sixty-nine patients (23%) identified as African American. One hundred sixty-eight (57%) patients had private insurance, 71 (24%) had Medicare, 40 (14%) had Medicaid, and 17 (6%) had no insurance. Insurance status was a predictor for any clinical response to NAC in both univariable and multivariable analyses (p<0.01), where odds of pCR or pPR were lower for patients with Medicare compared to private insurance (OR 0.32, 95% CI: 0.15-0.70, p<0.01). Other variables significant for the response to NAC included body mass index, hormone receptor status, clinical group stage, and Ki-67. Race did not influence the response to NAC. Insurance provider, body mass index, hormone receptor status, clinical group stage, and Ki-67 may be useful predictors of treatment outcomes. Future studies that assess the impacts of insurance status and other identified factors on treatment response may help evaluate outcomes in at-risk populations with factors that preclude full benefit from NAC.
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Affiliation(s)
- Yvonne Ho
- Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - Alexander Harris
- Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - Michael Wesolowski
- Biostatistics, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - Tamer Refaat
- Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - William Small
- Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, USA
| | - Tarita O Thomas
- Radiation Oncology, Loyola University Chicago Stritch School of Medicine, Maywood, USA.,Radiation Oncology, Henry Ford Health System, Detroit, USA
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Hu X, Chehal PK, Kaplan C, Krukowski RA, Lan RH, Stepanski E, Schwartzberg L, Vidal G, Graetz I. Characterization of Clinical Symptoms by Race Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer Before Starting Chemotherapy. JAMA Netw Open 2021; 4:e2112076. [PMID: 34061200 PMCID: PMC8170541 DOI: 10.1001/jamanetworkopen.2021.12076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Race disparities persist in breast cancer mortality rates. One factor associated with these disparities may be differences in symptom burden, which may reduce chemotherapy tolerance and increase early treatment discontinuation. OBJECTIVES To compare symptom burden by race among women with early-stage breast cancer before starting chemotherapy and quantify symptom differences explained by baseline characteristics. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of symptom burden differences by race among Black and White women with a diagnosis of stage I to III, hormone receptor-positive breast cancer who had a symptom report collected before chemotherapy initiation in a large cancer center in the southern region of the US from January 1, 2007, through December 31, 2015. Analyses were conducted from November 1, 2019, to March 31, 2021. Blinder-Oaxaca decomposition was used, adjusting for baseline sociodemographic and clinical characteristics. MAIN OUTCOMES AND MEASURES Four symptom composite scores with a mean (SD) of 50 (10) were reported before starting chemotherapy (baseline) and were derived from symptom items: general physical symptoms (11 items), treatment adverse effects (8 items), acute distress (4 items), and despair (7 items). Patients rated the severity of each symptom they experienced in the past week on a scale of 0 to 10 (where 0 indicates not a problem and 10 indicates as bad as possible). RESULTS A total of 1338 women (mean [SD] age, 54.6 [11.6] years; 420 Black women [31.4%] and 918 White women [68.6%]) were included in the study. Before starting chemotherapy, Black women reported a statistically significantly higher (ie, worse) symptom composite score than White women for adverse effects (44.5 vs 43.8) but a lower acute distress score (48.5 vs 51.0). Decomposition analyses showed that Black patients' characteristics were associated with higher symptom burden across all 4 scores. However, these differences were offset by relatively greater, statistically significant, unexplained physical, distress, and despair symptom reporting by White patients. CONCLUSIONS AND RELEVANCE In this study, before starting chemotherapy, Black patients with early-stage breast cancer reported significantly higher burden for symptoms that may be exacerbated with chemotherapy and lower distress symptoms compared with White patients. Future studies should explore how symptoms change before and after treatment and differ by racial/ethnic groups and how they are associated with treatment adherence and mortality disparities.
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Affiliation(s)
- Xin Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Puneet K. Chehal
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Cameron Kaplan
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of University of Southern California, Los Angeles
| | | | - Roy H. Lan
- College of Medicine, University of Tennessee Health Science Center, Memphis
| | | | - Lee Schwartzberg
- West Cancer Center and Research Institute, Germantown, Tennessee
| | - Gregory Vidal
- West Cancer Center and Research Institute, Germantown, Tennessee
- Division of Hematology and Oncology, University of Tennessee Health Science Center, Memphis
| | - Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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10
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Watt GP, John EM, Bandera EV, Malone KE, Lynch CF, Palmer JR, Knight JA, Troester MA, Bernstein JL. Race, ethnicity and risk of second primary contralateral breast cancer in the United States. Int J Cancer 2021; 148:2748-2758. [PMID: 33544892 DOI: 10.1002/ijc.33501] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 01/19/2023]
Abstract
Breast cancer survivors have a high risk of a second primary contralateral breast cancer (CBC), but there are few studies of CBC risk in racial/ethnic minority populations. We examined whether the incidence and risk factors for CBC differed by race/ethnicity in the United States. Women with a first invasive Stage I-IIB breast cancer diagnosis at ages 20-74 years between 2000 and 2015 in the Surveillance, Epidemiology, and End Results Program (SEER) 18 registries were followed through 2016 for a diagnosis of invasive CBC ≥1 year after the first breast cancer diagnosis. We used cause-specific Cox proportional hazards models to test the association between race/ethnicity and CBC, adjusting for age, hormone receptor status, radiation therapy, chemotherapy and stage at first diagnosis, and evaluated the impact of contralateral prophylactic mastectomy, socioeconomic status, and insurance status on the association. After a median follow-up of 5.9 years, 9247 women (2.0%) were diagnosed with CBC. Relative to non-Hispanic (NH) White women, CBC risk was increased in NH Black women (hazard ratio = 1.44, 95% CI 1.35-1.54) and Hispanic women (1.11, 95% CI 1.02-1.20), with the largest differences among women diagnosed at younger ages. Adjustment for contralateral prophylactic mastectomy, socioeconomic status and health insurance did not explain the associations. Therefore, non-Hispanic Black and Hispanic women have an increased risk of CBC that is not explained by clinical or socioeconomic factors collected in SEER. Large studies of diverse breast cancer survivors with detailed data on treatment delivery and adherence are needed to inform interventions to reduce this disparity.
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Affiliation(s)
- Gordon P Watt
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Esther M John
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - Kathleen E Malone
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Charles F Lynch
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, USA
| | - Julie R Palmer
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia A Knight
- Prosserman Centre for Population Health Research, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Melissa A Troester
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Jonine L Bernstein
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Korde LA, Somerfield MR, Carey LA, Crews JR, Denduluri N, Hwang ES, Khan SA, Loibl S, Morris EA, Perez A, Regan MM, Spears PA, Sudheendra PK, Symmans WF, Yung RL, Harvey BE, Hershman DL. Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline. J Clin Oncol 2021; 39:1485-1505. [PMID: 33507815 DOI: 10.1200/jco.20.03399] [Citation(s) in RCA: 376] [Impact Index Per Article: 125.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To develop guideline recommendations concerning optimal neoadjuvant therapy for breast cancer. METHODS ASCO convened an Expert Panel to conduct a systematic review of the literature on neoadjuvant therapy for breast cancer and provide recommended care options. RESULTS A total of 41 articles met eligibility criteria and form the evidentiary basis for the guideline recommendations. RECOMMENDATIONS Patients undergoing neoadjuvant therapy should be managed by a multidisciplinary care team. Appropriate candidates for neoadjuvant therapy include patients with inflammatory breast cancer and those in whom residual disease may prompt a change in therapy. Neoadjuvant therapy can also be used to reduce the extent of local therapy or reduce delays in initiating therapy. Although tumor histology, grade, stage, and estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) expression should routinely be used to guide clinical decisions, there is insufficient evidence to support the use of other markers or genomic profiles. Patients with triple-negative breast cancer (TNBC) who have clinically node-positive and/or at least T1c disease should be offered an anthracycline- and taxane-containing regimen; those with cT1a or cT1bN0 TNBC should not routinely be offered neoadjuvant therapy. Carboplatin may be offered to patients with TNBC to increase pathologic complete response. There is currently insufficient evidence to support adding immune checkpoint inhibitors to standard chemotherapy. In patients with hormone receptor (HR)-positive (HR-positive), HER2-negative tumors, neoadjuvant chemotherapy can be used when a treatment decision can be made without surgical information. Among postmenopausal patients with HR-positive, HER2-negative disease, hormone therapy can be used to downstage disease. Patients with node-positive or high-risk node-negative, HER2-positive disease should be offered neoadjuvant therapy in combination with anti-HER2-positive therapy. Patients with T1aN0 and T1bN0, HER2-positive disease should not be routinely offered neoadjuvant therapy.Additional information is available at www.asco.org/breast-cancer-guidelines.
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Affiliation(s)
- Larissa A Korde
- Clinical Investigations Branch, CTEP, DCTD, National Cancer Institute, Bethesda, MD
| | | | - Lisa A Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | | | | | | | - Alejandra Perez
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Plantation, FL
| | | | - Patricia A Spears
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | | | | | | | | | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center at Columbia University, New York, NY
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12
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Nugent BD, McCall MK, Connolly M, Mazanec SR, Sereika SM, Bender CM, Rosenzweig MQ. Protocol for Symptom Experience, Management, Outcomes, and Adherence in Women Receiving Breast Cancer Chemotherapy. Nurs Res 2020; 69:404-411. [PMID: 32520763 PMCID: PMC7483966 DOI: 10.1097/nnr.0000000000000450] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The 5-year survival for Black women with breast cancer in the United States is lower than White women for stage-matched disease. Our past and ongoing work and that of others suggest that symptom incidence, cancer-related distress, and ineffective communication contribute to racial disparity in dose reduction and early therapy termination. Although race is perhaps the most studied social determinant of health, it is clear that race alone does not account for all disparities. OBJECTIVES The aim of the study was to present a study protocol of Black and White women prescribed breast cancer chemotherapy. The aims are to (1) examine and compare chemotherapy received/prescribed over time and in total; (2a) examine and compare symptom incidence, distress, and management and clinical encounter, including patient-centeredness of care and management experience over time and (2b) correlate symptom incidence, distress, and management experience to Aim 1; and (3) explore the effects of social determinants of health, including age, income, education, zip code, and lifetime stress exposure, on Aims 1, 2a, and 2b. METHODS A longitudinal, repeated-measures (up to 18 time points), comparative, mixed-methods design is employed with 179 White and 179 Black women from 10 sites in Western Pennsylvania and Northeast Ohio over the course of chemotherapy and for 2 years following completion of therapy. RESULTS The study began in January 2018, with estimated complete data collection by late 2023. DISCUSSION This study is among the first to explore the mechanistic process for racial disparity in dosage and delay across the breast cancer chemotherapy course. It will be an important contribution to the explanatory model for breast cancer treatment disparity and may advance potential mitigation strategies for racial survival disparity.
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Affiliation(s)
- Bethany D Nugent
- Bethany D. Nugent, PhD, RN, is Research Associate, School of Nursing, University of Pittsburgh, Pennsylvania. Maura K. McCall, MSN, RN, is Graduate Student Researcher, School of Nursing, University of Pittsburgh, Pennsylvania. Mary Connolly, BSN, RN, is Project Director, School of Nursing, University of Pittsburgh, Pennsylvania. Susan M. Sereika, PhD, is Professor, School of Nursing, University of Pittsburgh, Pennsylvania. Catherine M. Bender, PhD, RN, FAAN, is Professor, School of Nursing, University of Pittsburgh, Pennsylvania. Margaret Q. Rosenzweig, PhD, CRNP-C, AOCNP, FAAN, is Professor, School of Nursing, University of Pittsburgh, Pennsylvania. Susan R. Mazanec, PhD, RN, AOCN, is Assistant Professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
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13
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Zhao Y, Xu G, Guo X, Ma W, Xu Y, Peltzer K, Chekhonin VP, Baklaushev VP, Hu N, Wang X, Liu Z, Zhang C. Early Death Incidence and Prediction in Stage IV Breast Cancer. Med Sci Monit 2020; 26:e924858. [PMID: 32778637 PMCID: PMC7441743 DOI: 10.12659/msm.924858] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The early death of patients is a global cancer issue. We aimed to identify the risk factors for early death in stage IV breast cancer. Predictive nomograms for early death evaluation were generated based on the risk factors. MATERIAL AND METHODS Based on the Surveillance, Epidemiology, and End Results (SEER) database, patients diagnosed with IV breast cancer were selected. The risk factors for early death (survival time ≤1 year) were identified using logistic regression model analysis. Predictive nomograms were constructed and internal validation was performed. RESULTS A total of 5998 (32.6%) breast cancer patients were diagnosed as early death in the construction cohort. Age older than 50 years, unmarried status, black race, uninsured status, triple-negative type, grade (II and III), tumor size >5 cm, and metastasis to lung, liver, and brain were risk factors for total early death, while Luminal B subtype, N1 stage, and surgical interventions were associated with lower risk of early death. As for cancer-specific and non-cancer-specific early death, several factors were not consistent between the 2 groups. Nomograms for all-cause, cancer-specific, and non-cancer-specific early death were constructed. The calibration curve showed satisfactory agreement. The areas under the ROC curve (AUC) were 78.3% (95% CI: 77.7-78.9%), 75.8% (75.1-76.4%), and 72.3% (71.6-72.9%), respectively. In the validation cohort, a total of 689 (19.3%) patients were diagnosed as early death and the calibration curve showed satisfactory agreement. The AUCs of the all-cause, cancer-specific, and non-cancer-specific early death prediction were 74.0% (95% CI: 72.5-75.4%), 73.5% (72.0-74.9%), and 68.6% (67.0-70.1%), respectively. CONCLUSIONS Nomograms were generated to predict early death, with good calibration and discrimination. The predictive model can provide a reference for identifying cases with high risk of early death among stage IV breast cancer patients and play an auxiliary role in guiding individual treatment.
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Affiliation(s)
- Yumei Zhao
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
| | - Guijun Xu
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
| | - Xinpeng Guo
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
| | - Wenjuan Ma
- Department of Breast Imaging, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
| | - Yao Xu
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
| | - Karl Peltzer
- Department of Research and Innovation, University of Limpopo, Turfloop, South Africa
| | - Vladimir P Chekhonin
- Department of Fundamental and Applied Neurobiology, V. P. Serbsky National Medical Research Center for Psychiatry and Narcology, The Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Vladimir P Baklaushev
- Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies, Federal Biomedical Agency of the Russian Federation, Moscow, Russian Federation
| | - Nan Hu
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
| | - Xin Wang
- Department of Epidemiology and Biostatistics, First Affiliated Hospital, Army Medical University, Chongqing, China (mainland)
| | - Zheng Liu
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland).,Department of Orthopedics, Heilongjiang Province Hospital, Harbin, Heilongjiang, China (mainland)
| | - Chao Zhang
- Department of Bone and Soft Tissue Tumors, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China (mainland)
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