Timing and Delays in Breast Cancer Evaluation and Treatment

The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach

BACKGROUND

Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies.

METHODS

We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and > 60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and > 60-day adjuvant delay.

RESULTS

We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25).

CONCLUSIONS

Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.

A mathematical model to study low-dose metronomic scheduling for chemotherapy

Metronomic chemotherapy refers to the frequent administration of chemotherapeutic agents at a lower dose and presents an attractive alternative to conventional chemotherapy with encouraging response rates. However, the schedule of the therapy, including the dosage of the drug, is usually based on empiricism. The confounding effects of tumor-endothelial-immune interactions during metronomic administration of drugs have not yet been explored in detail, resulting in an incomplete assessment of drug dose and frequency evaluations. The present study aimed to gain a mechanistic understanding of different actions of metronomic chemotherapy using a mathematical model. We have established an analytical condition for determining the dosage and frequency of the drug depending on its clearance rate for complete tumor elimination. The model also brings forward the immune-mediated clearance of the tumor during the metronomic administration of the chemotherapeutic agent. The results from the global sensitivity analysis showed an increase in the sensitivity of drug and immune-mediated killing factors toward the tumor population during metronomic scheduling. Our results emphasize metronomic scheduling over the maximum tolerated dose (MTD) and define a model-based approach for approximating the optimal schedule of drug administration to eliminate tumors while minimizing harm to the immune cells and the patient's body.

Time is of the Essence: Why Goals-of-Care Conversations and Prognosis Documentation Matters in Advanced Cancer Patients in an Integrated Health System

Background: Advanced cancer patients benefit less from aggressive therapies and more from goal-directed palliative management. Early and clearly documented goals-of-care discussions, including end-of-life decision making, are essential in this patient population. Integrated healthcare systems are comprehensive care models associated with improved quality of care and lower mortality compared to other healthcare models. The role of advance care planning within our system is understudied. Methods: Patients 18 years and older with a diagnosis of advanced-stage cancer were identified over a 6-month period. Expert panel review was performed to evaluate medical appropriateness of the selected diagnostic workup and management. The role and extent of care planning was reviewed in association with the clinical context. Results: In a cohort of 82 patients, evidence-based and individualized appropriateness of medical management was found to be consistent for all patients. Eighty-two percent of patients elected for oncologic-based treatment, 5% pursued active surveillance, and 11% did not receive treatment. Seventy-three percent of patients were referred to palliative care. Fifty-six percent of patients had a full goals-of-care conversation documented; yet only 9% of goals-of-care conversations were documented by an oncologist. Prognosis was documented fully for only 22% of patients. At the end of the study period, 43 patients were deceased (52%), further indicating the critical importance of documentation. Conclusions: Within our integrated health system, we found consistent guideline- and patient-directed diagnosis and management, along with frequent integration of palliative care services. Goals-of-care conversation and prognosis documentation, especially by the oncologist, remains an area of needed improvement.

Impact of the COVID-19 pandemic on breast cancer patient pathways and outcomes in the United Kingdom and the Republic of Ireland - a scoping review

The COVID-19 pandemic brought unplanned service disruption for breast cancer diagnostic, treatment and support services. This scoping review describes these changes and their impact in the UK and the Republic of Ireland based on studies published between January 2020 and August 2023. Thirty-four of 569 papers were included. Data were extracted and results thematically organized. Findings include fewer new cases; stage shift (fewer early- and more late-stage disease); and changes to healthcare organization, breast screening and treatment. Examples are accepting fewer referrals, applying stricter referral criteria and relying more on virtual consultations and multi-disciplinary meetings. Screening service programs paused during the pandemic before enacting risk-based phased restarts with longer appointment times to accommodate reduced staffing numbers and enhanced infection-control regimes. Treatments shifted from predominantly conventional to hypofractionated radiotherapy, fewer surgical procedures and increased use of bridging endocrine therapy. The long-term impact of such changes are unknown so definitive guidelines for future emergencies are not yet available. Cancer registries, with their large sample sizes and population coverage, are well placed to monitor changes to stage and survival despite difficulties obtaining definitive staging during diagnosis because surgery and pathological assessments are delayed. Multisite longitudinal studies can also provide guidance for future disaster preparedness.

Breast density knowledge and willingness to delay treatment for pre-operative breast cancer imaging among women with a personal history of breast cancer

BACKGROUND

Following a breast cancer diagnosis, it is uncertain whether women's breast density knowledge influences their willingness to undergo pre-operative imaging to detect additional cancer in their breasts. We evaluated women's breast density knowledge and their willingness to delay treatment for pre-operative testing.

METHODS

We surveyed women identified in the Breast Cancer Surveillance Consortium aged ≥ 18 years, with first breast cancer diagnosed within the prior 6-18 months, who had at least one breast density measurement within the 5 years prior to their diagnosis. We assessed women's breast density knowledge and correlates of willingness to delay treatment for 6 or more weeks for pre-operative imaging via logistic regression.

RESULTS

Survey participation was 28.3% (969/3,430). Seventy-two percent (469/647) of women with dense and 11% (34/322) with non-dense breasts correctly knew their density (p < 0.001); 69% (665/969) of all women knew dense breasts make it harder to detect cancers on a mammogram; and 29% (285/969) were willing to delay treatment ≥ 6 weeks to undergo pre-operative imaging. Willingness to delay treatment did not differ by self-reported density (OR:0.99 for non-dense vs. dense; 95%CI: 0.50-1.96). Treatment with chemotherapy was associated with less willingness to delay treatment (OR:0.67; 95%CI: 0.46-0.96). Having previously delayed breast cancer treatment more than 3 months was associated with an increased willingness to delay treatment for pre-operative imaging (OR:2.18; 95%CI: 1.26-3.77).

CONCLUSIONS

Understanding of personal breast density was not associated with willingness to delay treatment 6 or more weeks for pre-operative imaging, but aspects of a woman's treatment experience were.

CLINICALTRIALS

GOV : NCT02980848 registered December 2, 2016.

Analysis on status quo and related factors of delays in diagnosis and treatment of breast cancer in Ningxia Hui Autonomous Region

This study aimed to explore factors contributing to the delays in the diagnosis and treatment of breast cancer (BC) in Ningxia Hui Autonomous Region. We conducted a cohort analysis of 1012 patients with BC diagnosed at the General Hospital of Ningxia Medical University between January 2018 and December 2019. Sociodemographic data were collected through questionnaires, and clinical data were gathered and analyzed from relevant databases. Furthermore, observations were made regarding delays in the diagnosis and treatment of BC, followed by an analysis of the correlations between patient delay and both sociological factors within the population and clinical factors specific to patients with BC. Subsequently, the factors associated with patient delay and system delay were examined using Cox regression analysis, along with the inclusion of neoadjuvant therapy. In the prevention and treatment of BC in Ningxia, the patient delay rate was 33.20%, the diagnosis delay rate was 17.89%, the treatment delay rate was 0.0099% and the system delay rate was 41.60%. There was a higher proportion of patient delay and system delay in aged patients (age ≥ 61 years) with rural registered permanent residence (RPR), multiple clinical symptoms (such as nipple spillage, axillary abnormalities, etc), a T4 tumor size classification, and the initial use of neoadjuvant therapy. Besides, significant positive correlations were observed between patient delay and system delay time with BC stage. Patients aged 51 to 60 and those with molecular types (Limanal1B: ki-67 > 14%, Limanal1B: HER-2 positive) were prone to patient delay, whereas molecular characteristics influenced system delay, unrelated to sociodemographic factors. The study identifies significant age, residency, and tumor molecular subtype correlations with diagnostic and treatment delays in Ningxia's patients with BC, predominantly affecting women aged 41 to 60, especially urban dwellers. These findings underscore the need for targeted interventions to reduce delays and improve BC care in this region.

Biological Basis of Breast Cancer-Related Disparities in Precision Oncology Era

Precision oncology is based on deep knowledge of the molecular profile of tumors, allowing for more accurate and personalized therapy for specific groups of patients who are different in disease susceptibility as well as treatment response. Thus, onco-breastomics is able to discover novel biomarkers that have been found to have racial and ethnic differences, among other types of disparities such as chronological or biological age-, sex/gender- or environmental-related ones. Usually, evidence suggests that breast cancer (BC) disparities are due to ethnicity, aging rate, socioeconomic position, environmental or chemical exposures, psycho-social stressors, comorbidities, Western lifestyle, poverty and rurality, or organizational and health care system factors or access. The aim of this review was to deepen the understanding of BC-related disparities, mainly from a biomedical perspective, which includes genomic-based differences, disparities in breast tumor biology and developmental biology, differences in breast tumors' immune and metabolic landscapes, ecological factors involved in these disparities as well as microbiomics- and metagenomics-based disparities in BC. We can conclude that onco-breastomics, in principle, based on genomics, proteomics, epigenomics, hormonomics, metabolomics and exposomics data, is able to characterize the multiple biological processes and molecular pathways involved in BC disparities, clarifying the differences in incidence, mortality and treatment response for different groups of BC patients.

Rapid differentiation of estrogen receptor status in patient biopsy breast cancer aspirates with an optical nanosensor

Breast cancer is a substantial source of morbidity and mortality worldwide. It is particularly more difficult to treat at later stages, and treatment regimens depend heavily on both staging and the molecular subtype of the tumor. However, both detection and molecular analyses rely on standard imaging and histological method, which are costly, time-consuming, and lack necessary sensitivity/specificity. The estrogen receptor (ER) is, along with the progesterone receptor (PR) and human epidermal growth factor (HER-2), among the primary molecular markers which inform treatment. Patients who are negative for all three markers (triple negative breast cancer, TNBC), have fewer treatment options and a poorer prognosis. Therapeutics for ER+ patients are effective at preventing disease progression, though it is necessary to improve the speed of subtyping and distribution of rapid detection methods. In this work, we designed a near-infrared optical nanosensor using single-walled carbon nanotubes (SWCNT) as the transducer and an anti-ERα antibody as the recognition element. The nanosensor was evaluated for its response to recombinant ERα in buffer and serum prior to evaluation with ER- and ER+ immortal cell lines. We then used a minimal volume of just 10 μL from 26 breast cancer biopsy samples which were aspirated to mimic fine needle aspirates. 20 samples were ER+, while 6 were ER-, representing 13 unique patients. We evaluated the potential of the nanosensor by investigating several SWCNT chiralities through direct incubation or fractionation deployment methods. We found that the nanosensor can differentiate ER- from ER+ patient biopsies through a shift in its center wavelength upon sample addition. This was true regardless of which of the three SWCNT chiralities we observed. Receiver operating characteristic area under the curve analyses determined that the strongest classifier with an AUC of 0.94 was the (7,5) chirality after direct incubation and measurement, and without further processing. We anticipate that further testing and development of this nanosensor may push its utility toward field-deployable, rapid ER subtyping with potential for additional molecular marker profiling.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks

Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.

Association of Race, Ethnicity, Language, and Insurance with Time to Treatment Initiation Among Women with Breast Cancer at an Urban, Academic, Safety-Net Hospital

INTRODUCTION

Initial treatment for nonmetastatic breast cancer is resection or neoadjuvant systemic therapy, depending on tumor biology and patient factors. Delays in treatment have been shown to impact survival and quality of life. Little has been published on the performance of safety-net hospitals in delivering timely care for all patients.

METHODS

We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2019 at an academic, safety-net hospital. Time to treatment initiation was calculated for all patients. Consistent with a recently published Committee on Cancer timeliness metric, a treatment delay was defined as time from tissue diagnosis to treatment of greater than 60 days.

RESULTS

A total of 799 eligible women with stage 1-3 breast cancer met study criteria. Median age was 60 years, 55.7% were non-white, 35.5% were non-English-speaking, 18.9% were Hispanic, and 49.4% were Medicaid/uninsured. Median time to treatment was 41 days (IQR 27-56 days), while 81.1% of patients initiated treatment within 60 days. The frequency of treatment delays did not vary by race, ethnicity, insurance, or language. Diagnosis year was inversely associated with the occurrence of a treatment delay (OR: 0.944, 95% CI 0.893-0.997, p value: 0.039).

CONCLUSION

At our institution, race, ethnicity, insurance, and language were not associated with treatment delay. Additional research is needed to determine how our safety-net hospital delivered timely care to all patients with breast cancer, as reducing delays in care may be one mechanism by which health systems can mitigate disparities in the treatment of breast cancer.

Perioperative genetic testing and time to surgery in patients with breast cancer

BACKGROUND

Time to treatment has been identified as a quality metric, with longer time to treatment associated with poorer outcomes. Genetic evaluation is an integral part of treatment counseling for patients with breast cancer. With expanding indications for genetic testing and consideration of expansion of genetic testing to all patients with a personal history of breast cancer, this study aims to evaluate the effect of genetic evaluation on the time interval from initial surgical visit to surgery.

METHODS

A retrospective review of patients undergoing upfront surgery for stage 0-3 breast cancer from June 2022 to December 2022. Patient demographics, treatment characteristics, National Comprehensive Cancer Network criteria for genetic testing, and results were obtained.

RESULTS

The study included 492 patients (489 females). Eighty-one (16.2%) were ≤50 years of age at diagnosis. In total, 281 patients (57.1%) met National Comprehensive Cancer Network criteria for genetic testing and 199 consulted with a genetic counselor (72.4%). Seventy-six patients (27.6%) not meeting National Comprehensive Cancer Network criteria pursued genetic counseling. In total, 218 patients (79.3%) referred for genetic counseling completed testing. Mean turnaround time to genetic testing result was 11 days (range, 6-66 days). Twenty-six patients (11.9%) had a pathogenic or likely pathogenic variant. Twenty-four of these patients met National Comprehensive Cancer Network testing criteria (92.3%) and 2 did not (7.7%). The time to treatment for patients undergoing genetic testing was 33 vs 34 days in those without testing (P = .45). Three patients (11.5%) with pathogenic or likely pathogenic variants altered their initial surgical plan due to their genetic testing results. Seven patients with pathogenic or likely pathogenic variant results returning postoperatively did not undergo additional surgery.

CONCLUSION

Hereditary breast cancer evaluation and genetic testing did not appear to delay time to treatment for patients with breast cancer in our study cohort.

Prescribing pre- and post-operative physical activity interventions for people undergoing breast cancer surgery: A qualitative systematic review

INTRODUCTION

Undertaking physical activity, pre- and post-operatively, can benefit recovery time and improve post-surgical outcomes. One cohort of patients that have reported these benefits are those undergoing surgery for breast cancer. Yet, what remains unclear is the level to which physical activity interventions are implemented into standard surgical care for patients with breast cancer.

AIMS

This systematic review aimed to examine existing qualitative evidence focusing on pre- and post-operative physical activity interventions to better understand the benefits and shortcomings of physical activity within the surgical journey.

METHODS

A systematic literature search was undertaken in November 2022, across five databases: MEDLINE, PsycINFO, Embase, CINAHL, and Scopus. Qualitative studies involving people with breast cancer who had undertaken a physical activity intervention, either pre- and/or post-operatively, were included for analysis. The review was registered on PROSPERO: CRD42022372466 and performed according to PRISMA guidelines. The Critical Appraisal Skills Programme qualitative study checklist was used to assess study quality.

RESULTS

Fourteen studies were included, comprising the perspectives of 418 people receiving surgery for breast cancer. One study implemented preoperative physical activity interventions; the remaining studies focused on post-operative interventions. A narrative systematic review was undertaken due to heterogeneity in reported results. Four themes were developed by thematic analysis, centring on: (1) factors promoting engagement with physical activity interventions; (2) factors preventing engagement with physical activity interventions; (3) the impact of pre- and post-operative interventions on physical and psychological health; and (4) participant recommendations for pre- and post-operative interventions.

CONCLUSION

Pre- and post-operative physical activity interventions were well-accepted. Patients recognised factors which promoted or prevented engagement with interventions, as well as pre- and post-operative physical and psychological benefits that arose as a result. Evidence based co-design studies may further inform successful implementation of prescribed physical activity into standard care for surgical breast cancer patients.

Individual and area level factors associated with the breast cancer diagnostic-treatment interval in Queensland, Australia

BACKGROUND

Delays to breast cancer treatment can lead to more aggressive and extensive treatments, increased expenses, increased psychological distress, and poorer survival. We explored the individual and area level factors associated with the interval between diagnosis and first treatment in a population-based cohort in Queensland, Australia.

METHODS

Data from 3216 Queensland women aged 20 to 79, diagnosed with invasive breast cancer (ICD-O-3 C50) between March 2010 and June 2013 were analysed. Diagnostic dates were sourced from the Queensland Cancer Registry and treatment dates were collected via self-report. Diagnostics-treatment intervals were modelled using flexible parametric survival methods.

RESULTS

The median interval between breast cancer diagnosis and first treatment was 15 days, with an interquartile range of 9-26 days. Longer diagnostic-treatment intervals were associated with a lack of private health coverage, lower pre-diagnostic income, first treatments other than breast conserving surgery, and residence outside a major city. The model explained a modest 13.7% of the variance in the diagnostic-treatment interval [Formula: see text]. Sauerbrei's D was 0.82, demonstrating low to moderate discrimination performance.

CONCLUSION

Whilst this study identified several individual- and area-level factors associated with the time between breast cancer diagnosis and first treatment, much of the variation remained unexplained. Increased socioeconomic disadvantage appears to predict longer diagnostic-treatment intervals. Though some of the differences are small, many of the same factors have also been linked to screening and diagnostic delay. Given the potential for accumulation of delay at multiple stages along the diagnostic and treatment pathway, identifying and applying effective strategies address barriers to timely health care faced by socioeconomically disadvantaged women remains a priority.

Onco-Breastomics: An Eco-Evo-Devo Holistic Approach

Known as a diverse collection of neoplastic diseases, breast cancer (BC) can be hyperbolically characterized as a dynamic pseudo-organ, a living organism able to build a complex, open, hierarchically organized, self-sustainable, and self-renewable tumor system, a population, a species, a local community, a biocenosis, or an evolving dynamical ecosystem (i.e., immune or metabolic ecosystem) that emphasizes both developmental continuity and spatio-temporal change. Moreover, a cancer cell community, also known as an oncobiota, has been described as non-sexually reproducing species, as well as a migratory or invasive species that expresses intelligent behavior, or an endangered or parasite species that fights to survive, to optimize its features inside the host's ecosystem, or that is able to exploit or to disrupt its host circadian cycle for improving the own proliferation and spreading. BC tumorigenesis has also been compared with the early embryo and placenta development that may suggest new strategies for research and therapy. Furthermore, BC has also been characterized as an environmental disease or as an ecological disorder. Many mechanisms of cancer progression have been explained by principles of ecology, developmental biology, and evolutionary paradigms. Many authors have discussed ecological, developmental, and evolutionary strategies for more successful anti-cancer therapies, or for understanding the ecological, developmental, and evolutionary bases of BC exploitable vulnerabilities. Herein, we used the integrated framework of three well known ecological theories: the Bronfenbrenner's theory of human development, the Vannote's River Continuum Concept (RCC), and the Ecological Evolutionary Developmental Biology (Eco-Evo-Devo) theory, to explain and understand several eco-evo-devo-based principles that govern BC progression. Multi-omics fields, taken together as onco-breastomics, offer better opportunities to integrate, analyze, and interpret large amounts of complex heterogeneous data, such as various and big-omics data obtained by multiple investigative modalities, for understanding the eco-evo-devo-based principles that drive BC progression and treatment. These integrative eco-evo-devo theories can help clinicians better diagnose and treat BC, for example, by using non-invasive biomarkers in liquid-biopsies that have emerged from integrated omics-based data that accurately reflect the biomolecular landscape of the primary tumor in order to avoid mutilating preventive surgery, like bilateral mastectomy. From the perspective of preventive, personalized, and participatory medicine, these hypotheses may help patients to think about this disease as a process governed by natural rules, to understand the possible causes of the disease, and to gain control on their own health.

Low Hospital Volume Is Associated with Higher All-Cause Mortality in Black Women with Triple Negative Breast Cancer

INTRODUCTION

This study examines the association between hospital volume and all-cause mortality in Black women with triple negative breast cancer (TNBC) who received surgery and chemotherapy.

METHODS

Black women ages 18+ with stage I-III TNBC who received both surgery and chemotherapy were identified in the National Cancer Database (NCDB). Hospital volume was determined using the number of annual breast cancer cases divided by the number of years the hospital participated in the NCDB. Hospital annual volume quartiles ranged from Q1 (lowest) to Q4 (highest). Univariable analysis and multivariable logistic regression modeling with restricted cubic splines examined the effect of hospital volume on all-cause mortality.

RESULTS

Sixteen thousand five hundred fifty-six patients met the study criteria. All-cause mortality incidence was lower at higher volume compared to lower volume hospitals Q1 24.1% (95% CI: 22.8 to 25.4), Q2 21.8% (95% CI: 20.5 to 23.1), Q3 20.9% (95% CI: 19.6 to 22.1), Q4 19.0% (95% CI: 17.7 to 20.1), p<0.001. On multivariable analysis, treatment at the highest hospital volume quartile was associated with a 21% reduction in the odds of death compared to the lowest quartile [Q4 Vs. Q1, OR=0.79 (95% CI: 0.67 to 0.92)]. For every 100-patient increase in annual volume, all-cause mortality was reduced by 4% [OR=0.96 (95% CI: 0.94 to 0.98)]. There was a significant linear dose-dependent relationship between increasing hospital volume and all-cause mortality.

CONCLUSION

Black women treated at high-volume hospitals have lower all-cause mortality than those at low-volume hospitals. Future studies should examine the characteristics of high-volume hospitals associated with improved outcomes.

The Military Health System: Minimizing Disparities in Breast Cancer Treatment

BACKGROUND

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population.

METHODS

A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs.

RESULTS

Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004).

CONCLUSIONS

There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.

Timeliness of Multimodal Care for At-Risk Breast Cancer Patients at a Safety Net Institution

INTRODUCTION

Because limited data exist, we sought to evaluate timeliness of multimodal treatments in a safety net breast cancer population.

METHODS

Breast cancer patients treated at a safety net hospital from 2016 to 2020 were analyzed retrospectively. Time intervals were defined as primary time (PT) from diagnosis to initiation of primary intervention, secondary time (ST) from completion of primary to initiation of secondary intervention, and tertiary time (TT) from completion of secondary to initiation of tertiary intervention. Variables included primary language, insurance type, and race.

RESULTS

Of 223 patients, 99 (44.4%) primarily spoke Spanish, 29 (13.0%) were of Black race, and 184 (82.5%) had Medicaid or uninsured status. Median (IQR) age at diagnosis was 55 (48-62) years. Primary intervention was surgical in 127/216 (58.8%); secondary intervention was systemic in 38/169 (22.5%); and tertiary intervention was radiation in 67/80 (83.8%). Overall, median days (IQR) for PT were 69 (53, 98), ST were 65 (42, 95), and TT were 69 (43, 88). PT was significantly longer in Black [105 (76, 142) days] patients compared to non-Hispanic White patients [68 (51, 107) days, P = 0.031)] and White Hispanic patients [65 (53,91) days, P = 0.014]. There were no significant differences in PT, ST, or TT by spoken language or insurance type.

CONCLUSIONS

Black patients remain at risk due to prolonged time to intervention. Spanish-speaking status was not associated with inferior timeliness or completion of multimodal care at a safety net hospital. Identifying safety net hospital barriers to achieving benchmarks for timely completion of all phases of multimodal care warrants further attention.

Impact of the COVID-19 Pandemic on Delays to Breast Cancer Surgery: Ripples or Waves?

BACKGROUND

Adherence to current recommendations for optimal time from diagnosis to treatment for patients with breast cancer may have been disrupted by the COVID-19 pandemic. This study aimed to evaluate the impact of the pandemic on time to surgery or systemic treatment with chemotherapy or immunotherapy for patients diagnosed with breast cancer.

METHODS

Using the National Cancer Database, patients diagnosed with breast cancer in 2020 were compared to those diagnosed from 2018-2019 (Pre-COVID). Sub-analyses were performed for patients who were tested for COVID-19 and those who had a positive result in 2020. Multivariate logistic regression was used assess odds ratios for delayed time to surgery (DTS, defined as > 90 days) or systemic therapy (defined as > 120 days).

RESULTS

In total, 230,997 patients were diagnosed with breast cancer in 2018 and 2019 compared to 102,065 in 2020. Of the 2020 cohort, 47,659 (46.7%) received COVID-19 testing; of which, 3,158 (6.6%) resulted positive. A larger proportion of COVID-tested or COVID-positive patients had higher stage at diagnosis. DTS was more likely for patients who were diagnosed in 2020, uninsured or underinsured, non-white, Hispanic, less educated, or age < 70 years. Similar factors were predictive of delay to systemic therapy (less age < 70 years); however, diagnosis in 2020 was not.

CONCLUSION

The COVID-19 pandemic was associated with significant DTS for breast cancer but spared time to systemic therapy. Delays disproportionately impacted vulnerable and underserved patient populations. The true clinical effects of these delays may yet be realized for breast cancer patients.

Oncoplastic Breast Reduction: A Systematic Review of Postoperative Complications

Background

Breast-conserving therapy with oncoplastic reduction is a useful strategy for partial mastectomy defect reconstruction. The most recently published systematic review of oncoplastic breast reduction outcomes from 2015 showed wound dehiscence in 4.3%, hematoma in 0.9%, infection in 2.8%, and nipple necrosis in 0.9% of patients. We performed a systematic review of oncoplastic breast reduction literature, comparing outcomes and complication rates reported over the past 8 years.

Methods

Studies describing the use of oncoplastic breast reduction and discussion of postoperative complications were included. The primary outcome assessed was the postoperative complication rate; secondary outcomes analyzed were rates of margin expansion, completion mastectomy, and delays in adjuvant therapy due to complications.

Results

Nine articles met inclusion criteria, resulting in 1715 oncoplastic breast reduction patients. The mean rate of hematoma was 3%, nipple necrosis was 2%, dehiscence was 4%, infection was 3%, and seroma was 2%. The need for re-excision of margins occurred in 8% of patients, and completion mastectomy in 2%. Finally, delay in adjuvant treatment due to a postoperative complication occurred in 4% of patients.

Conclusions

Oncoplastic breast reduction is an excellent option for many patients undergoing breast-conserving therapy; however, postoperative complications can delay adjuvant radiation therapy. Results of this systematic literature review over the past 8 years showed a slight increase in complication rate compared to the most recent systematic review from 2015. With increased popularity and surgeon familiarity, oncoplastic breast reduction remains a viable option for reconstruction of partial mastectomy defects despite a slight increase in complication rate.

Prognosis stratification of patients with breast invasive carcinoma based on cysteine metabolism-disulfidptosis affinity

PURPOSE

The rise of female breast cancer has created a significant global public health issue that requires effective solutions. Disulfidptosis, a recently identified form of cell death characterized by an excessive accumulation of disulfides, has unique initiatory and regulatory mechanisms. The formation of disulfide bonds is a metabolic event typically associated with cysteines. This study aims to explore the potential of the affinity between cysteine metabolism and disulfidptosis in risk stratification for breast invasive carcinoma (BRCA).

METHODS

We used correlation analysis to decipher co-relation genes between cysteine metabolism and disulfidptosis (CMDCRGs). Both LASSO regression analysis and multivariate Cox regression analysis were employed to construct the prognostic signature. Additionally, we conducted investigations concerning subtype identification, functional enhancement, mutation landscape, immune infiltration, drug prioritization, and single-cell analysis.

RESULTS

We developed and validated a six-gene prognostic signature as an independent prognostic predictor for BRCA. The prognostic nomogram, based on risk score, demonstrated a favorable capability in predicting survival outcomes. We identified distinct gene mutations, functional enhancements, and immune infiltration patterns between the two risk groups. Four clusters of drugs were predicted as potentially effective for patients in the low-risk group. We identified seven cell clusters within the tumor microenvironment of breast cancer, and RPL27A was found to be widely expressed in this environment.

CONCLUSION

Multidimensional analyses confirmed the clinical utility of the cysteine metabolism-disulfidptosis affinity-based signature in risk stratification and guiding personalized treatment for patients with BRCA.

Experience with the safe admission of breast and thyroid cancer patients in non-endemic areas during an epidemic outbreak

Background

The outbreaks of infectious diseases, such as coronavirus disease 2019 (COVID-19), have seriously affected the normal work and life of the public, as well as the normal diagnosis and treatment of other diseases due to their strong infectivity, high population susceptibility, and diverse clinical manifestations. Breast and thyroid specialists in non-hotspot epidemic areas of COVID-19 must consider factors, including epidemic prevention and control, breast and thyroid cancers and diseases diagnosis and treatment, and access to medical resources to make a reasonable treatment choice and optimize the treatment process.

Methods

A cohort study was designed under our center's epidemic prevention and control strategy. The study was conducted between February 3 and April 19, 2020, to explore the safety of clinical diagnosis and treatment of breast and thyroid cancer patients during the epidemic. All the outpatients, inpatients, day-time chemotherapy patients, targeted therapy patients, and relevant medical staff in the observation period in the Department of Breast and Thyroid Surgery in Southwest Hospital in Chongqing municipality, China, were included to investigate the detection and infection rate of COVID-19 and suspected patients.

Results

During the observation period, 27,117 patients were admitted to the outpatient unit. We performed 394 inpatient surgeries and 411 day-time surgeries. In our center, 1,046 and 663 patients received day-time chemotherapy and targeted therapy, respectively. All the patients were diagnosed and treated promptly and safely. Three suspected COVID-19 patients were identified in the outpatient unit. Healthcare staff achieved a "zero" infection of COVID-19.

Conclusion

The spread and cross-infection of COVID-19 can be avoided in non-hotspot epidemic areas based on scientific prevention and control, and cancer patients can be diagnosed and treated on time. The prevention and control measure implemented in the COVID-19 epidemic for diagnosing and treating cancer patients was effective and can be referenced for other infectious disease outbreaks.

Associations between health insurance status, neighborhood deprivation, and treatment delays in women with breast cancer living in Georgia

BACKGROUND

Little is known regarding the association between insurance status and treatment delays in women with breast cancer and whether this association varies by neighborhood socioeconomic deprivation status.

METHODS

In this cohort study, we used medical record data of women diagnosed with breast cancer between 2004 and 2022 at two Georgia-based healthcare systems. Treatment delay was defined as >90 days to surgery or >120 days to systemic treatment. Insurance coverage was categorized as private, Medicaid, Medicare, other public, or uninsured. Area deprivation index (ADI) was used as a proxy for neighborhood-level socioeconomic status. Associations between delayed treatment and insurance status were analyzed using logistic regression, with an interaction term assessing effect modification by ADI.

RESULTS

Of the 14,195 women with breast cancer, 54% were non-Hispanic Black and 52% were privately insured. Compared with privately insured patients, those who were uninsured, Medicaid enrollees, and Medicare enrollees had 79%, 75%, and 27% higher odds of delayed treatment, respectively (odds ratio [OR]: 1.79, 95% confidence interval [CI]: 1.32-2.43; OR: 1.75, 95% CI: 1.43-2.13; OR: 1.27, 95% CI: 1.06-1.51). Among patients living in low-deprivation areas, those who were uninsured, Medicaid enrollees, and Medicare enrollees had 100%, 84%, and 26% higher odds of delayed treatment than privately insured patients (OR: 2.00, 95% CI: 1.44-2.78; OR: 1.84, 95% CI: 1.48-2.30; OR: 1.26, 95% CI: 1.05-1.53). No differences in the odds of delayed treatment by insurance status were observed in patients living in high-deprivation areas.

DISCUSSION/CONCLUSION

Insurance status was associated with treatment delays for women living in low-deprivation neighborhoods. However, for women living in neighborhoods with high deprivation, treatment delays were observed regardless of insurance status.

Effects of the COVID-19 pandemic on delays in diagnosis-to-treatment initiation for breast cancer in Brazil: a nationwide study

Background

Short period from diagnosis to breast cancer (BC) treatment initiation remains challenging for the public health system in Brazil, which may have been further affected by the coronavirus disease-2019 (COVID-19) pandemic. This study assessed BC diagnosis-to-treatment intervals (DTi) in Brazil and the possible effects of the COVID-19 outbreak on delays.

Methods

The Painel de Monitoramento de Tratamento Oncológico database was queried to obtain the number of Brazilian patients with a BC confirmed diagnosis and initiating cancer treatment in the pre-COVID-19 (2013-2019) and during the COVID-19 (2020-2021) periods, adopting a 60-day limit as timely treatment. A p-value of <0.05 was considered significant.

Results

A total of 315,951 cases were included (females: 99.3% and males: 0.7%), of which 251,667 and 64,284 records were computed before and during the COVID-19 years, respectively. Most patients failed to perform the first cancer treatment within 60 days (>60: 51.8%). We observed an upward trend in the number of BC treatments provided in the pre-COVID-19 years (r2 = 0.9575; p < 0.05), but the volume of treatments exhibited an average reduction of 24.6% yearly during the COVID-19 pandemic. The average DTi in days was 122.4, 122.5 and 122.3 in the total period studied, before and during the COVID-19 outbreak, respectively. The arrival of COVID-19 in Brazil increased the chances of treatment delay (OR = 1.043; p < 0.05) and inverted the proportion of early/advanced stages at BC diagnosis (55.8%/44.2%-48.4%/51.6%).

Conclusion

COVID-19 has imposed changes in BC care in Brazil, reducing the number of treatments provided by the Brazilian public health system, increasing the chances of delayed treatment initiation despite no differences in DTi averages being identified, and raising the proportion of advanced-stage diagnoses.

Ultrasound Guided Intraoperative Wire Localization Under General Anesthesia in Breast-Conserving Surgery

Breast-conserving surgery (BCS) is becoming an increasingly preferred surgical technique for treating breast cancer. For the last several decades, using a preoperative wire placed by a radiologist has been the gold standard to help guide surgeons to excise a suspicious mass. In recent years, there has been an increasing focus on using surgeon-performed intraoperative ultrasound (IOUS) during breast-conserving therapy, suggesting improved cosmetic outcomes and a decreased need for re-excision. However, studies have also highlighted that ultrasound may be uncomfortable for surgeons who have become most familiar with a wire-localization technique. Wire localization and intraoperative ultrasound are valuable tools that can improve the accuracy of tumor localization and reduce the need for re-excision. We present a 45-year-old female with a right breast mass, measuring breast imaging reporting and data system (BIRADS) 4A on preoperative ultrasound. Intraoperative wire-localization was performed by the surgeon utilizing ultrasound guidance. The right breast lesion was successfully excised with negative margins. The patient was discharged home and recovered well. Surgeon-performed intraoperative ultrasound can be combined with surgeon-performed wire localization to reduce the need for re-excision surgery and allow the surgeon to retain the familiarity of utilizing a gold-standard technique. Further research is needed to determine the optimal use of surgeon-performed IOUS and wire-localization, and its impact on long-term outcomes.

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

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.

Changes in the Utilization of Health Care Services by Cancer Patients during the COVID-19 Pandemic

PURPOSE

The first year of the COVID-19 pandemic in Korea elicited changes in healthcare service utilization. This study aimed to report changes in healthcare service utilization among cancer patients during the first year of the COVID-19 pandemic in Korea.

MATERIALS AND METHODS

We analyzed records from National Health Insurance Service Database and identified cancer patients as those with specific beneficiary codes ("V193" or "V194") assigned to cancer patients. We calculated percentage changes in the number of patients between 2019 and 2020 based on claims records for outpatient clinic visits, hospitalization, and emergency room visits by month, age group, residential areas, and hospital location.

RESULTS

The number of newly diagnosed cancer patients in 2020 decreased by 3.2%, compared to the previous year. The number of patients who visited an outpatient clinic, were hospitalized, and visited the emergency room decreased by 2.6%, 4.0%, and 3.5%, respectively, in 2020, compared to the year 2019.

CONCLUSION

During the first year of the COVID-19 pandemic, the number of newly diagnosed cancer patients decreased by 3.2%, compared to the previous year, and their utilization of healthcare services declined significantly after the outbreak of COVID-19.

Medicaid expansion, chemotherapy delays, and racial disparities among women with early-stage breast cancer

BACKGROUND

Medicaid expansion under the Affordable Care Act extends eligibility for participating states and has been associated with improved outcomes by facilitating access to care. Delayed initiation of adjuvant chemotherapy is associated with worse outcomes among patients with early-stage breast cancer (BC). The impact of Medicaid expansion in narrowing delays by race and ethnicity has not been studied, to our knowledge.

METHODS

This was a population-based study using the National Cancer Database. Patients diagnosed with primary early-stage BC between 2007 and 2017 residing in states that underwent Medicaid expansion in January 2014 were included. Time to chemotherapy initiation and proportion of patients experiencing chemotherapy delays (>60 days) were evaluated using difference-in-difference and Cox proportional hazards models in preexpansion and postexpansion periods according to race and ethnicity.

RESULTS

A total 100 643 patients were included (63 313 preexpansion and 37 330 postexpansion). After Medicaid expansion, the proportion of patients experiencing chemotherapy initiation delay decreased from 23.4% to 19.4%. The absolute decrease was 3.2, 5.3, 6.4, and 4.8 percentage points (ppt) for Black, Hispanic, White, and Other patients. Compared with White patients, statistically significant adjusted difference-in-differences were observed for Black (-2.1 ppt, 95% confidence interval [CI] = -3.7% to -0.5%) and Hispanic patients (-3.2 ppt, 95% CI = -5.6% to -0.9%). Statistically significant reductions in time to chemotherapy between expansion periods were observed among White patients (adjusted hazard ratio = .11, 95% CI = 1.09 to 1.12) and those belonging to racialized groups (adjusted hazard ratio  = 1.14, 95% CI = 1.11 to 1.17).

CONCLUSIONS

Among patients with early-stage BC, Medicaid expansion was associated with a reduction in racial disparities by decreasing the gap in the proportion of Black and Hispanic patients experiencing delays in adjuvant chemotherapy initiation.

COVID-19 and Breast Cancer: Analysis of Surgical Management of a Large Referral Center during the 2020-2021 Pandemic Period

BACKGROUND

Coronavirus disease-19 (COVID-19) has spread worldwide since December 2019 and was officially declared a pandemic in March 2020. Due to the rapid transmission and the high fatality rate, drastic emergency restrictions were issued, with a negative impact on routine clinical activities. In particular, in Italy, many authors have reported a reduction in the number of breast cancer diagnoses and critical problems in the management of patients who accessed the breast units during the dramatic first months of the pandemic. Our study aims to analyze the global impact of COVID-19 in the two years of the pandemic (2020-2021) on the surgical management of breast cancer by comparing them with the previous two years.

METHODS

In our retrospective study, we analyzed all cases of breast cancer diagnosed and surgically treated at the breast unit of "Città della Salute e della Scienza" in Turin, Italy, making a comparison between the 2018-2019 pre-pandemic period and the 2020-2021 pandemic period.

RESULTS

We included in our analysis 1331 breast cancer cases surgically treated from January 2018 to December 2021. A total of 726 patients were treated in the pre-pandemic years and 605 in the pandemic period (-121 cases, 9%). No significant differences were observed regarding diagnosis (screening vs. no screening) and timing between radiological diagnosis and surgery for both in situ and invasive tumors. There were no variations in the breast surgical approach (mastectomy vs. conservative surgery), while a reduction in axillary dissection compared to the sentinel lymph node in the pandemic period was observed (p-value < 0.001). Regarding the biological characteristics of breast cancers, we observed a greater number of grades 2-3 (p-value = 0.007), pT stage 3-4 breast cancer surgically treated without previous neoadjuvant chemotherapy (p-value = 0.03), and a reduction in luminal B tumors (p-value = 0.007).

CONCLUSIONS

Overall, we report a limited reduction in surgical activity for breast cancer treatment considering the entire pandemic period (2020-2021). These results suggest a prompt resumption of surgical activity similar to the pre-pandemic period.

SENODAY: A New Perspective of Handling Breast Cancer

BACKGROUND

To evaluate the feasibility of a same day breast cancer diagnosis and management protocol, consequently decreasing time to treatment and immediately reassuring patients with benign diagnosis.

MATERIALS AND METHODS

A total of 60 women underwent breast exam during SENODAY in our cancer center between January 2020 and December 2022. Patients are first seen by a breast surgeon who mentions whether the patient's history and physical exam are suspicious of malignancy. Patients are then sent to the radiologist who performs a complete radiologic assessment, classifies the lesions, and performs a biopsy when necessary. The specimen is sent to the pathologist who uses the imprint cytology technique to obtain a preliminary diagnosis. Effective counseling is established in case of breast cancer diagnosis.

RESULTS

Among 60 women, 25 patients were reassured by breast imaging and 35 underwent histopathological analysis (17 patients with a 1-day protocol and 18 with the standard definitive technique). Clinical examination was found to have a sensitivity of 100% and a specificity of 89.47%. The positive predictive value was 80 % and the negative predictive value was 100%. However, we did not find a strong correlation between imaging and definitive pathology. Moreover, on imprint cytology, sensitivity, specificity, PPV, and NPV were 100%. Finally, the mean time-to-treat was 28.6 days.

CONCLUSIONS

SENODAY reassured 68.3% of patients. It also offered effective counseling and a treatment plan to newly diagnosed breast cancer patients within 1 day. Same day histological diagnosis by imprint cytology is effective and feasible with an excellent accuracy.

Optimized process quality in certified breast centers through adherence to stringent diagnostic and therapeutic algorithms effects of structural as well as socio-demographic factors on start of therapy

PURPOSE

An increasing incidence of breast cancer can be observed worldwide. Since a delay of therapy can have a negative impact on prognosis, timely cancer care is an important quality indicator. By receiving treatment at a certified breast cancer center, the patient has the best chance of treatment in accordance with guidelines and the best prognosis. The identification of risk factors for a delay of therapy is of central importance and should be the basis for a continuous optimization of treatment at breast cancer centers.

METHODS

This retrospective study included women with breast cancer (primary diagnosis, relapse, or secondary malignancy) at the University Hospital Würzburg in 2019 and 2020. Data were retrieved from patients' records. Correlations and regression analyses were performed to detect potential risk factors for treatment delay.

RESULTS

Patients who received the histological confirmation of breast cancer at an external institution experienced a later therapy start than those patients who received the histological confirmation at the University Hospital Würzburg itself. (35.7 vs. 32.2 days). The interval between histological confirmation and the first consultation at the University Hospital Würzburg correlated statistically significant with age, distress and distance to the hospital.

CONCLUSION

Patients with an in-house diagnosis of breast cancer are treated more quickly than those whose diagnosis was confirmed in an external institution. We identified factors such as increased age, greater distance to the hospital as well as increased distress to prolong the time until start of oncological treatment. Intensified patient care should be offered to these subgroups.

Predictive Factors for Cancer Treatment Delay in a Racially Diverse and Socioeconomically Disadvantaged Urban Population

PURPOSE

Incremental delays in time to treatment initiation (TTI) have been shown to cause a proportional, increased independent risk of disease-specific mortality for breast cancer, colorectal cancer (CRC), head and neck cancer (HNC), non–small-cell lung cancer (NSCLC), and pancreatic cancer. Studies suggest that delays are associated with racial and socioeconomic disparities. We evaluated associations between patient factors and TTI to identify those associated with delay.

MATERIALS AND METHODS

This is a retrospective cohort study at an urban community-based academic center of patients diagnosed with or referred for curative-intent treatment of breast cancer, CRC, HNC, NSCLC, and pancreatic cancer from January 2019 to December 2021. Variables of interest included Charlson Comorbidity Index (CCI) score, insurance type, language preference, and inpatient admission 30 days before diagnosis. Factors associated with TTI delay, defined as TTI ≥ 30 days, were assessed using multivariable logistic regression.

RESULTS

Among 2,543 patients (69% female), the mean age was 63.4 years and the median TTI was 25 days (IQR, 6-44). Within multivariable models, patients treated as outpatient and not admitted 30 days before diagnosis experienced statistically significant greater delay for CRC (odds ratio [OR], 2.82; 95% CI, 1.71 to 4.66) and NSCLC (OR, 2.11; 95% CI, 1.31 to 3.39). Higher CCI score was associated with delay for HNC (OR, 2.63; 95% CI, 1.04 to 6.66) and NSCLC (OR, 1.75; 95% CI, 1.14 to 2.71). For breast cancer, uninsured and Spanish-speaking patients (OR, 1.79; 95% CI, 1.21 to 2.67) experienced increased TTI.

CONCLUSION

Care coordination/compliance (eg, inpatient 30 days before diagnosis), clinical (eg, medical comorbidities), and socioeconomic (eg, uninsured status) predictors for delayed TTI were identified and may inform delay minimizing interventions. Our data support evidence that TTI delays are associated with demographic and socioeconomic disparities. Existing disparities are likely exacerbated by delays that disproportionately affect patients with care coordination/compliance issues, multiple comorbidities, and lower socioeconomic status.

Time interval between diagnosis to treatment of breast cancer and the impact of health insurance coverage: a sub analysis of the AMAZONA III Study (GBECAM 0115)

PURPOSE

Breast cancer (BC) is the most common type of cancer among women in Brazil. Evidence shows that delayed treatment onset is associated with increased mortality. This study aimed to evaluate median days between diagnosis and treatment and factors associated with delayed start of treatment (> 60 days after diagnosis): stage, treatment received, subtype, epidemiological characteristics, and type of healthcare coverage.

METHODS

This analysis included 1709 stage I-III BC patients from AMAZONA III, a prospective, observational study, diagnosed from January 2016 to March 2018 in 22 centers in Brazil.

RESULTS

The median number of days from diagnosis to beginning of first oncologic treatment was 46 days (IQR 28-75) overall, 43 days (IQR 25-75) for stage I disease, 49 days (IQR 28-81) for stage II, and 44 days (IQR 30-68) for stage III, (p = 0.1180). According to first treatment received, diagnosis-to-treatment interval was 43 days (IQR 29-65) for neoadjuvant chemotherapy and 48 days (IQR 26-81) for surgery. Diagnosis-to-treatment interval was higher in women treated in the public system versus the private system (56 vs. 34 days, p < 0.0001). Patients in the public system had an increased odds of delayed treatment initiation (OR 4.74 95% CI 3.09-7.26, p < .0001). The longer interval from diagnosis to treatment in the public system was independent of clinical stage, type of treatment (systemic vs surgery first), subtype and region of the country.

CONCLUSION

By characterizing the delays in care delivery, our study will aid stakeholders to better design interventions and allocate resource to improve timely treatment for breast cancer in Brazil.

CLINICALTRIALS

gov Identifier: NCT02663973, registered on January, 26th, 2016.

Assurance of Timely Access to Breast Cancer Diagnosis and Treatment by a Regional Breast Health Clinic Serving Both Urban and Rural-Remote Communities

In response to breast cancer diagnostic regional wait times exceeding both national and provincial standards and to symptomatic patient referrals for diagnostic mammography taking longer than abnormal screening mammography referrals, the Rae Fawcett Breast Health Clinic (RFBHC) was opened in 2017 in a mid-sized Canadian hospital serving both urban and rural-remote communities. We investigated whether the RFBHC improved wait times to breast cancer diagnosis, improved compliance with national and provincial breast cancer standards, and decreased the wait time disparity associated with referral source. Statistical analyses of wait time differences were conducted between patients who were diagnosed with breast cancer prior to and after the RFBHC establishment. Study group compliance with national and provincial standards and wait time differences by referral source were also analysed. A survey was administered to assess overall patient experience with the RFBHC and clinic wait times. RFBHC patients had a shorter mean wait to breast cancer diagnosis (24.4 vs. 45.7 days, p ≤ 0.001) and a shorter mean wait to initial breast cancer treatment (49.1 vs. 78.9 days, p ≤ 0.001) than pre-RFBHC patients. After the RFBHC establishment, patients who attended the RFBHC had a shorter mean wait time to breast cancer diagnosis (24.4 vs. 36.9 days, p = 0.005) and to initial treatment (49.1 vs. 73.1 days, p ≤ 0.001) than patients who did not attend the clinic. Compliance with national and provincial breast cancer standards improved after the RFBHC establishment and the wait time disparity between screening mammography referrals and symptomatic patient referrals decreased. Survey results indicate that the RFBHC is meeting patient expectations. We concluded that the establishment of a breast health clinic in a Canadian center serving urban and rural-remote communities improved breast diagnostic services.

A systematic review of the impact of the COVID-19 pandemic on breast cancer screening and diagnosis

BACKGROUND

Breast cancer care has been affected by the COVID-19 pandemic. This systematic review aims to describe the observed pandemic-related changes in clinical and health services outcomes for breast screening and diagnosis.

METHODS

Seven databases (January 2020-March 2021) were searched to identify studies of breast cancer screening or diagnosis that reported observed outcomes before and related to the pandemic. Findings were presented using a descriptive and narrative approach.

RESULTS

Seventy-four studies were included in this systematic review; all compared periods before and after (or fluctuations during) the pandemic. None were assessed as being at low risk of bias. A reduction in screening volumes during the pandemic was found with over half of studies reporting reductions of ≥49%. A majority (66%) of studies reported reductions of ≥25% in the number of breast cancer diagnoses, and there was a higher proportion of symptomatic than screen-detected cancers. The distribution of cancer stage at diagnosis during the pandemic showed lower proportions of early-stage (stage 0-1/I-II, or Tis and T1) and higher proportions of relatively more advanced cases than that in the pre-pandemic period, however population rates were generally not reported.

CONCLUSIONS

Evidence of substantial reductions in screening volume and number of diagnosed breast cancers, and higher proportions of advanced stage cancer at diagnosis were found during the pandemic. However, these findings reflect short term outcomes, and higher-quality research examining the long-term impact of the pandemic is needed.

A Precise Approach for Radiotherapy of Breast Cancer

Radiotherapy is an integral part of the multidisciplinary management of breast cancer (BC). There have been multiple recent advances in the delivery of radiotherapy, reviewed with a critical discussion of the evidence from trials investigating adjuvant ultra-hypofractionation and partial breast irradiation for early-stage BC, and the locoregional management of lymph nodes in locally advanced BC. Multiple precision medicine-based approaches have been developed as prognostic and/or predictive for BC patients and identifying biomarkers of radioresistance could help identify patients that may benefit from dose-escalated radiotherapy or radiosensitizers. Radiotherapy after breast reconstruction is an area of current controversy in the field, and we evaluated the decision-making considerations in this situation. The oligometastatic state is an emerging field for many cancer sites based on recent trials investigating ablative radiotherapy for oligometastatic BC. This chapter is an overview of radiotherapy for BC, with a focus on recent advances in early-stage, locally advanced, and oligometastatic disease.

Advice from One Patient to Another: Qualitative Analysis of Patients' Perspectives About Chemotherapy Initiation

Purpose

Although the association between delays in (neo)adjuvant chemotherapy initiation and adverse outcomes is well-documented, patient perspective regarding the lived experience among those with breast cancer delay is sparse. Project Start was a qualitative study designed to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy. This report explores specific responses where patients with breast cancer provide insight and advice for newly diagnosed women on preparing for chemotherapy initiation and informs potential interventions to facilitate timely chemotherapy initiation.

Patients and Methods

Women diagnosed with primary invasive breast cancer who experienced a ≥60-day delay in (neo)adjuvant chemotherapy initiation were included. Participants completed semi-structured interviews exploring barriers and facilitators to starting chemotherapy. Interviews were transcribed and coded to identify themes.

Results

We enrolled (N = 22) participants with a median age at diagnosis of 53.5 years (range 27-70) who identified as Latina (n = 8), Black (n = 5), and non-Latina White (n = 9). Our participants indicated that engaging their medical teams and seeking support earlier were essential to initiate their treatment journeys. They emphasized being proactive and thorough in all aspects of their journey, particularly in processing medical recommendations, communicating with medical personnel, and identifying areas of need. Although explicit insight into chemotherapy delay was rare, participants expressed the importance of beginning treatment promptly. They shared advice on acquiring support (eg, financial, emotional, logistical, spiritual) and suggested connecting with breast cancer survivors to overcome the complex challenges of cancer care.

Conclusion

Patient perspectives regarding barriers and treatment facilitators help provide insight into the lived experience of cancer care journeys that can inform interventions to improve patient support and outcomes. We are using these results to develop a pilot study to test the acceptability and feasibility of a culturally tailored patient navigation intervention to increase self-efficacy and avoid treatment delays.

Clinical Delays and Comparative Outcomes in Younger and Older Adults with Colorectal Cancer: A Systematic Review

Outcome disparities between adults <50 with colorectal cancer (CRC) and older adults may be explained by clinical delays. This study synthesized the literature comparing delays and outcomes between younger and older adults with CRC. Databases were searched until December 2021. We included studies published after 1990 reporting delay in adults <50 that made comparisons to older adults. Comparisons were described narratively and stage between age groups was meta-analyzed. 39 studies were included representing 185,710 younger CRC patients and 1,422,062 older patients. Sixteen delay intervals were compared. Fourteen studies (36%) found significantly longer delays among younger adults, and nine (23%) found shorter delays among younger patients. Twelve studies compared time from symptom onset to diagnosis (N younger = 1538). Five showed significantly longer delays for younger adults. Adults <50 years also had higher odds of advanced stage (16 studies, pooled OR for Stage III/IV 1.76, 95% CI 1.52-2.03). Ten studies compared time from diagnosis to treatment (N younger = 171,726) with 4 showing significantly shorter delays for younger adults. All studies showing longer delays for younger adults examined pre-diagnostic intervals. Three studies compared the impact of delay on younger versus older adult. One showed longer delays were associated with advanced stage and worse survival in younger but not older adults. Longer delays among younger adults with CRC occur in pre-diagnostic intervals.

Time to surgery and survival in breast cancer

Background

This study aimed to investigate the effect of the time from diagnosis to breast cancer surgery on breast cancer patients’ prognosis.

Methods

Of the 1900 patients diagnosed with invasive (stage 1–3) breast cancer who underwent surgery in KUH between 2012 and 2019, 279 patients were enrolled in this study. All patients, including those who received neoadjuvant chemotherapy, were classified as Model 1 subjects, and those who received immediate surgical treatment were classified as Model 2 subjects. We conducted a Cox regression analysis to identify prognostic factors of breast cancer associated with the time from diagnosis to surgery.

Results

The univariate results indicated a sharp drop in both groups’ survival rates when the time to surgery was delayed for more than 8 weeks (Model 1 p = 0.000; Model 2 p = 0.001). In the multivariate analysis, the hazard ratio (HR) of Model 1increased (HR = 6.84, 95% CI 1.06–44.25) in response to a delay in surgery of more than 8 weeks. Smoking and the American Joint Committee on Cancer (AJCC) staging system had a negative effect on breast cancer prognosis, while hormone therapy had a positive effect.

Conclusion

For all patients, a delay in breast cancer surgery of more than 8 weeks was inversely associated with survival.

Treatment time interval in breast cancer: A population-based study on the impact of type and number of cancer centres attended

OBJECTIVES

We studied both the independent and combined effects of the places of biopsy and treatment on the treatment time interval based on a population-based study.

METHODS

We analysed the proportion of patients having a treatment time interval higher than the EUSOMA recommendation of 6 weeks, as a function of the number and the type of care centres the patients attended, from a French population-based regional cohort of women treated in 2015 for an incident invasive non-metastatic cancer (n = 505).

RESULTS

About 33% [95% CI: 27; 38] of patients had a treatment time interval higher than 6 weeks. About 48% of the patients underwent their biopsy and their initial treatment in the different centres. Results from multivariable analyses supported the impact of the type and number of centres attended on the proportion of time intervals over 6 weeks. This proportion was higher among patients with biopsy and treatment in different centres and among patients treated in a university hospital.

CONCLUSION

We pointed out the independent impact of the type and the number of care centres the patients attended, from biopsy to first treatment, on the treatment time interval, which is a well-known prognosis factor.

[Cancer during pregnancy: Proposal of a clinical care pathway based on a regional cohort]

OBJECTIVES

Cancer during pregnancy affects 1 in 1000 pregnancies. This situation requires multidisciplinary team, however there is no care pathway dedicated to these patients. The main objective was to describe oncological, obstetrical, and neonatal care through a regional inventory. Our secondary objective was to define a regional "cancer and pregnancy" care pathway.

MATERIAL AND METHOD

We carried out an observational, retrospective study from 2013 to 2019 including 48 women (all cancer types) from 2013 to 2019 in Occitania. Then, we defined an "optimal care pathway" and we assessed whether it was respected in the breast cancer subgroup of our cohort.

RESULTS

Live births occurred in 79% of the women included. Maternal treatment was initiated during pregnancy for 67% of our population (44% chemotherapy). The most frequent pregnancy complication was preterm delivery (39%), mainly iatrogenic (86.6%). No patient in the group of breast cancer benefited from all of the ten criteria of the "optimal care pathway" that we proposed.

CONCLUSIONS

A coordinated regional care pathway seems necessary to optimize communication between the healthcare providers (oncologists, gynecologists and multidisciplinary prenatal diagnosis centers, pharmacologists, pediatricians, psychologists, and general practitioners). This study identifies weaknesses in the management of women with cancer during pregnancy and suggests regional improvement opportunities.

Machine learning predicts the prognosis of breast cancer patients with initial bone metastases

Background

Bone is the most common metastatic site of patients with advanced breast cancer and the survival time is their primary concern; however, we lack accurate predictive models in clinical practice. In addition to this, primary surgery for breast cancer patients with bone metastases is still controversial.

Method

The data used for analysis in this study were obtained from the SEER database (2010-2019). We made a COX regression analysis to identify prognostic factors of patients with bone metastatic breast cancer (BMBC). Through cross-validation, we constructed an XGBoost model to predicting survival in patients with BMBC. We also investigated the prognosis of patients treated with neoadjuvant chemotherapy plus surgical and chemotherapy alone using propensity score matching and K-M survival analysis.

Results

Our validation results showed that the model has high sensitivity, specificity, and correctness, and it is the most accurate one to predict the survival of patients with BMBC (1-year AUC = 0.818, 3-year AUC = 0.798, and 5-year survival AUC = 0.791). The sensitivity of the 1-year model was higher (0.79), while the specificity of the 5-year model was higher (0.86). Interestingly, we found that if the time from diagnosis to therapy was ≥1 month, patients with BMBC had even better survival than those who started treatment immediately (HR = 0.920, 95%CI 0.869-0.974, P < 0.01). The BMBC patients with an income of more than USD$70,000 had better OS (HR = 0.814, 95%CI 0.745-0.890, P < 0.001) and BCSS (HR = 0.808 95%CI 0.735-0.889, P < 0.001) than who with income of < USD$50,000. We also found that compared with chemotherapy alone, neoadjuvant chemotherapy plus surgical treatment significantly improved OS and BCSS in all molecular subtypes of patients with BMBC, while only the patients with bone metastases only, bone and liver metastases, bone and lung metastases could benefit from neoadjuvant chemotherapy plus surgical treatment.

Conclusion

We constructed an AI model to provide a quantitative method to predict the survival of patients with BMBC, and our validation results indicate that this model should be highly reproducible in a similar patient population. We also identified potential prognostic factors for patients with BMBC and suggested that primary surgery followed by neoadjuvant chemotherapy might increase survival in a selected subgroup of patients.

Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries

BACKGROUND

Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood.

METHODS

We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence.

RESULTS

Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays.

CONCLUSIONS

Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban status.

Prognostic Implications of Treatment Delays for Patients with Non-muscle-invasive Bladder Cancer

BACKGROUND

Delay in treatment is a prognostic factor in muscle-invasive bladder cancer.

OBJECTIVE

To evaluate clinical outcomes associated with delays in diagnosis and treatment for patients with non-muscle invasive bladder cancer (NMIBC).

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective study we analyzed data for patients treated at our center between November 2008 and December 2016 for intermediate risk (IR) or high risk (HR) NMIBC with an additional intravesical treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Time delays from diagnosis to first transurethral resection (TT-TUR), from resection to restaging resection (TT-reTUR), and from the last resection to first instillation (TT-INST) of bacillus Calmette-Guérin (BCG) or mitomycin C (MMC) were documented. To identify the interval of time from which recurrence rates significantly increased, we used nonparametric series regression. Recurrence-free survival (RFS) and progression-free survival for patients in each time delay category were compared using the Kaplan-Meier method. Factors associated with tumor recurrence were analyzed in a multivariable model.

RESULTS AND LIMITATIONS

A total of 434 patients were included, of whom 168 (38.7%) had IR and 266 (61.3%) had HR NMIBC. Among the patients, 34.6% had reTUR, 63.6% received BCG, and 36.4% received MMC. The median TT-TUR, TT-reTUR, and TT-INST was 4.0 wk, 6.5 wk, and 7.0 wk, respectively. At 40 mo the rate of recurrence was 28.4% and the rate of progression was 7.3%. Nonparametric analysis revealed that each week in delay increased the risk of recurrence, starting from week 6 for TT-TUR for IR and HR cases, and starting from week 7 for TT-INST for IR cases. RFS was significantly lower with TT-TUR > 6 wk among patients in the IR (p < 0.001) and HR (p = 0.04) groups, and with TT-INST >7 wk for patients in the IR group (p = 0.001). TT-reTUR >7 wk had a significant negative impact on progression (p < 0.017). Multivariable analysis revealed that for IR and HR cases, multifocality (p = 0.02 and p = 0.007) and TT-TUR >6 wk (p = 0.001 and p = 0.03) were independent predictors of recurrence, while TT-INST >7 wk predicted recurrence (p = 0.04) for IR NMIBC.

CONCLUSIONS

Our results suggest that delays of >6 wk to first TUR in IR and HR NMIBC, and >7 wk to first instillation in IR cases are associated with increases in the risk of recurrence. TT-reTUR of >7 wk is also associated with higher risk of progression.

PATIENT SUMMARY

We evaluated the impact of treatment delays on outcomes for patients with intermediate- and high-risk bladder cancer not invading the bladder wall muscle. We found that delays from diagnosis to first bladder resection, from first resection to repeat resection, and from last resection to bladder instillation treatment increase the rates of cancer recurrence and progression. The medical team should avoid delays in treatment, even for low-grade bladder cancer.

Análise do Tempo para Início do Tratamento Oncológico no Brasil: Fatores Demográficos e Relacionados à Neoplasia

Introdução: E reservado a todo brasileiro com câncer, pela Lei dos 60 Dias, o direito de começar o tratamento em até dois meses. Todavia, estudos anteriores apontam a dificuldade dos pacientes em fazer valer essa normativa ao esbarrarem em problemáticas macroestruturais dos sistemas de saúde. Objetivo: Avaliar a influência de fatores demográficos e relacionados a neoplasia sobre o tempo para início do tratamento oncológico no Brasil. Método: Estudo seccional, desenvolvido com dados oriundos do PAINEL-Oncologia, uma base publica nacional, alimentada por diversas fontes de informação do Sistema Único de Saúde. Como variáveis de interesse, elegeram-se: a) tempo de tratamento; b) sexo; c) idade; d) diagnostico; e) estadiamento; f) modalidade terapêutica. Então, foi analisado o tempo transcorrido entre o diagnóstico e o início do tratamento oncológico. Resultados: Percebeu-se aumento exponencial, ao longo dos anos, da proporção de casos tratados oportunamente, isto e, em até 60 dias, como regulamenta a Lei. Entretanto, ainda e considerável a prevalência de atrasos no início do tratamento, sobretudo entre indivíduos idosos, do sexo masculino, com canceres em estádios menos avançados e que precisaram de radioterapia como primeira modalidade terapêutica. Além disso, o tempo de espera foi especialmente maior para os canceres de órgãos genitais masculinos, de cabeça e pescoço e de mama. Conclusão: Alguns fatores demográficos e relacionados a neoplasia estão envolvidos no atraso do início da terapia oncológica.

Black boxes and information pathways: An actor-network theory approach to breast cancer survivorship care

Many women diagnosed with breast cancer today can expect to live long after completing their treatment. This growing population of survivors encounters distinct post-treatment health and information needs. Existing survivorship care models take information as a given, black boxing it. I use Actor-Network Theory to examine how information actually works for women after they complete breast cancer treatment, and how it shapes their understanding of survivorship. I draw on in-depth interviews with breast cancer survivors (n = 82) and a wide range of providers (n = 84) in a medically underserved region of Southern California. Black boxes and information pathways convey experiential dimensions of cancer care; they are also metaphoric constructs. The black box metaphor refers to the cancer experience as a container; the pathways metaphor refers to a journey. Each of these metaphors expresses salient dimensions of the cancer experience and has implications for post-treatment survivorship. When healthcare information flows smoothly and invisibly, its pathways become black boxed. Black boxes can be helpful when they function effectively. But since black boxes conceal their inner workings, it is challenging to intervene when difficulties arise. I provide three examples of difficulties that complicate women's transition to post-treatment survivorship: (1) when survivors fail to recognize treatment-related late effects, (2) do not understand they have a terminal diagnosis, or (3) worry that their treatment accomplished nothing. Contextualized within survivorship scholarship, this study recommends opening black boxes to examine how information pathways could connect women differently to improve survivorship care.

Reduction in tumor grade and Ki-67 in postmenopausal patient with node-positive invasive ductal carcinoma following combination hormone replacement therapy cessation: a case report

Background

While praised for its benefits in treating symptoms related to menopausal changes, hormone replacement therapy (HRT) has been associated with an increased risk for hormone-dependent cancer development, particularly endometrial and breast. Few studies have elucidated the relationship between HRT cessation and hormone receptor-positive breast cancer proliferation. We report herein, to the best of our knowledge, the first case of 28.6% relative reduction in proliferation index marker Ki-67 in node-positive hormone receptor-positive breast cancer following HRT cessation.

Case Description

We report an unusual case of a 64-year-old female patient with longstanding HRT for fifteen years who underwent immediate discontinuation after diagnosis of poorly differentiated invasive ductal carcinoma. We observed a reduction in tumor grade from poorly differentiated at time of biopsy to moderately differentiated at time of surgery following cessation of HRT, as well as a reduction in the tumor proliferation index (Ki-67) from 70% to 50%. The patient has remained recurrence-free at the one-year mark postoperatively with continued follow-up.

Conclusions

This case highlights potential clinical benefits associated with HRT discontinuation in the postmenopausal population with preexisting hormone-dependent cancers with high proliferation index, as well as the usefulness of Ki-67 in measuring response to aromatase inhibition in this subpopulation of patients.

Keywords

Hormone replacement therapy (HRT); breast cancer; tumor grade; Ki-67; case report.

Consequences of the impact of COVID-19 pandemic on breast cancer at a single Italian institution

Aim: To evaluate the local impact of the coronavirus disease 2019 (COVID-19) pandemic on breast cancer (BC) care, with particular attention to the economical and psychological consequences of the possible delay of new diagnoses and treatments. Methods: Three years’ activity (from 2019 to 2021) has been compared. The number of BCs diagnosed from the total amount of mammographic and ultrasound (US) examinations performed in women aged more than 40 years old has been considered. A Pearson’s chi-squared test was performed to verify differences between results. Statistical significance was set at P ≤ 0.01. Results: A statistically significant difference was found in the number of BC diagnosed between screening and ambulatory care patients in both the 2019–2020 (χ2 = 24.93, P < 0.01) and 2019–2021 (χ2 = 29.93, P < 0.01) comparisons. No statistically significant difference was found in the data recorded between 2020 and 2021 (χ2 = 2.35, P > 0.01). By evaluating the specific age groups for each year, a statistically significant difference (P < 0.01) was found in the number of BC diagnosed in screening patients aged 50–69 years old in both 2019–2020 and 2019–2021 comparisons. The percentages of early BC diagnosed in 2019, 2020, and 2021 were 80.9%, 91.7%, and 89.8%, respectively. The adherence rates to screening in 2019, 2020, and 2021 were 67.5%, 45.2%, and 56.9%, respectively. Conclusions: Results showed a reduction of new diagnoses in the screening range during the pandemic in comparison with the previous period. The high percentage of early BC would seem to have prevented worsening outcomes. Nevertheless, women who have not undergone screening could present a more advanced stage disease in the following years. Consequently, the evaluation of possible solutions to guarantee an essential level of care with the purpose to avoid worsening patients’ outcomes and the increase in healthcare costs is mandatory.

Multiple mediation analysis of racial disparity in breast cancer survival

BACKGROUND

Racial (Black vs. White) disparities in breast cancer survival have proven difficult to mitigate. Targeted strategies aimed at the primary factors driving the disparity offer the greatest potential for success. The purpose of this study was to use multiple mediation analysis to identify the most important mediators of the racial disparity in breast cancer survival.

METHODS

This was a retrospective cohort study of non-Hispanic Black and non-Hispanic White women diagnosed with invasive breast cancer in Florida between 2004 and 2015. Cox regression was used to obtain unadjusted and adjusted hazard ratios (HR) with 95% confidence intervals (CI) for the association of race with 5- and 10-year breast cancer death. Multiple mediation analysis of tumor (advanced disease stage, tumor grade, hormone receptor status) and treatment-related factors (receipt of surgery, chemotherapy, radiotherapy, and hormone therapy) was used to determine the most important mediators of the survival disparity.

RESULTS

The study population consisted of 101,872 women of whom 87.0% (n = 88,617) were White and 13.0% were Black (n = 13,255). Black women experienced 2.3 times (HR, 2.27; 95% CI, 2.16-2.38) the rate of 5-year breast cancer death over the follow-up period, which decreased to a 38% increased rate (HR, 1.38; 95% CI, 1.31-1.45) after adjustment for age and the mediators of interest. Combined, all examined mediators explained 73% of the racial disparity in 5-year breast cancer survival. The most important mediators were: (1) advanced disease stage (44.8%), (2) nonreceipt of surgery (34.2%), and (3) tumor grade (18.2%) and hormone receptor status (17.6%). Similar results were obtained for 10-year breast cancer death.

CONCLUSION

These results suggest that additional efforts to increase uptake of screening mammography in hard-to-reach women, and, following diagnosis, access to and receipt of surgery may offer the greatest potential to reduce racial disparities in breast cancer survival for women in Florida.