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Wercholuk AN, Parikh AA, Snyder RA. The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population. JCO Oncol Pract 2022; 18:652-662. [DOI: 10.1200/op.22.00122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.
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Affiliation(s)
- Ashley N. Wercholuk
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Alexander A. Parikh
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
| | - Rebecca A. Snyder
- Division of Surgical Oncology, Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC
- Department of Public Health, Brody School of Medicine at East Carolina University, Greenville, NC
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2
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Smetherman D, Biggs K, Fayanju OM, Grosskreutz S, Khan Z, Malak S, Moseley T, Smith-Graziani D, Valero V, Lightfoote J. Racial and Ethnic Disparities in Breast Cancer: A Collaboration Between the American College of Radiology Commissions on Women and Diversity and Breast Imaging. JOURNAL OF BREAST IMAGING 2021; 3:712-720. [PMID: 38424936 DOI: 10.1093/jbi/wbab081] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Indexed: 03/02/2024]
Abstract
Since the 1980s, the mortality rate from breast cancer in the United States has dropped almost 40%. The quality of life and survival gains from early detection and improved treatment have not been shared equally by all ethnic groups, however. Many factors, including social determinants of health, unequal access to screening and oncologic care, and differences in incidence, tumor biology, and risk factors, have contributed to these unequal breast cancer outcomes. As breast radiologists approach their own patients, they must be aware that minority women are disproportionately affected by breast cancer at earlier ages and that non-Hispanic Black and Hispanic women are impacted by greater severity of disease than non-Hispanic White women. Guidelines that do not include women younger than 50 and/or have longer intervals between examinations could have a disproportionately negative impact on minority women. In addition, the COVID-19 pandemic could worsen existing disparities in breast cancer mortality. Increased awareness and targeted efforts to identify and mitigate all of the underlying causes of breast cancer disparities will be necessary to realize the maximum benefit of screening, diagnosis, and treatment and to optimize quality of life and mortality gains for all women. Breast radiologists, as leaders in breast cancer care, have the opportunity to address and reduce some of these disparities for their patients and communities.
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Affiliation(s)
- Dana Smetherman
- Ochsner Health, Department of Radiology, New Orleans, LA, USA
| | - Kelly Biggs
- James E. Van Zandt, VA Medical Center, Department of Radiology, Altoona, PA, USA
| | - Oluwadamilola M Fayanju
- Perelman School of Medicine, University of Pennsylvania, Department of Surgery, Philadelphia, PA, USA
| | | | - Zahra Khan
- Medina Global, Strategic Planning and Health Policy, Cambridge, MA, USA
| | - Sharp Malak
- St. Bernard's Healthcare, Department of Radiology, Jonesboro, AR, USA
| | - Tanya Moseley
- The University of Texas MD Anderson Cancer Center, Departments of Breast Surgical Oncology and Breast Imaging, Houston, TX, USA
| | | | - Vicente Valero
- The University of Texas MD Anderson Cancer Center, Breast Medical Oncology Department, Houston, TX, USA
| | - Johnson Lightfoote
- Pomona Valley Hospital Medical Center, Department of Radiology, Pomona, CA, USA
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3
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Sprague BL, Ahern TP, Herschorn SD, Sowden M, Weaver DL, Wood ME. Identifying key barriers to effective breast cancer control in rural settings. Prev Med 2021; 152:106741. [PMID: 34302837 PMCID: PMC8545865 DOI: 10.1016/j.ypmed.2021.106741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/01/2021] [Accepted: 07/18/2021] [Indexed: 11/18/2022]
Abstract
Breast cancer is the most common cancer and the second most common cause of cancer mortality among women in the United States. Efforts to promote breast cancer control in rural settings face specific challenges. Access to breast cancer screening, diagnosis, and treatment services is impaired by shortages of primary care and specialist providers, and geographic distance from medical facilities. Women in rural areas have comparable breast cancer mortality rates compared to women in urban settings, but this is due in large part to lower incidence rates and masks a substantial rural/urban disparity in breast cancer survival among women diagnosed with breast cancer. Mammography screening utilization rates are slightly lower among rural women than their urban counterparts, with a corresponding increase in late stage breast cancer. Differences in breast cancer survival persist after controlling for stage at diagnosis, largely due to disparities in access to treatment. Travel distance to treatment centers is the most substantial barrier to improved breast cancer outcomes in rural areas. While numerous interventions have been demonstrated in controlled studies to be effective in promoting treatment access and adherence, widespread dissemination in public health and clinical practice remains lacking. Efforts to improve breast cancer control in rural areas should focus on implementation strategies for improving access to breast cancer treatments.
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Affiliation(s)
- Brian L Sprague
- Vermont Center on Behavior and Health, University of Vermont Larner College of Medicine, Burlington, VT, USA; Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA; University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT, USA; Department of Radiology, University of Vermont Larner College of Medicine, Burlington, VT, USA.
| | - Thomas P Ahern
- Vermont Center on Behavior and Health, University of Vermont Larner College of Medicine, Burlington, VT, USA; Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA; University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Sally D Herschorn
- University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT, USA; Department of Radiology, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Michelle Sowden
- Department of Surgery, University of Vermont Larner College of Medicine, Burlington, VT, USA; University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Donald L Weaver
- University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT, USA; Department of Pathology, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Marie E Wood
- Vermont Center on Behavior and Health, University of Vermont Larner College of Medicine, Burlington, VT, USA; University of Vermont Cancer Center, University of Vermont Larner College of Medicine, Burlington, VT, USA; Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
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Anders CK, LeBoeuf NR, Bashoura L, Faiz SA, Shariff AI, Thomas A. What's the Price? Toxicities of Targeted Therapies in Breast Cancer Care. Am Soc Clin Oncol Educ Book 2021; 40:55-70. [PMID: 32421449 DOI: 10.1200/edbk_279465] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Agents with mechanisms novel to breast cancer care have been approved to treat breast cancer. These agents include drugs that target cyclin-dependent kinases, phosphoinositide 3-kinase PI3KCA gene mutations, PARP, checkpoint regulation, and novel antibody-drug conjugates. However, these novel approaches bring a risk of toxicities quite different from those of conventional cytotoxic chemotherapy. Here, we review these agents and discuss related adverse events, with particular attention to endocrine, pulmonary, and dermatologic toxicities. Endocrine toxicities associated with novel cancer therapies for breast cancer are distinct and often present with symptoms related to the specific hormonal deficiencies and rarely hormonal excess. Given the complex and sometimes irreversible nature of these toxicities, once recognized, transdisciplinary management with an endocrinologist experienced with managing drug-related toxicities is encouraged. Drug-related pneumonitis is a serious concern with new targeted therapies. Presentation may not be easily distinguished, and a multidisciplinary team approach can optimize patient care. Heightened awareness is crucial for early detection and treatment. Management should follow recommendations provided by the National Cancer Institute Common Terminology Criteria for Adverse Events and agent-specific guidelines. Cutaneous toxicities from anticancer therapies represent a common and often poorly characterized challenge for patients with breast cancer. Although our understanding of dermatologic effects from novel therapies continues to improve, the breadth of toxicities spans all dermatologic conditions. Targeted therapies offer effective and often novel therapeutic strategies for patients with breast cancer but also bring new adverse event profiles. In this era, it will be important both to closely follow monitoring recommendations and to remain vigilant for emerging toxicities.
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Affiliation(s)
- Carey K Anders
- Division of Medical Oncology, Duke Cancer Institute, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Nicole R LeBoeuf
- Department of Dermatology, Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA
| | - Lara Bashoura
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Saadia A Faiz
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Afreen I Shariff
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Alexandra Thomas
- Division of Hematology and Oncology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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Smith-Graziani D, Lei X, Giordano SH, Zhao H, Karuturi M, Chavez-MacGregor M. Delayed initiation of adjuvant chemotherapy in older women with breast cancer. Cancer Med 2020; 9:6961-6971. [PMID: 32767723 PMCID: PMC7541132 DOI: 10.1002/cam4.3363] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/14/2020] [Accepted: 07/19/2020] [Indexed: 11/25/2022] Open
Abstract
Background Adjuvant chemotherapy benefits early‐stage breast cancer (BC) patients. Older women receive guideline‐adherent treatment less frequently and experience treatment delays more frequently. We evaluated factors associated with delaying adjuvant chemotherapy and the delays’ survival impact in a large population–based cohort of elderly BC patients. Methods Patients age >66 years diagnosed 2001‐2015 with localized or regional BC were identified in the SEER‐Medicare and Texas Cancer Registry‐Medicare databases. Time from surgery to chemotherapy (TTC) was categorized into four groups: 0‐30, 31‐60, 61‐90, and >90 days. We identified predictors of delays, estimated overall (OS) and BC‐specific (BCSS) survival, and determined the association between TTC and outcome adjusting for other variables. Results Among 28,968 women (median age 71 years), median TTC was 43 days. 10.7% of patients experienced TTC >90 days. Older age, Black or Hispanic race/ethnicity, unmarried status, more comorbidities, hormone receptor‐positivity, mastectomy, Oncotype DX testing, and full state buy‐in were associated with increased risk of delay. Five‐year OS estimates by TTC group were 0.82, 0.81, 0.80, and 0.74, respectively (p<.001). BCSS demonstrated a similar trend (p<.001). Chemotherapy delay was associated with worse OS (HR=1.33, 95%CI 1.25‐1.40) and BCSS (HR=1.39, 95%CI 1.27‐1.53). In subgroup analysis, delayed chemotherapy was associated with worse OS and BCSS among patients with hormone receptor–positive (HR=1.56, 95%CI 0.97‐2.51), HER2‐positive (HR=1.99, 95%CI 1.04‐3.79), and triple‐negative (HR=2.15, 95%CI 1.38‐3.36) tumors. Conclusion Chemotherapy delays are associated with worse survival in older BC patients. Providers should avoid delays and initiate chemotherapy ≤90 days after surgery regardless of patients’ BC subtype or age.
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Affiliation(s)
- Demetria Smith-Graziani
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Meghan Karuturi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mariana Chavez-MacGregor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Clustering datasets with demographics and diagnosis codes. J Biomed Inform 2020; 102:103360. [PMID: 31904428 DOI: 10.1016/j.jbi.2019.103360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 11/30/2019] [Accepted: 12/16/2019] [Indexed: 11/21/2022]
Abstract
Clustering data derived from Electronic Health Record (EHR) systems is important to discover relationships between the clinical profiles of patients and as a preprocessing step for analysis tasks, such as classification. However, the heterogeneity of these data makes the application of existing clustering methods difficult and calls for new clustering approaches. In this paper, we propose the first approach for clustering a dataset in which each record contains a patient's values in demographic attributes and their set of diagnosis codes. Our approach represents the dataset in a binary form in which the features are selected demographic values, as well as combinations (patterns) of frequent and correlated diagnosis codes. This representation enables measuring similarity between records using cosine similarity, an effective measure for binary-represented data, and finding compact, well-separated clusters through hierarchical clustering. Our experiments using two publicly available EHR datasets, comprised of over 26,000 and 52,000 records, demonstrate that our approach is able to construct clusters with correlated demographics and diagnosis codes, and that it is efficient and scalable.
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Canney M, Induruwage D, McCandless LC, Reich HN, Barbour SJ. Disease-specific incident glomerulonephritis displays geographic clustering in under-serviced rural areas of British Columbia, Canada. Kidney Int 2019; 96:421-428. [DOI: 10.1016/j.kint.2019.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/07/2019] [Accepted: 02/14/2019] [Indexed: 12/12/2022]
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8
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Thomas A, Rhoads A, Pinkerton E, Schroeder MC, Conway KM, Hundley WG, McNally LR, Oleson J, Lynch CF, Romitti PA. Incidence and Survival Among Young Women With Stage I-III Breast Cancer: SEER 2000-2015. JNCI Cancer Spectr 2019; 3:pkz040. [PMID: 31392297 PMCID: PMC6668585 DOI: 10.1093/jncics/pkz040] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/23/2019] [Accepted: 06/05/2019] [Indexed: 01/24/2023] Open
Abstract
Background Although recent findings suggest that de novo stage IV breast cancer is increasing in premenopausal women in the United States, contemporary incidence and survival data are lacking for stage I-III cancer. Methods Women aged 20-29 (n = 3826), 30-39 (n = 34 585), and 40-49 (n = 126 552) years who were diagnosed with stage I-III breast cancer from 2000 to 2015 were identified from the Surveillance, Epidemiology, and End Results 18 registries database. Age-adjusted, average annual percentage changes in incidence and 5- and 10-year Kaplan-Meier survival curves were estimated by race and ethnicity, stage, and hormone receptor (HR) status and grade (low to well and moderately differentiated; high to poorly and undifferentiated) for each age decade. Results The average annual percentage change in incidence was positive for each age decade and was highest among women aged 20-29 years. Increased incidence was driven largely by HR+ cancer, particularly HR+ low-grade cancer in women aged 20-29 and 40-49 years. By 2015, incidence of HR+ low- and high-grade cancer each independently exceeded incidence of HR- cancer in each age decade. Survival for HR+ low- and high-grade cancer decreased with decreasing age; survival for HR- cancer was similar across age decades. Among all women aged 20-29 years, 10-year survival for HR+ high-grade cancer was lower than that for HR+ low-grade or HR- cancer. Among women aged 20-29 years with stage I cancer, 10-year survival was lowest for HR+ high-grade cancer. Conclusions HR+ breast cancer is increasing in incidence among premenopausal women, and HR+ high-grade cancer was associated with reduced survival among women aged 20-29 years. Our findings can help guide further evaluation of preventive, diagnostic, and therapeutic strategies for breast cancer among premenopausal women.
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Affiliation(s)
- Alexandra Thomas
- Department of Internal Medicine, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Anthony Rhoads
- Department of Epidemiology, College of Public Health, Division of Health Services Research, Department of Biostatistics, , University of Iowa, Iowa City, IA
| | - Elizabeth Pinkerton
- Department of Epidemiology, College of Public Health, Division of Health Services Research, Department of Biostatistics, , University of Iowa, Iowa City, IA
| | | | - Kristin M Conway
- Department of Epidemiology, College of Public Health, Division of Health Services Research, Department of Biostatistics, , University of Iowa, Iowa City, IA
| | - William G Hundley
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Lacey R McNally
- Department of Cancer Biology, Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Jacob Oleson
- College of Public Health, University of Iowa, Iowa City, IA.,Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA
| | - Charles F Lynch
- Department of Epidemiology, College of Public Health, Division of Health Services Research, Department of Biostatistics, , University of Iowa, Iowa City, IA
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, Division of Health Services Research, Department of Biostatistics, , University of Iowa, Iowa City, IA.,College of Public Health, University of Iowa, Iowa City, IA.,Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA
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9
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Li SS, Hayes D, Tobias JD, Morgan WJ, Tumin D. Health insurance and use of recommended routine care in adults with cystic fibrosis. CLINICAL RESPIRATORY JOURNAL 2018; 12:1981-1988. [DOI: 10.1111/crj.12767] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/14/2017] [Accepted: 01/09/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Susan S. Li
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Department of Internal Medicine; The Ohio State University College of Medicine; Columbus Ohio
| | - Don Hayes
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Department of Internal Medicine; The Ohio State University College of Medicine; Columbus Ohio
- Department of Surgery; The Ohio State University College of Medicine; Columbus Ohio
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus Ohio
| | - Joseph D. Tobias
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus Ohio
- Department of Anesthesiology; The Ohio State University College of Medicine; Columbus Ohio
| | - Wayne J. Morgan
- Department of Pediatrics; University of Arizona; Tucson Arizona
| | - Dmitry Tumin
- Department of Pediatrics; Nationwide Children's Hospital; Columbus Ohio
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus Ohio
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Sheppard VB, de Mendoza AH, He J, Jennings Y, Edmonds MC, Oppong BA, Tadesse MG. Initiation of Adjuvant Endocrine Therapy in Black and White Women With Breast Cancer. Clin Breast Cancer 2017; 18:337-346.e1. [PMID: 29422259 DOI: 10.1016/j.clbc.2017.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/20/2017] [Accepted: 12/01/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Adjuvant endocrine therapy reduces risk of recurrence and mortality in women with hormone receptor-positive breast cancer, yet many women never initiate it. We examined the influence of race, sociocultural factors, and process-of-care factors on initiation of adjuvant endocrine therapy in a racially diverse sample. PATIENTS AND METHODS Eligible women were originally recruited for the Narrowing the Gaps in Adjuvant Therapy Study (2006-2011). Sociocultural and process-of-care factors were collected via telephone surveys before adjuvant therapy. Clinical factors were abstracted from charts. Penalized LASSO (least absolute shrinkage and selection operator) logistic regression model was used to identify variables associated with initiation. RESULTS Of the 270 women, 55.6% were black and the rest were white. Most women (74.8%) initiated therapy. A significant interaction (P = .008) was found between race and age. Black women aged ≤ 50 years had the lowest initiation (59.7%) compared to black women > 50 years (87.1%), white women ≤ 50 years (73.7%), or white women > 50 years (72.0%). Multivariate analysis found that younger black women exhibited a marginally higher risk of noninitiation compared to older black women. Additionally, ratings of financial access, presence of comorbidities, and levels of communication were all associated with endocrine therapy initiation. CONCLUSION Black women ≤ 50 years of age and women with financial constraints may be important subgroups for interventions. Patient-provider communication appears to be an important leverage point to foster therapy uptake.
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Affiliation(s)
- Vanessa B Sheppard
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA.
| | | | - Jun He
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yvonne Jennings
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Megan C Edmonds
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Bridget A Oppong
- Georgetown University Medical Center, Georgetown University, Washington, DC
| | - Mahlet G Tadesse
- Department of Mathematics and Statistics, Georgetown University, Washington, DC
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