Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors

PURPOSE

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors.

METHODS

During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity.

RESULTS

The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed.

CONCLUSION

In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors

Purpose

The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care.

Methods

We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt.

Results

During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination.

Conclusions

Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06752-8.

The Role of Race and Insurance Status in Access to Genetic Counseling and Testing Among High-Risk Breast Cancer Patients

Purpose

The role of germline genetic testing in breast cancer patients is crucial, especially in the setting of the recent trials showing the benefit of PARP inhibitors. The goal of this study was to identify racial disparities in genetic counseling and testing in patients with high-risk breast cancer.

Methods

Patients with 2 unique breast cancer diagnoses were examined to understand demographics, insurance coverage, characteristics of breast cancer, and whether they were recommended for and received genetic counseling and testing.

Results

A total of 69 patients with a dual diagnosis of breast cancer between the years 2000 and 2017 were identified (42% identified as White compared to 58% that identified as non-White). White patients were more likely to be recommended for genetic counseling (OR = 2.85; 95% CI, 1.07-7.93, P < .05), be referred for genetic counseling (OR = 3.17; 95% CI, 1.19-8.86, P < .05), receive counseling (OR = 3.82; 95% CI, 1.42-10.83, P < .01), and undergo genetic testing (OR = 2.88; 95% CI, 0.97-9.09, P = .056) compared to non-White patients. Patients with private insurance were significantly more likely to be recommended for genetic counseling (OR 5.63, P < .005), referred (OR 6.11, P < .005), receive counseling (OR 4.21, P < .05), and undergo testing (OR 4.10, P < .05). When controlled for insurance, there was no significant racial differences in the rates of GC recommendation, referral, counseling, or testing.

Conclusion

The findings of this study suggest that disparities in genetic counseling and testing are largely driven by differences in health insurance.

Understanding mortality among hematology oncology patients identified from hospital administrative data

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Background: Hospital administrative data has large ramifications for quality of care and quality improvement projects. Unexpected inpatient mortality among patients with a hematology/oncology (H/O) diagnostic related group (DRG) is not widely studied and reported. We sought to investigate the unexpected inpatient mortality rate among cancer patients who were admitted to a large, urban, tertiary care safety net teaching hospital. Methods: We obtained the hospital’s adjusted mortality rate and evaluated the subset of specific observed/expected deaths ratio (O/E) of patients with a primary H/O diagnosis. We reviewed each case that was identified as an unexpected inpatient mortality from 2016 to 2018. A chart abstraction tool was designed for data abstraction that included demographics, location of admission, comorbid conditions, if mortality was expected, if documentation was reflective of the severity of the illness. Two independent reviewers abstracted each chart. A third reviewer assessed each case to make a final determination regarding expected mortality based on medical complexity and if documentation was reflective of severity of illness. Results: On review of the inpatient mortality data, the O/E for the H/O diagnostic related group (DRG) from Vizient was 1.14. Twenty two cases were identified as having an unexpected death. Among those cases, 23% of patients were transferred from an outside hospital, and 23% of patients did not have a known cancer diagnosis on admission. In the majority of cases, initial documentation did not accurately reflect severity of illness and/or specialists in hematology or oncology were not consulted at time of diagnosis. We noted the majority of patients were not followed by a hematologist/oncologist within the hospital system (63.6%). In 55% of patients, the cause of death was acute respiratory failure, and 14% of patients had an Advance Directive/DNAR in the chart prior to admission. Delayed antibiotics in febrile neutropenia and a missed blood transfusion reaction were among causes of unexpected deaths. Conclusions: Hospital generated data reported that mortality among H/O patients was greater than projected, however careful chart review of each case demonstrated a significant number of cases that were expected but the severity of illness was not documented properly to account for the death. Templates for proper documentation using the Vizient mortality variables is a key area to lower unexpected inpatient mortality.

The Influence of Culture on Healthy Relationship Formation and Teen Dating Violence: A Qualitative Analysis of South Asian Female Youth Residing in the United States

Teen dating violence (TDV) has well-documented detrimental health effects. Scant research has examined the perspectives of ethnically diverse youth about the impact of culture on TDV. We sought to explore the intersection between culture and TDV specifically for South Asian youth residing in the United States. We conducted semi-structured interviews with South Asian youth aged 16 to 21 years. Interviews included three aims: (a) exploring participants' perspectives on TDV and healthy relationships within the South Asian community, (b) examining how different components of their cultural identity affect their romantic relationships, and (c) understanding ideas for TDV prevention programs for South Asian youth. Interview transcripts were coded using thematic analysis. Twenty-five adolescent females participated; the majority (76%) trace their heritage to India, were born abroad (62%), and are in college (80%). The majority believed that dating was stigmatized within the South Asian community, forcing youth to hide relationships from their parents. Participants described aspects of culture that may negatively impact relationships (e.g., patriarchal attitudes and fear of stigma), as well as those that may protect teens (e.g., close-knit community). Conflicts about dating due to generational differences were also discussed. Participants suggested programs for South Asian youth focused on engaging parents in conversations about TDV and promoting gender equity. About half thought TDV prevention programs should be culturally tailored for South Asian youth, while others believed multicultural programs would be more effective. Although South Asian culture may confer some protection for youth experiencing TDV, stigma against dating and generational differences may create unique challenges. Future work should examine how to mediate parent-adolescent cultural conflicts around dating.

Abstract PS13-26: Effect of an outpatient pharmacy team to improve management and adherence to oral chemotherapy

Introduction Oral chemotherapy agents have become increasingly common for the treatment of various malignancies, specifically in the metastatic setting. In metastatic breast cancer, oral chemotherapy is now considered the standard of care for first-line treatment due to progression-free survival and overall survival benefits. Oral agents are also considered to be a convenient and less toxic therapy option, improving quality of life. However, these benefits are offset by challenges in the delay to initiation of therapy, adherence, and toxicity management which may lead to high co-pays, delays in treatment, increased clinic visits, and non-adherence. These issues can be augmented at a safety net hospital charged to care for the most vulnerable patients. Close monitoring and follow-up are critical but can be complex and pose an additional burden on the treating oncologist. Pharmacists can serve as an extender to the oncologist and may help mitigate many of these clinical and operational barriers through adherence strategies, toxicity management, care coordination, and optimization of dosing schedules and regimens. Methods/Materials We conducted a quality improvement (QI) initiative aimed to decrease the average number of treatment day delays experienced by patients receiving oral chemotherapy for the treatment of MBC during the first six cycles of chemotherapy. A secondary aim was to improve adherence and patient-provider satisfaction. A protocol was designed and implemented utilizing pharmacists to provide assistance with obtaining the medications through a specialty pharmacy, oral chemotherapy counseling, toxicity assessments, and strategies to help optimize oral adherence (OPTIMAL protocol). Pharmacists conducted live in-person visits and telemedicine visits at weekly to monthly intervals to supplement the ongoing routine care of the oncology provider. All treatment and supportive care recommendations, in addition to any identified barriers, were communicated to the provider. Results A baseline assessment of 63 patients receiving oral oncolytic therapy from December 1st, 2018 through November 26th, 2019 was completed. Patients experienced most delays during cycle 1, with an average of 14.5 days of delay (range 1 - 34 days). The most common reasons for delay throughout the first six cycles of therapy were toxicity development, receipt of medication from the pharmacy, and patient adherence. A separate analysis of patients on CDK4/6 inhibitors (n=8) identified an average treatment day delay of 7.7 days (range 3.2 - 15.3 days) during the first six cycles of chemotherapy. Over a 7-month period, fifteen patients were enrolled in the OPTIMAL protocol and experienced an average treatment day delay of 2.9 days (range 0 - 6.8 days) during the first six cycles. Pharmacists made 206 documented interventions amongst the patients on the protocol, encompassing medication reconciliations, therapy counseling, and clinical recommendations. Eleven patients reported treatment-related toxicities, resulting in six therapy modifications and two-dose modifications. Four patients experienced progression on oral oncolytic therapy and subsequently went on to other treatment options. Conclusion Our protocol to incorporate pharmacists in initial and follow-up clinic visits at an outpatient breast cancer clinic within a safety net hospital was associated with decreased treatment day delays. Pharmacists performed a large number of meaningful clinical and operational interventions to facilitate medication treatment in a, particularly vulnerable population. This intervention supports the valuable and versatile role pharmacists can play in co-managing patients with the rest of the healthcare team.

Citation Format: Jasmine Patel, David Michael Hughes, Kathryn Quinn, Tsion Fikre, Naomi Ko. Effect of an outpatient pharmacy team to improve management and adherence to oral chemotherapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS13-26.

Hepatitis C Virus Infection and Chemotherapy in Breast Cancer: A Retrospective Chart Analysis

BACKGROUND

Breast cancer and hepatitis C virus (HCV) infection are major health problems in the U.S. Despite these highly prevalent diseases, there is limited information on the effect of HCV infection among patients with breast cancer receiving chemotherapy and the potential challenges they face during treatment. Currently, there are no guidelines for chemotherapy administration in HCV-positive patients with breast cancer.

MATERIALS AND METHODS

We performed a retrospective case-control analysis on six patients with breast cancer with active HCV infection and 12 HCV-negative matched controls who received chemotherapy between January 2000 and April 2015. We investigated dose delays, dose changes, hospitalization, hematologic reasons for dose delays, and variation in blood counts during chemotherapy from the patients' medical records. Fisher's exact test was used for statistical comparison of the outcome variables between the two groups.

RESULTS

When compared with the HCV-negative patients, the HCV-positive group was at a significantly higher risk of dose delays (100% vs. 33%, p value .013), dose changes (67% vs. 8%, p value .022), hospitalization during chemotherapy (83% vs. 25%, p value .043), and hematotoxicity related dose delays (83% vs. 8%, p value .003). HCV-positive patients took a longer time to complete treatment than the HCV-negative group.

CONCLUSION

Patients with HCV receiving chemotherapy for breast cancer are more likely to experience complications such as dose delays, dose modifications, and hospitalization. Future studies to confirm our findings and investigate on the effect of concurrent HCV and breast cancer treatment are warranted.

IMPLICATIONS FOR PRACTICE

This study found that hepatitis C infection is associated with a greater risk of treatment delays and dose modifications in patients with breast cancer receiving cytotoxic chemotherapy. Hepatitis C-positive patients have a higher treatment burden with dose changes, hospitalizations, and longer treatment periods than noninfected patients. Further prospective investigations to confirm these findings are warranted in a larger patient population. Given that hepatitis C infection can be curable with direct-acting antivirals, treatment of hepatitis C may alleviate treatment challenges during chemotherapy and improve survival for patients with breast cancer.

Significance and prospects of an orphan crop tef

Tef is a resilient crop from the Horn of Africa with significant importance in food and nutrition security, and currently gaining global popularity as health and performance food. Tef [Eragrostis tef (Zucc.) Trotter] is the most important cereal of Ethiopia in terms of production, consumption and cash crop value. In Ethiopia, tef is annually grown on about 3 million ha with total grain production of over 5 million tons. As such, it accounts for about 30% of the total cultivated area and one-fifth of the gross grain production of all cereals cultivated in the country. In spite of its supreme economic and agricultural significance in Ethiopia, its productivity is relatively low with national average yield of about 1.7 t/ha. This has primarily been due to the very little scientific improvement done on the crop. Tef has still been an "orphan crop" since it is globally a very much under-researched crop owing to its localized importance. Scientific research on tef in Ethiopia began in the late 1950s. The main objective of this paper is to provide an overview of the significance and major production constraints of tef, and the major achievements made to date in various tef research aspects including breeding, agronomy, crop protection, and agricultural economics and extension. Based on these reviews, the paper eventually concludes with remarks on the way forward by emphasizing on the identification of the major gaps and the improvement efforts required for realizing the ever-needed breakthrough in the productivity and production of the crop. The major focal areas of future efforts include increasing productivity of both grain and biomass, systematic conservation and mining of the genetic resources, tackling the lodging malady, mechanization of the crop's husbandry, understanding the overall physiology of the crop especially with respect to stress tolerance, unraveling the nutritional qualities, and development of recipes and value-added products.

The impact of domestic violence exposure on South Asian children in the United States: Perspectives of domestic violence agency staff

The South Asian community is the fastest growing ethnic group in the United States, and past research suggests that South Asian domestic violence (DV) survivors may require culturally-specific resources. Similarly, South Asian children in the US exposed to DV may have unique responses and needs, but this has not been explored to date. The objective of this study was to examine the specific needs of South Asian children exposed to DV from the vantage point of staff from South Asian DV agencies across the United States. Thirty interviews were conducted, with data coded and consolidated into larger themes using thematic analysis. Participants described several factors important to understanding the impact of DV on South Asian children including the role of the extended family, identifying with two cultures, fear about what the South Asian community will think, gender differences, and the importance of projecting an image of perfection. Participants also discussed development of culturally-tailored resources. This study suggests the importance of framing South Asian children's experiences within the context of interweaving South Asian and American cultural values, with careful attention paid to how potential culture clashes between parents and children may impact the way children process trauma. Further work should triangulate these themes with children, parents, and extended family, as well as collaborate with South Asian DV agencies to design child-focused programs.