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Mutter RW, Chauhan C, Goetz MP, Wright JL. Revisiting Combined Modality Therapy in Older Patients With Luminal Breast Cancer Through the Patient Lens. J Clin Oncol 2024; 42:2121-2125. [PMID: 38564696 DOI: 10.1200/jco.23.02289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/08/2024] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | - Jean L Wright
- Department of Radiation Oncology, John Hopkins University School of Medicine, Baltimore, MD
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Chiu AS, Hoxha I, Jensen CB, Saucke MC, Pitt SC. Medical Maximizing Preferences and Beliefs About Cancer Among US Adults. JAMA Netw Open 2024; 7:e2417098. [PMID: 38874925 PMCID: PMC11179133 DOI: 10.1001/jamanetworkopen.2024.17098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/16/2024] [Indexed: 06/15/2024] Open
Abstract
Importance Medical overutilization contributes to significant health care expenditures and exposes patients to questionably beneficial surgery and unnecessary risk. Objectives To understand public attitudes toward medical utilization and the association of these attitudes with beliefs about cancer. Design, Setting, and Participants In this cross-sectional survey study conducted from August 26 to October 28, 2020, US-based, English-speaking adults were recruited from the general public using Prolific Academic, a research participant platform. Quota-filling was used to obtain a sample demographically representative of the US population. Adults with a personal history of cancer other than nonmelanoma skin cancer were excluded. Statistical analysis was completed in July 2022. Main Outcome and Measures Medical utilization preferences were characterized with the validated, single-item Maximizer-Minimizer Elicitation Question. Participants preferring to take action in medically ambiguous situations (hereafter referred to as "maximizers") were compared with those who leaned toward waiting and seeing (hereafter referred to as "nonmaximizers"). Beliefs and emotions about cancer incidence, survivability, and preventability were assessed using validated measures. Logistic regression modeled factors associated with preferring to maximize medical utilization. Results Of 1131 participants (mean [SD] age, 45 [16] years; 568 women [50.2%]), 287 (25.4%) were classified as maximizers, and 844 (74.6%) were classified as nonmaximizers. Logistic regression revealed that self-reporting very good or excellent health status (compared with good, fair, or poor; odds ratio [OR], 2.01 [95% CI, 1.52-2.65]), Black race (compared with White race; OR, 1.88 [95% CI, 1.22-2.89]), high levels of cancer worry (compared with low levels; OR, 1.62 [95% CI, 1.09-2.42]), and overestimating cancer incidence (compared with accurate estimation or underestimating; OR, 1.58 [95% CI, 1.09-2.28]) were significantly associated with maximizing preferences. Those who believed that they personally had a higher-than-average risk of developing cancer were more likely to be maximizers (23.6% [59 of 250] vs 17.4% [131 of 751]; P = .03); this factor was not significant in regression analyses. Conclusions and Relevance In this survey study of US adults, those with medical maximizing tendencies more often overestimated the incidence of cancer and had higher levels of cancer-related worry. Targeted and personalized education about cancer and its risk factors may help reduce overutilization of oncologic care.
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Affiliation(s)
- Alexander S Chiu
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ines Hoxha
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Catherine B Jensen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
- Department of Surgery, University of Michigan, Ann Arbor
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Susan C Pitt
- Department of Surgery, University of Michigan, Ann Arbor
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Minami CA, Jin G, Freedman RA, Schonberg MA, King TA, Mittendorf EA. Physician-level variation in axillary surgery in older adults with T1N0 hormone receptor-positive breast cancer: A retrospective population-based cohort study. J Geriatr Oncol 2024; 15:101795. [PMID: 38759256 DOI: 10.1016/j.jgo.2024.101795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION We sought to determine how considerations specific to older adults impact between- and within-surgeon variation in axillary surgery use in women ≥70 years with T1N0 HR+ breast cancer. MATERIALS AND METHODS Females ≥70 years with T1N0 HR+/HER2-negative breast cancer diagnosed from 2013 to 2015 in SEER-Medicare were identified and linked to the American Medical Association Masterfile. The outcome of interest was axillary surgery. Key patient-level variables included the Charlson Comorbidity Index (CCI) score, frailty (based on a claims-based frailty index score), and age (≥75 vs <75). Multilevel mixed models with surgeon clusters were used to estimate the intracluster correlation coefficient (ICC) (between-surgeon variance), with 1-ICC representing within-surgeon variance. RESULTS Of the 4410 participants included, 6.1% had a CCI score of ≥3, 20.7% were frail, and 58.3% were ≥ 75 years; 86.1% underwent axillary surgery. No surgeon omitted axillary surgery in all patients, but 42.3% of surgeons performed axillary surgery in all patients. In the null model, 10.5% of the variance in the axillary evaluation was attributable to between-surgeon differences. After adjusting for CCI score, frailty, and age in mixed models, between-surgeon variance increased to 13.0%. DISCUSSION In this population, axillary surgery varies more within surgeons than between surgeons, suggesting that surgeons are not taking an "all-or-nothing" approach. Comorbidities, frailty, and age accounted for a small proportion of the variation, suggesting nuanced decision-making may include additional, unmeasured factors such as differences in surgeon-patient communication.
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Affiliation(s)
- Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
| | - Mara A Schonberg
- Harvard Medical School, Boston, MA, United States of America; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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Coles CE, Earl H, Anderson BO, Barrios CH, Bienz M, Bliss JM, Cameron DA, Cardoso F, Cui W, Francis PA, Jagsi R, Knaul FM, McIntosh SA, Phillips KA, Radbruch L, Thompson MK, André F, Abraham JE, Bhattacharya IS, Franzoi MA, Drewett L, Fulton A, Kazmi F, Inbah Rajah D, Mutebi M, Ng D, Ng S, Olopade OI, Rosa WE, Rubasingham J, Spence D, Stobart H, Vargas Enciso V, Vaz-Luis I, Villarreal-Garza C. The Lancet Breast Cancer Commission. Lancet 2024; 403:1895-1950. [PMID: 38636533 DOI: 10.1016/s0140-6736(24)00747-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 12/18/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Affiliation(s)
| | - Helena Earl
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Benjamin O Anderson
- Global Breast Cancer Initiative, World Health Organisation and Departments of Surgery and Global Health Medicine, University of Washington, Seattle, WA, USA
| | - Carlos H Barrios
- Oncology Research Center, Hospital São Lucas, Porto Alegre, Brazil
| | - Maya Bienz
- Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, London, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David A Cameron
- Institute of Genetics and Cancer and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Wanda Cui
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Prudence A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Reshma Jagsi
- Emory University School of Medicine, Atlanta, GA, USA
| | - Felicia Marie Knaul
- Institute for Advanced Study of the Americas, University of Miami, Miami, FL, USA; Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA; Tómatelo a Pecho, Mexico City, Mexico
| | - Stuart A McIntosh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | | | | | - Jean E Abraham
- Department of Oncology, University of Cambridge, Cambridge, UK
| | | | | | - Lynsey Drewett
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Farasat Kazmi
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Dianna Ng
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Szeyi Ng
- The Institute of Cancer Research, London, UK
| | | | - William E Rosa
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | | | | | | | | | | | - Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, Monterrey, Mexico
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Broman KK, Hughes TM, Bredbeck BC, Sun J, Kirichenko D, Carr MJ, Sharma A, Bartlett EK, Nijhuis AAG, Thompson JF, Hieken TJ, Kottschade L, Downs J, Gyorki DE, Stahlie E, van Akkooi A, Ollila DW, O'shea K, Song Y, Karakousis G, Moncrieff M, Nobes J, Vetto J, Han D, Hotz M, Farma JM, Deneve JL, Fleming MD, Perez M, Baecher K, Lowe M, Bagge RO, Mattsson J, Lee AY, Berman RS, Chai H, Kroon HM, Teras J, Teras RM, Farrow NE, Beasley GM, Hui JYC, Been L, Kruijff S, Sinco B, Sarnaik AA, Sondak VK, Zager JS, Dossett LA. International Center-Level Variation in Utilization of Completion Lymph Node Dissection and Adjuvant Systemic Therapy for Sentinel Lymph Node-Positive Melanoma at Major Referral Centers. Ann Surg 2023; 277:e1106-e1115. [PMID: 35129464 PMCID: PMC10097464 DOI: 10.1097/sla.0000000000005370] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine overall trends and center-level variation in utilization of completion lymph node dissection (CLND) and adjuvant systemic therapy for sentinel lymph node (SLN)-positive melanoma. SUMMARY BACKGROUND DATA Based on recent clinical trials, management options for SLN-positive melanoma now include effective adjuvant systemic therapy and nodal observation instead of CLND. It is unknown how these findings have shaped practice or how these contemporaneous developments have influenced their respective utilization. METHODS We performed an international cohort study at 21 melanoma referral centers in Australia, Europe, and the United States that treated adults with SLN-positive melanoma and negative distant staging from July 2017 to June 2019. We used generalized linear and multinomial logistic regression models with random intercepts for each center to assess center-level variation in CLND and adjuvant systemic treatment, adjusting for patient and disease-specific characteristics. RESULTS Among 1109 patients, performance of CLND decreased from 28% to 8% and adjuvant systemic therapy use increased from 29 to 60%. For both CLND and adjuvant systemic treatment, the most influential factors were nodal tumor size, stage, and location of treating center. There was notable variation among treating centers in management of stage IIIA patients and use of CLND with adjuvant systemic therapy versus nodal observation alone for similar risk patients. CONCLUSIONS There has been an overall decline in CLND and simultaneous adoption of adjuvant systemic therapy for patients with SLN-positive melanoma though wide variation in practice remains. Accounting for differences in patient mix, location of care contributed significantly to the observed variation.
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Affiliation(s)
- Kristy K Broman
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | | | - Amanda A G Nijhuis
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - John F Thompson
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | | | | | | | | | - Emma Stahlie
- Netherlands Cancer institute, Amsterdam, The Netherlands
| | | | | | | | - Yun Song
- University of Gothenburg, Gothenburg, Sweden
| | | | - Marc Moncrieff
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Jenny Nobes
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - John Vetto
- Oregon Health & Science University, Portland, OR
| | - Dale Han
- Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | | | | | | | - Jan Mattsson
- University Medical Center, Groningen, Netherlands
| | | | | | - Harvey Chai
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Hidde M Kroon
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Juri Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Roland M Teras
- North Estonia Medical Centre Foundation, Tallinn, Estonia
| | | | | | | | | | | | | | - Amod A Sarnaik
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Vernon K Sondak
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Jonathan S Zager
- Moffitt Cancer Center, Tampa, FL
- University of South Florida Morsani College of Medicine, Tampa, FL
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English K, Alcorn SR, Tran HT, Smith KL, Wilkinson M, Hirose KT, O'Donnell M, Croog V, Wright JL. Adjuvant treatment decisions among adults aged 65 years and older with early-stage hormone receptor positive breast cancer seen in a simple multidisciplinary clinic versus standard consultation. J Geriatr Oncol 2023; 14:101503. [PMID: 37126898 DOI: 10.1016/j.jgo.2023.101503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 03/15/2023] [Accepted: 04/12/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Randomized studies support de-escalation of adjuvant therapy for a target population of older adults ≥65 years with stage I, estrogen-receptor (ER) positive breast cancer after breast conserving surgery. We sought to evaluate the impact of a simplified multidisciplinary clinic (s-MDC) in this population by comparing treatment patterns and patient perceptions of adjuvant radiation therapy (RT) and hormone therapy (HT) between patients seen in s-MDC vs. standard consultations. MATERIALS AND METHODS Medical records were retrospectively reviewed for patients in the above target population who underwent surgery between August 2020 and May 2022 at our institution. Two cohorts were included: (1) patients seen in s-MDC, and (2) patients seen in standard clinic separately by medical and radiation oncology (non-s-MDC cohort). The non-s-MDC patients declined, could not attend, and/or were not referred to the s-MDC. Patients in the s-MDC cohort were prospectively administered validated questionnaires to evaluate patient reported data including the Decision Autonomy Preference Scale (DAPS), e-Prognosis, and Medical Maximizing-Minimizing Scale (MMS). Chi square, t-tests, and non-parametric equivalents compared demographics, and logistic regression evaluated RT and HT use and survey score outcomes between cohorts. RESULTS A total of 127 patients met inclusion criteria, with 33 s-MDC and 94 non-s-MDC patients. There was no difference between the cohorts in age, margin status, histology, grade, or focality. In the s-MDC cohort there were significantly more patients without sentinel lymph node biopsy (71.3% vs 42.4%, p = 0.003) and mean tumor size was smaller (0.69 vs. 0.96 cm, p < 0.003), and Charlson comborbidity index (CCI) was higher (5.21 vs 4.96, p = 0.038). There was no significant difference in receipt of RT (65% s-MDC vs 77% standard; odds ratio [OR] = 0.55, p = 0.189), HT (78% ss-MDC vs 72% standard; OR = 1.36, p = 0.513), or both (50% s-MDC vs 59% standard; OR = 0.7, p = 0.429). The s-MDC cohort was significantly more likely to undergo accelerated (vs. standard hypofractionated) RT (70% vs 39%; OR = 3.59, p = 0.020). In s-MDC patients with completed questionnaires (n = 33), all whose selected "mostly patient (n=6)" based decision making by DAPS chose RT while all "mostly doctor (n=1)" chose no RT. Based on e-Prognosis, there were lower odds of RT for increasing Schonberg score/ higher 10 yr mortality risk (OR 0.600, p = 0.048). MMS score ≥ 40 ("maximizer") was strongly linked with the use of RT (OR 18.57, p = 0.011). DISCUSSION For adults ≥65 years with early stage, ER positive breast cancer, s-MDC participation was not significantly associated with lower use of adjuvant RT or HT versus standard consultation but was significantly associated with shorter RT courses. DAPS and MMS results indicate that patient treatment preference may be predictable, highlighting an opportunity to tailor consultation discussions and recommendations based on intrinsic patient preferences and individual goals.
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Affiliation(s)
- Keara English
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Sara R Alcorn
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Hanh-Tam Tran
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Karen Lisa Smith
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Mary Wilkinson
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Kelly Tadken Hirose
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Maureen O'Donnell
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Victoria Croog
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America
| | - Jean L Wright
- The Johns Hopkins Department of Radiation Oncology, 401 North Broadway, Weinberg Building, Suite 1440, Baltimore, MD 21287, United States of America.
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Mott NM, Markovitz NH, Wang T, Hughes TM, Pilewskie M, Jagsi R, Dossett LA. Avoiding Overtreatment of Women ≥70 With Early-Stage Breast Cancer: A Provider-Level Deimplementation Strategy. J Surg Res 2023; 284:124-130. [PMID: 36566589 DOI: 10.1016/j.jss.2022.11.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION National guidelines recommend against routine axillary staging with sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy (RT) in women ≥70 y with early-stage, hormone receptor-positive, HER2-negative breast cancer and clinically negative axilla; however, these practices remain common. METHODS We conducted a prospective pilot study from August 2021 to 2022 using an intervention targeting breast surgeons and radiation oncologists in Michigan that aimed to reduce SLNB and RT in eligible patients. The intervention consisted of (1) a geriatric assessment, (2) an assessment of the patient's medical maximizing-minimizing preferences, and (3) a tailored script with counterpoints to reasons patients commonly seek SLNB or RT. At the end of the study period, participants completed a survey providing feedback with the primary outcomes being: acceptability, appropriateness, feasibility, and intention and motivation to use the materials based on validated measures. RESULTS Participants (n = 23) included 15 breast surgeons and 8 radiation oncologists. Collectively, the materials were used with 115 patients. Considering all materials holistically, acceptability, appropriateness, and feasibility of the intervention were high; participants also intended and were motivated to use the intervention. Scores across all measures were highest for the geriatric assessment and lowest for the tailored script. The major barriers to using the intervention were limited time and instances of disagreement on treatment recommendations among surgeons and radiation oncologists. CONCLUSIONS The omission of SLNB and adjuvant RT should be discussed in appropriately selected patients. A multifaceted provider-level deimplementation strategy may be an effective means for achieving this goal.
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Affiliation(s)
- Nicole M Mott
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Bredbeck BC, Mott NM, Wang T, Sinco BR, Hughes TM, Nathan H, Dossett LA. Facility-Level Variation of Low-Value Breast Cancer Treatments in Older Women with Early-Stage Breast Cancer: Analysis of a Statewide Claims Registry. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11631-z. [PMID: 35380309 DOI: 10.1245/s10434-022-11631-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Since 2004, national guidelines have supported the omission of sentinel lymph node biopsy (SLNB) and radiotherapy for women ≥ 70 years of age with early-stage, hormone receptor-positive (HR+) breast cancer, but many women continue to receive at least one of these services. Provider- and patient-level factors may contribute to persistent utilization, but the role of facility-level factors is unknown. We aimed to determine facility-level variation of SLNB and adjuvant radiotherapy utilization in older women with early-stage, HR+ breast cancer undergoing breast-conserving surgery (BCS). Additionally, we aimed to explore factors associated with SLNB and radiotherapy utilization and the intra-facility correlation in their utilization. METHODS We conducted a retrospective cohort study using a statewide registry of claims data. We included women ≥70 years of age diagnosed with breast cancer who underwent BCS from 2012 to 2019 at 80 hospitals in the Michigan Value Collaborative. The main outcome was inter-facility rates and variation of SLNB and radiotherapy, as well as intra-facility correlation in their utilization. RESULTS The cohort included 7253 women (median age 77 years). Only 20% (n = 1440) underwent BCS alone, whereas 71% (n = 5122) underwent SLNB and 52% (n = 3793) received radiotherapy. Inter-facility rates of SLNB ranged from 35 to 82% (median 70%), and radiotherapy ranged from 19 to 72% (median 49%). SLNB and radiotherapy were positively correlated (r = 0.27, p = 0.016). CONCLUSIONS SLNB and radiotherapy rates remain high with significant variation in utilization at the facility level. High utilizers of SLNB are likely to be high utilizers of radiotherapy, suggesting the opportunity for strategic targeting of these facilities and their clinicians.
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Affiliation(s)
- Brooke C Bredbeck
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Nicole M Mott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Brandy R Sinco
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
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9
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Broman KK, Richman J, Bhatia S. Evidence and implementation gaps in management of sentinel node-positive melanoma in the United States. Surgery 2022; 172:226-233. [PMID: 35120732 DOI: 10.1016/j.surg.2021.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/25/2021] [Accepted: 12/17/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Melanoma clinical trials demonstrated that completion lymph node dissection is low value for most sentinel lymph node-positive patients. Contemporaneous trials of adjuvant systemic immunotherapy and BRAF/MEK targeted therapy showed improved recurrence-free survival in high-risk sentinel lymph node-positive patients. To better understand how oncologic evidence is incorporated into practice (implementation), we evaluated factors associated with discontinuation of completion lymph node dissection and adoption of systemic treatment at United States Commission on Cancer-accredited centers. METHODS In a retrospective cohort study of adults with sentinel lymph node-positive melanoma treated from 2012 to 2017 using the National Cancer Database, we evaluated use of completion lymph node dissection and adjuvant systemic treatment using mixed-effects logistic regression, reporting results as odds ratios with 95% confidence intervals. RESULTS Among 10,240 sentinel lymph node-positive melanoma patients, performance of completion lymph node dissection declined from 60% to 27%. Adjuvant systemic treatment increased from 29% to 43% (37% in stage IIIA patients, 46% in IIIB-C). Completion lymph node dissection was less common with lower extremity tumors (odds ratio = 0.53, 95% confidence interval = 0.44-0.64) and more common with multiple positive sentinel lymph nodes (odds ratio = 2.36, 95% confidence interval = 2.08-2.67), treatment at a high- or moderate-volume center (odds ratiohigh = 1.49, 95% confidence interval = 1.05-2.12; odds ratiomoderate = 1.32, 95% confidence interval = 1.05-1.64), and receipt of systemic therapy (odds ratio = 1.44, 95% confidence interval = 1.27-1.63). The increased likelihood of completion lymph node dissection in patients receiving adjuvant systemic treatment persisted in the most recent study years and in patients with a single positive sentinel lymph node. CONCLUSION At a population level, completion lymph node dissection declined and adjuvant systemic treatment increased, reflecting evidence-responsive care. Variation in persistent use of completion lymph node dissection and in provision of adjuvant treatment for lower risk patients highlights residual gaps in both evidence and implementation.
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Affiliation(s)
- Kristy K Broman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL; Department of Surgery, University of Alabama at Birmingham, AL.
| | - Joshua Richman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, AL
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10
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Dossett LA, Mott NM, Bredbeck BC, Wang T, Jobin CTC, Hughes TM, Hawley ST, Zikmund-Fisher BJ. Using Tailored Messages to Target Overuse of Low-Value Breast Cancer Care in Older Women. J Surg Res 2022; 270:503-512. [PMID: 34801801 PMCID: PMC8734932 DOI: 10.1016/j.jss.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND National recommendations allow for the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy in women ≥ 70 y/o with early-stage, hormone-receptor positive invasive breast cancer, but these therapies remain common. Previous work demonstrates an individual's maximizing-minimizing trait-an inherent preference for more or less medical care-may influence the preference for low-value care. MATERIALS AND METHODS We recruited an equal number of women ≥ 70 yrs who were maximizers, minimizers, or neutral based on a validated measure between September 2020 and November 2020. Participants were presented a hypothetical breast cancer diagnosis before randomization to one of three follow-up messages: maximizer-tailored, minimizer-tailored, or neutral. Tailored messaging aimed to redirect maximizers and minimizers toward declining SLNB and radiotherapy. The main outcome measure was predicted probability of choosing SLNB or radiotherapy. RESULTS The final analytical sample (n = 1600) was 515 maximizers (32%), 535 neutral (33%) and 550 (34%) minimizers. Higher maximizing tendency positively correlated with electing both SLNB and radiotherapy on logistic regression (P < 0.01). Any tailoring (maximizer- or minimizer-tailored) reduced preference for SLNB in maximizing and neutral women but had no effect in minimizing women. Tailoring had no impact on radiotherapy decision, except for an increased probability of minimizers electing radiotherapy when presented with maximizer-tailored messaging. CONCLUSIONS Maximizing-minimizing tendencies are associated with treatment preferences among women facing a hypothetical breast cancer diagnosis. Targeted messaging may facilitate avoidance of low-value breast cancer care, particularly for SLNB.
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Affiliation(s)
- Lesly A. Dossett
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA,University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA
| | - Nicole M. Mott
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brooke C. Bredbeck
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA,University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Ton Wang
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA,University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Chad TC. Jobin
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Tasha M. Hughes
- University of Michigan, Department of Surgery, Ann Arbor, MI, USA,University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA
| | - Sarah T. Hawley
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA,University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA,University of Michigan, Department of Health Education and Health Behavior, Ann Arbor, MI, USA
| | - Brian J. Zikmund-Fisher
- Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA,University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA,University of Michigan, Department of Health Education and Health Behavior, Ann Arbor, MI, USA
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11
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Skorstad M, de Rooij BH, Jeppesen MM, Bergholdt SH, Ezendam NPM, Bohlin T, Jensen PT, Lindemann K, van de Poll L, Vistad I. Self-management and adherence to recommended follow-up after gynaecological cancer: results from the international InCHARGE study. Int J Gynecol Cancer 2021; 31:1106-1115. [PMID: 33858949 DOI: 10.1136/ijgc-2020-002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the relationship between self-management skills and adherence to follow-up guidelines among gynecological cancer survivors in the Netherlands, Norway, and Denmark, and to assess the relationship between adherence to follow-up programs and use of additional healthcare services. METHODS For this international, multicenter, cross-sectional study, we recruited gynecological cancer survivors 1-5 years after completion of treatment. Information on follow-up visits, use of healthcare resources, self-management (measured by the Health Education Impact Questionnaire), clinical characteristics, and demographics were obtained by validated questionnaires. Participants were categorized as adherent if they attended the number of follow-up visits recommended by national guidelines, non-adherent if they had fewer visits than recommended, or over-users if they had more visits than recommended. RESULTS Of 4455 invited survivors, 2428 (55%) returned the questionnaires, and 911 survivors were included in the analyses. Survivors with high self-management most frequently adhered to recommended follow-up. Non-adherent survivors showed lower self-management in the health-directed activity domain (OR 1.54, 95% CI 1.03 to 2.32) than adherent survivors. No other associations between self-management and follow-up adherence were revealed. Non-adherent survivors tended to have endometrial cancer, surgical treatment only, be older, and be Danish residents. Over-users reported more follow-up visits and also used additional healthcare services more frequently than adherent survivors. CONCLUSION Low self-management appears to reduce the likelihood of adherence to national guidelines for gynecological cancer follow-up. Focusing on patient education for survivors at risk of low self-management to ensure adherence to recommended follow-up may improve personalization of follow-up.
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Affiliation(s)
- Mette Skorstad
- Department of Gynaecology and Obstetrics, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Belle H de Rooij
- Department of Medical and Clinical Psychology, IKNL, Utrecht, Utrecht, Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
| | - Mette Moustgaard Jeppesen
- Department of Gynaecology and Obstetrics, Hospital Lillebaelt Middelfart Hospital, Middelfart, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Stinne Holm Bergholdt
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Nicole Paulina Maria Ezendam
- Department of Medical and Clinical Psychology, IKNL, Utrecht, Utrecht, Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
| | - Tonje Bohlin
- Department of Gynaecology and Obstetrics, Vestfold Hospital Trust, Tonsberg, Norway
| | - Pernille Tine Jensen
- Faculty of Health Science, Aarhus University, Aarhus, Denmark.,Department of Gynecology and Obstetrics, Aarhus Universitetshospital, Aarhus, Denmark
| | - Kristina Lindemann
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lonneke van de Poll
- Department of Medical and Clinical Psychology, IKNL, Utrecht, Utrecht, Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands.,Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Ingvild Vistad
- Department of Gynaecology and Obstetrics, Sorlandet Hospital Kristiansand, Kristiansand, Norway.,Department of Clinical Science, University of Bergen Faculty of Medicine and Dentistry, Bergen, Norway
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12
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Mott N, Dossett LA. ASO Author Reflections: Can Medical Maximizing-Minimizing Preferences Inform De-implementation Efforts for Low-Value Breast Cancer Services in Older Women? Ann Surg Oncol 2020; 27:884-885. [PMID: 32761327 DOI: 10.1245/s10434-020-09009-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/28/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Nicole Mott
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA.
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