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Freeman HD, Burke LC, Humphrey JG, Wilbers AJ, Vora H, Khorfan R, Solomon NL, Namm JP, Ji L, Lum SS. Fragmentation of care in breast cancer: greater than the sum of its parts. Breast Cancer Res Treat 2024:10.1007/s10549-024-07442-3. [PMID: 39096403 DOI: 10.1007/s10549-024-07442-3] [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: 05/20/2024] [Accepted: 07/19/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Fragmentation of care (FC, the receipt of care at > 1 institution) has been shown to negatively impact cancer outcomes. Given the multimodal nature of breast cancer treatment, we sought to identify factors associated with FC and its effects on survival of breast cancer patients. METHODS A retrospective analysis was performed of surgically treated, stage I-III breast cancer patients in the 2004-2020 National Cancer Database, excluding neoadjuvant therapy recipients. Patients were stratified into two groups: FC or non-FC care. Treatment delay was defined as definitive surgery > 60 days after diagnosis. Multivariable logistic regression was performed to identify factors predictive of FC, and survival was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS Of the 531,644 patients identified, 340,297 (64.0%) received FC. After adjustment, FC (OR 1.27, 95% CI 1.25-1.29) was independently associated with treatment delay. Factors predictive of FC included Hispanic ethnicity (OR 1.04, 95% CI: 1.01-1.07), treatment at comprehensive community cancer programs (OR 1.06, 95% CI: 1.03-1.08) and integrated network cancer programs (OR 1.55, 95% CI: 1.51-1.59), AJCC stage II (OR 1.06, 95% CI 1.05-1.07) and stage III tumors (OR 1.06, 95% CI: 1.02-1.10), and HR + /HER2 + tumors (OR 1.05, 95% CI: 1.02-1.07). Treatment delay was independently associated with increased risk of mortality (HR 1.23, 95% CI 1.20-1.26), whereas FC (HR 0.87, 95% CI 0.86-0.88) showed survival benefit. CONCLUSIONS While treatment delay negatively impacts survival in breast cancer patients, our findings suggest FC could be a marker for multispecialty care that may mitigate some of these effects.
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Affiliation(s)
- Hadley D Freeman
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Linnea C Burke
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Ja'Neil G Humphrey
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Ashley J Wilbers
- Division of Breast Surgery, Department of Surgery, Washington University, St. Louis, MO, USA
| | - Halley Vora
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Rhami Khorfan
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Naveenraj L Solomon
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Jukes P Namm
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Liang Ji
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Sharon S Lum
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA.
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Gupta A, Chant ED, Mohile S, Vogel RI, Parsons HM, Blaes AH, Booth CM, Rocque GB, Dusetzina SB, Ganguli I. Health Care Contact Days Among Older Cancer Survivors. JCO Oncol Pract 2024; 20:943-952. [PMID: 38452315 PMCID: PMC11268556 DOI: 10.1200/op.23.00590] [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] [Received: 09/14/2023] [Revised: 11/10/2023] [Accepted: 12/13/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Health care contact days-days spent receiving health care outside the home-represent an intuitive, practical, and person-centered measure of time consumed by health care. METHODS We linked 2019 Medicare Current Beneficiary Survey and traditional Medicare claims data for community-dwelling older adults with a history of cancer. We identified contact days (ie, spent in a hospital, emergency department, skilled nursing facility, or inpatient hospice or receiving ambulatory care including an office visit, procedure, treatment, imaging, or test) and described patterns of total and ambulatory contact days. Using weighted Poisson regression models, we identified factors associated with contact days. RESULTS We included 1,168 older adults representing 4.51 million cancer survivors (median age, 76.4 years, 52.8% women). The median (IQR) time from cancer diagnosis was 65 (27-126) months. In 2019, these adults had mean (standard deviation) total contact days of 28.4 (27.6) and ambulatory contact days of 24.2 (23.6). These included days for tests (8.0 [8.8]), imaging (3.6 [4.1]), visits with any clinicians (12.4 [11.5]), and visits with primary care clinicians (4.4 [4.7]), and nononcology specialists (7.1 [9.4]) specifically. Sixty-four percent of days with a nonvisit ambulatory service (eg, a test) were not on the same day as a clinician visit. Factors associated with more total contact days included younger age, lower income, more chronic conditions, poor self-rated health, and tendency to "go to doctor as soon as feel bad." CONCLUSION Older adult cancer survivors spent nearly 1 month of the year receiving health care outside the home. This care was largely ambulatory, often delivered by nononcologists, and varied by factors beyond clinical characteristics. These results highlight the need to recognize patient burdens and improve survivorship care delivery, including through care coordination.
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Affiliation(s)
| | - Emma D. Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - Supriya Mohile
- Department of Medicine, University of Rochester, Rochester, NY
| | | | | | | | | | | | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
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Amboree TL, Montealegre JR, Parker SL, Garg A, Damgacioglu H, Schmeler KM, Chiao EY, Hill EG, Sonawane K, Deshmukh AA, Adsul P. National Breast, Cervical, and Colorectal Cancer Screening Use in Federally Qualified Health Centers. JAMA Intern Med 2024; 184:671-679. [PMID: 38683574 PMCID: PMC11059050 DOI: 10.1001/jamainternmed.2024.0693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/07/2024] [Indexed: 05/01/2024]
Abstract
Importance Federally qualified health centers (FQHCs) deliver health care to nearly 30 million underserved persons across the US, yet nationwide and state-level breast, cervical, and colorectal cancer screening use in FQHCs is not described. Furthermore, it is unknown how the underscreened FQHC population contributes to the total underscreened population at national and state levels. Objective To describe national- and state-level breast, cervical, and colorectal cancer screening use among individuals served by FQHCs in the US and to estimate the percentage of underscreened individuals in the general population served by FQHCs. Design, Setting, and Participants This cross-sectional analysis of cancer screening used data from January 1 through December 31, 2020, from the FQHC Uniform Data System, reported by 1364 FQHCs across the US, and self-reported estimates from the Behavioral Risk Factor Surveillance System. Participants were 16 696 692 US adults served by FQHCs who were eligible for breast (age, 50-74 years), cervical (age, 21-64 years), and colorectal (age, 50-75 years) cancer screening. Analyses were conducted between January 1 and June 30, 2023. Exposures Breast, cervical, and colorectal cancer screening. Main Outcomes and Measures Percentages of breast, cervical, and colorectal cancer screening-eligible individuals up to date on screening. Results A total of 3 162 882 breast, 7 444 465 cervical, and 6 089 345 colorectal screening-eligible individuals were served by FQHCs in 2020. Nationally, screening use in FQHCs was 45.4% (95% CI, 45.4%-45.5%) for breast cancer, 51.0% (95% CI, 51.0%-51.1%) for cervical cancer, and 40.2% (95% CI, 40.1%-40.2%) for colorectal cancer. Screening use among the US general population was 78.2% (95% CI, 77.6%-78.9%) for breast cancer, 82.9% (95% CI, 82.3%-83.4%) for cervical cancer, and 72.3% (95% CI, 71.7%-72.8%) for colorectal cancer. The contribution of the underscreened population served by FQHCs to the national underscreened general population was 16.9% (95% uncertainty interval [UI], 16.4%-17.4%) for breast cancer, 29.7% (95% UI, 28.8%-30.7%) for cervical cancer, and 14.7% (95% UI, 14.4%-15.0%) for colorectal cancer. Conclusions and Relevance Findings from this national cross-sectional study indicated major gaps in cancer screening use in FQHCs in the US. Improved prevention is urgently needed to address screening disparities.
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Affiliation(s)
- Trisha L Amboree
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Jane R Montealegre
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Susan L Parker
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston
| | - Ashvita Garg
- Department of Public Health Science, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Haluk Damgacioglu
- Department of Public Health Science, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth Y Chiao
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Elizabeth G Hill
- Department of Public Health Science, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Kalyani Sonawane
- Department of Public Health Science, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Ashish A Deshmukh
- Department of Public Health Science, Medical University of South Carolina, Charleston
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Prajakta Adsul
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque
- Cancer Control and Population Sciences Research Program, University of New Mexico Comprehensive Cancer Center, Albuquerque
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Plichta JK, Thomas SM, Wang X, McDuff SGR, Kimmick G, Hwang ES. Survival among patients with untreated metastatic breast cancer: "What if I do nothing?". Breast Cancer Res Treat 2024; 205:333-347. [PMID: 38438700 PMCID: PMC11102301 DOI: 10.1007/s10549-024-07265-2] [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: 09/11/2023] [Accepted: 01/19/2024] [Indexed: 03/06/2024]
Abstract
PURPOSE We sought to assess survival outcomes of patients with de novo metastatic breast cancer (dnMBC) who did not receive treatment irrespective of the reason. METHODS Adults with dnMBC were selected from the NCDB (2010-2016) and stratified based on receipt of treatment (treated = received at least one treatment and untreated = received no treatments). Overall survival (OS) was estimated using the Kaplan-Meier method, and groups were compared. Cox proportional hazards models were used to identify factors associated with OS. RESULTS Of the 53,240 patients with dnMBC, 92.1% received at least one treatment (treated), and 7.9% had no documented treatments, irrespective of the reason (untreated). Untreated patients were more likely to be older (median 68 y vs 61 y, p < 0.001), have higher comorbidity scores (p < 0.001), have triple-negative disease (17.8% vs 12.6%), and a higher disease burden (≥ 2 metastatic sites: 38.2% untreated vs 29.2% treated, p < 0.001). The median unadjusted OS in the untreated subgroup was 2.5 mo versus 36.4 mo in the treated subgroup (p < 0.001). After adjustment, variables associated with a worse OS in the untreated cohort included older age, higher comorbidity scores, higher tumor grade, and triple-negative (vs HR + /HER2-) subtype (all p < 0.05), while the number of metastatic sites was not associated with survival. CONCLUSIONS Patients with dnMBC who do not receive treatment are more likely to be older, present with comorbid conditions, and have clinically aggressive disease. Similar to those who do receive treatment, survival in an untreated population is associated with select patient and disease characteristics. However, the prognosis for untreated dnMBC is dismal.
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Affiliation(s)
- Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, DUMC 3513, Durham, NC, 27710, USA.
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.
- Duke Cancer Institute, Durham, NC, USA.
| | - Samantha M Thomas
- Duke Cancer Institute, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Xuanji Wang
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Susan G R McDuff
- Duke Cancer Institute, Durham, NC, USA
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Gretchen Kimmick
- Duke Cancer Institute, Durham, NC, USA
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, DUMC 3513, Durham, NC, 27710, USA
- Duke Cancer Institute, Durham, NC, USA
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Collins ML, Mack SJ, Whitehorn GL, Till BM, Grenda TR, Evans NR, Gordon SW, Okusanya OT. Access to Guideline Concordant Care for Node-Positive Non-Small Cell Lung Cancer in the United States. Ann Thorac Surg 2024; 117:568-575. [PMID: 37995842 DOI: 10.1016/j.athoracsur.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/01/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND This study sought to determine whether seeking care at multiple Commission on Cancer (CoC) hospitals is associated with different rates of receiving guideline-concordant care (GCC) among patients with non-small cell lung cancer (NSCLC). METHODS The National Cancer Database was queried for the years 2004 to 2018 for patients with margin-negative pT1 to pT3 N1 to N2 M0 noncarcinoid NSCLC without neoadjuvant therapy. GCC was defined as chemotherapy for pN1 disease and as chemotherapy with or without radiation for pN2 disease. Patients who received care at >1 facility were examined separately. Factors previously associated with barriers to care were compared between groups. Kaplan-Meier analysis with log-rank tests analyzed 5-year overall survival (OS). Propensity score matching was performed to compare the effect sizes of race, insurance status, and income. RESULTS In total 44,531 patients met inclusion criteria, 11,980 (26.9%) of whom sought care at >1 CoC institution. Among patients with pN1 disease, 5565 (76.7%) received GCC if they visited >1 facility vs 13,995 (68.5%) patients who sought care at 1 facility (P < .001). For patients with pN2 disease, 3991 (84.4%) received GCC if they visited >1 facility vs9369 (77.4%) patients receiving care at 1 facility (P < .001). Visiting >1 facility was associated with higher OS at 5 years (4784 [54.35%] vs 10,215 [45.62%]; P < .001). CONCLUSIONS Visiting >1 CoC institution is associated with higher rates of GCC for individuals with pN1 to pN2 lung cancer. Patients who received care at >1 facility had higher OS at 5 years. Further study is warranted to identify factors associated with the ability of patients to seek care at multiple facilities.
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Affiliation(s)
- Micaela L Collins
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Shale J Mack
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory L Whitehorn
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Brian M Till
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Tyler R Grenda
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Nathaniel R Evans
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Sarah W Gordon
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Olugbenga T Okusanya
- Division of Esophageal and Thoracic Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
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Patel VR, Ramesh V, Tsai AK, Sedhom R, Westanmo AD, Blaes AH, Vogel RI, Parsons HM, Hanna TP, Ganguli I, Dusetzina SB, Rocque GB, Booth CM, Gupta A. Health Care Contact Days Experienced by Decedents With Advanced GI Cancer. JCO Oncol Pract 2023; 19:1031-1038. [PMID: 37738532 PMCID: PMC10667015 DOI: 10.1200/op.23.00232] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/05/2023] [Accepted: 08/14/2023] [Indexed: 09/24/2023] Open
Abstract
PURPOSE Frequent visits to health care facilities can be time intensive and all-consuming for people with cancer. We measured health care contact days (days with healthcare contact outside the home) among decedents with advanced GI cancer and examined sources of contact days, their associations with demographic and clinical factors, and their temporal patterns over the course of illness. METHODS We conducted a retrospective cohort study using a tumor registry and electronic medical record data for decedents with stage IV GI cancer between 2011 and 2019 in a large health care network in MN. We determined contact days from diagnosis to death using chart review. Using multivariable beta regression adjusted for sociodemographic and clinical characteristics offset by survival, we calculated adjusted estimates of contact days and determined patient-level factors associated with percentage of contact days. RESULTS We identified 809 patients eligible for analysis (median [IQR] age at diagnosis, 65 [56-73] years). The median (IQR) overall survival was 175 (56-459) days. Patients spent a median (IQR) of 25.8% (17.4%-39.1%) of these as contact days. Of these days, 83.6% were spent on outpatient visits. In the multivariable analysis, older age, Black race, and never receiving systemic cancer-directed treatment were associated with a higher percentage of contact days. The percentage of contact days was highest in the first month after diagnosis (39.6%) and before death (32.2%), with a more moderate middle phase (U-shaped curve). CONCLUSION Decedents with advanced GI cancer spend 1 in 4 days alive with health care contact, despite a median survival of under 6 months. This is even higher immediately postdiagnosis and near death. These findings highlight the need to understand sources of variation, benchmark appropriate care, and deliver more efficient care for this vulnerable population with limited time.
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Affiliation(s)
- Vishal R. Patel
- Dell Medical School, The University of Texas at Austin, Austin, TX
| | | | | | - Ramy Sedhom
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Anders D. Westanmo
- Department of Pharmacy, Minneapolis VA Health Care System, Minneapolis, MN
| | | | | | | | - Timothy P. Hanna
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, ON, Canada
| | - Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Gabrielle B. Rocque
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Arjun Gupta
- University of Minnesota, Minneapolis, MN
- Costs of Care, Cambridge, MA
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7
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Wieder R, Adam N. Racial Disparities in Breast Cancer Treatments and Adverse Events in the SEER-Medicare Data. Cancers (Basel) 2023; 15:4333. [PMID: 37686609 PMCID: PMC10486612 DOI: 10.3390/cancers15174333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Despite lower incidence rates, African American (AA) patients have shorter survival from breast cancer (BC) than white (W) patients. Multiple factors contribute to decreased survival, including screening disparities, later presentation, and access to care. Disparities in adverse events (AEs) may contribute to delayed or incomplete treatment, earlier recurrence, and shortened survival. Here, we analyzed the SEER-Medicare dataset, which captures claims from a variety of venues, in order to determine whether the cancer care venues affect treatment and associated adverse events. We investigated a study population whose claims are included in the Outpatient files, consisting of hospital and healthcare facility venues, and a study population from the National Claims History (NCH) files, consisting of claims from physicians, office practices, and other non-institutional providers. We demonstrated statistically and substantively significant venue-specific differences in treatment rates, drugs administered, and AEs from treatments between AA and W patients. We showed that AA patients in the NCH dataset received lower rates of treatment, but patients in the Outpatient dataset received higher rates of treatment than W patients. The rates of recorded AEs per treatment were higher in the NCH setting than in the Outpatient setting in all patients. AEs were consistently higher in AA patients than in W patients. AA patients had higher comorbidity indices and were younger than W patients, but these variables did not appear to play roles in the AE differences. The frequency of specific anticancer drugs administered in cancer- and venue-specific circumstances and their associated AEs varied between AA and W patients. The higher AE rates were due to slightly higher frequencies in the administration of drugs with higher associated AE rates in AA patients than in W patients. Our investigations demonstrate significant differences in treatment rates and associated AEs between AA and W patients with BC, depending on the venues of care, likely contributing to differences in outcomes.
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Affiliation(s)
- Robert Wieder
- Rutgers New Jersey Medical School and the Cancer Institute of New Jersey, 185 South Orange Avenue, MSB F671, Newark, NJ 07103, USA
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8
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Hines RB, Zhu X, Lee E, Eames B, Chmielewska K, Johnson AM. Health insurance and neighborhood poverty as mediators of racial disparities in advanced disease stage at diagnosis and nonreceipt of surgery for women with breast cancer. Cancer Med 2023; 12:15414-15423. [PMID: 37278365 PMCID: PMC10417299 DOI: 10.1002/cam4.6127] [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: 12/05/2022] [Revised: 04/26/2023] [Accepted: 05/14/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND In our recent study, advanced disease stage and nonreceipt of surgery were the most important mediators of the racial disparity in breast cancer survival. The purpose of this study was to quantify the racial disparity in these two intermediate outcomes and investigate mediation by the more proximal mediators of insurance status and neighborhood poverty. METHODS This was a cross-sectional study of non-Hispanic Black and non-Hispanic White women diagnosed with first primary invasive breast cancer in Florida between 2004 and 2015. Log-binomial regression was used to obtain prevalence ratios (PR) with 95% confidence intervals (CIs). Multiple mediation analysis was used to assess the role of having Medicaid/being uninsured and living in high-poverty neighborhoods on the race effect. RESULTS There were 101,872 women in the study (87.0% White, 13.0% Black). Black women were 55% more likely to be diagnosed with advanced disease stage at diagnosis (PR, 1.55; 95% CI, 1.50-1.60) and nearly twofold more likely to not receive surgery (PR, 1.97; 95% CI, 1.90-2.04). Insurance status and neighborhood poverty explained 17.6% and 5.3% of the racial disparity in advanced disease stage at diagnosis, respectively; 64.3% remained unexplained. For nonreceipt of surgery, insurance status explained 6.8% while neighborhood poverty explained 3.2%; 52.1% was unexplained. CONCLUSIONS Insurance status and neighborhood poverty were significant mediators of the racial disparity in advanced disease stage at diagnosis with a smaller impact on nonreceipt of surgery. However, interventions designed to improve breast cancer screening and receipt of high-quality cancer treatment must address additional barriers for Black women with breast cancer.
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Affiliation(s)
- Robert B. Hines
- Department of Population Health SciencesUniversity of Central Florida College of MedicineOrlandoFloridaUSA
| | - Xiang Zhu
- Research Administration ‐ OperationsUniversity of Central Florida College of MedicineOrlandoFloridaUSA
| | - Eunkyung Lee
- Department of Health SciencesCollege of Health Professions and SciencesUniversity of Central FloridaOrlandoFloridaUSA
| | - Bradley Eames
- Department of Medical EducationUniversity of Central Florida College of MedicineOrlandoFloridaUSA
| | - Karolina Chmielewska
- Department of Medical EducationUniversity of Central Florida College of MedicineOrlandoFloridaUSA
| | - Asal M. Johnson
- Department of Environmental Sciences and StudiesPublic Health Program, Stetson UniversityDeLandFloridaUSA
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9
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Riggan KA, Rousseau A, Halyard M, James SE, Kelly M, Phillips D, Allyse MA. "There's not enough studies": Views of black breast and ovarian cancer patients on research participation. Cancer Med 2023; 12:8767-8776. [PMID: 36647342 PMCID: PMC10134334 DOI: 10.1002/cam4.5622] [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: 10/07/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Black breast and ovarian cancer patients are underrepresented in clinical cancer trials disproportionate to the prevalence of these cancers in Black females. Historically, lower enrollment has been attributed to individualized factors, including medical mistrust, but more recently structural factors, including systemic racism, have received additional scrutiny. We interviewed Black women with a personal or family history of breast and ovarian cancer to understand their views and experiences related to research participation. METHODS Qualitative interviews were conducted via telephone or video conference and transcribed verbatim. Transcripts were qualitatively analyzed for iterative themes related to the offer and participation in cancer clinical trials and research studies, impact on cancer care, and recommendations to increase enrollment of Black patients. RESULTS Sixty-one Black women completed an interview. Participants expressed that Black women are underrepresented in cancer research, and that this negatively impacted their own care. Many cited past historical abuses, including the Tuskegee syphilis trial, as a potential factor for lower enrollment but suggested that lower enrollment was better understood in the context of the entirety of their healthcare experiences, including present-day examples of patient mistreatment or dismissal. Participants suggested that proactive community engagement, transparency, and increased representation of Black research team members were strategies likely to foster trust and bolster research participation. CONCLUSION(S) Medical mistrust is only a partial factor in the lower participation of Black patients in cancer research. Researchers should implement the strategies identified by our participants to promote diverse enrollment and ensure that Black patients are included in future therapeutic advances.
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Affiliation(s)
| | - Abigail Rousseau
- Biomedical Ethics Research ProgramMayo ClinicRochesterMinnesotaUSA
| | - Michele Halyard
- Department of Radiation OncologyMayo ClinicPhoenixArizonaUSA
- Coalition of Blacks Against Breast CancerPhoenixArizonaUSA
- ADVANCE Community Advisory BoardPhoenixArizonaUSA
| | - Sarah E. James
- Department of Radiation OncologyMayo ClinicPhoenixArizonaUSA
- Coalition of Blacks Against Breast CancerPhoenixArizonaUSA
| | - Marion Kelly
- Coalition of Blacks Against Breast CancerPhoenixArizonaUSA
- ADVANCE Community Advisory BoardPhoenixArizonaUSA
- Department of Community EngagementMayo ClinicScottsdaleArizonaUSA
| | - Daphne Phillips
- ADVANCE Community Advisory BoardPhoenixArizonaUSA
- Department of Speech PathologyMayo ClinicPhoenixArizonaUSA
| | - Megan A. Allyse
- Biomedical Ethics Research ProgramMayo ClinicRochesterMinnesotaUSA
- Department of Obstetrics & GynecologyMayo ClinicRochesterMinnesotaUSA
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10
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Rhodin KE, Raman V, Jensen CW, Kang L, Nussbaum DP, Tong BC, Blazer DG, D'Amico TA. Multi-institutional Care in Clinical Stage II and III Esophageal Cancer. Ann Thorac Surg 2023; 115:370-377. [PMID: 35872035 PMCID: PMC9851933 DOI: 10.1016/j.athoracsur.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/08/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Management of clinical stage II or III esophageal cancer requires multidisciplinary care. Multi-institutional care has been associated with worse survival in other malignant diseases. This study aimed to determine the impact of multi-institutional care on survival in patients with stage II or III esophageal cancer. METHODS The 2004 to 2016 National Cancer Database was queried for patients with clinical stage II or III esophageal cancer who received neoadjuvant chemotherapy with or without radiation therapy followed by surgical resection. Patients were stratified into 2 groups: multi-institutional or single-institution care. Survival between groups was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. Multivariable logistic regression was performed to identify factors associated with multi-institutional care. RESULTS Overall, 11 399 patients met study criteria: 6569 (57.6%) received multi-institutional care and 4,830 (42.4%) received care at a single institution. In a multivariable analysis, factors associated with multi-institutional care were later year of diagnosis, greater distance from treating facility, residence in an urban or rural setting (vs metro), and residence in states without Medicaid expansion. Care at a single institution was associated with Black race, lack of insurance, and treatment at higher-volume or academic centers. Despite these differences, patients who received multi-institutional care had survival comparable to that in patients who received care at a single institution (HR, 0.97; 95% CI, 0.92-1.03; P = .30). CONCLUSIONS In this National Cancer Database analysis, multi-institutional care was not associated with inferior overall survival. As complex cancer care becomes more regionalized, patients may consider receiving part of their cancer care closer to home, whereas traveling to surgical centers of excellence should be encouraged.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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11
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Caparso C, Friese CR. Technology Supports to Cancer Care Teams: Promises and Pitfalls. JCO Oncol Pract 2023; 19:13-15. [PMID: 36516372 DOI: 10.1200/op.22.00657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Cinzia Caparso
- Department of Systems, Populations, and Leadership, Center for Improving Patient and Population Health, School of Nursing, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
| | - Christopher R Friese
- Department of Systems, Populations, and Leadership, Center for Improving Patient and Population Health, School of Nursing, Rogel Cancer Center, University of Michigan, Ann Arbor, MI
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12
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Rhodin KE, Raman V, Eckhoff A, Liu A, Creasy J, Nussbaum DP, Blazer DG. Patterns and Impact of Fragmented Care in Stage II and III Gastric Cancer. Ann Surg Oncol 2022; 29:5422-5431. [PMID: 35723791 PMCID: PMC9378672 DOI: 10.1245/s10434-022-12031-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of "fragmented" care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival. METHODS The 2006-2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed "coordinated" and "fragmented" care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods. RESULTS Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05). CONCLUSIONS For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Austin Eckhoff
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Annie Liu
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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13
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Henry TL, Britz JB, Louis JS, Bruno R, Oronce CIA, Georgeson A, Ragunanthan B, Green MM, Doshi N, Huffstetler AN. Health Equity: The Only Path Forward for Primary Care. Ann Fam Med 2022; 20:175-178. [PMID: 35165088 PMCID: PMC8959751 DOI: 10.1370/afm.2789] [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: 08/19/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 11/09/2022] Open
Abstract
The 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report on Implementing High-Quality Primary Care identifies 5 high-level objectives regarding payment, access, workforce development, information technology, and implementation. Nine junior primary care leaders (3 internal medicine, 3 family medicine, 3 pediatrics) invited from broad geographies, practice settings, and academic backgrounds used appreciative inquiry to identify priorities for the future of primary care. Highlighting the voices of these early career clinicians, we propose a response to the report from the perspective of early career primary care physicians. Health equity must be the foundation of the future of primary care. Because Barbara Starfield's original 4 Cs (first contact, coordination, comprehensiveness, and continuity) may not be inclusive of the needs of under-resourced communities, we promote an extension to include 5 additional Cs: convenience, cultural humility, structural competency, community engagement, and collaboration. We support the NASEM report's priorities and its focus on achieving health equity. We recommend investing in local communities and preparatory programs to stimulate diverse individuals to serve in health care. Finally, we support a blended value-based care model with risk adjustment for the social complexity of our patients.Appeared as Annals "Online First" article.
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Affiliation(s)
- Tracey L Henry
- Emory University School of Medicine, Division of General Medicine and Geriatrics, Atlanta, Georgia
| | - Jacqueline B Britz
- Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond, Virginia
| | - Joshua St Louis
- Department of Family Medicine, Tufts University School of Medicine, Boston, Massachusetts; Lawrence Family Medicine Residency, Lawrence, Massachusetts
| | | | - Carlos Irwin A Oronce
- Veterans Affairs Advanced Health Services Research Fellowship, Greater Los Angeles VA Healthcare System, Los Angeles, California.,David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | | | | | - Neeti Doshi
- University of California San Francisco Department of Pediatrics, San Francisco, California
| | - Alison N Huffstetler
- Virginia Commonwealth University, Department of Family Medicine and Population Health, Richmond, Virginia
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14
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Polite B, D Tucker-Seeley R, Winkfield KM, Hicks-Courant K. Health Equity for Black Americans: The Past Cannot Be Prologue. JCO Oncol Pract 2021; 17:252-254. [PMID: 33974835 DOI: 10.1200/op.21.00219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Blase Polite
- University of Chicago Medical Center, Chicago, IL
| | - Reginald D Tucker-Seeley
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles, CA.,USC Norris Comprehensive Cancer Center, Los Angeles, CA
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