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Roberts A, Hallet J, Nguyen L, Coburn N, Wright FC, Gandhi S, Jerzak K, Eisen A, Look Hong NJ. Neoadjuvant chemotherapy for triple-negative and Her2 +ve breast cancer: striving for the standard of care. Breast Cancer Res Treat 2024; 206:227-244. [PMID: 38676808 DOI: 10.1007/s10549-024-07282-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/07/2024] [Indexed: 04/29/2024]
Abstract
PURPOSE Neoadjuvant chemotherapy (NAC) for triple-negative (TN) and Her2-positive (HER2) breast cancers is supported by international guidelines as it can decrease extent of surgery, provide prognostic information, and allow response-driven adjuvant therapies. Our goal was to describe practice patterns for patients with TN and HER2-positive breast cancer and identify the factors associated with the receipt of NAC versus surgery as initial treatment. METHODS A retrospective population-based cohort study of adult women diagnosed with stage I-III TN or HER2-positive breast cancer (2012-2020) in Ontario was completed using linked administrative datasets. The primary outcome was NAC as first treatment. The association between NAC and patient, tumor, and practice-related factors was examined using multivariable logistic regression models. RESULTS Of 14,653 patients included, 23.9% (n = 3500) underwent NAC as first treatment. Patients who underwent NAC were more likely to be younger and have larger tumors, node-positive disease, and stage 3 disease. Of patients who underwent surgery first, 8.8% were seen by a medical oncologist prior to surgery. On multivariable analysis, increasing tumor size (T2 vs T1/T0: 2.75 (2.31-3.28)) and node-positive (N1 vs N0: OR 3.54 (2.92-4.30)) disease were both associated increased odds of receiving NAC. CONCLUSION A considerable proportion of patients with TN and HER2-positive breast cancer do not receive NAC as first treatment. Of those, most were not assessed by both a surgeon and medical oncologist prior to initiating therapy. This points toward potential gaps in multidisciplinary assessment and disparities in receipt of guideline-concordant care.
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Affiliation(s)
- Amanda Roberts
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada.
| | - Julie Hallet
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
| | | | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
- ICES, Toronto, ON, Canada
| | - Frances C Wright
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
| | - Sonal Gandhi
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
- Department of Medicine, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Katarzyna Jerzak
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
- Department of Medicine, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Andrea Eisen
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
- Department of Medicine, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Nicole J Look Hong
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Sunnybrook Research Institute, 2075 Bayview Ave, T2-063, Toronto, ON, M4N 3M5, Canada
- ICES, Toronto, ON, Canada
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Jooya A, Qureshi D, Phillips WJ, Leigh J, Webber C, Aggarwal A, Tanuseputro P, Morgan S, Macrae R, Ong M, Bourque JM. Variation in Access to Palliative Radiotherapy in Prostate Cancer: A Population-Based Study in Canada. Cureus 2024; 16:e54582. [PMID: 38523960 PMCID: PMC10957792 DOI: 10.7759/cureus.54582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND As a result of improvements in cancer therapies, patients with metastatic malignancies are living longer, and the role of palliative radiotherapy has become increasingly recognized. However, access to adequate palliative radiotherapy may continue to be a challenge, as is evident from the high proportion of patients dying of prostate cancer who never receive palliative radiotherapy. The main objective of this investigation is to identify and describe the factors associated with the receipt of palliative radiation treatment in a decedent cohort of prostate cancer patients in Ontario. METHODOLOGY Population-based administrative databases from Ontario, Canada, were used to identify prostate cancer decedents, 65 years or older who received androgen deprivation therapy between January 1, 2013, and December 31, 2018. Baseline and treatment characteristics were analyzed using univariate and multivariate logistic regression models for association with receipt of radiotherapy in a two-year observation period before death. RESULTS We identified 3,788 prostate cancer decedents between 2013 and 2018; among these, 49.9% received radiotherapy in the two years preceding death. There were statistically significant positive associations between receipt of radiotherapy and younger age at diagnosis (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1-2.3); higher stage at diagnosis (OR 1.3, 95% CI 1.1-1.7); receipt of care at a regional cancer center (OR 1.8, 95% CI 1.3-2.4); and involvement of radiation oncologists (OR 155.1, 95% CI 83.3-288.7) or medical oncologists (OR 1.4, 95% CI 1.1-1.8). However, there were no associations between receipt of radiotherapy and income, distance to the nearest cancer center, involvement of urologists in cancer care, healthcare administrative region, home-care involvement, or number of hospitalizations in the observation period. CONCLUSIONS We found the utilization of palliative radiotherapy for prostate cancer patients in Ontario varies depending on age, stage at diagnosis, number of comorbidities, registration at regional cancer centers, and involvement of oncologists. There were no differences detected based on income or distance from a cancer center. The findings of this study represent an important opportunity to facilitate better access to palliative radiotherapy and referrals to multidisciplinary regional cancer centers, to improve the quality of life of this patient population.
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Affiliation(s)
- Alborz Jooya
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network (UHN), Toronto, CAN
| | - Daniel Qureshi
- Department of Public Health, London School of Hygiene and Tropical Medicine, London, GBR
| | | | - Jennifer Leigh
- Department of Medicine, The Ottawa Hospital, Ottawa, CAN
| | - Colleen Webber
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, CAN
| | - Ajay Aggarwal
- Department of Oncology, Guy's Cancer Centre, London, GBR
| | - Peter Tanuseputro
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, CAN
| | - Scott Morgan
- Department of Radiation Oncology, University of Ottawa, Ottawa, CAN
| | - Robert Macrae
- Department of Radiation Oncology, University of Ottawa, Ottawa, CAN
| | - Michael Ong
- Division of Medical Oncology, Department of Internal Medicine, University of Ottawa, Ottawa, CAN
| | - Jean-Marc Bourque
- Department of Radiation Oncology, Montreal University Health Center, Montreal, CAN
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3
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Fabregas JC, Riley KE, Brant JM, George TJ, Orav EJ, Lam MB. Association of social determinants of health with late diagnosis and survival of patients with pancreatic cancer. J Gastrointest Oncol 2022; 13:1204-1214. [PMID: 35837201 DOI: 10.21037/jgo-21-788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/30/2022] [Indexed: 12/22/2022] Open
Abstract
Background Pancreatic cancer disparities have been described. However, it is unknown if they contribute to a late diagnosis and survival of patients with metastatic disease. Identifying their role is important as it will open the door for interventions. We hypothesize that social determinants of health (SDH) such as income, education, race, and insurance status impact (I) stage of diagnosis of PC (Stage IV vs. other stages), and (II) overall survival (OS) in Stage IV patients. Methods Using the National Cancer Database, we evaluated a primary outcome of diagnosis of Stage IV PC and a secondary outcome of OS. Primary predictors included race, income, education, and insurance. Covariates included age, sex and Charlson-Deyo comorbidity score. Univariate, multivariable logistic regression models evaluated risk of a late diagnosis. Univariate, multivariable Cox proportional hazards model examined OS. 95% confidence intervals were used. Results 230,877 patients were included, median age of 68 years (SD 12.1). In univariate analysis, a better education, higher income, and insurance decreased the odds of Stage IV PC, while Black race increased it. In multivariable analysis, education [>93% high-school completion (HSC) vs. <82.4%, OR 0.96 (0.93-0.99)] and insurance [private vs. no, OR 0.72 (0.67-0.74)] significantly decreased the risk of a late diagnosis, whereas Black race increased the odds [vs. White, OR 1.09 (1.07-1.12)]. In univariate Cox analysis, having a higher income, insurance and better education improved OS, while Black race worsened it. In multivariable Cox, higher income [>$63,333 (vs. <$40,277), HR 0.87 (0.85-0.89)] and insurance [private vs. no, HR 0.77 (0.74-0.79)] improved OS. Conclusions SDH impacted the continuum of care for patients with advanced pancreatic cancer, including stage at diagnosis and overall survival.
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Affiliation(s)
- Jesus C Fabregas
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Kristen E Riley
- Harvard Medical School, Department of Medicine, Boston, MA, USA
| | | | - Thomas J George
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA.,University of Florida Health Cancer Center, Gainesville, FL, USA
| | - E John Orav
- Harvard Medical School, Department of Medicine, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Miranda B Lam
- Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Department of Radiation Oncology, Boston, MA, USA.,Harvard T. H. Chan School of Public Health, Department of Health Policy and Management, Boston, MA, USA
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Torres MB, Dixon MEB, Gusani NJ. Undertreatment of Pancreatic Cancer: The Intersection of Bias, Biology, and Geography. Surg Oncol Clin N Am 2021; 31:43-54. [PMID: 34776063 DOI: 10.1016/j.soc.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is the third leading cause of cancer deaths in the United States. Black patients with pancreatic cancer experience higher incidence and increased mortality. Although racial biologic differences exist, socioeconomic status, insurance type, physician bias, and patient beliefs contribute to the disparities in outcomes observed among patients who are Black, indigenous, and people of color.
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Affiliation(s)
- Madeline B Torres
- General Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, 500 University Avenue MC H149, Hershey, PA 17033, USA. https://twitter.com/MadelineBTorres
| | - Matthew E B Dixon
- Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, 500 University Avenue MC H070, Hershey, PA 17036, USA. https://twitter.com/mebdixon
| | - Niraj J Gusani
- Section of Surgical Oncology, Baptist MD Anderson Cancer Center, 1301 Palm Avenue, Jacksonville, FL 32207, USA.
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Yee EK, Coburn NG, Zuk V, Davis LE, Mahar AL, Liu Y, Gupta V, Darling G, Hallet J. Geographic impact on access to care and survival for non-curative esophagogastric cancer: a population-based study. Gastric Cancer 2021; 24:790-799. [PMID: 33550518 DOI: 10.1007/s10120-021-01157-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Among patients not undergoing curative-intent therapy for esophagogastric cancer, access to care may vary. We examined the geographic distribution of care delivery and survival and their relationship with distance to cancer centres for non-curative esophagogastric cancer, hypothesising that patients living further from cancer centres have worse outcomes. METHODS We conducted a population-based analysis of adults with non-curative esophagogastric cancer from 2005 to 2017 using linked administrative healthcare datasets in Ontario, Canada. Outcomes were medical oncology consultation, receipt of chemotherapy, and overall survival. Using geographic information system analysis, we mapped locations of cancer centres and outcomes across census divisions. Bivariate choropleth maps identified regional outcome discordances. Multivariable regression models assessed the relationship between distance from patient residence to the nearest cancer centre and outcomes, adjusting for demographic, clinical, and socioeconomic factors. RESULTS Of 10,228 patients surviving a median 5.1 months (IQR: 2.0-12.0), 68.5% had medical oncology consultation and 32.2% received chemotherapy. Certain distances (reference ≤ 10 km) were associated with lower consultation [relative risk 0.79 (95% CI 0.63-0.97) for ≥ 101 km], chemotherapy receipt [relative risk 0.67 (95% CI 0.53-0.85) for ≥ 101 km], and overall survival [hazard ratio 1.07 (95% CI 1.02-1.13) for 11-50 km, hazard ratio 1.13 (95% CI 1.04-1.23) for 51-100 km]. CONCLUSION A third of patients did not see medical oncology and most did not receive chemotherapy. Outcomes exhibited high geographic variability. Location of residence influenced outcomes, with inferior outcomes at certain distances > 10 km from cancer centres. These findings are important for designing interventions to reduce access disparities for non-curative esophagogastric cancer care.
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Affiliation(s)
- Elliott K Yee
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Natalie G Coburn
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Victoria Zuk
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Laura E Davis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ying Liu
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Vaibhav Gupta
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gail Darling
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, ON, Canada
| | - Julie Hallet
- Cancer Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Surgery, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Department of Surgery, University of Toronto, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada.
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