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Henderson JT, Webber EM, Weyrich MS, Miller M, Melnikow J. Screening for Breast Cancer: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2024; 331:1931-1946. [PMID: 38687490 DOI: 10.1001/jama.2023.25844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Importance Breast cancer is a leading cause of cancer mortality for US women. Trials have established that screening mammography can reduce mortality risk, but optimal screening ages, intervals, and modalities for population screening guidelines remain unclear. Objective To review studies comparing different breast cancer screening strategies for the US Preventive Services Task Force. Data Sources MEDLINE, Cochrane Library through August 22, 2022; literature surveillance through March 2024. Study Selection English-language publications; randomized clinical trials and nonrandomized studies comparing screening strategies; expanded criteria for screening harms. Data Extraction and Synthesis Two reviewers independently assessed study eligibility and quality; data extracted from fair- and good-quality studies. Main Outcomes and Measures Mortality, morbidity, progression to advanced cancer, interval cancers, screening harms. Results Seven randomized clinical trials and 13 nonrandomized studies were included; 2 nonrandomized studies reported mortality outcomes. A nonrandomized trial emulation study estimated no mortality difference for screening beyond age 74 years (adjusted hazard ratio, 1.00 [95% CI, 0.83 to 1.19]). Advanced cancer detection did not differ following annual or biennial screening intervals in a nonrandomized study. Three trials compared digital breast tomosynthesis (DBT) mammography screening with digital mammography alone. With DBT, more invasive cancers were detected at the first screening round than with digital mammography, but there were no statistically significant differences in interval cancers (pooled relative risk, 0.87 [95% CI, 0.64-1.17]; 3 studies [n = 130 196]; I2 = 0%). Risk of advanced cancer (stage II or higher) at the subsequent screening round was not statistically significant for DBT vs digital mammography in the individual trials. Limited evidence from trials and nonrandomized studies suggested lower recall rates with DBT. An RCT randomizing individuals with dense breasts to invitations for supplemental screening with magnetic resonance imaging reported reduced interval cancer risk (relative risk, 0.47 [95% CI, 0.29-0.77]) and additional false-positive recalls and biopsy results with the intervention; no longer-term advanced breast cancer incidence or morbidity and mortality outcomes were available. One RCT and 1 nonrandomized study of supplemental ultrasound screening reported additional false-positives and no differences in interval cancers. Conclusions and Relevance Evidence comparing the effectiveness of different breast cancer screening strategies is inconclusive because key studies have not yet been completed and few studies have reported the stage shift or mortality outcomes necessary to assess relative benefits.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Portland, Oregon
| | - Elizabeth M Webber
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Portland, Oregon
| | - Meghan S Weyrich
- University of California Davis Center for Healthcare Policy and Research, Sacramento
| | - Marykate Miller
- University of California Davis Center for Healthcare Policy and Research, Sacramento
| | - Joy Melnikow
- University of California Davis Center for Healthcare Policy and Research, Sacramento
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Nicholson WK, Silverstein M, Wong JB, Barry MJ, Chelmow D, Coker TR, Davis EM, Jaén CR, Krousel-Wood M, Lee S, Li L, Mangione CM, Rao G, Ruiz JM, Stevermer JJ, Tsevat J, Underwood SM, Wiehe S. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2024; 331:1918-1930. [PMID: 38687503 DOI: 10.1001/jama.2024.5534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Importance Among all US women, breast cancer is the second most common cancer and the second most common cause of cancer death. In 2023, an estimated 43 170 women died of breast cancer. Non-Hispanic White women have the highest incidence of breast cancer and non-Hispanic Black women have the highest mortality rate. Objective The USPSTF commissioned a systematic review to evaluate the comparative effectiveness of different mammography-based breast cancer screening strategies by age to start and stop screening, screening interval, modality, use of supplemental imaging, or personalization of screening for breast cancer on the incidence of and progression to advanced breast cancer, breast cancer morbidity, and breast cancer-specific or all-cause mortality, and collaborative modeling studies to complement the evidence from the review. Population Cisgender women and all other persons assigned female at birth aged 40 years or older at average risk of breast cancer. Evidence Assessment The USPSTF concludes with moderate certainty that biennial screening mammography in women aged 40 to 74 years has a moderate net benefit. The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of screening mammography in women 75 years or older and the balance of benefits and harms of supplemental screening for breast cancer with breast ultrasound or magnetic resonance imaging (MRI), regardless of breast density. Recommendation The USPSTF recommends biennial screening mammography for women aged 40 to 74 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of supplemental screening for breast cancer using breast ultrasonography or MRI in women identified to have dense breasts on an otherwise negative screening mammogram. (I statement).
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Affiliation(s)
| | | | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
| | | | | | | | - Esa M Davis
- University of Maryland School of Medicine, Baltimore
| | | | | | - Sei Lee
- University of California, San Francisco
| | - Li Li
- University of Virginia, Charlottesville
| | | | - Goutham Rao
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Joel Tsevat
- The University of Texas Health Science Center, San Antonio
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3
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Howard EC, Murray Horwitz ME, Gunn CM, Bak S, Nelson KP, Morton S, Flacks-Dunning JG, Battaglia TA. Burden and trajectory of social needs after breast cancer diagnosis at a safety-net hospital. Breast Cancer Res Treat 2024:10.1007/s10549-024-07389-5. [PMID: 38851661 DOI: 10.1007/s10549-024-07389-5] [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: 01/28/2024] [Accepted: 05/22/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE Unmet social needs pose barriers to cancer care, contributing to adverse outcomes and health inequities. A better understanding of how social needs change after cancer diagnosis can inform more effective, equity-focused interventions. METHODS In this study, we examined self-reported social needs at 0, 3, and 6 months after a breast cancer diagnosis in a racially diverse, multilingual sample (n = 222) enrolled in patient navigation intervention at an urban safety-net hospital. At each timepoint, respondents completed surveys about social needs related to employment, disability benefits, housing and utilities, and personal and family stability. RESULTS Over three-quarters (78%, n = 175) reported ≥ 1 social need, and 46% (n = 102) reported ≥ 3 social needs. The most frequently reported need was housing and utilities (64%, n = 142), followed by employment (40%, n = 90). Individuals from minoritized groups more frequently reported an increased number of social needs over time, compared with their White counterparts (p = 0.02). CONCLUSION Our findings suggest that despite navigation, many cancer patients from historically underrepresented populations continue to experience social concerns over the first 6 months of treatment. Further research, conducted with historically underrepresented populations in research, is needed to better understand the social needs of breast cancer patients to inform effective and equitable interventions.
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Affiliation(s)
- Eileen C Howard
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, 02118, USA.
| | - Mara E Murray Horwitz
- Section of General Internal Medicine, Women's Health Unit, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, 02118, USA
| | - Christine M Gunn
- Section of General Internal Medicine, Women's Health Unit, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, 02118, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, 02118, USA
- The Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Cancer Center, Geisel School of Medicine, Lebanon, NH, 03755, USA
| | - Sharon Bak
- Section of General Internal Medicine, Women's Health Unit, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, 02118, USA
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, 02118, USA
| | - Samantha Morton
- Samantha Morton Consulting, Boston, USA
- Formerly of MLPB (f/k/a Medical-Legal Partnership | Boston), Boston, USA
| | | | - Tracy A Battaglia
- Section of General Internal Medicine, Women's Health Unit, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, 02118, USA
- Yale School of Medicine, Yale Cancer Center, New Haven, 06510, USA
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4
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Dunn MR, Metwally EM, Vohra S, Hyslop T, Henderson LM, Reeder-Hayes K, Thompson CA, Lafata JE, Troester MA, Butler EN. Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study. Cancer Causes Control 2024; 35:825-837. [PMID: 38217760 PMCID: PMC11045315 DOI: 10.1007/s10552-023-01833-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/16/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations. METHODS This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified. RESULTS Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina. CONCLUSIONS Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.
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Affiliation(s)
- Matthew R Dunn
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Eman M Metwally
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sanah Vohra
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Terry Hyslop
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Louise M Henderson
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Pulmonary Disease and Critical Care Medicine, Department of Radiology, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Division of Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Caroline A Thompson
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer Elston Lafata
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Melissa A Troester
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Eboneé N Butler
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
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5
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Dontchos BN, Dodelzon K, Sonnenblick E, Reig B, Coffey K, Kacharia VS, Grimm LJ. Current Practice and Variation in Same-Day Services in Breast Imaging: A Multi-Institutional National Survey of the Society of Breast Imaging Membership. JOURNAL OF BREAST IMAGING 2024; 6:133-140. [PMID: 38340340 DOI: 10.1093/jbi/wbad111] [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: 10/25/2023] [Indexed: 02/12/2024]
Abstract
OBJECTIVE The availability of same-day services in breast imaging is an important topic given potential advantages for timely diagnoses and patient experiences, but there are potential barriers that lead facilities to not offer these services. We sought to understand current practice patterns and radiologist perspectives on offering same-day services. METHODS The Society of Breast Imaging (SBI) Patient Care & Delivery Committee developed a 19-question survey that was emailed to all 3449 active members of the SBI in May 2023. An exemption from the institutional review board was obtained at the lead author's institution. The survey consisted of 19 questions that were designed to understand the scope, perceptions, barriers, and logistics of same-day services. Comparisons were made between responses for offering same-day services (screening interpretation, diagnostic examinations, biopsies) and respondent demographics. RESULTS A total of 437 American and Canadian members participated, yielding a response rate of 12.7%. Respondents were most commonly in private practice (43.0%, 188/437), working in an outpatient medical center-based clinic (41.9%, 183/437), and without trainees (64.5%, 282/437). Respondents estimated 12.1% of screening examinations were interpreted while patients waited, which was significantly more common in free-standing breast imaging clinics (P = .028) and practices without trainees (P = .036). Respondents estimated 15.0% of diagnostic examinations were performed same day, which was more common in academic and private practices (P = .03) and practices without trainees (P = .01). Respondents estimated 11.5% of biopsies were performed the same day as the recommendation, which had no association with practice type/context, presence of trainees, number of mammography units, number of radiologists, or number of technologists. Long patient travel distance and limited patient mobility were the most cited reasons for offering patients same-day services. CONCLUSION Offering same-day breast imaging services varies among institutions and may be influenced by factors such as practice context and type and the presence of trainees.
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Affiliation(s)
- Brian N Dontchos
- Department of Radiology, Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | | | - Emily Sonnenblick
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Beatriu Reig
- Department of Radiology, New York University Langone Health, New York, NY, USA
| | - Kristen Coffey
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Vidhi S Kacharia
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Lars J Grimm
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
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6
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Grimm LJ, Shelby RA, Destounis SV, Knippa EE, Langman EL, Nedrud MA, Musick A, Yoon S, Johnson K, Baker J, Taylor-Cho M, Soo MS. Now or Later? Patient Satisfaction and Anxiety Among Women Undergoing Breast Biopsies Performed the Same Day as Recommended Versus a Later Day. J Am Coll Radiol 2024; 21:415-424. [PMID: 37820836 DOI: 10.1016/j.jacr.2023.07.028] [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: 04/27/2023] [Revised: 07/03/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE The aim of this study was to determine differences in patient satisfaction and anxiety among women undergoing core-needle breast biopsies performed the same day as recommended versus a future date. METHODS After institutional review board exemption was granted, a survey was administered to patients at four sites on the day of imaging-guided core-needle breast biopsy. The survey was available from November 2020 through January 2022. Questions pertained to biopsy timing (same day versus later day), pre- and postbiopsy satisfaction with overall breast-care experience, biopsy wait-time satisfaction, pre- and postbiopsy anxiety, radiologist-patient communication, demographics, life stressors, breast cancer history, and risk factors. Comparisons were made between same-day and later-day biopsies by multivariable analysis. RESULTS Of 974 respondents (response rate 65.6%), almost half were scheduled for same-day biopsies (47.8% [466 of 974]). In multivariate analyses, same-day biopsies were associated with higher prebiopsy overall breast-care satisfaction (P < .001), higher wait-time satisfaction (P < .001), and higher prebiopsy (P = .001) and postbiopsy anxiety (P = .001). Better radiologist-patient communication was associated with lower prebiopsy anxiety (P < .001) and greater prebiopsy overall (P < .001) and wait-time (P < .001) satisfaction. Compared with White women, Black women reported lower postbiopsy anxiety (P < .001) but also lower prebiopsy satisfaction (P = .03) and wait-time satisfaction (P < .001). CONCLUSIONS Same-day versus later-day biopsies resulted in better prebiopsy overall breast-care and wait-time patient satisfaction scores; however, no satisfaction differences were noted after biopsy. Clinically significant anxiety was associated with both same- and later-day biopsies but was higher for same-day biopsies. Higher anxiety levels correlated with lower overall satisfaction, suggesting that interventions to reduce anxiety and improve communication could improve patient experiences during same-day biopsies.
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Affiliation(s)
- Lars J Grimm
- Department of Radiology, Duke University, North Carolina.
| | - Rebecca A Shelby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
| | | | - Emily E Knippa
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eun L Langman
- Department of Radiology, Duke University, North Carolina
| | | | | | - Sora Yoon
- Department of Radiology, Duke University, North Carolina
| | - Karen Johnson
- Department of Radiology, Duke University, North Carolina
| | - Jay Baker
- Vice Chair, Department of Radiology, Duke University, North Carolina
| | | | - Mary Scott Soo
- Department of Radiology, Duke University, North Carolina
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Pleasant V. A Public Health Emergency: Breast Cancer Among Black Communities in the United States. Obstet Gynecol Clin North Am 2024; 51:69-103. [PMID: 38267132 DOI: 10.1016/j.ogc.2023.11.001] [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] [Indexed: 01/26/2024]
Abstract
While Black people have a similar incidence of breast cancer compared to White people, they have a 40% increased death rate. Black people are more likely to be diagnosed with aggressive subtypes such as triple-negative breast cancer. However, despite biological factors, systemic racism and social determinants of health create delays in care and barriers to treatment. While genetic testing holds incredible promise for Black people, uptake remains low and results may be challenging to interpret. There is a need for more robust, multidisciplinary, and antiracist interventions to reverse breast cancer-related racial disparities.
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Affiliation(s)
- Versha Pleasant
- Department of Obstetrics and Gynecology, Cancer Genetics & Breast Health Clinic, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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8
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Wilkerson AD, Gentle CK, Ortega C, Al-Hilli Z. Disparities in Breast Cancer Care-How Factors Related to Prevention, Diagnosis, and Treatment Drive Inequity. Healthcare (Basel) 2024; 12:462. [PMID: 38391837 PMCID: PMC10887556 DOI: 10.3390/healthcare12040462] [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: 12/16/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
Breast cancer survival has increased significantly over the last few decades due to more effective strategies for prevention and risk modification, advancements in imaging detection, screening, and multimodal treatment algorithms. However, many have observed disparities in benefits derived from such improvements across populations and demographic groups. This review summarizes published works that contextualize modern disparities in breast cancer prevention, diagnosis, and treatment and presents potential strategies for reducing disparities. We conducted searches for studies that directly investigated and/or reported disparities in breast cancer prevention, detection, or treatment. Demographic factors, social determinants of health, and inequitable healthcare delivery may impede the ability of individuals and communities to employ risk-mitigating behaviors and prevention strategies. The disparate access to quality screening and timely diagnosis experienced by various groups poses significant hurdles to optimal care and survival. Finally, barriers to access and inequitable healthcare delivery patterns reinforce inequitable application of standards of care. Cumulatively, these disparities underlie notable differences in the incidence, severity, and survival of breast cancers. Efforts toward mitigation will require collaborative approaches and partnerships between communities, governments, and healthcare organizations, which must be considered equal stakeholders in the fight for equity in breast cancer care and outcomes.
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Affiliation(s)
- Avia D Wilkerson
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Corey K Gentle
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Camila Ortega
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Zahraa Al-Hilli
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH 44195, USA
- Breast Center, Integrated Surgical Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Jhumkhawala V, Lobaina D, Okwaraji G, Zerrouki Y, Burgoa S, Marciniak A, Densley S, Rao M, Diaz D, Knecht M, Sacca L. Social determinants of health and health inequities in breast cancer screening: a scoping review. Front Public Health 2024; 12:1354717. [PMID: 38375339 PMCID: PMC10875738 DOI: 10.3389/fpubh.2024.1354717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/18/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction This scoping review aims to highlight key social determinants of health associated with breast cancer screening behavior in United States women aged ≥40 years old, identify public and private databases with SDOH data at city, state, and national levels, and share lessons learned from United States based observational studies in addressing SDOH in underserved women influencing breast cancer screening behaviors. Methods The Arksey and O'Malley York methodology was used as guidance for this review: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results. Results The 72 included studies were published between 2013 and 2023. Among the various SDOH identified, those related to socioeconomic status (n = 96) exhibited the highest frequency. The Health Care Access and Quality category was reported in the highest number of studies (n = 44; 61%), showing its statistical significance in relation to access to mammography. Insurance status was the most reported sub-categorical factor of Health Care Access and Quality. Discussion Results may inform future evidence-based interventions aiming to address the underlying factors contributing to low screening rates for breast cancer in the United States.
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Affiliation(s)
- Vama Jhumkhawala
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Diana Lobaina
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Goodness Okwaraji
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Yasmine Zerrouki
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Sara Burgoa
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Adeife Marciniak
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Sebastian Densley
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Meera Rao
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Daniella Diaz
- Charles E. Schmidt College of Science, Boca Raton, FL, United States
| | - Michelle Knecht
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Lea Sacca
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
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Arevalo M, Pickering TA, Vernon SW, Fujimoto K, Peskin MF, Farias AJ. Racial/ethnic disparities in the association between patient care experiences and receipt of initial surgical breast cancer care: findings from SEER-CAHPS. Breast Cancer Res Treat 2024; 203:553-564. [PMID: 37906395 DOI: 10.1007/s10549-023-07148-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 09/27/2023] [Indexed: 11/02/2023]
Abstract
PURPOSE We determined whether racial/ethnic differences in patient experiences with care influence timeliness and type of initial surgical breast cancer treatment for a sample of female Medicare cancer patients. METHODS We conducted a retrospective cohort study using the linked Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset. The outcomes were: (1) time-to-initial surgical treatment, and (2) type of treatment [breast conserving surgery (BCS) vs. mastectomy]. The indicators were reports of four types of patient experiences with care including doctor communication, getting care quickly, getting needed care, and getting needed Rx. Interaction terms in each multivariable logistic model examined if the associations varied by race/ethnicity. RESULTS Of the 2069 patients, 84.6% were White, 7.6% Black and 7.8% Hispanic. After adjusting for potential confounders, non-Hispanic Black patients who provided excellent reports of their ability to get needed prescriptions had lower odds of receiving surgery within 2-months of diagnosis, compared to NH-Whites who provided less than excellent reports (aOR: 0.29, 95% CI 0.09-0.98). There were no differences based on 1-month or 3-month thresholds. We found no other statistically significant effect of race/ethnicity. As to type of surgery, among NH Blacks, excellent reports of getting care quickly were associated with higher odds of receiving BCS versus mastectomy (aOR: 2.82, 95% CI 1.16-6.85) compared to NH Whites with less than excellent reports. We found no other statistically significant differences by race/ethnicity. CONCLUSION Experiences with care are measurable and modifiable factors that can be used to assess and improve aspects of patient-centered care. Improvements in patient care experiences of older adults with cancer, particularly among minorities, may help to eliminate racial/ethnic disparities in timeliness and type of surgical treatment.
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Affiliation(s)
- Mariana Arevalo
- Department of Health Promotion & Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA.
- Health Outcomes & Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.
| | - Trevor A Pickering
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sally W Vernon
- Department of Health Promotion & Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Kayo Fujimoto
- Department of Health Promotion & Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Melissa F Peskin
- Department of Health Promotion & Behavioral Sciences, School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Albert J Farias
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
- Gehr Family Center for Health System Science, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
- Cancer Control Research Program, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA, USA
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Lee I, Luo Y, Carretta H, LeBlanc G, Sinha D, Rust G. Latent pathway-based Bayesian models to identify intervenable factors of racial disparities in breast cancer stage at diagnosis. Cancer Causes Control 2024; 35:253-263. [PMID: 37702967 DOI: 10.1007/s10552-023-01785-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities. METHODS We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis. RESULTS Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction. CONCLUSIONS Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women.
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Affiliation(s)
- Inkoo Lee
- Department of Statistics, Rice University, Houston, USA
| | - Yi Luo
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, USA
| | - Henry Carretta
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, USA
| | - Gabrielle LeBlanc
- MD Class of 2023, Florida State University College of Medicine, Tallahassee, USA
| | - Debajyoti Sinha
- Department of Statistics, Florida State University, Tallahassee, USA
| | - George Rust
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, USA.
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12
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Jones V, Schroeder MC, Roberson ML, De Andrade J, Lizarraga IM. Differential response to neoadjuvant endocrine therapy for Black/African American and White women in NCDB. Breast Cancer Res Treat 2024; 203:125-134. [PMID: 37740855 PMCID: PMC10771585 DOI: 10.1007/s10549-023-07106-8] [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] [Received: 05/18/2023] [Accepted: 08/23/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE Compared to White women, there are higher mortality rates in Black/African American (BAA) women with hormone receptor-positive breast cancer (HR + BC) which may be partially due to differences in treatment resistance. We assessed factors associated with response to neoadjuvant endocrine therapy (NET). METHODS The National Cancer Database (NCDB) was queried for women with clinical stage I-III HR + BC diagnosed 2006-2017 and treated with NET. Univariate and multivariate analyses described associations between the sample, duration of NET, and subsequent treatment response, defined by changes between clinical and pathological staging. RESULTS The analytic sample included 9864 White and 1090 BAA women. Compared to White women, BAA women were younger, had more co-morbidities, were higher stage at presentation, and more likely to have > 24 weeks of NET. After excluding those with unknown pT/N/M, 3521 White and 365 BAA women were evaluated for NET response. On multivariate analyses, controlling for age, stage, histology, HR positivity, and duration of NET, BAA women were more likely to downstage to pT0/Tis (OR 3.0, CI 1.2-7.1) and upstage to Stage IV (OR 2.4, CI 1.002-5.6). None of the women downstaged to pT0/Tis presented with clinical stage III disease; only 2 of the women upstaged to Stage IV disease presented with clinical Stage I disease. CONCLUSION Independent of NET duration and clinical stage at presentation, BAA women were more likely to experience both complete tumor response and progression to metastatic disease. These results suggest significant heterogeneity in tumor biology and warrant a more nuanced therapeutic approach to HR + BC.
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Affiliation(s)
- Veronica Jones
- Department of Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA, 91010, USA.
| | - Mary C Schroeder
- Division of Health Services Research, University of Iowa College of Pharmacy, 180 S Grand Ave, Iowa City, IA, 52242, USA
| | - Mya L Roberson
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - James De Andrade
- Department of Surgery, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Ingrid M Lizarraga
- Department of Surgery, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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13
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Yoon SC, Taylor-Cho MW, Charles MG, Grimm L. Racial Disparities in Breast Imaging Wait Times Before and After the Implementation of a Same-Day Biopsy Program. JOURNAL OF BREAST IMAGING 2023; 5:159-166. [PMID: 38416937 DOI: 10.1093/jbi/wbad003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Indexed: 03/01/2024]
Abstract
OBJECTIVE To examine time from screening to diagnostic workup, biopsy, and surgery for non-Hispanic White (NHW) and Black women following implementation of a same-day biopsy program. METHODS All NHW and Black women with BI-RADS category 0 screening mammogram at Duke University Hospital were identified between August 1, 2020, and August 1, 2021. Patient characteristics were recorded. Time between screening mammogram, diagnostic workup, breast biopsy, surgical consultation, and surgery were recorded. Comparisons were made between NHW and Black women using a multivariable regression model. Diagnostic imaging to biopsy time interval was compared to historical averages before same-day biopsy implementation. RESULTS There were 2156 women: 69.9% NHW (1508/2156) and 30.1% Black (648/2156). Mean ± standard deviation time from screening to diagnostic imaging overall was 13.5 ± 32.5 days but longer for Black (18.0 ± 48.3 days) than for NHW women (11.5 ± 22.2 days) (P < 0.001). The mean time from diagnostic mammogram to biopsy was 5.9 ± 18.9 days, longer for Black (9.0 ± 27.9 days) than for NHW women (4.4 ± 11.8 days) (P = 0.017). The same-day biopsy program shortened the time from diagnostic imaging to biopsy overall (12.5 ± 12.4 days vs 5.9 ± 18.9 days; P < 0.001), with a significant reduction for NHW women (12.4 ± 11.7 days vs 4.4 ± 11.8 days) (P < 0.001) but not Black women (11.5 ± 9.9 days vs 9.0 ± 27.9 days) (P = 0.527). CONCLUSION Disparities exist along the breast imaging pathway. A same-day biopsy program benefited NHW women more than Black women.
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Affiliation(s)
- Sora C Yoon
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | | | - Matthew G Charles
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
| | - Lars Grimm
- Duke University Medical Center, Department of Radiology, Durham, NC, USA
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14
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Vijayaraghavan GR, Guembou IM, Vedantham S. The Current State of Timeliness in the Breast Cancer Diagnosis Journey: Abnormal Screening to Biopsy. Semin Ultrasound CT MR 2023; 44:56-61. [PMID: 36792274 DOI: 10.1053/j.sult.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There are several steps involved in a breast cancer diagnosis, starting from the initial abnormal screening mammogram. Each step from the additional imaging to a biopsy provokes anxiety. Timely attention to these appointments will not only help allay anxiety but also provide better care. While breast facilities routinely audit their performance, currently timeliness is not one of the audit parameters. The role of timeliness as a robust quality tool is gaining attention. In this study, we review the timeline of care at our facility over a 1-year period (October 2021- September 2022) and compare them with those reported by National Quality Measures for Breast Centers (NQMBC). Race, ethnicity, location, and type of facility affect the outcome of care and contribute to delays in providing care. In this manuscript, we outline some of the major factors. Societal guidelines outlining some metrics for timeliness may be a useful first step.
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Affiliation(s)
- Gopal R Vijayaraghavan
- Department of Radiology, University of Massachusetts Chan School of Medicine, UMass Memorial Healthcare, Worcester, MA.
| | - Isabelle M Guembou
- CITC (Center for Innovation and Transformational Change), UMass Memorial Healthcare, Worcester, MA
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15
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Dao K, Afran A, LeBedis C, Fishman MDC. The Impact of Social Determinants of Health on the Time Between Diagnostic Breast Imaging and Biopsy at a Safety Net Hospital. J Am Coll Radiol 2023; 20:393-401. [PMID: 36682645 DOI: 10.1016/j.jacr.2022.12.012] [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: 09/02/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Although social determinants of health (SDH) are thought to be associated with health outcomes, there is limited literature on the direct impact of SDH on delays in breast cancer diagnosis via breast imaging. Identifying SDH associated with longer lapses (defined in this study as a time interval between two events) between imaging and biopsy is essential to early-stage detection of breast cancer, which has a significant impact on survival. Previous work demonstrated associations between both housing and food insecurity with longer lapses between diagnostic imaging and biopsy. We aim to expand upon this retrospective analysis with a longer study period, more participants, and improved data cleaning techniques to better understand how SDH may affect the lapse between imaging and biopsy. METHODS This retrospective study was institutional review board approved and HIPAA compliant. Informed consent was waived. Patients who underwent screening mammography between January 1, 2015, and January 1, 2020, were assessed for timing of recommended biopsy due to a BI-RADS category 4 or 5. SDH were assessed with the unique Tool for Health & Resilience in Vulnerable Environments screening questionnaire developed at Boston Medical Center. Associations between imaging and biopsy timing and eight explanatory SDH variables (food insecurity, housing insecurity, ability to pay for medications, transportation access, ability to pay for utilities, caretaking needs, employment, and desire for more education) were assessed with multivariate Cox proportional hazard modeling, as well as demographic data. RESULTS There were 2,885 unique patients who underwent 3,142 unique diagnostic imaging studies and were included in the multivariate analysis. Of those 3,142 imaging studies, 196 (6.2%) had not yet been followed by the recommended biopsy by the end of the study period; 2,271 patients (78.7%) had SDH data in at least one domain; and the individual domains ranged from 962 patients (32.1%) with complete data for education to 2,175 patients (75.4%) with complete data for food insecurity. A positive screen for at least one SDH was associated with a longer lapse between diagnostic imaging and biopsy (P = .048). Furthermore, housing insecurity alone was nearly associated with longer lapses between diagnostic imaging and biopsy (P = .059). Those who desired more education were found to have shorter lapses between diagnostic imaging and biopsy (P = .037). CONCLUSIONS Only a positive screen of the aggregate of all SDH (using a novel tool developed at our safety net hospital) was associated with a statistically significant lengthening of this lapse. Of the eight SDH screened, housing insecurity was the closest to association with longer lapses between diagnostic imaging and biopsy, whereas patients who desired more education were found to have statistically significant shorter lapses; however, this survey domain had the lowest completion rate. CLINICAL RELEVANCE Identification of which SDH might affect the time from imaging to biopsy can potentially inform targeted programs to intervene. Government and health system interventions addressing SDH, notably housing insecurity, could allow for shorter time to breast cancer diagnosis and treatment.
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Affiliation(s)
- Kevin Dao
- Boston University School of Medicine, Boston, Massachusetts, and Ascension St Joseph Hospital, Chicago, Illinois.
| | - Aaron Afran
- Boston University School of Medicine, Boston, Massachusetts, and The Mount Sinai Hospital, New York, New York
| | - Christina LeBedis
- Vice Chair of Research, Assistant Professor of Radiology, and Radiologist, Body Imaging, Boston University School of Medicine, Boston, Massachusetts; and Boston Medical Center, Boston, Massachusetts
| | - Michael D C Fishman
- Assistant Professor of Radiology, Radiologist, Breast Imaging, Wellcoaches Certified Health and Wellness Coach, Boston University School of Medicine, Boston, Massachusetts; and Boston Medical Center, Boston, Massachusetts
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16
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Nguyen DL, Ambinder EB, Myers KS, Oluyemi E. Addressing Disparities Related to Access of Multimodality Breast Imaging Services Before and During the COVID-19 Pandemic. Acad Radiol 2022; 29:1852-1860. [PMID: 35562265 PMCID: PMC8947962 DOI: 10.1016/j.acra.2022.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/16/2022] [Accepted: 03/19/2022] [Indexed: 01/26/2023]
Abstract
Despite technological advancements focused on reducing breast cancer mortality through early detection, there have been reported disparities in the access to these imaging services with underserved patient populations (including racial minority groups and patients of low socioeconomic status) showing underutilization compared to other patient groups. These underserved populations tend to have more advanced breast cancer presentations, in part due to delays in diagnosis resulting in later stage of disease presentation. To make matters worse, the COVID-19 pandemic declared in March 2020 has resulted in significant healthcare disruptions leading to extensive delays in breast imaging services which are expected to negatively impact breast cancer mortality long-term. Given the worsening disparity in breast cancer mortality among racial/ethnic minorities and financially disadvantaged groups, it is vital to address these disparity gaps with the goal of reducing the barriers to timely breast cancer diagnosis and addressing breast cancer mortality differences among breast cancer patients. Therefore, this review aims to provide a discussion highlighting the disparities related to breast imaging access, the effects of the COVID-19 pandemic on these disparities, current targeted interventions implemented in breast imaging practices to reduce these disparities, and future directions on the journey to reducing disparity gaps for breast imaging patients. Tackling the root cause factors of the persistent breast cancer-related disparities is critical to meeting the needs of patients who are disadvantaged and can lead to continued improvement in the quality of individualized care for patients who have higher breast cancer morbidity and mortality risks.
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17
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Lawson MB, Bissell MCS, Miglioretti DL, Eavey J, Chapman CH, Mandelblatt JS, Onega T, Henderson LM, Rauscher GH, Kerlikowske K, Sprague BL, Bowles EJA, Gard CC, Parsian S, Lee CI. Multilevel Factors Associated With Time to Biopsy After Abnormal Screening Mammography Results by Race and Ethnicity. JAMA Oncol 2022; 8:1115-1126. [PMID: 35737381 PMCID: PMC9227677 DOI: 10.1001/jamaoncol.2022.1990] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Importance Diagnostic delays in breast cancer detection may be associated with later-stage disease and higher anxiety, but data on multilevel factors associated with diagnostic delay are limited. Objective To evaluate individual-, neighborhood-, and health care-level factors associated with differences in time from abnormal screening to biopsy among racial and ethnic groups. Design, Setting, and Participants This prospective cohort study used data from women aged 40 to 79 years who had abnormal results in screening mammograms conducted in 109 imaging facilities across 6 US states between 2009 and 2019. Data were analyzed from February 21 to November 4, 2021. Exposures Individual-level factors included self-reported race and ethnicity, age, family history of breast cancer, breast density, previous breast biopsy, and time since last mammogram; neighborhood-level factors included geocoded education and income based on residential zip codes and rurality; and health care-level factors included mammogram modality, screening facility academic affiliation, and facility onsite biopsy service availability. Data were also assessed by examination year. Main Outcome and Measures The main outcome was unadjusted and adjusted relative risk (RR) of no biopsy within 30, 60, and 90 days using sequential log-binomial regression models. A secondary outcome was unadjusted and adjusted median time to biopsy using accelerated failure time models. Results A total of 45 186 women (median [IQR] age at screening, 56 [48-65] years) with 46 185 screening mammograms with abnormal results were included. Of screening mammograms with abnormal results recommended for biopsy, 15 969 (34.6%) were not resolved within 30 days, 7493 (16.2%) were not resolved within 60 days, and 5634 (12.2%) were not resolved within 90 days. Compared with White women, there was increased risk of no biopsy within 30 and 60 days for Asian (30 days: RR, 1.66; 95% CI, 1.31-2.10; 60 days: RR, 1.58; 95% CI, 1.15-2.18), Black (30 days: RR, 1.52; 95% CI, 1.30-1.78; 60 days: 1.39; 95% CI, 1.22-1.60), and Hispanic (30 days: RR, 1.50; 95% CI, 1.24-1.81; 60 days: 1.38; 95% CI, 1.11-1.71) women; however, the unadjusted risk of no biopsy within 90 days only persisted significantly for Black women (RR, 1.28; 95% CI, 1.11-1.47). Sequential adjustment for selected individual-, neighborhood-, and health care-level factors, exclusive of screening facility, did not substantially change the risk of no biopsy within 90 days for Black women (RR, 1.27; 95% CI, 1.12-1.44). After additionally adjusting for screening facility, the increased risk for Black women persisted but showed a modest decrease (RR, 1.20; 95% CI, 1.08-1.34). Conclusions and Relevance In this cohort study involving a diverse cohort of US women recommended for biopsy after abnormal results on screening mammography, Black women were the most likely to experience delays to diagnostic resolution after adjusting for multilevel factors. These results suggest that adjustment for multilevel factors did not entirely account for differences in time to breast biopsy, but unmeasured factors, such as systemic racism and other health care system factors, may impact timely diagnosis.
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Affiliation(s)
- Marissa B. Lawson
- Department of Radiology, University of Washington School of Medicine, Seattle
| | - Michael C. S. Bissell
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis
| | - Diana L. Miglioretti
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis School of Medicine, Davis,Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Joanna Eavey
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Christina H. Chapman
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor,University of Wisconsin–Madison School of Medicine and Public Health, Madison
| | - Jeanne S. Mandelblatt
- Department of Oncology, Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Tracy Onega
- Department of Population Health Sciences, University of Utah, Huntsman Cancer Institute, Salt Lake City
| | - Louise M. Henderson
- Departments of Radiology and Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Garth H. Rauscher
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago
| | - Karla Kerlikowske
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco,General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco
| | - Brian L. Sprague
- Departments of Surgery and Radiology, University of Vermont Cancer Center, University of Vermont, Burlington
| | - Erin J. A. Bowles
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | - Charlotte C. Gard
- Department of Economics, Applied Statistics, and International Business, New Mexico State University, Las Cruces
| | | | - Christoph I. Lee
- Department of Radiology, University of Washington School of Medicine, Seattle,Department of Health Services, University of Washington School of Public Health, Seattle
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18
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Miles RC. Addressing Racial and Ethnic Differences in Diagnostic Resolution of Abnormal Mammographic Findings. JAMA Oncol 2022; 8:1126-1127. [PMID: 35737428 DOI: 10.1001/jamaoncol.2022.1864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Randy C Miles
- Department of Radiology, Denver Health, Denver, Colorado
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Houzard S, Courtois E, Le Bihan Benjamin C, Erbault M, Arnould L, Barranger E, Coussy F, Couturaud B, Cutuli B, de Cremoux P, de Reilhac P, de Seze C, Foucaut AM, Gompel A, Honoré S, Lesur A, Mathelin C, Verzaux L, Bousquet PJ. Monitoring breast cancer care quality at national and local level using the French National Cancer Cohort. Clin Breast Cancer 2022; 22:e832-e841. [DOI: 10.1016/j.clbc.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 11/25/2022]
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Vang SS, Dunn A, Margolies LR, Jandorf L. Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients. J Gen Intern Med 2022; 37:1619-1625. [PMID: 35212876 PMCID: PMC9130416 DOI: 10.1007/s11606-021-07189-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 10/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics. OBJECTIVES To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics. DESIGN Electronic medical record review of abnormal screening mammograms. SUBJECTS Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337). MAIN MEASURES Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors. KEY RESULTS Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively. CONCLUSIONS A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.
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Affiliation(s)
- Suzanne S Vang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA.
| | - Alexandra Dunn
- MD/MPH Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laurie R Margolies
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, and The Dubin Breast Center, Mount Sinai Hospital, New York, NY, USA
| | - Lina Jandorf
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1077, New York, NY, 10029, USA
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21
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Trivedi U, Omofoye TS, Marquez C, Sullivan CR, Benson DM, Whitman GJ. Mobile Mammography Services and Underserved Women. Diagnostics (Basel) 2022; 12:902. [PMID: 35453950 PMCID: PMC9032638 DOI: 10.3390/diagnostics12040902] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 02/05/2023] Open
Abstract
Breast cancer, the second most common cause of cancer in women, affects people across different ages, ethnicities, and incomes. However, while all women have some risk of breast cancer, studies have found that some populations are more vulnerable to poor breast cancer outcomes. Specifically, women with lower socioeconomic status and of Black and Hispanic ethnicity have been found to have more advanced stages of cancer upon diagnosis. These findings correlate with studies that have found decreased use of screening mammography services in these underserved populations. To alleviate these healthcare disparities, mobile mammography units are well positioned to provide convenient screening services to enable earlier detection of breast cancer. Mobile mammography services have been operating since the 1970s, and, in the current pandemic, they may be extremely helpful. The COVID-19 pandemic has significantly disrupted necessary screening services, and reinstatement and implementation of accessible mobile screenings may help to alleviate the impact of missed screenings. This review discusses the history and benefits of mobile mammography, especially for underserved women.
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Affiliation(s)
- Usha Trivedi
- Rutgers New Jersey Medical School, 187 S W Orange, Newark, NJ 07103, USA;
| | - Toma S. Omofoye
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030, USA; (T.S.O.); (C.M.); (C.R.S.)
| | - Cindy Marquez
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030, USA; (T.S.O.); (C.M.); (C.R.S.)
| | - Callie R. Sullivan
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030, USA; (T.S.O.); (C.M.); (C.R.S.)
| | - Diane M. Benson
- Office of Health Policy, The University of Texas MD Anderson Cancer Center, 7007 Bertner Avenue, Unit 1677, Houston, TX 77030, USA;
| | - Gary J. Whitman
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1350, Houston, TX 77030, USA; (T.S.O.); (C.M.); (C.R.S.)
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22
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Green VL. Breast Cancer Risk Assessment and Management of the High-Risk Patient. Obstet Gynecol Clin North Am 2022; 49:87-116. [DOI: 10.1016/j.ogc.2021.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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23
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DeBenedectis CM, Spalluto LB, Americo L, Bishop C, Mian A, Sarkany D, Kagetsu NJ, Slanetz PJ. Health Care Disparities in Radiology-A Review of the Current Literature. J Am Coll Radiol 2022; 19:101-111. [PMID: 35033297 DOI: 10.1016/j.jacr.2021.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/31/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Health care disparities exist in all medical specialties, including radiology. Raising awareness of established health care disparities is a critical component of radiology's efforts to mitigate disparities. Our primary objective is to perform a comprehensive review of the last 10 years of literature pertaining to disparities in radiology care. Our secondary objective is to raise awareness of disparities in radiology. METHODS We reviewed English-language medicine and health services literature from the past 10 years (2010-2020) for research that described disparities in any aspect of radiologic imaging using radiology search terms and key words for disparities in OVID. Relevant studies were identified with adherence to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS The search yielded a total 1,890 articles. We reviewed the citations and abstracts with the initial search yielding 1,890 articles (without duplicates). Of these, 1,776 were excluded based on the criteria set forth in the methods. The remaining unique 114 articles were included for qualitative synthesis. DISCUSSION We hope this article increases awareness and inspires action to address disparities and encourages research that further investigates previously identified disparities and explores not-yet-identified disparities.
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Affiliation(s)
- Carolynn M DeBenedectis
- Vice-Chair, Education; Director, Radiology Residency Program; Department of Radiology, President-elect, New England Roentgen Ray Society; and Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Lucy B Spalluto
- Vice-Chair, Health Equity; Director, Women in Radiology; Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Ingram Cancer Center, Nashville, Tennessee; Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research; and Education and Clinical Center (GRECC), Nashville, Tennessee
| | - Lisa Americo
- Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Casey Bishop
- Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Asim Mian
- Director, Radiology Residency Program; Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - David Sarkany
- Director, Radiology Residency Program; Department of Radiology, Staten Island University Hospital Northwell Health, Staten Island, New York
| | - Nolan J Kagetsu
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Priscilla J Slanetz
- Vice-Chair, Academic Affairs; Associate Program Director, Radiology Residency Program, Boston Medical Center; President-elect Massachusetts Radiologic Society; Secretary, Association of University Radiologists; Chair, Breast Imaging Panel 2, ACR Appropriateness Guidelines Committee; and Department of Radiology, Boston Medical Center, Boston, Massachusetts
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Ambinder EB, Oluyemi E, Kong X, Nguyen DL, Visvanathan K. Disparities in the uptake of digital breast tomosynthesis for breast cancer screening: A retrospective cohort study. Breast J 2021; 27:872-876. [PMID: 34668275 DOI: 10.1111/tbj.14292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
We present a retrospective cohort study evaluating the utilization and effectiveness of digital breast tomosynthesis (DBT) for breast cancer screening with a focus on racial differences. 46,236 females underwent screening mammography between 4/1/2013 and 3/30/2020, during which there was an increase in DBT utilization from 18.8% in year 1 to 89.6% in year 7. Black and Asian women were significantly less likely to have a screening study with DBT compared to White women. Overall, the DBT group had a lower recall rate (9.1% versus 11.2%, p < 0.001) and higher cancer detection rate (6.0 vs 4.1, p < 0.001) compared to the FFDM group.
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Affiliation(s)
- Emily B Ambinder
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Eniola Oluyemi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Xiangrong Kong
- Bloomberg School of Public Health, Johns Hopkins, Baltimore, MD, USA.,Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Derek L Nguyen
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Kala Visvanathan
- Bloomberg School of Public Health, Johns Hopkins, Baltimore, MD, USA.,Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medicine, Baltimore, MD, USA
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Luo Y, Carretta H, Lee I, LeBlanc G, Sinha D, Rust G. Naïve Bayesian network-based contribution analysis of tumor biology and healthcare factors to racial disparity in breast cancer stage-at-diagnosis. Health Inf Sci Syst 2021; 9:35. [PMID: 34631040 DOI: 10.1007/s13755-021-00165-5] [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: 05/04/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022] Open
Abstract
Background Variation in breast cancer stage at initial diagnosis (including racial disparities) is driven both by tumor biology and healthcare factors. Methods We studied women age 67-74 with initial diagnosis of breast cancer from 2006 through 2014 in the SEER-Medicare database. We extracted variables related to tumor biology (histologic grade and hormone receptor status) and healthcare factors (screening mammography [SM] utilization and time delay from mammography to diagnostic biopsy). We used naïve Bayesian networks (NBNs) to illustrate the relationships among patient-specific factors and stage-at-diagnosis for African American (AA) and white patients separately. After identifying and controlling confounders, we conducted counterfactual inference through the NBN, resulting in an unbiased evaluation of the causal effects of individual factors on the expected utility of stage-at-diagnosis. An NBN-based decomposition mechanism was developed to evaluate the contributions of each patient-specific factor to an actual racial disparity in stage-at-diagnosis. 2000 bootstrap samples from our training patients were used to compute the 95% confidence intervals (CIs) of these contributions. Results Using a causal-effect contribution analysis, the relative contributions of each patient-specific factor to the actual racial disparity in stage-at-diagnosis were as follows: tumor grade, 45.1% (95% CI: 44.5%, 45.8%); hormone receptor status, 5.0% (4.5%, 5.4%); mammography utilization, 23.1% (22.4%, 24.0%); and biopsy delay 26.8% (26.1%, 27.3%). Conclusion The modifiable mechanisms of mammography utilization and biopsy delay drive about 49.9% of racial difference in stage-at-diagnosis, potentially guiding more targeted interventions to eliminate cancer outcome disparities. Supplementary Information The online version contains supplementary material available at 10.1007/s13755-021-00165-5.
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Affiliation(s)
- Yi Luo
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL USA
| | - Henry Carretta
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL USA
| | - Inkoo Lee
- Department of Statistics, Florida State University, 117 N. Woodward Ave., Tallahassee, FL USA
| | - Gabrielle LeBlanc
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL USA
| | - Debajyoti Sinha
- Department of Statistics, Florida State University, 117 N. Woodward Ave., Tallahassee, FL USA
| | - George Rust
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL USA
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Poteat T, Adams MA, Malone J, Geffen S, Greene N, Nodzenski M, Lockhart A, Su IH, Dean LT. Delays in breast cancer care by race and sexual orientation: Results from a national survey with diverse women in the United States. Cancer 2021; 127:3514-3522. [PMID: 34287838 PMCID: PMC8684596 DOI: 10.1002/cncr.33629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/19/2020] [Accepted: 01/19/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Despite known differences in breast cancer by both race and sexual orientation, data on the intersectional experiences of Black sexual minority women (BSMW) along the care continuum are scant. This study sought to understand delays in breast cancer care by examining the intersection of race and sexual orientation. METHODS This online, cross-sectional survey enrolled racially and sexually diverse women aged ≥ 35 years who had been diagnosed with breast cancer within the prior 10 years or had an abnormal screening in the prior 24 months. The authors calculated summary statistics by race/sexual orientation categories, and they conducted univariate and multivariable modeling by using multiple imputation for missing data. RESULTS BSMW (n = 101) had the highest prevalence of care delays with 5.17-fold increased odds of a care delay in comparison with White heterosexual women (n = 298) in multivariable models. BSMW reported higher intersectional stigma and lower social support than all other groups. In models adjusted for race, sexual orientation, and income, intersectional stigma was associated with a 2.43-fold increase in care delays, and social support was associated with a 32% decrease in the odds of a care delay. CONCLUSIONS Intersectional stigma may be an important driver of breast cancer inequities for BSMW. Reducing stigma and ensuring access to appropriate social support that addresses known barriers can be an important approach to reducing inequities in the breast cancer care continuum.
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Affiliation(s)
- Tonia Poteat
- University of North Carolina Chapel Hill, Department of Social Medicine, CB #7240, Chapel Hill, NC 27599
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N Wolfe Street, Baltimore, MD 21205
| | | | - Jowanna Malone
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N Wolfe Street, Baltimore, MD 21205
| | - Sophia Geffen
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N Wolfe Street, Baltimore, MD 21205
| | - Naomi Greene
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624 North Broadway Street, Baltimore, MD 21205
| | - Michael Nodzenski
- University of North Carolina Chapel Hill, Department of Biostatistics, CB #7420, Chapel Hill, NC 27599
| | - Alex Lockhart
- University of North Carolina Chapel Hill, Department of Biostatistics, CB #7420, Chapel Hill, NC 27599
| | - I-Hsuan Su
- University of North Carolina Chapel Hill, Department of Biostatistics, CB #7420, Chapel Hill, NC 27599
| | - Lorraine T. Dean
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N Wolfe Street, Baltimore, MD 21205
- Johns Hopkins School of Medicine, Department of Oncology, 720 Rutland Ave, Baltimore, MD 21205
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Disparities in Same-Day Diagnostic Imaging in Breast Cancer Screening: Impact of an Immediate-Read Screening Mammography Program Implemented During the COVID-19 Pandemic. AJR Am J Roentgenol 2021; 218:270-278. [PMID: 34494449 DOI: 10.2214/ajr.21.26597] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND. The need for second visits between screening mammography and diagnostic imaging contributes to disparities in the time to breast cancer diagnosis. During the COVID-19 pandemic, an immediate-read screening mammography program was implemented to reduce patient visits and decrease time to diagnostic imaging. OBJECTIVE. The purpose of this study was to measure the impact of an immediate-read screening program with focus on disparities in same-day diagnostic imaging after abnormal findings are made at screening mammography. METHODS. In May 2020, an immediate-read screening program was implemented whereby a dedicated breast imaging radiologist interpreted all screening mammograms in real time; patients received results before discharge; and efforts were made to perform any recommended diagnostic imaging during the visit (performed by different radiologists). Screening mammographic examinations performed from June 1, 2019, through October 31, 2019 (preimplementation period), and from June 1, 2020, through October 31, 2020 (postimplementation period), were retrospectively identified. Patient characteristics were recorded from the electronic medical record. Multivariable logistic regression models incorporating patient age, race and ethnicity, language, and insurance type were estimated to identify factors associated with same-day diagnostic imaging. Screening metrics were compared between periods. RESULTS. A total of 8222 preimplementation and 7235 postimplementation screening examinations were included; 521 patients had abnormal screening findings before implementation, and 359 after implementation. Before implementation, 14.8% of patients underwent same-day diagnostic imaging after abnormal screening mammograms. This percentage increased to 60.7% after implementation. Before implementation, patients who identified their race as other than White had significantly lower odds than patients who identified their race as White of undergoing same-day diagnostic imaging after receiving abnormal screening results (adjusted odds ratio, 0.30; 95% CI, 0.10-0.86; p = .03). After implementation, the odds of same-day diagnostic imaging were not significantly different between patients of other races and White patients (adjusted odds ratio, 0.92; 95% CI, 0.50-1.71; p = .80). After implementation, there was no significant difference in race and ethnicity between patients who underwent and those who did not undergo same-day diagnostic imaging after receiving abnormal results of screening mammography (p > .05). The rate of abnormal interpretation was significantly lower after than it was before implementation (5.0% vs 6.3%; p < .001). Cancer detection rate and PPV1 (PPV based on positive findings at screening examination) were not significantly different before and after implementation (p > .05). CONCLUSION. Implementation of the immediate-read screening mammography program reduced prior racial and ethnic disparities in same-day diagnostic imaging after abnormal screening mammograms. CLINICAL IMPACT. An immediate-read screening program provides a new paradigm for improved screening mammography workflow that allows more rapid diagnostic workup with reduced disparities in care.
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Abraham P, Bishay AE, Farah I, Williams E, Tamayo-Murillo D, Newton IG. Reducing Health Disparities in Radiology Through Social Determinants of Health: Lessons From the COVID-19 Pandemic. Acad Radiol 2021; 28:903-910. [PMID: 34001438 DOI: 10.1016/j.acra.2021.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 04/22/2021] [Indexed: 12/20/2022]
Abstract
During the COVID-19 pandemic, the disproportionate morbidity and mortality borne by racial minorities, patients of lower socioeconomic status, and patients lacking health insurance reflect the critical role of social determinants of health, which are manifestations of entrenched structural inequities. In radiology, social determinants of health lead to disparate use of imaging services through multiple intersecting contributors, on both the provider and patient side, affecting diagnosis and treatment. Disparities on the provider side include ordering of initial or follow-up imaging studies and providing standard-of-care interventional procedures, while patient factors include differences in awareness of screening exams and confidence in the healthcare system. Disparate utilization of mammography and lung cancer screening lead to delayed diagnosis, while differential provision of minimally invasive interventional procedures contributes to differential outcomes related to treatment. Interventions designed to mitigate social determinants of health could help to equalize the healthcare system. Here we review disparities in access and health outcomes in radiology. We investigate underlying contributing factors in order to identify potential policy changes that could promote more equitable health in radiology.
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29
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Dean LT, Greene N, Adams MA, Geffen SR, Malone J, Tredway K, Poteat T. Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women. Psychooncology 2021; 30:1145-1150. [PMID: 33689190 PMCID: PMC8273081 DOI: 10.1002/pon.5670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black-White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening. METHODS This cross-sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9-item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self-reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011. RESULTS Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity. CONCLUSIONS SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.
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Affiliation(s)
- Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Naomi Greene
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mary Anne Adams
- ZAMI NOBLA: National Organization of Black Lesbians on Aging, East Point, Georgia, USA
| | - Sophia R. Geffen
- Center for Health Equity Education & Advocacy, Cambridge Health Alliance, Cambridge, Massachusetts, USA
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kristi Tredway
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tonia Poteat
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Social Medicine, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
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Twahir M, Oyesegun R, Yarney J, Gachii A, Edusa C, Nwogu C, Mangutha G, Anderson P, Benjamin E, Müller B, Ngoh C. Real-world challenges for patients with breast cancer in sub-Saharan Africa: a retrospective observational study of access to care in Ghana, Kenya and Nigeria. BMJ Open 2021; 11:e041900. [PMID: 33653746 PMCID: PMC7929861 DOI: 10.1136/bmjopen-2020-041900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To evaluate medical resource utilisation and timeliness of access to specific aspects of a standard care pathway for breast cancer at tertiary centres in sub-Saharan Africa. DESIGN Data were retrospectively abstracted from records of patients with breast cancer treated within a prespecified 2-year period between 2014 and 2017. The study protocol was approved by local institutional review boards. SETTING Six tertiary care institutions in Ghana, Kenya and Nigeria were included. PARTICIPANTS Health records of 862 patients with breast cancer were analysed: 299 in Ghana; 314 in Kenya; and 249 in Nigeria. INTERVENTIONS As directed by the treating physician. OUTCOME MEASURES Parameters selected for evaluation included healthcare resource and use, medical procedure turnaround times and out-of-pocket (OOP) payment patterns. RESULTS Use of mammography or breast ultrasonography was <45% in all three countries. Across the three countries, 78%-88% of patients completed tests for hormone receptors and human epidermal growth factor receptor 2 (HER2). Most patients underwent mastectomy (64%-67%) or breast-conserving surgery (15%-26%). Turnaround times for key procedures, such as pathology, surgery and systemic therapy, ranged from 1 to 5 months. In Ghana and Nigeria, most patients (87%-93%) paid for diagnostic tests entirely OOP versus 30%-32% in Kenya. Similarly, proportions of patients paying OOP only for treatments were high: 45%-79% in Ghana, 8%-20% in Kenya and 72%-89% in Nigeria. Among patients receiving HER2-targeted therapy, the average number of cycles was five for those paying OOP only versus 14 for those with some insurance coverage. CONCLUSIONS Patients with breast cancer treated in tertiary facilities in sub-Saharan Africa lack access to timely diagnosis and modern systemic therapies. Most patients in Ghana and Nigeria bore the full cost of their healthcare and were more likely to be employed and have secondary or postsecondary education. Access to screening/diagnosis and appropriate care is likely to be substantively lower for the general population.
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31
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Greene N, Malone J, Adams MA, Dean LT, Poteat T. "This is some mess right here": Exploring interactions between Black sexual minority women and health care providers for breast cancer screening and care. Cancer 2021; 127:74-81. [PMID: 32990978 PMCID: PMC7865953 DOI: 10.1002/cncr.33219] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/13/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Few studies have explored how the intersection of race and sexual identity contribute to breast cancer disparities for Black sexual minority women (SMW). Issues within patient-provider relationships, including bias, contribute to health disparities for minority groups. The authors used constructs from self-determination theory (SDT) to explore the nature of health care provider interactions in breast cancer screening and care among Black SMW. METHODS Participants were sampled nationally through social media, targeted emails, and referrals. Qualitative, in-depth interviews were conducted with 15 Black cisgender SMW, ages 38 to 64 years, who had a breast cancer diagnosis or recent abnormal mammogram. Interviews were conducted face-to-face or online, audio-recorded, and transcribed verbatim. Two analysts coded the interviews. Codes were analyzed across interviews to identify themes salient to SDT. RESULTS Themes aligned with the SDT constructs of relatedness and autonomy. Some participants discussed feeling most understood by Black and/or female providers who shared at least 1 of their identities. Feeling understood through shared identity contributed to participants feeling seen and heard by their providers. Participants who discussed negative experiences with providers believed that the provider made negative assumptions about them based on their race and/or sexual orientation. CONCLUSIONS When interacting with health care providers for breast cancer screening and care, Black SMW face specific challenges related to their multiply marginalized social position. Reducing health care provider bias toward Black SMW may improve patients' desires to continue in care. Providing equitable care while acknowledging and respecting women with multiply marginalized identities may improve the nature of these interactions.
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Affiliation(s)
- Naomi Greene
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society
| | - Jowanna Malone
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology
| | - Mary Anne Adams
- ZAMI NOBLA: National Organization of Black Lesbians on Aging
| | - Lorraine T. Dean
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology
- Sidney Kimmel Cancer Center, Department of Oncology
| | - Tonia Poteat
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology
- University of North Carolina Chapel Hill School of Medicine, Department of Social Medicine
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Melchior NM, Sachs DB, Gauvin G, Chang C, Wang CE, Sigurdson ER, Daly JM, Aggon AA, Hayes SB, Obeid EI, Bleicher RJ. Treatment times in breast cancer patients receiving neoadjuvant vs adjuvant chemotherapy: Is efficiency a benefit of preoperative chemotherapy? Cancer Med 2020; 9:2742-2751. [PMID: 32096915 PMCID: PMC7163083 DOI: 10.1002/cam4.2912] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/10/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/OBJECTIVE Delays in times to surgery, chemotherapy, and radiotherapy impair survival in breast cancer patients. Neoadjuvant chemotherapy (NAC) confers equivalent survival to adjuvant chemotherapy (AC), but it remains unknown which approach facilitates faster initiation and completion of treatment. METHODS Women ≥18 years old with nonrecurrent, noninflammatory, clinical stage I-III breast cancer diagnosed between 2004 and 2015 who underwent both surgery and chemotherapy were reviewed from the National Cancer Database. RESULTS Among 155 606 women overall, 28 241 patients received NAC and 127 365 patients received AC. NAC patients had higher clinical T and N stages (35.8% T3/4 vs 4.9% T3/4; 14.4% N2/3 vs 3.7% N2/3). After adjusting for stage and other factors, NAC patients had longer times to begin treatment (36.1 vs 35.4 days adjusted, P = .15), and took significantly longer to start radiotherapy (240.8 vs 218.2 days adjusted, P < .0001), and endocrine therapy (301.6 vs 275.7 days adjusted, P < .0001). Unplanned readmissions (1.2% vs 1.7%), 30-day mortality (0.04% vs 0.01%), and 90-day mortality (0.30% vs 0.08%) were all low and clinically insignificant between NAC and AC. CONCLUSION Compared to patients receiving AC, those receiving NAC do not start treatment sooner. In addition, patients receiving NAC do not complete treatment faster. Although there are clear indications for administering NAC vs AC, rapidity of treatment should not be considered a benefit of giving chemotherapy preoperatively.
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Affiliation(s)
- Nicole M Melchior
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Darren B Sachs
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Gabrielle Gauvin
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Cecilia Chang
- Biostatistics Core, NorthShore University HealthSystem Research Institute, Evanston, IL, USA
| | - Chihsiung E Wang
- Biostatistics Core, NorthShore University HealthSystem Research Institute, Evanston, IL, USA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - John M Daly
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Allison A Aggon
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elias I Obeid
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Dong J, Esham KS, Boehm L, Karim SA, Lin M, Mao D, Wang F, Fein D, Wang H, Studenmund C, Weidner RA, Noubary F, Freund KM, Erban JK, Parsons SK. Timeliness of Treatment Initiation in Newly Diagnosed Patients With Breast Cancer. Clin Breast Cancer 2020; 20:e27-e35. [PMID: 31439436 DOI: 10.1016/j.clbc.2019.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/06/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Evidence-based timeliness benchmarks have been established to assess quality of breast cancer care, as delays in treatment are associated with poor clinical outcomes. However, few studies have evaluated how current breast cancer care meets these benchmarks and what factors may delay the timely initiation of treatment. PATIENTS AND METHODS Demographic and disease characteristics of 377 newly diagnosed patients with breast cancer who initiated treatment at Tufts Medical Center (2009-2015) were extracted from electronic medical records. Time from diagnosis to initial surgery and time from diagnosis to initiation of hormone therapy were estimated with Kaplan-Meier curves. Multivariable regression analysis was used to identify factors associated with treatment delays. Thematic analysis was performed to categorize reasons for delay. RESULTS Of 319 patients who had surgery recommended as the first treatment, 248 (78%) met the 45-day benchmark (median, 28 days; 25th-75th %, 19-43). After adjusting for potential confounders, multivariable regression analysis revealed that negative hormone receptor status (odds ratio, 3.48; 95% confidence interval, 1.44-8.43) and mastectomy (odds ratio, 4.07; 95% confidence interval, 2.10-8.06) were significantly associated with delays in surgery. Delays were mostly owing to clinical complexity or logistical/financial reasons. Of 241 patients eligible for hormone therapy initiation, 232 (96%) met the 1-year benchmark (median, 147 days; 25th-75th %, 79-217). CONCLUSION Most patients met timeliness guidelines for surgery and initiation of hormone therapy, although risk factors for delay were identified. Knowledge of reasons for breast cancer treatment delay, including clinical complexity and logistical/financial issues, may allow targeting interventions for patients at greatest risk of care delays.
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Affiliation(s)
- Jinghui Dong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Kimberly S Esham
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Hematology/Oncology, Tufts Medical Center, Boston, MA
| | - Lauren Boehm
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Sabrina A Karim
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Mingqian Lin
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Daqin Mao
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Fengqing Wang
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Daniel Fein
- Department of Medicine, Tufts Medical Center, Boston, MA
| | - Hanyin Wang
- Department of Medicine, Tufts Medical Center, Boston, MA
| | - Christine Studenmund
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Ruth Ann Weidner
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Farzad Noubary
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Karen M Freund
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA; Department of Medicine, Tufts Medical Center, Boston, MA
| | - John K Erban
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Hematology/Oncology, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts Medical Center, Boston, MA
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Hematology/Oncology, Tufts Medical Center, Boston, MA; Department of Medicine, Tufts Medical Center, Boston, MA; Department of Pediatrics, Tufts University School of Medicine, Boston, MA.
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Malone J, Snguon S, Dean LT, Adams MA, Poteat T. Breast Cancer Screening and Care Among Black Sexual Minority Women: A Scoping Review of the Literature from 1990 to 2017. J Womens Health (Larchmt) 2019; 28:1650-1660. [PMID: 30882262 PMCID: PMC6919240 DOI: 10.1089/jwh.2018.7127] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: Black women are more likely to be diagnosed at later stages of breast cancer compared with White women due to lower frequency of screening and lack of timely follow-up after abnormal screening results. Disparities in breast cancer screening, risk, and mortality are present within both Black women and sexual minority communities; however, there exists limited research concerning breast cancer care among Black sexual minority women. Materials and Methods: This scoping review examines the literature from 1990 to 2017 of the breast cancer care continuum among Black sexual minority women, including behavioral risk factors, screening, treatment, and survivorship. A total of 91 articles were identified through PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. Fifteen articles were selected for data extraction, which met the criteria for including Black/African American women, discussing breast cancer care among both racial and sexual minorities, and being a peer-reviewed article. Results: The 15 articles were primarily within urban contexts, and defined sexual minorities as lesbian or bisexual women. Across all the studies, Black sexual minority women were highly under-represented, and key conclusions are not fully applicable to Black sexual minority women. Sexual minority women had a higher prevalence of breast cancer risk factors (i.e., nulliparity, fewer mammograms, higher alcohol intake, and lower oral contraceptive use). Furthermore, some studies noted homophobia from health providers as potential barriers to engagement in care for sexual minority women. Conclusions: The lack of studies concerning Black sexual minority women in breast cancer care indicates the invisibility of a group that experiences multiple marginalized identities. More research is needed to capture the dynamics of the breast cancer care continuum for Black sexual minority women.
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Affiliation(s)
- Jowanna Malone
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Sevly Snguon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Lorraine T. Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Tonia Poteat
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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Lovejoy LA, Eaglehouse YL, Hueman MT, Mostoller BJ, Shriver CD, Ellsworth RE. Evaluation of Surgical Disparities Between African American and European American Women Treated for Breast Cancer Within an Equal-Access Military Hospital. Ann Surg Oncol 2019; 26:3838-3845. [PMID: 31410609 DOI: 10.1245/s10434-019-07706-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Survival disparities between African American women (AAW) and European American women (EAW) with invasive breast cancer may be attributable, in part, to access to or quality of medical care. In this study, we evaluated surgical disparities between AAW and EAW treated within an equal-access military treatment facility (MTF). METHODS All AAW (N = 271) and EAW (N = 628) with Stage I-III breast cancer who had their initial diagnosis performed at Murtha Cancer Center at Walter Reed National Military Medical Center were identified. Differences in surgical interval (time between diagnosis and definitive breast surgery) and surgical procedures were evaluated using χ2 and Student t-tests while survival was analyzed using Kaplan-Meier survival estimates and log-rank tests. A P value < 0.05 was used to define significance. RESULTS Surgical intervals did not differ significantly between populations with an average of 36.3 days in AAW and 33.9 days in EAW. Frequency of the percentage of women undergoing reexcision, mastectomy, and prophylactic removal of the contralateral breast did not differ significantly between populations. Likewise, frequency of sentinel lymph node biopsy and 5-year survival were not significantly different between AAW compared to EAW. DISCUSSION Surgical intervals and procedures were similar between AAW and EAW treated within an equal-access MTF. These data demonstrate that the availability of quality surgical care to all patients with stage I-III breast cancer may eliminate survival disparities between AAW and EAW, emphasizing the importance of equalizing access to breast care.
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Affiliation(s)
- Leann A Lovejoy
- Chan Soon-Shiong Institute of Molecular Medicine, Windber, PA, USA
| | - Yvonne L Eaglehouse
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, and Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Matthew T Hueman
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Craig D Shriver
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rachel E Ellsworth
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, and Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA. .,Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, and Henry M. Jackson Foundation for the Advancement of Military Medicine, Windber, PA, USA.
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Dontchos BN, Narayan AK, Seidler M, Mercaldo SF, Miles RC, Ebert E, Lehman CD. Impact of a Same-Day Breast Biopsy Program on Disparities in Time to Biopsy. J Am Coll Radiol 2019; 16:1554-1560. [PMID: 31152690 DOI: 10.1016/j.jacr.2019.05.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/13/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Disparities in breast cancer diagnosis are established. In usual practice, biopsies are performed days or weeks after recommendation. Our aim was to measure the impact of a same-day biopsy program on disparities in time from biopsy recommendation to performance. METHODS After Institutional Review Board approval, we identified all diagnostic examinations leading to biopsy pre- (September 2016 to March 2017) and post- (September 2017 to March 2018) implementation of our same-day biopsy program. We compared demographic characteristics (age, race, language, and insurance) and biopsy information (days from biopsy recommendation to biopsy, and proportion of same-day biopsies in all biopsies) in pre- versus postimplementation groups. Multivariable linear and logistic models in pre- and postimplementation groups assessed if days from biopsy recommendation to biopsy and having a same-day biopsy were associated with patient subgroups. RESULTS In all, 663 and 482 patients underwent biopsy during pre- and postimplementation periods, respectively. Patient subgroups were similar between periods. For all patients, the same-day biopsy program decreased median time from diagnostic examination to biopsy from 8 (interquartile range: 4-13) to 0 (interquartile range: 0-4) days (P < .001). During the pre-implementation period, nonwhite patients and having Medicare insurance were associated with longer days to biopsy (nonwhite Adjusted Coefficient: 2.31, 95% confidence interval [CI]: 0.58-4.03; insurance Adjusted Coefficient: 2.47, 95% CI: 0.58-4.37; P < .05), after adjustment. During the postimplementation period, the previously seen disparities did not persist (nonwhite Adjusted Coefficient: -0.416, 95% CI: -2.16-1.33; insurance Adjusted Coefficient: 0.812, 95% CI: -1.18-2.80; P > .05). CONCLUSION There was no evidence of racial/ethnic or insurance disparities in time from biopsy recommendation to performance after implementation of a same-day biopsy program.
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Affiliation(s)
| | | | | | | | - Randy C Miles
- Massachusetts General Hospital, Boston, Massachusetts
| | - Emily Ebert
- Massachusetts General Hospital, Boston, Massachusetts
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Eaglehouse YL, Georg MW, Shriver CD, Zhu K. Racial Differences in Time to Breast Cancer Surgery and Overall Survival in the US Military Health System. JAMA Surg 2019; 154:e185113. [PMID: 30673075 DOI: 10.1001/jamasurg.2018.5113] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Racial disparities in time to surgery (TTS) after a breast cancer diagnosis and whether these differences account for disparities in overall survival have been understudied in the US population. Objectives To compare TTS in non-Hispanic black (NHB) and non-Hispanic white (NHW) women with breast cancer and to examine whether racial differences in TTS may explain possible racial disparities in overall survival in a universal health care system. Design, Setting, and Participants Retrospective cohort identified from the Department of Defense Central Cancer Registry and Military Health System Data Repository linked databases containing records between January 1, 1998, and December 31, 2008, of 998 NHB women and 3899 NHW women who received a diagnosis of stages I to III breast cancer and underwent breast-conserving surgery (BCS) or mastectomy in the US Military Health System during the study period. Data analyses were conducted from July 5, 2017, to December 29, 2017. Main Outcomes and Measures The main outcome was time to breast cancer surgery. Non-Hispanic black and NHW women were compared at the 25th, 50th (median), 75th, and 90th percentiles of TTS by using multivariable quantile regression. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs for all-cause death in NHB compared with NHW women after controlling for potential confounders first without and then with TTS. Results Among the 4887 NHB and NHW women in the cohort, the mean (SD) age was 50.0 (9.4) years. The median TTS was 21 days (95% CI, 20.6-21.4 days) among NHW women and 22 days (95% CI, 20.6-23.4 days) among NHB women. Non-Hispanic black women had a significantly greater estimated TTS at the 75th (3.6 days; 95% CI, 1.6-5.5 days) and 90th (8.9 days; 95% CI, 5.1-12.6 days) percentiles than NHW women in multivariable models. The estimated differences were similar by surgery type. Non-Hispanic black women had a higher adjusted risk for death (HR, 1.45; 95% CI, 1.06-2.01) compared with NHW women among patients receiving breast-conserving surgery. The risks were similar between races among those receiving mastectomy (HR, 1.06; 95% CI, 0.76-1.48). The HRs remained similar after adding TTS to the Cox proportional hazards regression models. Conclusions and Relevance This study's results indicate that time to breast cancer surgery was delayed for NHB compared with NHW women in the Military Health System. However, the racial differences in TTS did not explain the observed racial differences in overall survival among women who received breast-conserving surgery.
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Affiliation(s)
- Yvonne L Eaglehouse
- John P. Murtha Cancer Center, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Matthew W Georg
- John P. Murtha Cancer Center, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Craig D Shriver
- John P. Murtha Cancer Center, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Kangmin Zhu
- John P. Murtha Cancer Center, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Preventive Medicine and Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland
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