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Bickell NA, Shah A, Castaldi M, Lewis T, Sickles A, Arora S, Clarke K, Kemeny M, Srinivasan A, Fei K, Franco R, Parides M, Pappas P, McAlearney AS. Caution Ahead: Research Challenges of a Randomized Controlled Trial Implemented to Improve Breast Cancer Treatment at Safety-Net Hospitals. J Oncol Pract 2018; 14:e158-e167. [PMID: 29298115 PMCID: PMC6550054 DOI: 10.1200/jop.2017.026534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To implement and test a Web-based tracking and feedback (T&F) tool to close referral loops and reduce adjuvant breast cancer treatment underuse in safety-net hospitals (SNHs). PATIENT AND METHODS We randomly assigned 10 SNHs, identified patients with new stage 1 to stage 3 breast cancer, assessed their connection with the oncologist, and relayed this information to surgeons for follow-up. We interviewed key informants about the tool's usefulness. We conducted intention-to-treat and pre- and poststudy analyses to assess the T&F tool and implementation effectiveness, respectively. RESULTS Between the study start and intervention implementation, several hospitals reorganized care delivery and 49% of patients scheduled to undergo breast cancer surgery were ineligible because they already were in contact with an oncologist. One high-volume hospital closed. Despite randomization of hospitals, intervention (INT) hospitals had fewer white patients (5% v 16%; P = .0005), and more underuse (28% v 15%; P = .002) compared with usual care (UC) hospitals. Over time, INT hospitals with poorer follow-up significantly reduced underuse compared with UC hospitals (INT hospitals, from 33% to 9%, P = .001 v UC hospitals, from 15% to 11%, P = .5). There was no difference in underuse (9% at INT hospitals, 11% at UC hospitals; P = .8). Hospitals with better follow-up (odds ratio, 0.85; 95% CI, 0.73 to 0.98) had less underuse. In settings with poor follow-up and tracking approaches, key informants found the tool useful. The rapidly changing delivery landscape posed significant challenges to this implementation research. CONCLUSION A T&F tool did not significantly reduce adjuvant underuse but may help reduce underuse in SNHs with poor follow-up capabilities. Inability to discern T&F effectiveness is likely due to encountered challenges that inform lessons for future implementation research.
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Affiliation(s)
- Nina A. Bickell
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Ajay Shah
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Maria Castaldi
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Theophilus Lewis
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Alan Sickles
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Shalini Arora
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Kevin Clarke
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Margaret Kemeny
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Anitha Srinivasan
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Kezhen Fei
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Rebeca Franco
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Michael Parides
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Peter Pappas
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
| | - Ann Scheck McAlearney
- Icahn School of Medicine at Mount Sinai, Metropolitan Hospital Center, New York; Bronx-Lebanon Hospital Center, Jacobi Medical Center, Bronx; Kings County Hospital Center, NYU Lutheran Medical Center, Brooklyn Hospital Center, Brooklyn; Elmhurst Hospital Center, Elmhurst; Queens Cancer Center, Jamaica, NY; Newark Beth Israel Medical Center, Newark, NJ; and The Ohio State University, Columbus, OH
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Chance WW, Ortiz-Ortiz KJ, Liao KP, Zavala Zegarra DE, Stauder MC, Giordano SH, Tortolero-Luna G, Guadagnolo BA. Underuse of Radiation Therapy After Breast Conservation Surgery in Puerto Rico: A Puerto Rico Central Cancer Registry-Health Insurance Linkage Database Study. J Glob Oncol 2017; 4:1-9. [PMID: 30241162 PMCID: PMC6180809 DOI: 10.1200/jgo.2016.008664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose To identify rates of postoperative radiation therapy (RT) after breast
conservation surgery (BCS) in women with stage I or II invasive breast
cancer treated in Puerto Rico and to examine the sociodemographic and health
services characteristics associated with variations in receipt of RT. Methods The Puerto Rico Central Cancer Registry–Health Insurance Linkage
Database was used to identify patients diagnosed with invasive breast cancer
between 2008 and 2012 in Puerto Rico. Claims codes identified the type of
surgery and the use of RT. Logistic regression models were used to examine
the independent association between sociodemographic and clinical
covariates. Results Among women who received BCS as their primary definitive treatment, 64%
received adjuvant RT. Significant predictors of RT after BCS included
enrollment in Medicare (odds ratio [OR], 2.14; 95% CI, 1.46 to 3.13;
P ≤ .01) and dual eligibility for Medicare and
Medicaid (OR, 1.61; 95% CI, 1.14 to 2.27; P < .01).
In addition, it was found that RT was more likely to have been received in
certain geographic locations, including the Metro-North (OR, 2.20; 95% CI,
1.48 to 3.28; P < .01), North (OR, 1.78; 95% CI,
1.20 to 2.64; P < .01), West (OR, 4.04; 95% CI, 2.61
to 6.25; P < .01), and Southwest (OR, 2.79; 95% CI,
1.70 to 4.59; P < .01). Furthermore, patients with
tumor size > 2.0 cm and ≤ 5.0 cm (OR, 0.61; 95% CI, 0.40 to
0.93; P = .02) and those with tumor size > 5.0 cm
(OR, 0.37; 95% CI, 0.15 to 0.92; P = .03) were found to be
significantly less likely to receive RT. Conclusion Underuse of RT after BCS was identified in Puerto Rico. Patients enrolled in
Medicare and those who were dually eligible for Medicaid and Medicare were
more likely to receive RT after BCS compared with patients with Medicaid
alone. There were geographic variations in the receipt of RT on the
island.
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Affiliation(s)
- William W Chance
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Karen J Ortiz-Ortiz
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Kai-Ping Liao
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Diego E Zavala Zegarra
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Michael C Stauder
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Sharon H Giordano
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Guillermo Tortolero-Luna
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - B Ashleigh Guadagnolo
- William W. Chance, Kai-Ping Liao, Michael C. Stauder, Sharon H. Giordano, and B. Ashleigh Guadagnolo, The University of Texas MD Anderson Cancer Center, Houston, TX; and Karen J. Ortiz-Ortiz, Diego E. Zavala Zegarra, and Guillermo Tortolero-Luna, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
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Campbell JE, Janitz AE, Vesely SK, Lloyd D, Pate A. Patterns of Care for Localized Breast Cancer in Oklahoma, 2003-2006. Women Health 2015; 55:975-95. [PMID: 26133913 DOI: 10.1080/03630242.2015.1061095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Despite well-established clinical guidelines for breast cancer treatment, Standard of Care (SOC) is not universal in the U.S. The purpose of this study was to describe the extent to which patients receive guideline-based, stage-specific treatments for localized female breast cancer in Oklahoma. Data were obtained from the Oklahoma Central Cancer Registry for the period 2003-2006. We included localized, invasive female breast cancers and analyzed both treatment and demographic factors. We used the National Comprehensive Cancer Network (NCCN) treatment guidelines to determine SOC. Among women who received breast conserving surgery (BCS), we used logistic regression to evaluate factors related to SOC. In Oklahoma, 92 percent of the 4,177 localized breast cancer patients were treated with recognized SOC. In women aged ≥65 years with BCS, those ≥75 years had a lower adjusted odds of meeting SOC than did those without insurance, with comorbid conditions, or whose comorbid status was unknown. Among women aged <65 years, those with Medicare/Medicaid, Medicare only, or without insurance, along with comorbid conditions, had a lower adjusted odds of meeting SOC. Overall, 92 percent of women met SOC. Factors such as age, insurance type, and comorbid conditions were associated with meeting SOC.
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Affiliation(s)
- Janis E Campbell
- a Department of Biostatistics and Epidemiology , College of Public Health, University of Oklahoma Health Sciences Center , Oklahoma City , Oklahoma , USA
| | - Amanda E Janitz
- a Department of Biostatistics and Epidemiology , College of Public Health, University of Oklahoma Health Sciences Center , Oklahoma City , Oklahoma , USA
| | - Sara K Vesely
- a Department of Biostatistics and Epidemiology , College of Public Health, University of Oklahoma Health Sciences Center , Oklahoma City , Oklahoma , USA
| | - Dana Lloyd
- b Department of Health Information Management , Southwestern Oklahoma State University , Weatherford , Oklahoma , USA
| | - Anne Pate
- c School of Nursing and Allied Health Sciences , Southwestern Oklahoma State University , Weatherford , Oklahoma , USA
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Parsons HM, Lathrop KI, Schmidt S, Mazo-Canola M, Trevino-Jones J, Speck H, Karnad AB. Breast cancer treatment delays in a majority minority community: is there a difference? J Oncol Pract 2014; 11:e144-53. [PMID: 25515722 DOI: 10.1200/jop.2014.000141] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE Recent studies from large nationwide cancer databases have consistently shown that Hispanic women with breast cancer have delays in treatment initiation compared with non-Hispanic white women. However, time to treatment initiation has not been studied in a community where Hispanics are the majority. PATIENTS AND METHODS We conducted a retrospective, observational study of 362 female patients with breast cancer treated at a large National Cancer Institute (NCI) -designated cancer center with a largely Hispanic population. We examined the relationship between race/ethnicity and time from mammogram to biopsy as well as time from biopsy to treatment initiation using Kaplan-Meier analyses and multivariable Cox proportional hazards regression. RESULTS Half of the female patients with breast cancer were of Hispanic descent (50.0%; n = 181). Hispanic patients were more likely to be obese, have an Eastern Cooperative Oncology Group functional status ≥ 1, and have higher histologic grade disease (all P ≤ .05); no differences in American Joint Committee on Cancer stage at diagnosis were observed. After comprehensive adjustment for demographic and clinical characteristics, we found no significant differences between Hispanic versus non-Hispanic white patients in time from mammogram to biopsy (hazard ratio [HR], 0.91; 95% CI, 0.68 to 1.21) or time from biopsy to treatment (HR, 1.13; 95% CI, 0.69 to 1.88). CONCLUSION Hispanic women and Non-Hispanic white women with breast cancer treated at an NCI-designated cancer center had similar times to biopsy and treatment initiation. These findings suggest that in majority minority communities with large cancer centers, racial disparities can be reduced. With a growing Hispanic population throughout the United States, future studies should examine the long-term impact on improved breast cancer survival in this population.
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Affiliation(s)
- Helen M Parsons
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
| | - Kate I Lathrop
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
| | - Susanne Schmidt
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
| | - Marcela Mazo-Canola
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
| | - Jessica Trevino-Jones
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
| | - Heather Speck
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
| | - Anand B Karnad
- University of Texas Health Science Center at San Antonio; and Cancer Therapy and Research Center, San Antonio, TX
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Smith GL, Shih YCT, Xu Y, Giordano SH, Smith BD, Perkins GH, Tereffe W, Woodward WA, Buchholz TA. Racial disparities in the use of radiotherapy after breast-conserving surgery: a national Medicare study. Cancer 2010; 116:734-41. [PMID: 20014181 DOI: 10.1002/cncr.24741] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In prior studies, the use of standard breast cancer treatments has varied by race, but previous analyses were not nationally representative. Therefore, in a comprehensive, national cohort of Medicare patients, racial disparities in the use of radiotherapy (RT) after breast-conserving surgery (BCS) for invasive breast cancer were quantified. METHODS A national Medicare database was used to identify all beneficiaries (age >65 years) treated with BCS for incident invasive breast cancer in 2003. Claims codes identified RT use, and Medicare demographic data indicated race. Logistic regression modeled RT use in white, black, and other-race patients, adjusted for demographic, clinical, and socioeconomic covariates. RESULTS Of 34,080 women, 91% were white, 6% were black, and 3% were another race. The mean age of the patients was 76 +/- 7 years. Approximately 74% of whites, 65% of blacks, and 66% of other-race patients received RT (P < .001). After covariate adjustment, whites were found to be significantly more likely to receive RT than blacks (odds ratio, 1.48; 95% confidence interval, 1.34-1.63 [P < .001]). Disparities between white and black patients varied by geographic region, with blacks in areas of the northeastern and southern United States demonstrating the lowest rates of RT use (57% in these regions). In patients age <70 years, racial disparities persisted. Specifically, 83% of whites, 73% of blacks, and 78% of other races in this younger group received RT (P < .001). CONCLUSIONS In this comprehensive national sample of older breast cancer patients, substantial racial disparities were identified in RT use after BCS across much of the United States. Efforts to improve breast cancer care require overcoming these disparities, which exist on a national scale.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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