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Liggett JR, Norris EA, Rush TM, Sicignano NM, Oxner C. The Military Health System: Minimizing Disparities in Breast Cancer Treatment. Mil Med 2023; 188:494-502. [PMID: 37948201 DOI: 10.1093/milmed/usad218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 05/30/2023] [Indexed: 11/12/2023] Open
Abstract
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.
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Affiliation(s)
| | - Emily A Norris
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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Darmon S, Lovejoy LA, Shriver CD, Zhu K, Ellsworth RE. Nondisparate Survival of Non-Hispanic Black Women With Breast Cancer Despite Less Favorable Pathology: Effect of Access to and Provision of Care Within a Military Health Care System. Health Equity 2023; 7:178-184. [PMID: 36942312 PMCID: PMC10024578 DOI: 10.1089/heq.2022.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 03/12/2023] Open
Abstract
Introduction Breast cancer mortality rates are 40% higher in non-Hispanic Blacks (NHBs) than in non-Hispanic White (NHWs) in the United States. All women treated within the Murtha Cancer Center at Walter Reed National Military Medical Center (MCC/WRNMMC) have health insurance and are provided multidisciplinary health care. Pathological factors and outcomes of NHBs and NHWs treated within the MCC/WRNMMC were evaluated to determine whether equal-access health care reduces disparate phenotypes and survival between the racial groups. Methods Between 2001 and 2018, 368 NHB and 819 NHW women were diagnosed with breast cancer at MCC/WRNMMC. Differences between NHBs and NHWs in epidemiological and pathological characteristics were evaluated. Overall and breast cancer-specific 5- and 10-year survival rates were compared between races. Results Compared with NHWs, NHBs were significantly more likely to have a body mass index ≥30 kg/m2, to be unmarried, to have tumors of higher grade, later stage, with lymph node metastases, and to be hormone receptor negative (HR-)/human epidermal growth factor receptor 2 positive (HER2+) or triple negative. After adjustment for demographic factors, NHBs remained significantly more likely to have tumors diagnosed at a higher grade and later stage, and to be HR-/HER2+ or triple negative. Neither 5- nor 10-year overall or breast cancer-specific survival differed significantly between the racial groups after adjusting for demographic and pathological variables. Discussion Despite having tumors with less favorable pathological characteristics, overall and disease-free survival disparities were not observed for NHBs treated at MCC/WRNMMC. These data suggest that survival disparities of NHBs with breast cancer can be diminished with provision of quality care.
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Affiliation(s)
- Sarah Darmon
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Leann A. Lovejoy
- Chan Soon-Shiong Institute of Molecular Medicine at Windber, Windber, Pennsylvania, USA
| | - Craig D. Shriver
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kangmin Zhu
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Rachel E. Ellsworth
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
- Address correspondence to: Rachel E. Ellsworth, PhD, Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 620 Seventh Street, Windber, PA 15963, USA,
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Escobar N, DiMaggio C, Pocock B, Pescovitz A, McCalla S, Joseph KA. Effects of COVID-19 on Surgical Delays in Patients with Breast Cancer in NYC Public Hospitals: A Multicenter Study. Ann Surg Oncol 2023; 30:23-30. [PMID: 36109414 PMCID: PMC9483518 DOI: 10.1245/s10434-022-12491-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Increased time to surgery (TTS) is associated with decreased survival in patients with breast cancer. In early 2020, elective surgeries were canceled to preserve resources for patients with coronavirus disease 2019 (COVID-19). This study attempts to measure the effect of mandated operating room shutdowns on TTS in patients with breast cancer. PATIENTS AND METHODS This multicenter retrospective study compares 51 patients diagnosed with breast cancer at four public hospitals from January to June 2020 with 353 patients diagnosed from January 2017 to June 2018. Demographics, tumor characteristics, treatment regimens, and TTS for patients were statistically compared using parametric, nonparametric, and Cox proportional hazards regression modeling. RESULTS Across all centers, there was a non-statistically significant increase in median TTS from 59 days in the pre-COVID period to 65 days during COVID (p = 0.9). There was, however, meaningful variation across centers. At center A, the median TTS decreased from 57 to 51 days, center C's TTS decreased from 83 to 64 days, and in center D, TTS increased from 42 to 129 days. In a multivariable Cox proportional hazards model for the pre-COVID versus COVID period effect on TTS, center was an important confounding variable, with notable differences for centers C and D compared with the referent category of center A (p = 0.04, p = 0.006). CONCLUSION Data suggest that, while mandated operating room shutdowns did not result in an overall statistically significant delay in TTS, there were important differences between centers, indicating that, even in a unified multicenter public hospital system, COVID-19 may have resulted in delayed and potentially disparate care.
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Affiliation(s)
- Natalie Escobar
- Department of Surgery, NYU Grossman School of Medicine, NYC Health and Hospitals/Bellevue, New York, NY USA
| | - Charles DiMaggio
- Department of Surgery, NYU Grossman School of Medicine, NYC Health and Hospitals/Bellevue, New York, NY USA
| | - Benjamin Pocock
- Department of Surgery, NYC Health + Hospitals/Elmhurst, Queens, NY USA
| | - Allison Pescovitz
- Department of Surgery, NYC Health + Hospitals/Queens, Queens, NY USA
| | - Sydney McCalla
- Department of Surgery, NYC Health + Hospitals/Lincoln, Bronx, NY USA
| | - Kathie-Ann Joseph
- Department of Surgery, NYU Grossman School of Medicine, NYC Health and Hospitals/Bellevue, New York, NY USA ,NYU Langone Health’s Institute for Excellence in Health Equity, New York, USA
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Escobar N, Joseph KA. ASO Author Reflections: Same but Different: Implications of Surgical Delays for Breast Cancer Patients Treated in NYC Public Hospitals During the COVID-19 Pandemic. Ann Surg Oncol 2023; 30:31-32. [PMID: 36197559 PMCID: PMC9533985 DOI: 10.1245/s10434-022-12540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Natalie Escobar
- Department of Surgery, NYU Grossman School of Medicine, NYC Health and Hospitals/Bellevue, New York, NY USA
| | - Kathie-Ann Joseph
- Department of Surgery, NYU Grossman School of Medicine, NYC Health and Hospitals/Bellevue, New York, NY USA ,NYU Langone Health’s Institute for Excellence in Health Equity, New York, NY USA
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Villegas-Echeverri JD, Ganyaglo GYK, Aklilu FA, Wasson M. FIGO statement: Disparities in patients' access to benign gynecological surgery. Int J Gynaecol Obstet 2022; 158:499-501. [PMID: 35819011 DOI: 10.1002/ijgo.14323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Juan Diego Villegas-Echeverri
- Unidad de Laparoscopia Ginecológica Avanzada y Dolor Pélvico, Pereira, Colombia.,FIGO Division of Benign Surgery, London, UK
| | - Gabriel Y K Ganyaglo
- Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Ghana.,FIGO Committee on Urogynaecology and Pelvic Floor Disorders, London, UK
| | - Fekade Ayenachew Aklilu
- International Fistula Alliance, Sydney Olympic Park, New South Wales, Australia.,FIGO Committee on Obstetric Fistula, London, UK
| | - Megan Wasson
- Department of Gynecologic Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, USA.,FIGO Committee on Minimal Access Surgery, London, UK
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Mazumder A, Jimenez A, Ellsworth RE, Freedland SJ, George S, Bainbridge MN, Haricharan S. The DNA damage repair landscape in Black women with breast cancer. Ther Adv Med Oncol 2022; 14:17588359221075458. [PMID: 35154416 PMCID: PMC8829704 DOI: 10.1177/17588359221075458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/06/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Estrogen receptor positive (ER+) breast cancer is one of the most commonly diagnosed malignancies in women irrespective of their race or ethnicity. While Black women with ER+ breast cancer are 42% more likely to die of their disease than White women, molecular mechanisms underlying this disparate outcome are understudied. Recent studies identify DNA damage repair (DDR) genes as a new class of endocrine therapy resistance driver that contributes to poor survival among ER+ breast cancer patients. Here, we systematically analyze DDR regulation in the tumors and normal breast of Black women and its impact on survival outcome. METHOD Mutation and up/downregulation of 104 DDR genes in breast tumor and normal samples from Black patients relative to White counterparts was assessed. For DDR genes that were differently regulated in the tumor samples from Black women in multiple datasets associations with survival outcome were tested. RESULTS Overall, Black patient tumors upregulate or downregulate RNA levels of a wide array of single strand break repair (SSBR) genes relative to their white counterparts and uniformly upregulate double strand break repair (DSBR) genes. This DSBR upregulation was also detectable in samples of normal breast tissue from Black women. Eight candidate DDR genes were reproducibly differently regulated in tumors from Black women and associated with poor survival. A unique DDR signature comprised of simultaneous upregulation of homologous recombination gene expression and downregulation of SSBR genes was enriched in Black patients. This signature associated with cell cycle dysregulation (p < 0.001), a hallmark of endocrine therapy resistance, and concordantly, with significantly worse survival outcomes in all datasets analyzed (hazard ratio of 9.5, p < 0.001). CONCLUSION These results constitute the first systematic analysis of DDR regulation in Black women and provide strong rationale for refining biomarker profiles to ensure precision medicine for underserved populations.
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Affiliation(s)
- Aloran Mazumder
- Aging, Cancer and Immuno-oncology Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Athena Jimenez
- Aging, Cancer and Immuno-oncology Program, NCI-Designated Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA, USA
| | - Rachel E. Ellsworth
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Stephen J. Freedland
- Division of Urology, Department of Surgery and the Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
| | - Sophia George
- Division of Gynecologic Oncology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
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Escobar N, Crown A, Pocock B, Joseph KA. The Devastating Impact of the COVID-19 Pandemic on Breast Cancer Care Among Medically Underserved Populations at Two New York City Public Hospitals. ANNALS OF SURGERY OPEN 2020; 1:e018. [PMID: 37637441 PMCID: PMC10455062 DOI: 10.1097/as9.0000000000000018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/14/2020] [Indexed: 12/31/2022] Open
Abstract
The COVID-19 pandemic has stretched hospitals to their capacities and has forced them to restructure and divert resources to accommodate the influx of critically ill patients. Surgical specialties are particularly vulnerable to restructuring given the need for highly trained personnel with intensive care unit (ICU) experience and procedural skills and need for ventilators and spaces that can function as ICUs. The diversion of hospital resources and redeployment of staff to the care of COVID patients has led to unintended consequences, including delays in care for patients with oncologic diagnoses, such as breast cancer. These unintended consequences are illustrated by the COVID-19 experiences of 2 New York City public hospitals: Bellevue Hospital and Elmhurst Hospital. The Breast Services of both hospitals treat the city's vulnerable, medically underserved breast cancer patients. Despite similar patient populations, Bellevue and Elmhurst had divergent COVID-19 experiences. With a larger surge capacity and an affiliation with New York University, the Breast Service at Bellevue Hospital was able to continue to offer essential breast operations, albeit at reduced volumes, whereas the Breast Service at Elmhurst Hospital was completely shut down. These experiences serve as a harbinger of the continually widening health care disparities and force hospital systems and policymakers to critically examine the impact of the COVID-19 pandemic on underserved patient populations that receive care at smaller public hospitals.
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Affiliation(s)
- Natalie Escobar
- From the Department of Surgery, Bellevue Hospital Medical Center, NYU Langone Medical Center, New York, NY
| | - Angelena Crown
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Ben Pocock
- Department of Surgery, Elmhurst Hospital Medical Center, Elmhurst, NY
| | - Kathie-Ann Joseph
- From the Department of Surgery, Bellevue Hospital Medical Center, NYU Langone Medical Center, New York, NY
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Hueman MT, Shriver CD, Ellsworth RE. ASO Author Reflections: Mitigating Survival Disparities in African American Women with Breast Cancer within the US Military Healthcare System-The Impact of Equivalent Care. Ann Surg Oncol 2019; 26:843-844. [PMID: 31659638 DOI: 10.1245/s10434-019-08007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Matthew T Hueman
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Craig D Shriver
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Rachel E Ellsworth
- Clinical Breast Care Project, Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, and Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.
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