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Katz SJ, Ye C. Biological Sex Inequality in Rheumatology Wait Times During the COVID-19 Pandemic. J Rheumatol 2023; 50:1346-1349. [PMID: 36921972 DOI: 10.3899/jrheum.221213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To examine the effect of biological sex on wait times to first rheumatology appointment in a central triage system before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS Deidentified data of all referred patients between November 2019 and June 2022 were extracted from the electronic medical record. Variables, including time from referral to first appointment, biological sex, referral period, urgency status, age, and geographic location were collected and analyzed. RESULTS Twelve thousand eight hundred seventeen referrals were identified. Wait times increased by 24.23 days in the peri-COVID period (P < 0.001). In the pre-COVID period, there was no significant difference in wait times by biological sex or age. Triage urgency was a predictor of wait time, with semiurgent referrals seen 8.94 days (95% CI -15.90 to -1.99) sooner than routine referrals and urgent referrals seen 25.42 days (95% CI -50.36 to -0.47) sooner than routine referrals. In the peri-COVID period, there was a significant difference in wait time by biological sex with women waiting on average 10.03 days (95% CI 6.98-13.09) longer than men (P < 0.001). Older patients had shorter wait times than younger patients, with a difference of -4.64 days for every 10-year increase in age (95% CI -5.49 to -3.78). Triage urgency continued to be a predictor of wait time. CONCLUSION Women and younger patients appear to have been affected by wait time increases during the COVID-19 pandemic. This finding should be further investigated to determine its pervasiveness across other specialities and to better understand the underlying cause of this finding.
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Affiliation(s)
- Steven J Katz
- S.J. Katz, MD, C. Ye, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada.
| | - Carrie Ye
- S.J. Katz, MD, C. Ye, MD, Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
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Yuan JH, Huang Y, Rosgen BK, Donnelly S, Lan X, Katz SJ. Burnout and fatigue amongst internal medicine residents: A cross-sectional study on the impact of alternative scheduling models on resident wellness. PLoS One 2023; 18:e0291457. [PMID: 37708198 PMCID: PMC10501672 DOI: 10.1371/journal.pone.0291457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Fatigue and burnout are prevalent among resident physicians across Canada. Shifts exceeding 24 hours are commonly purported as detrimental to resident health and performance. Residency training programs have employed strategies towards understanding and intervening upon the complex issue of resident fatigue, where alternative resident scheduling models have been an area of active investigation. This study sought to characterize drivers and outcomes of fatigue and burnout amongst internal medicine residents across different scheduling models. METHODS We conducted cross-sectional surveys were among internal medicine resident physicians at the University of Alberta. We collected anonymized socioeconomic demographics and medical education background, and estimated associations between demographic or work characteristics and fatigue and burnout outcomes. RESULTS Sixty-nine participants competed burnout questionnaires, and 165 fatigue questionnaires were completed (response rate of 48%). The overall prevalence of burnout was 58%. Lower burnout prevalence was noted among respondents with dependent(s) (p = 0.048), who identified as a racial minority (p = 0.018), or completed their medical degree internationally (p = 0.006). The 1-in-4 model was associated with the highest levels of fatigue, reported increased risk towards personal health (OR 4.98, 95%CI 1.77-13.99) and occupational or household harm (OR 5.69, 95%CI 1.87-17.3). Alternative scheduling models were not associated with these hazards. CONCLUSIONS The 1-in-4 scheduling model was associated with high rates of resident physician fatigue, and alternative scheduling models were associated with less fatigue. Protective factors against fatigue are best characterized as strong social supports outside the workplace. Further studies are needed to characterize the impacts of alternative scheduling models on resident education and patient safety.
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Affiliation(s)
- Jack H. Yuan
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Yiming Huang
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brianna K. Rosgen
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Donnelly
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Xiaoyang Lan
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Steven J. Katz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Mullins MA, Atluri N, Abrahamse P, Radhakrishnan A, Hamilton AS, Ward KC, Hawley ST, Katz SJ, Wallner LP. Primary care provider attitudes about and tendency to use non-recommended surveillance tests after curative breast cancer treatment. Breast Cancer Res Treat 2023; 200:391-398. [PMID: 37296280 PMCID: PMC10706825 DOI: 10.1007/s10549-023-06994-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Little is known about the factors contributing to the receipt of non-recommended surveillance testing among early-stage breast cancer survivors. We assessed primary care providers (PCP) attitudes about and tendency to order non-recommended surveillance testing for asymptomatic early-stage breast cancer survivors post-adjuvant chemotherapy. METHODS A stratified random sample of PCPs identified by early-stage breast cancer survivors were surveyed (N = 518, 61% response rate). PCPs were asked how likely they would be to order bone scans, imaging and/or tumor marker testing using a clinical vignette of an early-stage asymptomatic patient where these tests are non-recommended. A composite tendency to order score was created and categorized by tertiles (low, moderate, high). PCP-reported factors associated with high and moderate tendency to order non-recommended testing (vs. low) were estimated using multivariable, multinomial logistic regression. RESULTS In this sample, 26% reported a high tendency to order non-recommended surveillance tests during survivorship for early-stage breast cancer survivors. PCPs who identified as family practice physicians and PCPs reporting more confidence in ordering surveillance testing were more likely to report a high tendency to order non-recommended testing (vs. low) ((aOR family practice 2.09, CI 1.2, 3.8; aOR more confidence 1.9, CI 1.1, 3.3). CONCLUSIONS In this population-based sample of PCPs caring for breast cancer survivors, over a quarter of PCPs reported they would order non-recommended surveillance testing for asymptomatic early-stage breast cancer survivors. Efforts to better support PCPs and disseminate information about appropriate surveillance for cancer survivors are warranted.
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Affiliation(s)
- Megan A Mullins
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Paul Abrahamse
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Archana Radhakrishnan
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ann S Hamilton
- Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sarah T Hawley
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Department of Health Behavior and Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Katz
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109, USA.
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
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Kurian AW, Abrahamse P, Furgal A, Ward KC, Hamilton AS, Hodan R, Tocco R, Liu L, Berek JS, Hoang L, Yussuf A, Susswein L, Esplin ED, Slavin TP, Gomez SL, Hofer TP, Katz SJ. Germline Genetic Testing After Cancer Diagnosis. JAMA 2023; 330:43-51. [PMID: 37276540 PMCID: PMC10242510 DOI: 10.1001/jama.2023.9526] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023]
Abstract
Importance Germline genetic testing is recommended by practice guidelines for patients diagnosed with cancer to enable genetically targeted treatment and identify relatives who may benefit from personalized cancer screening and prevention. Objective To describe the prevalence of germline genetic testing among patients diagnosed with cancer in California and Georgia between 2013 and 2019. Design, Setting, and Participants Observational study including patients aged 20 years or older who had been diagnosed with any type of cancer between January 1, 2013, and March 31, 2019, that was reported to statewide Surveillance, Epidemiology, and End Results registries in California and Georgia. These patients were linked to genetic testing results from 4 laboratories that performed most germline testing for California and Georgia. Main Outcomes and Measures The primary outcome was germline genetic testing within 2 years of a cancer diagnosis. Testing trends were analyzed with logistic regression modeling. The results of sequencing each gene, including variants associated with increased cancer risk (pathogenic results) and variants whose cancer risk association was unknown (uncertain results), were evaluated. The genes were categorized according to their primary cancer association, including breast or ovarian, gastrointestinal, and other, and whether practice guidelines recommended germline testing. Results Among 1 369 602 patients diagnosed with cancer between 2013 and 2019 in California and Georgia, 93 052 (6.8%) underwent germline testing through March 31, 2021. The proportion of patients tested varied by cancer type: male breast (50%), ovarian (38.6%), female breast (26%), multiple (7.5%), endometrial (6.4%), pancreatic (5.6%), colorectal (5.6%), prostate (1.1%), and lung (0.3%). In a logistic regression model, compared with the 31% (95% CI, 30%-31%) of non-Hispanic White patients with male breast cancer, female breast cancer, or ovarian cancer who underwent testing, patients of other races and ethnicities underwent testing less often: 22% (95% CI, 21%-22%) of Asian patients, 25% (95% CI, 24%-25%) of Black patients, and 23% (95% CI, 23%-23%) of Hispanic patients (P < .001 using the χ2 test). Of all pathogenic results, 67.5% to 94.9% of variants were identified in genes for which practice guidelines recommend testing and 68.3% to 83.8% of variants were identified in genes associated with the diagnosed cancer type. Conclusions and Relevance Among patients diagnosed with cancer in California and Georgia between 2013 and 2019, only 6.8% underwent germline genetic testing. Compared with non-Hispanic White patients, rates of testing were lower among Asian, Black, and Hispanic patients.
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Affiliation(s)
- Allison W. Kurian
- Department of Medicine, School of Medicine, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Allison Furgal
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann S. Hamilton
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| | - Rachel Hodan
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California
| | - Rachel Tocco
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Lihua Liu
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles
| | - Jonathan S. Berek
- Department of Obstetrics and Gynecology, School of Medicine, Stanford University, Stanford, California
| | | | | | | | | | | | - Scarlett L. Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco
| | - Timothy P. Hofer
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Steven J. Katz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Katz SJ, Abrahamse P, Hodan R, Kurian AW, Rankin A, Tocco RS, Rios-Ventura S, Ward KC, An LC. Cascade Genetic Risk Education and Testing in Families With Hereditary Cancer Syndromes: A Pilot Study. JCO Oncol Pract 2023; 19:e848-e858. [PMID: 36921235 PMCID: PMC10332838 DOI: 10.1200/op.22.00677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/07/2023] [Indexed: 03/17/2023] Open
Abstract
PURPOSE Cascade genetic risk evaluation in families with hereditary cancer can reduce the burden of disease but the rate of germline genetic testing in relatives of patients at risk is low. METHODS We identified all 277 women diagnosed with breast cancer in Georgia in 2017 who linked to a clinically actionable germline pathogenic variant through a Surveillance, Epidemiology, and End Results registry-variant linkage initiative. We surveyed them, and then invited eligible respondents to an online platform hosted by a navigator that offered cancer genetic risk education and germline genetic testing to untested relatives. We randomly assigned patient-family clusters at the time of the patient enrollment offer to free versus $50 (USD) test cost. Patients invited relatives to join the study through personalized e-mail. Enrolled relatives received online cancer genetic education and the opportunity to order clinical germline genetic testing through the platform. The primary outcome was the number of relatives who ordered genetic testing. RESULTS One hundred twenty-five of 277 patients completed surveys (45.2%). Most respondents were eligible for the trial offer (113 of 125; 90.4%). In the free testing arm, 20 of 56 eligible patients participated (35.7% of eligible respondents) and they invited 28 relatives: 12 relatives enrolled and 10 ordered testing. In the $50 (USD) arm, 16 of 57 eligible patients participated (28.1%) and they invited 38 relatives: 18 relatives enrolled and 17 ordered testing. CONCLUSION Cascade genetic testing in families with hereditary cancer syndromes accrued through a population-based cancer registry can be achieved through an online platform that offers genetic risk education and low-cost testing to relatives. A modest charge did not appear to influence the percentage of participating patients, numbers of participating relatives, and numbers of relatives who received genetic testing.
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Affiliation(s)
- Steven J. Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Health Management and Policy, School of Public Health, University of Michigan Ann Arbor, MI
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rachel Hodan
- Cancer Genetics, Stanford Health Care, Stanford, CA
| | - Allison W. Kurian
- Department of Medicine, Stanford University, Stanford, CA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Aaron Rankin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rachel S. Tocco
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Sonia Rios-Ventura
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lawrence C. An
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Katz SJ, Hall JJ. COVID-19 information uptake amongst a rheumatology interested population. Clin Rheumatol 2023; 42:1491-1493. [PMID: 36892709 PMCID: PMC9995713 DOI: 10.1007/s10067-023-06571-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Steven J Katz
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Jill J Hall
- Faculty of Pharmacy and Pharmaceutical Sciences and Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Eldeiry L, Katz SJ. A rheumatology practice profile: Implications for subspeciality training in the era of advanced therapies. Musculoskeletal Care 2023; 21:249-252. [PMID: 36082878 DOI: 10.1002/msc.1696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/08/2022]
Affiliation(s)
| | - Steven J Katz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Semaka A, Katz SJ. Rheumatology Image of the Month: A Low Resource Innovation With Measurable Results. J Med Educ Curric Dev 2023; 10:23821205231164027. [PMID: 36936181 PMCID: PMC10021094 DOI: 10.1177/23821205231164027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 02/24/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Strategies to increase confidence in rheumatology knowledge are valuable for medical trainees and residents. A web-based teaching innovation was implemented in an attempt to increase rheumatology exposure for internal medicine residents. METHODS An Image of the Month webpage was established, where a practicing rheumatologist would post a new image that could be answered online by internal medicine residents. Cumulative data was analyzed to determine the extent and change in rheumatology exposure. RESULTS The Image of the Month webpage posted images for a total of 76 months between July 2010 to May 2017, with a total of 1326 submitted responses. The proportion of residents who only participated in Image of the Month and only did a rheumatology rotation averaged 36.1% and 16.5%, respectively. The proportion of residents who only participated in Image of the Month was higher than the proportion who only did a rheumatology rotation for all of the 7 time periods assessed. A total of 491 residents participated in Image of the Month, with an average of 54.9% of residents participating each year. Overall, on average, 52 residents had 1 or more submissions, 3.6 entries were submitted per resident, and 17.4 entries were submitted per month. Junior residents (PGY1) participated more often than senior residents (PGY3). CONCLUSIONS The Image of the Month webpage successfully improves internal medicine resident exposure to rheumatology with minimal resources and manpower required. Further study is necessary to determine the impact this exposure may have on the abilities and confidence levels of internal medicine residents.
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Affiliation(s)
- Amy Semaka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton,
Canada
| | - Steven J Katz
- Division of Rheumatology, Department of Medicine, University of
Alberta, Edmonton, Canada
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Kurian AW, Abrahamse P, Hamilton AS, Caswell-Jin JL, Gomez SL, Hofer TJ, Ward KC, Katz SJ. Chemotherapy Regimens Received by Women With BRCA1/2 Pathogenic Variants for Early Stage Breast Cancer Treatment. JNCI Cancer Spectr 2022; 6:6611726. [PMID: 35723570 PMCID: PMC9305849 DOI: 10.1093/jncics/pkac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/06/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Genetic testing is widespread among breast cancer patients; however, no guideline recommends using germline genetic testing results to select a chemotherapy regimen. It is unknown whether breast cancer patients who carry pathogenic variants (PVs) in BRCA1 and/or 2 (BRCA1/2) or other cancer-associated genes receive different chemotherapy regimens than noncarriers. METHODS We linked Surveillance, Epidemiology, and End Results registry records from Georgia and California to germline genetic testing results from 4 clinical laboratories. Patients who 1) had stages I-III breast cancer, either hormone receptor (HR) positive and HER2 negative or triple negative (TNBC), diagnosed in 2013-2017; 2) received chemotherapy; and 3) were linked to genetic results were included. Chemotherapy details were extracted from Surveillance, Epidemiology, and End Results text fields completed by registrars. We examined whether PV carriers received more intensive regimens (HR-positive,HER2-negative: ≥3 drugs including an anthracycline; TNBC: ≥4 drugs including an anthracycline and platinum) and/or less standard breast cancer agents (a platinum). All statistical tests were 2-sided. RESULTS Among 2293 patients, 1451 had HR-positive, HER2-negative disease, and 842 had TNBC. On multivariable analysis of women with HR-positive, HER2-negative disease, receipt of a more intensive chemotherapy regimen varied statistically significantly by genetic results (P = .02), with platinum receipt more common among BRCA1/2 PV carriers (odds ratio = 2.44, 95% confidence interval = 1.36 to 4.38; P < .001). Among women with TNBC, chemotherapy agents did not vary significantly by genetic results. CONCLUSION BRCA1/2 PV carriers with HR-positive, HER2-negative breast cancer had twofold higher odds than noncarriers of receiving a platinum, as part of a more intensive chemotherapy regimen. This likely represents overtreatment and emphasizes the need to monitor how genetic testing results are managed in oncology practice.
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Affiliation(s)
- Allison W Kurian
- Correspondence to: Allison W. Kurian, MD, MSc, Department of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Alway Building, Room M121M, Stanford, CA 94305-5405, USA (e-mail: )
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health and Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ann S Hamilton
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Scarlett L Gomez
- Department of Epidemiology & Biostatistics and Hellen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Timothy J Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Katz SJ, Wang D. Comparing Entrustable Professional Activity Scores Given by Faculty Physicians and Senior Trainees to First-Year Residents. Cureus 2022; 14:e25798. [PMID: 35836450 PMCID: PMC9273189 DOI: 10.7759/cureus.25798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/05/2022] Open
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Katz SJ, Tocco R, Hawley ST, An L, Hodan R, Ward KC, Kurian AW. A pilot study to increase cascade genetic testing in families with hereditary cancer syndromes. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.10602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10602 Background: There is great need to build and evaluate tools and strategies to improve cascade genetic risk evaluation in families at high risk for hereditary cancer. The Genetic Information and Family Testing (GIFT) Trial (CA254822) is a population-based intervention that examines features of a virtual platform that provides genetic risk education (GRE) and low-cost genetic testing (GT) to relatives of adult patients diagnosed with cancer in 2018-19 in Georgia and California and tested positive for a clinically relevant germline pathogenic variant (PV). We present findings of a pilot study intended to inform the GIFT Trial protocol and platform features. Methods: We surveyed 277 women diagnosed with breast cancer in 2017, reported to the Georgia SEER registry, and received genetic testing (95% of whom had a clinically relevant PV). We then invited respondent patients to enroll in the intervention phase which provided online GRE, human pretest genetic navigator support, and an offer of low-cost GT through Color Health, Inc. to all untested 1st or 2nd degree relatives. Respondent patients were eligible for the intervention if they reported a PV on genetic testing and had at least one relative who had not received GT. Enrolled patients invited relatives through the platform by providing email addresses. Family clusters were block randomized to free vs $50 test costs at the time of the initial patient invitation. Results: At study midpoint, 117 of 277 patients (42%) had returned surveys: median age was 51 and 22% were African American. The most frequent PVs reported by the patients were BRCA1/2 (41%), CHEK2 (21%), and PALB2 (8%). Half (54%) had previously encouraged all of their brothers to get GT and 71% had encouraged all of their sisters to get GT. Three-quarters (78%) strongly agreed it was important for relatives to understand their genetic risk for cancer, and half (54%) strongly agreed they would like to make it easier for relatives to get genetic testing. The median number of patient-reported untested relatives in a family was 8.5 (25th-75th percentile: 4-14). Most respondent patients were eligible for the intervention phase (N = 108, 93%). About one-quarter had enrolled in the intervention at midpoint (16 of 53 in no-cost arm vs 16 of 55 in $50 arm). Patients in the no-cost arm invited 21 relatives, 10 of whom had enrolled with 8 ordering GT (38% of invited relatives). Patients in the $50 arm invited 38 relatives, 18 of whom had enrolled with 17 ordering GT (45% of invited relatives). Overall, about half of enrolled relatives (46%) were men. Conclusions: Breast cancer patients with PVs make substantial efforts to communicate with family members about genetic risk; but they strongly endorse the need for additional support to facilitate this complex communication. Interim pilot findings suggest that a low-cost online navigator-supported intervention can directly engage relatives with little difference in GT uptake by test cost arms.
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Affiliation(s)
| | | | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Katz SJ. Staff and resident perceptions on the introduction of a team based multi-specialty resident night shift system. PLoS One 2022; 17:e0268569. [PMID: 35588439 PMCID: PMC9119506 DOI: 10.1371/journal.pone.0268569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/03/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives
To determine the perceptions of staff and resident physicians on the impact of implementation of a new team based multi-specialty resident night shift system.
Methods
An electronic survey was distributed anonymously to all resident physicians in the Core Internal Medicine residency program at the University of Alberta. A similar survey was distributed to staff physicians in the 4 specialties impacted by this new system: hematology, respirology, nephrology and gastroenterology.
Results
74 physicians completed the survey. A majority of respondents (67%) indicated the new system was a positive change. Most shared it was better than traditional 1 in 4 call (65%), with resident physicians appreciating the team based nature of the system (65%), and just more than half of residents (55%) indicating this system improved their overall wellness. Most respondents (78%) did not feel the additional handover required had a negative impact. Respondents indicated daytime teaching and feedback improved as a result of this system (52%) with most others indicating it had no impact, although overnight feedback remained a challenge.
Conclusion
The implementation of this new team based system was well accepted by both staff and resident physicians across a number of domains. Future study is required to determine its impact on access and quality of care.
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Affiliation(s)
- Steven J. Katz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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Berlin NL, Abrahamse P, Momoh AO, Katz SJ, Jagsi R, Hamilton AS, Ward KC, Hawley ST. Perceived financial decline related to breast reconstruction following mastectomy in a diverse population-based cohort. Cancer 2022; 128:1284-1293. [PMID: 34847259 PMCID: PMC8882150 DOI: 10.1002/cncr.34048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite mandated insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed on to women through cost-sharing arrangements and high-deductible health plans. In this population-based study, the authors assessed perceived financial and employment declines related to breast reconstruction following mastectomy. METHODS Women with early-stage breast cancer (stages 0-II) diagnosed between July 2013 and May 2015 who underwent mastectomy were identified through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles and were surveyed. Primary outcome measures included patients' appraisal of their financial and employment status after cancer treatment. Multivariable models evaluated the association between breast reconstruction and primary outcomes. RESULTS Among 883 patients with breast cancer who underwent mastectomy, 44.2% did not undergo breast reconstruction, and 55.8% underwent reconstruction. Overall, 21.9% of the cohort reported being worse off financially since their diagnosis (25.8% with reconstruction vs 16.6% without reconstruction; P = .002). Women who underwent reconstruction reported higher out-of-pocket medical expenses (32.1% vs 15.6% with expenses greater than $5000; P < .001). Reconstruction was independently associated with a perceived decline in financial status (odds ratio, 1.92; 95% confidence interval, 1.15-3.22; P = .013). Among women who were employed at the time of their diagnosis, there was no association between reconstruction and a perceived decline in employment status (P = .927). CONCLUSIONS In this diverse cohort of women who underwent mastectomy, those who elected to undergo reconstruction experienced higher out-of-pocket medical expenses and self-reported financial decline. Patients, providers, and policymakers should be aware of the potential financial implications related to reconstruction despite mandatory insurance coverage.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan.,National Clinician Scholars Program, Institute for Health Policy and Innovation, Ann Arbor, Michigan
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Health Care Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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14
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Kurian AW, Abrahamse P, Ward KC, Hamilton AS, Deapen D, Berek JS, Hoang L, Yussuf A, Dolinsky J, Brown K, Slavin T, Hofer TP, Katz SJ. Association of Family Cancer History With Pathogenic Variants in Specific Breast Cancer Susceptibility Genes. JCO Precis Oncol 2021; 5:PO.21.00261. [PMID: 34977446 PMCID: PMC8710333 DOI: 10.1200/po.21.00261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/12/2021] [Accepted: 11/22/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Family cancer history is an important component of genetic testing guidelines that estimate which patients with breast cancer are most likely to carry a germline pathogenic variant (PV). However, we do not know whether more extensive family history is differentially associated with PVs in specific genes. METHODS All women diagnosed with breast cancer in 2013-2017 and reported to statewide SEER registries of Georgia and California were linked to clinical genetic testing results and family history from two laboratories. Family history was defined as strong (suggestive of PVs in high-penetrance genes such as BRCA1/2 or TP53, including male breast, ovarian, pancreatic, sarcoma, or multiple female breast cancers), moderate (any other cancer history), or none. Among established breast cancer susceptibility genes (ATM, BARD1, BRCA1, BRCA2, CDH1, CHEK2, NF1, PALB2, PTEN, RAD51C, RAD51D, and TP53), we evaluated PV prevalence according to family history extent and breast cancer subtype. We used a multivariable model to test for interaction between affected gene and family history extent for ATM, BRCA1/2, CHEK2, and PALB2. RESULTS A total of 34,865 women linked to genetic results. Higher PV prevalence with increasing family history extent (P < .001) was observed only with BRCA1 (3.04% with none, 3.22% with moderate, and 4.06% with strong history) and in triple-negative breast cancer with PALB2 (0.75% with none, 2.23% with moderate, and 2.63% with strong history). In a multivariable model adjusted for age and subtype, there was no interaction between family history extent and PV prevalence for any gene except PALB2 (P = .037). CONCLUSION Extent of family cancer history is not differentially associated with PVs across established breast cancer susceptibility genes and cannot be used to personalize genes selected for testing.
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Affiliation(s)
- Allison W. Kurian
- Departments of Medicine and of Epidemiology & Population Health, Stanford University, Stanford, CA,Allison W. Kurian, MD, MSc, Department of Medicine and of Epidemiology & Population Health, Stanford University School of Medicine, HRP Redwood Building, Room T254A, 150 Governor's Lane, Stanford, CA 94305; e-mail:
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI,Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Ann S. Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Dennis Deapen
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jonathan S. Berek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Stanford Women's Cancer Center, Stanford University, Stanford, CA
| | | | | | | | | | | | - Timothy P. Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Steven J. Katz
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
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15
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Abstract
Multiple imputation is a well-established general technique for analyzing data with missing values. A convenient way to implement multiple imputation is sequential regression multiple imputation, also called chained equations multiple imputation. In this approach, we impute missing values using regression models for each variable, conditional on the other variables in the data. This approach, however, assumes that the missingness mechanism is missing at random, and it is not well-justified under not-at-random missingness without additional modification. In this paper, we describe how we can generalize the sequential regression multiple imputation imputation procedure to handle missingness not at random in the setting where missingness may depend on other variables that are also missing but not on the missing variable itself, conditioning on fully observed variables. We provide algebraic justification for several generalizations of standard sequential regression multiple imputation using Taylor series and other approximations of the target imputation distribution under missingness not at random. Resulting regression model approximations include indicators for missingness, interactions, or other functions of the missingness not at random missingness model and observed data. In a simulation study, we demonstrate that the proposed sequential regression multiple imputation modifications result in reduced bias in the final analysis compared to standard sequential regression multiple imputation, with an approximation strategy involving inclusion of an offset in the imputation model performing the best overall. The method is illustrated in a breast cancer study, where the goal is to estimate the prevalence of a specific genetic pathogenic variant.
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Affiliation(s)
| | | | - Michael R Elliot
- Department of Biostatistics, 1259University of Michigan, USA.,Survey Methodology Program, Institute for Social Research, USA
| | - Allison W Kurian
- Departments of Medicine and Epidemiology and Population Health, 6429Stanford University, USA
| | - Steven J Katz
- Department of Internal Medicine, 1259University of Michigan, USA
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16
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Kurian AW, Abrahamse P, Bondarenko I, Hamilton AS, Deapen D, Gomez SL, Morrow M, Berek JS, Hofer TP, Katz SJ, Ward KC. Association of Genetic Testing Results with Mortality Among Women with Breast Cancer or Ovarian Cancer. J Natl Cancer Inst 2021; 114:245-253. [PMID: 34373918 DOI: 10.1093/jnci/djab151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/15/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Breast cancer and ovarian cancer patients increasingly undergo germline genetic testing. However, little is known about cancer-specific mortality among carriers of a pathogenic variant (PV) in BRCA1/2 or other genes in a population-based setting. METHODS Georgia and California Surveillance Epidemiology and End Results (SEER) registry records were linked to clinical genetic testing results. Women were included who had stages I-IV breast cancer or ovarian cancer diagnosed in 2013-2017; received chemotherapy; and linked to genetic testing results. Multivariable Cox proportional hazard models were used to examine the association of genetic results with cancer-specific mortality. RESULTS 22,495 breast and 4,320 ovarian cancer patients were analyzed, with a median follow-up of 41 months. PVs were present in 12.7% of breast cancer patients with estrogen and/or progesterone receptor-positive, HER2-negative cancer, 9.8% with HER2-positive cancer, 16.8% with triple-negative breast cancer and 17.2% with ovarian cancer. Among triple-negative breast cancer patients, cancer-specific mortality was lower with BRCA1 (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.35-0.69) and BRCA2 PVs (HR = 0.60, 95% CI = 0.41-0.89), and equivalent with PVs in other genes (HR = 0.65, 95% CI = 0.37-1.13), versus non-carriers. Among ovarian cancer patients, cancer-specific mortality was lower with PVs in BRCA2 (HR = 0.35, 95% CI = 0.25-0.49) and genes other than BRCA1/2 (HR = 0.47, 95% CI = 0.32-0.69). No PV was associated with higher cancer-specific mortality. CONCLUSIONS Among breast cancer and ovarian cancer patients treated with chemotherapy in the community, BRCA1/2 and other gene PV carriers had equivalent or lower short-term cancer-specific mortality than non-carriers. These results may reassure newly diagnosed patients and longer follow-up is ongoing.
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and of Epidemiology & Population Health, Stanford University, Stanford, California
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Irina Bondarenko
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Dennis Deapen
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Scarlett L Gomez
- Department of Epidemiology & Biostatistics and Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Jonathan S Berek
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and Stanford Women's Cancer Center, Stanford University, Stanford, California
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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17
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Abstract
Background The etiology and pathophysiology of sarcoidosis remains unclear, with epidemiologic studies limited by its relatively low prevalence. The internet has prompted patients to seek information about medical diagnoses online; Google Trends provides access to an anonymized version of this data, which has a new role in epidemiology. We hypothesize that there is seasonal variation in the relative search interest of sarcoidosis, which would suggest seasonal variation in the incidence of sarcoidosis. Methods Google Trends was used to assess the relative search volume from 2010 to 2020 for “sarcoidosis” and “sarcoid” in 7 countries. ANOVA with multiple comparisons was performed to compare the mean relative search volume by month and by season for each country, with a p-value less than 0.05 indicating statistical significance. Results Our analysis revealed a significant seasonal variation in search popularity in 4 of the 7 countries and in the Northern Hemispheric countries combined. Direct comparison showed search terms to be more popular in spring, specifically March & April, than in the winter. Southern Hemisphere data was not statistically significant but showed a trend towards a nadir in December and a peak in September and October. Conclusions Overall, these findings suggest seasonal variation with a possible peak in spring and nadir in winter. This supports the hypothesis that sarcoidosis has seasonal variation and is more commonly diagnosed in spring, but more evidence is needed to support this, as well as investigation into the pathophysiology of sarcoidosis to explain this phenomenon. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01602-7.
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Affiliation(s)
- Amanda Stanton
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Steven J Katz
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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18
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Kurian AW, Abrahamse P, Hamilton AS, Deapen D, Gomez SL, Morrow M, Berek JS, Katz SJ, Ward KC. Cancer-specific mortality associated with germline genetic testing results among women with breast cancer or ovarian cancer treated with chemotherapy. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10517 Background: Breast and ovarian cancer patients increasingly undergo germline genetic testing. While studies suggest a greater chemotherapy benefit for carriers of BRCA1/2 pathogenic variants, little is known about whether pathogenic variants in other genes are associated with cancer mortality. Methods: Georgia and California Surveillance, Epidemiology and End Results (SEER) registry records of women diagnosed with breast cancer or ovarian cancer from 2013-2017 were linked to results of clinical germline genetic testing from four participating laboratories. Patients were included if they linked to a genetic result, had stages I-III breast cancer or I-IV epithelial ovarian cancer and received chemotherapy. Multivariable Cox proportional hazard models were used to examine the association of genetic results, demographic and clinical factors with cancer-specific mortality. Results: 21,348 breast and 4,320 ovarian cancer patients were analyzed with median follow-up of 41 months. Pathogenic variants were present in 12% of patients with estrogen and progesterone receptor-positive, HER2-negative breast cancer, 9% with HER2-positive breast cancer, 17% with triple-negative breast cancer and 18% with ovarian cancer. Pathogenic variants were most common in BRCA1/2, CHEK2, PALB2, ATM and BRIP1. Among triple-negative breast cancer patients, mortality was lower with pathogenic variants in BRCA1 (hazard ratio (HR) 0.27, 95% confidence interval (CI) 0.17-0.45) and genes other than BRCA1/2 (HR 0.33, CI 0.13-0.81) versus no pathogenic variant. Genetic results were not associated with mortality in other breast cancer subtypes. Among ovarian cancer patients, mortality was lower with pathogenic variants in BRCA2 (HR 0.36, CI 0.26-0.49) and in genes other than BRCA1/2 (HR 0.48, CI 0.33-0.70). Conclusions: Among breast and ovarian cancer patients treated with chemotherapy, those with germline pathogenic variants in several cancer-associated genes had equivalent or lower short-term mortality than those testing negative. These results may guide patient counseling and clinical trial design.
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Affiliation(s)
- Allison W. Kurian
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | | | - Ann S. Hamilton
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan S. Berek
- Stanford Women's Cancer Center, Stanford Cancer Institute, Stanford, CA
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19
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Kurian AW, Ward KC, Abrahamse P, Bondarenko I, Hamilton AS, Deapen D, Morrow M, Berek JS, Hofer TP, Katz SJ. Time Trends in Receipt of Germline Genetic Testing and Results for Women Diagnosed With Breast Cancer or Ovarian Cancer, 2012-2019. J Clin Oncol 2021; 39:1631-1640. [PMID: 33560870 DOI: 10.1200/jco.20.02785] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Genetic testing is important for breast and ovarian cancer risk reduction and treatment, yet little is known about its evolving use. METHODS SEER records of women of age ≥ 20 years diagnosed with breast or ovarian cancer from 2013 to 2017 in California or Georgia were linked to the results of clinical germline testing through 2019. We measured testing trends, rates of variants of uncertain significance (VUS), and pathogenic variants (PVs). RESULTS One quarter (25.2%) of 187,535 patients with breast cancer and one third (34.3%) of 14,689 patients with ovarian cancer were tested; annually, testing increased by 2%, whereas the number of genes tested increased by 28%. The prevalence of test results by gene category for breast cancer cases in 2017 were BRCA1/2, PVs 5.2%, and VUS 0.8%; breast cancer-associated genes or ovarian cancer-associated genes (ATM, BARD1, BRIP1, CDH1, CHEK2, EPCAM, MLH1, MSH2, MSH6, NBN, NF1, PALB2, PMS2, PTEN, RAD51C, RAD51D, STK11, and TP53), PVs 3.7%, and VUS 12.0%; other actionable genes (APC, BMPR1A, MEN1, MUTYH, NF2, RB1, RET, SDHAF2, SDHB, SDHC, SDHD, SMAD4, TSC1, TSC2, and VHL) PVs 0.6%, and VUS 0.5%; and other genes, PVs 0.3%, and VUS 2.6%. For ovarian cancer cases in 2017, the prevalence of test results were BRCA1/2, PVs 11.0%, and VUS 0.9%; breast or ovarian genes, PVs 4.0%, and VUS 12.6%; other actionable genes, PVs 0.7%, and VUS 0.4%; and other genes, PVs 0.3%, and VUS 0.6%. VUS rates doubled over time (2013 diagnoses: 11.2%; 2017 diagnoses: 26.8%), particularly for racial or ethnic minorities (47.8% Asian and 46.0% Black, v 24.6% non-Hispanic White patients; P < .001). CONCLUSION A testing gap persists for patients with ovarian cancer (34.3% tested v nearly all recommended), whereas adding more genes widened a racial or ethnic gap in VUS results. Most PVs were in 20 breast cancer-associated genes or ovarian cancer-associated genes; testing other genes yielded mostly VUS. Quality improvement should focus on testing indicated patients rather than adding more genes.
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and of Epidemiology & Population Health, Stanford University, Stanford, CA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Irina Bondarenko
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Dennis Deapen
- Department of Preventive Medicine in the Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jonathan S Berek
- Department of Obstetrics and Gynecology and Women's Cancer Center, Stanford University, Stanford, CA
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan and Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
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20
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Radhakrishnan A, Wallner LP, Skolarus TA, Abrahamse PH, Kollipara AS, Katz SJ, Hawley ST. Primary Care Providers' Perceptions About Participating in Low-Risk Prostate Cancer Treatment Decisions. J Gen Intern Med 2021; 36:447-454. [PMID: 33123958 PMCID: PMC7878590 DOI: 10.1007/s11606-020-06318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Primary care provider's (PCP) role in cancer care is expanding and may include supporting patients in their treatment decisions. However, the degree to which PCPs engage in this role for low-risk prostate cancer is unknown. OBJECTIVE Characterize PCP perceptions regarding their role in low-risk prostate cancer treatment decision-making. DESIGN Cross-sectional, national survey. MAIN MEASURES For men with low-risk prostate cancer, PCP reports of (1) confidence in treatment decision-making (high vs. low); (2) intended participation in key aspects of active surveillance treatment decision-making (more vs. less). KEY RESULTS A total of 347 from 741 eligible PCPs responded (adjusted response rate 56%). Half of respondent PCPs (50.3%) reported high confidence about engaging in low-risk prostate cancer treatment decision-making. The odds of PCPs reporting high confidence were greater among those in solo practice (vs working with > 1 PCP) (OR 2.18; 95% CI 1.14-4.17) and with higher volume of prostate cancer patients (> 15 vs. 6-10 in past year) (OR 2.16; 95% CI 1.02-4.61). PCP report of their intended participation in key aspects of active surveillance treatment decision-making varied: discussing worry (62.4%), reviewing benefits (48.5%) and risks (41.8%), and reviewing all treatment options (34.2%). PCPs who reported high confidence had increased odds of more participation in all aspects of active surveillance decision-making: reviewing all treatment options (OR 3.11; 95% CI 1.82-5.32), discussing worry (OR 2.12; 95% CI 1.28-3.51), and reviewing benefits (OR 3.13; 95% CI 1.89-5.16) and risks (OR 3.20; 95% CI 1.91-5.36). CONCLUSIONS The majority of PCPs were confident about engaging with patients in low-risk prostate cancer treatment decision-making, though their intended participation varied widely across four key aspects of active surveillance care. With active surveillance being considered for other low-risk cancers (such as breast and thyroid), understanding factors influencing PCP involvement will be instrumental to supporting team-based cancer care.
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Affiliation(s)
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Paul H Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Adam S Kollipara
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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21
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Kurian AW, Ward KC, Abrahamse P, Hamilton AS, Katz SJ. Predicted Chemotherapy Benefit for Breast Cancer Patients With Germline Pathogenic Variants in Cancer Susceptibility Genes. JNCI Cancer Spectr 2021; 5:pkaa083. [PMID: 33426465 PMCID: PMC7785044 DOI: 10.1093/jncics/pkaa083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/31/2020] [Indexed: 11/30/2022] Open
Abstract
Breast cancer patients increasingly undergo genetic testing. To examine chemotherapy indications for germline pathogenic variant (PV) carriers, we linked results of germline testing to Georgia and California Surveillance, Epidemiology, and End Results registry records, including 21-gene recurrence score (RS) results, for breast cancer patients diagnosed in 2013-2017. All statistical tests were 2-sided. Patients (N=37 349) had RS results of whom 714 had BRCA1, BRCA2, CHEK2, ATM, PALB2, or Lynch syndrome (MLH1, MSH2, MSH6, PMS2) PVs. For women aged 50 years or older at breast cancer diagnosis, RS often exceeded the chemotherapy benefit threshold (≥26) with BRCA1 (71.7% vs 14.4% with none; P <.001), PALB2 (37.1%; P = .001), and BRCA2 (44.3%; P < .001) PVs. Results were similar for women diagnosed at younger than 50 years of age. PVs in BRCA1, but not BRCA2, PALB2, ATM, CHEK2, or Lynch syndrome genes, were associated with elevated RS on multivariable analysis (P < .001). Results may inform RS testing decisions in breast cancer patients with PVs.
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Affiliation(s)
- Allison W Kurian
- Department of Medicine and of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Paul Abrahamse
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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22
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Katz SJ. The Influence of Applicant and Reviewer Gender on Resident Selection for Internal Medicine. J Med Educ Curric Dev 2021; 8:23821205211016502. [PMID: 34104786 PMCID: PMC8150434 DOI: 10.1177/23821205211016502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/16/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND While gender bias in medicine, including physician training, has been well described, less is known about gender bias in the selection process for post graduate residency training programs. This analysis reviews the potential role of gender on resident selection for an internal medicine residency program. METHODS File review and interview overall and component scores were analyzed based on the gender of the applicant. File review scores were further analyzed based on the reviewer's gender. RESULTS Women applicants scored higher than men applicants on their file review. There were no differences in any one component score except for leadership in art. Women file reviewers scored applicants higher than men file reviewers, but there was no difference between gender scores. There was no difference in overall or component interview scores between men or women applicants. Scoring did not impact the expected rank performance of applicants based on gender at any stage of the selection process. CONCLUSIONS While higher scores were observed in women applicants upon their file review, and women reviewers provided higher file review scores, this did not appear to impact the expected number of women and men applicants at each stage of the applicant process. This suggests a potential lack of gender bias at these stages of applicant selection.
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Affiliation(s)
- Steven J Katz
- Steven J Katz, University of Alberta, 8-130 Clinical Sciences Building, Edmonton, AB T6G 2G3, Canada.
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23
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Patel MA, Shah JL, Abrahamse PH, Jagsi R, Katz SJ, Hawley ST, Veenstra CM. A population-based study of invitation to and participation in clinical trials among women with early-stage breast cancer. Breast Cancer Res Treat 2020; 184:507-518. [PMID: 32757135 PMCID: PMC7606336 DOI: 10.1007/s10549-020-05844-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/28/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE Although many studies clearly demonstrate disparities in cancer clinical trial enrollment, there is a lack of consensus on potential causes. Furthermore, virtually nothing is known about associations between patients' decision-making style and their participation in clinical trials. METHODS Women with newly diagnosed, stage 0-II breast cancer reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries in 2013-2014 were surveyed approximately seven months after diagnosis. We investigated two primary outcome variables: (1) invitation to participate in a clinical trial, (2) participation in a clinical trial. We evaluated bivariate associations using Chi-squared tests and used multivariable logistic regression models to investigate associations between patient variables, including decision-making style, and the primary outcomes. RESULTS 2578 patients responded (71% response rate); 30% were > age 65, 18% were black, 18% were Latina, 29% had ≤ high school education. 10% of patients reported invitation to participate in a clinical trial; 5% reported participation in a clinical trial. After adjustment younger age, receipt of chemotherapy or radiation, disease stage, and a more rational (versus more intuitive) decision-making style were associated with a higher odds of invitation to participate. Being married was associated with a higher odds of participation; having an annual family income ≥ $40,000 was associated with a lower odds of participation. CONCLUSIONS 10% of patients reported invitation to participate in a clinical trial, and half of these reported participation. Invitation to participate varied by age and decision-making style, and participation varied by marital status and income.
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Affiliation(s)
- Monica A Patel
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer L Shah
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Paul H Abrahamse
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- US Department of Veterans Affairs Health Services Research and Development, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Christine M Veenstra
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA.
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
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Katz SJ, Morrow M, Kurian AW. Trends in germline genetic testing and results into survivorship for women diagnosed with breast cancer or ovarian cancer, 2013 to 2017. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
273 Background: Genetic testing is increasingly central to breast and ovarian cancer prevention and treatment. Yet, little is known about trends and disparities in receipt of testing and test results after diagnosis. Methods: We linked all female patients with breast or ovarian cancer diagnosed from 2013-2017 in Georgia and California and reported to SEER registries to genetic testing results from four laboratories (Ambry Genetics, GeneDx, Invitae, Myriad Genetics). We combined test results from all labs with SEER data. We classified a test as a multigene panel (MGP) if it included other genes in addition to BRCA1/2. We grouped pathogenic variants (PVs) by level of evidence that supported clinical testing: BRCA1/2; other genes associated with well-established syndromes (syndromic genes); genes whose cancer association is less certain (emerging genes); and any other tested genes (other genes). We categorized patients with a variant of unknown significance (VUS) in any gene but no PVs as VUS-only. We examined trends in receipt of testing and test results overall and by race/ethnic groups. Results: One quarter (25.5%) of 198,001 breast cancer patients, and 34.5% of 15,461 ovarian cancer patients had genetic tests. Test rates increased by only 2% annually; while the number of genes tested per patient increased by 28%. The mean number of genes tested rose from 10 to 35 during the study period. In early 2013, 18.3% of testers had a PV or VUS result, which increased to 37.2% in late 2017. The upward trend was largely due to increase in VUS-only findings. The proportion of tested breast cancer patients with any PV increased from 9.1% to 9.9%: PVs in BRCA1/2 decreased from 7.5% to 5.0% (p<.001), while PV yield for the two other clinical categories (syndromic and emerging genes) increased from 1.6% to 4.9% (p<.001). PVs in any of the other 61 genes were very rare (<1%). By contrast, the VUS rate in breast cancer patients increased markedly from 9.6% in 2013 to 26.2% in 2017. The VUS rate was higher in racial/ethnic minorities (41.0% Asian, 36.5%% Black, 28.0% Latinas versus 25.6% non-Hispanic Whites diagnosed in 2017; p<.001). We observed similar findings for patients with ovarian cancer. Conclusions: A large gap persists in testing ovarian cancer patients (35% versus 100% recommended). Testing more genes per patient was associated with a substantial racial/ethnic gap in VUS with little difference in yield on clinically relevant PVs. Testing a limited subset of genes may optimize yield-to-noise of genetic testing, particularly for racial/ethnic minorities.
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Affiliation(s)
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Berlin NL, Momoh AO, Abrahamse P, Katz SJ, Jagsi R, Hawley ST. Financial and employment toxicity related to breast reconstruction following mastectomy in a diverse population-based cohort. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
78 Background: Despite mandated private insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed onto women who seek these procedures through cost-sharing arrangements and high-deductible health plans. In this population-based study, we sought to characterize financial and employment toxicities related to pursuing breast reconstruction following mastectomy. Methods: Women (white, African American, and Latina-English and Spanish speaking) with early stage breast cancer (stages 0-II) diagnosed between July 2013 to September 2014 and who underwent mastectomy were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries and surveyed. Primary outcome measures included patient-reported appraisal of financial toxicity and employment status following breast cancer treatment using previously developed measures. Multivariable models evaluated the association between breast reconstruction and self-reported financial and employment status. Results: Among 868 breast cancer patients who underwent mastectomy, 43.5% (n = 378) did not undergo breast reconstruction and 56.5% (n = 490) underwent reconstruction. 43.4% of the cohort reported being worse off financially since their diagnosis (49.4% with reconstruction vs. 35.0% without reconstruction, P< .001). Among women who were employed at time of breast cancer diagnosis (n = 535), 70.2% who underwent reconstruction reported being worse off regarding employment status compared to 51.1% who did not undergo reconstruction ( P< .001). Receipt of reconstruction was independently associated with a self-reported decline in financial status (Odds Ratio (OR) 2.1, 95% Confidence Interval (CI) 1.4-3.4, P= .001). Similarly, reports of being worse off regarding employment status were also higher in those who underwent reconstruction vs. not (OR 2.2, 95% CI 1.2-3.8, P= .006). Spanish-speaking Latina women more often reported being worse off regarding employment status (OR 4.3, 95% CI 2.1-9.0, P< .001) than white women. Conclusions: In this diverse cohort of women who underwent mastectomy for early stage breast cancer, women who elected to undergo reconstruction experienced more self-reported financial and employment toxicities. Patients should be counseled regarding the potential costs related to these procedures. Policy-makers should be aware of the financial barriers for women who undergo reconstruction despite mandatory insurance coverage in the United States.
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Wallner LP, Abrahamse P, Radhakrishnan A, An LC, Griggs JJ, Schott AF, Ayanian J, Sales A, Katz SJ, Hawley ST. Improving the delivery of team-based survivorship care after primary breast cancer treatment through a multi-level intervention. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7056 Background: The delivery of team-based survivorship care after primary cancer treatment remains challenging, in part due to a lack of effective interventions. We developed a multi-level intervention for breast cancer patients and their primary care and medical oncology providers to improve the delivery of team-based survivorship care called ConnectedCancerCare (CCC). CCC includes a patient-facing, personalized mobile website, and tailored feedback letters to providers. Methods: We conducted a pilot randomized controlled trial in a breast oncology clinic to establish the feasibility and acceptability of CCC. Women within one year of completing primary treatment for stages 0-II breast cancer were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed online surveys at baseline and 3 months, ascertaining their knowledge about PCP roles in their survivorship care, their communication with their PCP about team-based care, and whether they scheduled a follow-up visit with their PCP. Multiple measures of acceptability were collected among women in the intervention arm (n = 28). Qualitative interviews were conducted at the completion of the study with 5 PCPs, 6 oncology providers, and 10 intervention patients to identify barriers and facilitators to implementing CCC. Results: Among 160 eligible women invited to participate, 66 women completed the baseline survey and were randomized (41% participation rate), and 54 completed the 3-month follow-up survey (83% response rate). Women in the intervention arm found the content of the CCC website to be highly acceptable, with 82% reporting it was easy to use, and 86% reporting they would recommend it to other patients. A greater proportion of women randomized to CCC (vs. control) reported scheduling a PCP follow-up visit (64% vs. 42%) and communicating with their PCP about provider roles (67% vs. 18%). Women in the CCC arm also reported higher mean knowledge scores regarding team-based cancer care (3.7 vs. 3.4). Providers noted challenges to implementing CCC, including integration into electronic medical records, and supporting sustained engagement with CCC over time. Conclusions: Our findings suggest deploying CCC in medical oncology practices is feasible, and the intervention content is acceptable among breast cancer patients. CCC shows promise for improving understanding and communication about provider roles in survivorship care, and facilitating patients to follow up with their PCP early in the survivorship period. Clinical trial information: NCT03618017 .
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Kurian AW, Ward KC, Abrahamse P, Hamilton AS, Deapen D, Morrow M, Jagsi R, Katz SJ. Association of Germline Genetic Testing Results With Locoregional and Systemic Therapy in Patients With Breast Cancer. JAMA Oncol 2020; 6:e196400. [PMID: 32027353 PMCID: PMC7042883 DOI: 10.1001/jamaoncol.2019.6400] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/07/2019] [Indexed: 12/14/2022]
Abstract
Importance The increasing use of germline genetic testing may have unintended consequences on treatment. Little is known about how women with pathogenic variants in cancer susceptibility genes are treated for breast cancer. Objective To determine the association of germline genetic testing results with locoregional and systemic therapy use in women diagnosed with breast cancer. Design, Setting, and Participants For this population-based cohort study, data from women aged 20 years or older who were diagnosed with stages 0 to III breast cancer between 2014 and 2016 were accrued from the Surveillance, Epidemiology and End Results (SEER) registries of Georgia and California. The women underwent genetic testing within 3 months after diagnosis and were reported to the Georgia and California SEER registries by December 1, 2017. Exposures Pathogenic variant status based on linked results of clinical germline genetic testing by 4 laboratories that did most such testing in the studied regions. Main Outcomes and Measures Potential deviation of treatment from practice guidelines was assessed in the following clinical scenarios: (1) surgery: receipt of bilateral mastectomy by women eligible for less extensive unilateral surgery (unilateral breast tumor); (2) radiotherapy: omission in women indicated for postlumpectomy radiotherapy (all lumpectomy recipients except age ≥70 with stage I, estrogen and/or progesterone receptor [ER/PR] positive, ERBB2 [formerly HER2]-negative disease); and (3) chemotherapy: receipt by women eligible to consider chemotherapy omission (stages I-II, ER/PR-positive, ERBB2-negative, and 21-gene recurrence score of 0-30, which was the upper limit of the intermediate risk range during the study years). The adjusted percentage treated and adjusted odds ratio (OR) are reported based on multivariable modeling for each treatment-eligible group. Results A total of 20 568 women (17.3%) of 119 198 were eligible (mean [SD] age, 51.4 [12.2]). Compared with women whose test results were negative, those with BRCA1/2 pathogenic variants were more likely to receive bilateral mastectomy for a unilateral tumor (61.7% vs 24.3%; OR, 5.52, 95% CI, 4.73-6.44), less likely to receive postlumpectomy radiotherapy (50.2% vs 81.5%; OR, 0.22, 95% CI, 0.15-0.32), and more likely to receive chemotherapy for early-stage, ER/PR-positive disease (38.0% vs 30.3%; OR, 1.76, 95% CI, 1.31-2.34). Similar patterns were seen with pathogenic variants in other breast cancer-associated genes (ATM, CDH1, CHEK2, NBN, NF1, PALB2, PTEN, and TP53) but not with variants of uncertain significance. Conclusions and Relevance Women with pathogenic variants in BRCA1/2 and other breast cancer-associated genes were found to have distinct patterns of breast cancer treatment; these may be less concordant with practice guidelines, particularly for radiotherapy and chemotherapy.
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Affiliation(s)
- Allison W. Kurian
- Department of Medicine, Stanford University, Stanford, California
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Paul Abrahamse
- Department of Medicine, University of Michigan School of Public Health, Ann Arbor
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor
| | - Ann S. Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Dennis Deapen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Monica Morrow
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Steven J. Katz
- Department of Medicine, University of Michigan School of Public Health, Ann Arbor
- Department of Health Management & Policy, University of Michigan School of Public Health, Ann Arbor
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Momoh AO, Griffith KA, Hawley ST, Morrow M, Ward KC, Hamilton AS, Shumway D, Katz SJ, Jagsi R. Postmastectomy Breast Reconstruction: Exploring Plastic Surgeon Practice Patterns and Perspectives. Plast Reconstr Surg 2020; 145:865-876. [PMID: 32221191 PMCID: PMC8099170 DOI: 10.1097/prs.0000000000006627] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Within the multidisciplinary management of breast cancer, variations exist in the reconstructive options offered and care provided. The authors evaluated plastic surgeon perspectives on important issues related to breast cancer management and reconstruction and provide some insight into factors that influence these perspectives. METHODS Women diagnosed with early-stage breast cancer (stages 0 to II) between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries. These women were surveyed and identified their treating plastic surgeons. Surveys were sent to the identified plastic surgeons to collect data on specific reconstruction practices. RESULTS Responses from 134 plastic surgeons (74.4 percent response rate) were received. Immediate reconstruction (79.7 percent) was the most common approach to timing, and expander/implant reconstruction (72.6 percent) was the most common technique reported. Nearly one-third of respondents (32.1 percent) reported that reimbursement influenced the proportion of autologous reconstructions performed. Most (82.8 percent) reported that discussions about contralateral prophylactic mastectomy were initiated by patients. Most surgeons (81.3 to 84.3 percent) felt that good symmetry is achieved with unilateral autologous reconstruction with contralateral symmetry procedures in patients with small or large breasts; a less pronounced majority (62.7 percent) favored unilateral implant reconstructions in patients with large breasts. In patients requiring postmastectomy radiation therapy, one-fourth of the surgeons (27.6 percent) reported that they seldom recommend delayed reconstruction, and 64.9 percent reported recommending immediate expander/implant reconstruction. CONCLUSIONS Reconstructive practices in a modern cohort of plastic surgeons suggest that immediate and implant reconstructions are performed preferentially. Respondents perceived a number of factors, including surgeon training, time spent in the operating room, and insurance reimbursement, to negatively influence the performance of autologous reconstruction.
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Affiliation(s)
- Adeyiza O Momoh
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Kent A Griffith
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Sarah T Hawley
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Monica Morrow
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Kevin C Ward
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Ann S Hamilton
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Dean Shumway
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Steven J Katz
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Reshma Jagsi
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Steven J Katz
- Departments of Health Management and Policy, School of Public Health, and Internal Medicine, University of Michigan, Ann Arbor, MI
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Kurian AW, Abrahamse P, Ward K, Hamilton AS, Deapen D, Shak S, Katz SJ. Abstract P6-08-02: 21-gene recurrence score results according to germline pathogenic variants in BRCA1, BRCA2, PALB2, ATM, CHEK2 and Lynch Syndrome genes. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p6-08-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
BACKGROUND: Women diagnosed with breast cancer increasingly undergo multiplex sequencing of germline cancer susceptibility genes. Little is known about cancer prognosis and predicted chemotherapy benefit, which are measured from the tumor by the 21-gene recurrence score (21G), according to germline pathogenic variants (PVs) in BRCA1/2 and other commonly sequenced genes.
METHODS: Surveillance Epidemiology and End Results (SEER) data for all women aged 20 years and older, diagnosed with breast cancer in 2013-2016 and reported to Georgia and California statewide SEER registries (N=158,480) by December 1, 2017 were linked to germline genetic testing results from four laboratories that performed nearly all clinical testing. 21G results were obtained from SEER and the testing laboratory. We examined 21G among all patients who were eligible for 21G testing (estrogen receptor (ER) and/or progesterone receptor (PR)-positive, HER2-negative, T stage 1-2, N stage 0-1), N=84,128. We report the median 21G score according to germline testing results, with multivariable modeling adjusting for age, tumor size, grade and lymph node involvement.
RESULTS: 23,508 patients eligible for 21G testing linked to a recurrence score result (27.9%) of whom 6,951 (29.7%) had germline testing. Mean 21G score was slightly higher in women diagnosed at age less than 50 years (18.0, 95% confidence interval (CI) 17.8-18.3) versus at age 50 years and older (17.0, CI 16.9-17.1). 402 women had a PV in BRCA1, BRCA2, CHEK2, ATM, PALB2 or the Lynch Syndrome genes (MLH1, MSH2, MSH6, PMS2). The table shows mean 21G scores by PV, which were highest for BRCA1 (33.6) followed by PALB2 (24.1) and BRCA2 (23.2), compared to women who had a negative germline test (17.3) or no germline test (17.0). The proportion of patients with a high 21G score (26-100, a range for which chemotherapy is indicated) was increased with PVs in BRCA1 (63.2% versus 14.6% with a negative germline test, p<0.001), PALB2 (36.7%, p=0.01), and BRCA2 (35.4%, p<0.001). In a multivariable model controlling for clinical factors, BRCA1 PV (beta coefficient=11.9, CI 7.6-15.5) and PALB2 PV (beta coefficient=4.7, CI 0.6 - 8.9) were independently associated with 21G score.
CONCLUSIONS: BRCA1/2 and PALB2 PVs are associated with higher 21G scores (mean 23-34), while ATM, CHEK2 and Lynch Syndrome gene PVs are not associated with substantially higher 21G scores than in women testing negative or untested (mean 17-18). These results can inform decision-making about 21G testing and chemotherapy use among breast cancer patients who carry PVs in commonly tested cancer susceptibility genes.
Table. 21 gene recurrence (21G) score according to germline genetic testing resultsGermline genetic testing resultsNMean 21G score95% confidence interval21G score 26-100, %P-value, % 21G score 26-100BRCA1 pathogenic variant (PV)5733.629.1-38.163.2%<0.001PALB2 PV3024.120.6-27.736.7%0.001BRCA2 PV16423.221.7-24.835.4%<0.001ATM PV4519.917.5-22.420.0%0.398Lynch Syndrome PV (MLH1, MSH2, MSH6, PMS2)2319.413.9-24.821.7%0.404CHEK2 PV9119.017.5-20.514.3%0.757Variant of uncertain significance in any gene97817.917.2-18.616.6%0.093Negative5,49517.317.1-17.614.6%ReferenceNo germline genetic test16,55717.016.8-17.115.3%0.209
Citation Format: Allison W Kurian, Paul Abrahamse, Kevin Ward, Ann S. Hamilton, Dennis Deapen, Steven Shak, Steven J. Katz. 21-gene recurrence score results according to germline pathogenic variants in BRCA1, BRCA2, PALB2, ATM, CHEK2 and Lynch Syndrome genes [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-08-02.
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Abstract
Importance The American College of Surgeons Oncology Group (ACOSOG) Z0011 study demonstrated the safety of sentinel node biopsy alone in clinically node-negative women with metastases in 1 or 2 sentinel nodes treated with breast conservation. Little is known about surgeon perspectives regarding when axillary lymph node dissection (ALND) can be omitted. Objectives To determine surgeon acceptance of ACOSOG Z0011 findings, identify characteristics associated with acceptance of ACOSOG Z0011 results, and examine the association between acceptance of the Society of Surgical Oncology and American Society for Radiation Oncology negative margin of no ink on tumor and surgeon preference for ALND. Design, Setting, and Participants A survey was sent to 488 surgeons treating a population-based sample of women with early-stage breast cancer (N = 5080). The study was conducted from July 1, 2013, to August 31, 2015. Main Outcomes and Measures Surgeons were categorized as having low, intermediate, or high propensity for ALND according to the outer quartiles of ALND scale distribution. A multivariable linear regression model was used to confirm independent associations. Results Of the 488 surgeons invited to participate, 376 (77.0%) responded and 359 provided complete information regarding propensity for ALND derived from 5 clinical scenarios. Mean surgeon age was 53.7 (range, 31-80) years; 277 (73.7%) were male; 142 (37.8%) treated 20 or fewer breast cancers annually and 108 (28.7%) treated more than 50. One hundred seventy-five (49.0%) recommended ALND for 1 macrometastasis. Of low-propensity surgeons who recommended ALND, only 1 (1.1%) approved ALND for any nodal metastases compared with 69 (38.6%) and 85 (95.5%) of selective and high-propensity surgeons (P < .001), respectively. In multivariable analysis, lower ALND propensity was significantly associated with higher breast cancer volume (21-50: -0.19; 95% CI, -0.39 to 0.02; >51: -0.48; 95% CI, -0.71 to -0.24; P < .001), recommendation of a minimal margin width (1-5 mm: -0.10; 95% CI, -0.43 to 0.22; no ink on tumor: -0.53; 95% CI, -0.82 to -0.24; P < .001), participation in a multidisciplinary tumor board (1%-9%: -0.25; 95% CI, -0.55 to 0.05; >9%: -0.37; 95% CI, -0.63 to -0.11; P = .02), and Los Angeles Surveillance, Epidemiology, and End Results site (-0.18; 95% CI, -0.35 to -0.01; P = .04). Conclusions and Relevance This study shows substantial variation in surgeon acceptance of more limited surgery for breast cancer, which is associated with higher breast cancer volume and multidisciplinary interactions, suggesting the potential for overtreatment of many patients and the need for education targeting lower-volume breast surgeons.
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Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - M Chandler McLeod
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Dean Shumway
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
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Katz SJ, Bondarenko I, Ward KC, Hamilton AS, Morrow M, Kurian AW, Hofer TP. Association of Attending Surgeon With Variation in the Receipt of Genetic Testing After Diagnosis of Breast Cancer. JAMA Surg 2019; 153:909-916. [PMID: 29971344 DOI: 10.1001/jamasurg.2018.2001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Genetic testing after diagnosis of breast cancer is common, but little is known about the influence of the surgeon on the variation in testing. Objectives To quantify and explain the association of attending surgeon with rates of genetic testing after diagnosis of breast cancer. Design, Setting, and Participants This population-based study identified 7810 women with stages 0 to II breast cancer treated between July 1, 2013, and August 31, 2015, through the Surveillance, Epidemiology, and End Results registries for the state of Georgia, as well as Los Angeles County, California. Surveys were sent approximately 2 months after surgery. Also surveyed were 488 attending surgeons identified by the patients. Main Outcomes and Measures The study examined the association of surgeon with variation in the receipt of genetic testing using information from patient and surgeon surveys merged to Surveillance, Epidemiology, and End Results and genetic testing data obtained from 4 laboratories. Results In total, 5080 women (69.6%) of 7303 who were eligible (mean [SD] age, 61.4 [0.8] years) and 377 surgeons (77.3%) of 488 (mean [SD] age, 53.8 [10.7] years) responded to the survey. Approximately one-third (34.5% [1350 of 3910] of patients had an elevated risk of mutation carriage, and 27.0% (1056 of 3910) overall had genetic testing. Surgeons had practiced a mean (SE) of 20.9 (0.6) years, and 28.9% (107 of 370) treated more than 50 cases of new breast cancer per year. The odds of a patient receiving genetic testing increased more than 2-fold (odds ratio, 2.48; 95% CI, 1.85-3.31) if she saw a surgeon with an approach 1 SD above that of a surgeon with the mean test rate. Approximately one-third (34.1%) of the surgeon variation was explained by patient volume and surgeon attitudes about genetic testing and counseling. If a patient with higher pretest risk saw a surgeon at the 5th percentile of the surgeon distribution, she would have a 26.3% (95% CI, 21.9%-31.2%) probability of testing compared with 72.3% (95% CI, 66.7%-77.2%) if she saw a surgeon at the 95th percentile. Conclusions and Relevance In this study, the attending surgeon was associated with the receipt of genetic testing after a breast cancer diagnosis. Variation in surgeon attitudes about genetic testing and counseling may explain a substantial amount of this association.
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Affiliation(s)
- Steven J Katz
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
| | - Irina Bondarenko
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Kevin C Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Keck School of Medicine, University of Southern California, Los Angeles
| | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Allison W Kurian
- Department of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University, Stanford, California
| | - Timothy P Hofer
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
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Kurian AW, Ward KC, Hamilton AS, Deapen DM, Abrahamse P, Bondarenko I, Li Y, Hawley ST, Morrow M, Jagsi R, Katz SJ. Uptake, Results, and Outcomes of Germline Multiple-Gene Sequencing After Diagnosis of Breast Cancer. JAMA Oncol 2019; 4:1066-1072. [PMID: 29801090 DOI: 10.1001/jamaoncol.2018.0644] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Low-cost sequencing of multiple genes is increasingly available for cancer risk assessment. Little is known about uptake or outcomes of multiple-gene sequencing after breast cancer diagnosis in community practice. Objective To examine the effect of multiple-gene sequencing on the experience and treatment outcomes for patients with breast cancer. Design, Setting, and Participants For this population-based retrospective cohort study, patients with breast cancer diagnosed from January 2013 to December 2015 and accrued from SEER registries across Georgia and in Los Angeles, California, were surveyed (n = 5080, response rate = 70%). Responses were merged with SEER data and results of clinical genetic tests, either BRCA1 and BRCA2 (BRCA1/2) sequencing only or including additional other genes (multiple-gene sequencing), provided by 4 laboratories. Main Outcomes and Measures Type of testing (multiple-gene sequencing vs BRCA1/2-only sequencing), test results (negative, variant of unknown significance, or pathogenic variant), patient experiences with testing (timing of testing, who discussed results), and treatment (strength of patient consideration of, and surgeon recommendation for, prophylactic mastectomy), and prophylactic mastectomy receipt. We defined a patient subgroup with higher pretest risk of carrying a pathogenic variant according to practice guidelines. Results Among 5026 patients (mean [SD] age, 59.9 [10.7] years), 1316 (26.2%) were linked to genetic results from any laboratory. Multiple-gene sequencing increasingly replaced BRCA1/2-only testing over time: in 2013, the rate of multiple-gene sequencing was 25.6% and BRCA1/2-only testing, 74.4%; in 2015 the rate of multiple-gene sequencing was 66.5% and BRCA1/2-only testing, 33.5%. Multiple-gene sequencing was more often ordered by genetic counselors (multiple-gene sequencing, 25.5% and BRCA1/2-only testing, 15.3%) and delayed until after surgery (multiple-gene sequencing, 32.5% and BRCA1/2-only testing, 19.9%). Multiple-gene sequencing substantially increased rate of detection of any pathogenic variant (multiple-gene sequencing: higher-risk patients, 12%; average-risk patients, 4.2% and BRCA1/2-only testing: higher-risk patients, 7.8%; average-risk patients, 2.2%) and variants of uncertain significance, especially in minorities (multiple-gene sequencing: white patients, 23.7%; black patients, 44.5%; and Asian patients, 50.9% and BRCA1/2-only testing: white patients, 2.2%; black patients, 5.6%; and Asian patients, 0%). Multiple-gene sequencing was not associated with an increase in the rate of prophylactic mastectomy use, which was highest with pathogenic variants in BRCA1/2 (BRCA1/2, 79.0%; other pathogenic variant, 37.6%; variant of uncertain significance, 30.2%; negative, 35.3%). Conclusions and Relevance Multiple-gene sequencing rapidly replaced BRCA1/2-only testing for patients with breast cancer in the community and enabled 2-fold higher detection of clinically relevant pathogenic variants without an associated increase in prophylactic mastectomy. However, important targets for improvement in the clinical utility of multiple-gene sequencing include postsurgical delay and racial/ethnic disparity in variants of uncertain significance.
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Affiliation(s)
- Allison W Kurian
- Departments of Medicine and Health Research and Policy, Stanford University, Stanford, California
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Department of Preventive Medicine in the Keck School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Dennis M Deapen
- Department of Preventive Medicine in the Keck School of Medicine, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Abrahamse
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Irina Bondarenko
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
| | - Sarah T Hawley
- Department of Internal Medicine, Division of General Medicine, Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, and Veterans Administration Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor
| | - Monica Morrow
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, New York, New York
| | - Reshma Jagsi
- Center for Bioethics and Social Science in Medicine, Oncology, Department of Radiation, University of Michigan, Ann Arbor
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Wallner LP, Abrahamse P, Radhakrishnan A, Hamilton AS, Ward KC, Hawley ST, Katz SJ. Primary care providers propensity to order non-recommended surveillance testing after curative breast cancer treatment. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
52 Background: Team-based cancer care models promote primary care providers taking on a larger role in survivorship care. However, little is known about PCP attitudes toward and propensity to order non-recommended surveillance testing. Methods: A stratified random sample of PCPs identified by early-stage breast cancer patients diagnosed in 2013-15 who participated in iCanCare Study (Georgia and Los Angeles SEER registries) were surveyed about their experiences caring for cancer patients (N = 519, 58% response rate). PCPs were asked in a clinical vignette whether they would order non-recommended bone scans, other imaging (i.e. PET) or tumor marker testing (i.e. CA-125) in an asymptomatic, early-stage breast cancer survivor. A composite score was created by averaging their responses to the individual items, and categorized by tertiles into low, selective and high propensity to order non-recommended testing. PCP confidence in their knowledge about appropriate testing was also measured (5 pt. Likert-type scale; not all all-very confident) and compared with propensity to order. Multivariable, weighted, multinomial logistic regression was used to then evaluate PCP-reported factors associated with high and selective propensity to order non-recommended testing (vs. low). Results: In this sample, 32% of PCPs had a low propensity, 40% selective, and 28% a high propensity to order non-recommended surveillance tests. Of the 80% of PCPs who reported they were confident in their knowledge about appropriate testing, 27% had a high propensity to order. PCPs practicing in staff-model HMOs were less likely to have a high or selective propensity to order (vs. low) when compared to PCPs in private practice. (high aOR: 0.4, 95%CI: 0.2-0.7; selective aOR: 0.3, 95%CI: 0.2-0.6). Conclusions: Over a quarter of PCPs had a high propensity to order non-recommended surveillance testing for early-stage breast cancer patients, yet the majority reported they were confident in their knowledge about appropriate surveillance testing. Efforts to increase PCP knowledge about the specifics of breast cancer surveillance may be warranted to reduce the overuse of non-recommended testing during survivorship.
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Affiliation(s)
| | | | | | - Ann S. Hamilton
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Katz SJ, Morrow M, Kurian AW. Adherence to breast cancer treatment guidelines according to pathogenic variants in cancer susceptibility genes in a population-based cohort. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.27_suppl.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
34 Background: Increasing use of germline genetic testing may have unintended consequences on breast cancer treatment. We do not know whether treatment deviates from guidelines for women with pathogenic variants (PV) in cancer susceptibility genes. Methods: SEER data for all women aged ≥20 years, diagnosed with breast cancer in 2014-15 and reported to Georgia and California registries (N=77,588) by December 1, 2016 were linked to germline genetic testing results from 4 laboratories that did nearly all clinical testing. We examined first course of therapy of stage <IV patients who linked to a genetic test: bilateral mastectomy (BLM) in candidates for surgery (unilateral, stages 0-III); post-lumpectomy radiation in those with an indication (all but age ≥70, stage I, hormone receptor (HR)-positive and HER2-negative); and chemotherapy in those without definitive indication (stage I-II, HR-positive, HER2-negative and 21-gene recurrence score <30). We report the percent treated based on multivariable modeling, adjusted for age, race, stage, grade, insurance and socioeconomic status. Results: The table shows that 9% of patients who linked to a genetic test result had a PV (N=1,283). Compared to women with negative results, those with BRCA1/2 PVs were more likely to receive BLM, more likely to receive chemotherapy without definitive indication, and less likely to receive indicated radiation as initial treatment. Lower-magnitude effects were seen with other PVs but not variants of uncertain significance (VUS). Conclusions: In a population-based setting, women with PVs in BRCA1/2 or other cancer susceptibility genes may have higher risk of receiving locoregional and systemic treatment that does not follow guidelines. [Table: see text]
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Affiliation(s)
| | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, NY
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Momoh AO, Griffith KA, Hawley ST, Morrow M, Ward KC, Hamilton AS, Shumway D, Katz SJ, Jagsi R. Patterns and Correlates of Knowledge, Communication, and Receipt of Breast Reconstruction in a Modern Population-Based Cohort of Patients with Breast Cancer. Plast Reconstr Surg 2019; 144:303-313. [PMID: 31348333 PMCID: PMC6662624 DOI: 10.1097/prs.0000000000005803] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Disparities persist in the receipt of breast reconstruction after mastectomy, and little is known about the nature of communication received by patients and potential variations that may exist. METHODS Women with early-stage breast cancer (stages 0 to II) diagnosed between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries and surveyed to collect additional data on demographics, treatment, and decision-making experiences. Treating general/oncologic surgeons were also surveyed. Primary outcomes measures included self-reported communication-related measures on receipt of information on breast reconstruction and on the receipt of breast reconstruction. RESULTS The authors analyzed 936 women who underwent mastectomy for unilateral breast cancer. Four hundred eighty-four (51.7 percent) underwent mastectomy with reconstruction. Women who were older and for whom English was not their primary spoken language had lower odds of being informed by a doctor about breast reconstruction. Ultimately, women who were older, were Asian, had invasive disease, had bronchitis/emphysema, and had lower income were less likely to undergo breast reconstruction. Breast reconstruction was performed more often in patients undergoing bilateral mastectomies (OR, 3.27; 95 percent CI, 2.26 to 4.75). Women cared for by surgeons with higher volumes of breast cancer patients (≥51 patients per year) were more likely to undergo breast reconstruction (OR, 2.43; 95 percent CI, 1.40 to 4.20). CONCLUSION To eliminate existing disparities, increased efforts should be made in consultations for surgical management of breast cancer to provide information to all patients regarding the option of breast reconstruction, the possibility of immediate reconstruction, and insurance coverage of all stages of reconstruction.
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Affiliation(s)
- Adeyiza O Momoh
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Kent A Griffith
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Sarah T Hawley
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Monica Morrow
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Kevin C Ward
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Ann S Hamilton
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Dean Shumway
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Steven J Katz
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Reshma Jagsi
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, and the Department of Internal Medicine, Department of Health Management and Policy, University of Michigan; the Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Rollins School of Public Health, Emory University; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
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Wallner LP, Li Y, McLeod MC, Gargaro J, Kurian AW, Jagsi R, Radhakrishnan A, Hamilton AS, Ward KC, Hawley ST, Katz SJ. Primary care provider-reported involvement in breast cancer treatment decisions. Cancer 2019; 125:1815-1822. [PMID: 30707773 PMCID: PMC6509002 DOI: 10.1002/cncr.31998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/14/2018] [Accepted: 12/24/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Treatment decisions for patients with early-stage breast cancer often involve discussions with multiple oncology providers. However, the extent to which primary care providers (PCPs) are involved in initial treatment decisions remains unknown. METHODS A stratified random sample of PCPs identified by newly diagnosed patients with early-stage breast cancer from the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries were surveyed (n = 517; a 61% response rate). PCPs were asked how frequently they discussed surgery, radiation, and chemotherapy options with patients; how comfortable they were with these discussions; whether they had the necessary knowledge to participate in decision making; and what their confidence was in their ability to help (on 5-item Likert-type scales). Multivariate logistic regression was used to identify PCP-reported attitudes associated with more PCP participation in each treatment decision. RESULTS In this sample, 34% of PCPs reported that they discussed surgery, 23% discussed radiation, and 22% discussed chemotherapy options with their patients. Of those who reported more involvement in surgical decisions, 22% reported that they were not comfortable having a discussion, and 17% did not feel that they had the necessary knowledge to participate in treatment decision making. PCPs who positively appraised their ability to participate were more likely to participate in all 3 decisions (odds ratio [OR] for surgery, 6.01; 95% confidence interval [CI], 4.16-8.68; OR for radiation, 8.37; 95% CI, 5.16-13.58; OR for chemotherapy, 6.56; 95% CI, 4.23-10.17). CONCLUSIONS A third of PCPs reported participating in breast cancer treatment decisions, yet gaps in their knowledge about decision making and in their confidence in their ability to help exist. Efforts to increase PCPs' knowledge about breast cancer treatment options may be warranted.
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Affiliation(s)
- Lauren P. Wallner
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States
- University of Michigan, Department of Epidemiology
| | - Yun Li
- University of Michigan, Department of Biostatistics
| | | | - Joan Gargaro
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States
| | - Allison W. Kurian
- Stanford University, Departments of Medicine and Health Research & Policy
| | - Reshma Jagsi
- University of Michigan, Department of Radiation Oncology and Center for Bioethics and Social Sciences in Medicine
| | - Archana Radhakrishnan
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States
| | - Ann S. Hamilton
- University of Southern California Keck School of Medicine, Department of Preventive Medicine
| | - Kevin C. Ward
- Emory University Rollins School of Public Health, Department of Epidemiology
| | - Sarah T. Hawley
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States
- University of Michigan School of Public Health, Department of Health Management and Policy
- University of Michigan School of Public Health, Department of Health Behavior and Education
| | - Steven J. Katz
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States
- University of Michigan School of Public Health, Department of Health Management and Policy
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Kurian AW, Ward KC, Abrahamse P, Hamilton AS, Deapen D, Morrow M, Katz SJ. Breast cancer treatment according to pathogenic variants in cancer susceptibility genes in a population-based cohort. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
560 Background: Increasing use of germline genetic testing may have unintended consequences on breast cancer treatment. We do not know whether treatment deviates from guidelines for women with pathogenic variants (PV) in cancer susceptibility genes. Methods: SEER data for all women aged ≥20 years, diagnosed with breast cancer in 2014-15 and reported to Georgia and California registries (N = 77,588) by December 1, 2016 were linked to germline genetic testing results from 4 laboratories that did nearly all clinical testing. We examined first course of therapy (before recurrence or progression) of stage < IV patients who linked to a genetic test: bilateral mastectomy (BLM) in candidates for surgery (unilateral, stages 0-III); post-lumpectomy radiation in those with an indication (all but age ≥70, stage I, hormone receptor (HR)-positive and HER2-negative); and chemotherapy in those without a definitive indication (stage I-II, HR-positive, HER2-negative and 21-gene recurrence score < 30). We report the percent treated based on multivariable modeling, adjusted for age, race, stage, grade, insurance and socioeconomic status. Results: The table shows that 9% of patients who linked to a genetic test result had a PV (N = 1,283). Compared to women with negative results,women with BRCA1/2 PVs were more likely to receive BLM, more likely to receive chemotherapy without definitive indication, and less likely to receive indicated radiation in their first course of therapy. Lower-magnitude effects were seen with other PVs but not variants of uncertain significance (VUS). Conclusions: In a population-based setting, women with PVs in BRCA1/2 or other cancer susceptibility genes may have a higher risk of receiving locoregional and systemic treatment that does not follow guidelines. [Table: see text]
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Affiliation(s)
| | | | | | | | | | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, NY
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Kurian AW, Ward KC, Howlader N, Deapen D, Hamilton AS, Mariotto A, Miller D, Penberthy LS, Katz SJ. Genetic Testing and Results in a Population-Based Cohort of Breast Cancer Patients and Ovarian Cancer Patients. J Clin Oncol 2019; 37:1305-1315. [PMID: 30964716 PMCID: PMC6524988 DOI: 10.1200/jco.18.01854] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 01/18/2023] Open
Abstract
PURPOSE Genetic testing for cancer risk has expanded rapidly. We examined clinical genetic testing and results among population-based patients with breast and ovarian cancer. METHODS The study included all women 20 years of age or older diagnosed with breast or ovarian cancer in California and Georgia between 2013 and 2014 and reported to the SEER registries covering the entire state populations. SEER data were linked to results from four laboratories that performed nearly all germline cancer genetic testing. Testing use and results were analyzed at the gene level. RESULTS There were 77,085 patients with breast cancer and 6,001 with ovarian cancer. Nearly one quarter of those with breast cancer (24.1%) and one third of those with ovarian cancer (30.9%) had genetic test results. Among patients with ovarian cancer, testing was lower in blacks (21.6%; 95% CI, 18.1% to 25.4%; v whites, 33.8%; 95% CI, 32.3% to 35.3%) and uninsured patients (20.8%; 95% CI, 15.5% to 26.9%; v insured patients, 35.3%; 95% CI, 33.8% to 36.9%). Prevalent pathogenic variants in patients with breast cancer were BRCA1 (3.2%), BRCA2 (3.1%), CHEK 2 (1.6%), PALB2 (1.0%), ATM (0.7%), and NBN (0.4%); in patients with ovarian cancer, prevalent pathogenic variants were BRCA1 (8.7%), BRCA2 (5.8%), CHEK2 (1.4%), BRIP1 (0.9%), MSH2 (0.8%), and ATM (0.6%). Racial/ethnic differences in pathogenic variants included BRCA1 (ovarian cancer: whites, 7.2%; 95% CI, 5.9% to 8.8%; v Hispanics, 16.1%; 95% CI, 11.8% to 21.2%) and CHEK2 (breast cancer: whites, 2.3%; 95% CI, 1.8% to 2.8%; v blacks, 0.1%; 95% CI, 0% to 0.8%). When tested for all genes that current guidelines designate as associated with their cancer type, 7.8% of patients with breast cancer and 14.5% of patients with ovarian cancer had pathogenic variants. CONCLUSION Clinically-tested patients with breast and ovarian cancer in two large, diverse states had 8% to 15% prevalence of actionable pathogenic variants. Substantial testing gaps and disparities among patients with ovarian cancer are targets for improvement.
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Veenstra CM, Wallner LP, Abrahamse P, Janz NK, Katz SJ, Hawley ST. Understanding the engagement of key decision support persons in patient decision making around breast cancer treatment. Cancer 2019; 125:1709-1716. [PMID: 30633326 PMCID: PMC6486440 DOI: 10.1002/cncr.31956] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/20/2018] [Accepted: 11/29/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with breast cancer involve multiple decision support persons (DSPs) in treatment decision making, yet little is known about DSP engagement in decision making and its association with patient appraisal of the decision process. METHODS Patients newly diagnosed with breast cancer reported to Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries in 2014-2015 were surveyed 7 months after their diagnosis. The individual most involved in each respondent's decision making (the key DSP) was surveyed. DSP engagement was measured across 3 domains: 1) informed about decisions, 2) involved in decisions, and 3) aware of patient preferences. Patient decision appraisal included subjective decision quality (SDQ) and deliberation. This study evaluated bivariate associations with chi-square tests between domains of DSP engagement and independent DSP variables. Analysis of variance and multivariable logistic regression were used to compare domains of DSP engagement with patient decision appraisal. RESULTS In all, 2502 patients (68% response rate) and 1203 eligible DSPs (70% response rate) responded. Most DSPs were husbands/partners or daughters, were white, and were college graduates. Husbands/partners were more likely to be more informed, involved, and aware (all P values < .01). English- and Spanish-speaking Latinos had a higher extent of (P = .02) but lower satisfaction with involvement (P < .01). A highly informed DSP was associated with higher odds of patient-reported SDQ (odds ratio, 1.46; 95% confidence interval, 1.03-2.08; P = .03). A highly aware DSP was associated with higher odds of patient-reported deliberation (odds ratio, 1.83; 95% confidence interval, 1.36-2.47; P < .01). CONCLUSIONS In this population-based study, informal DSPs were engaged with and positively contributed to patients' treatment decision making. To improve decision quality, future interventions should incorporate DSPs.
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Affiliation(s)
- Christine M. Veenstra
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Lauren P. Wallner
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | - Paul Abrahamse
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Nancy K. Janz
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI
| | - Steven J. Katz
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI
| | - Sarah T. Hawley
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI
- Ann Arbor Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
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Morrow M, Jagsi R, Katz SJ. Undissected Axilla and Axillary Radiotherapy-In Reply. JAMA Oncol 2019; 5:742-743. [PMID: 30869742 DOI: 10.1001/jamaoncol.2019.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Steven J Katz
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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Radhakrishnan A, Li Y, Furgal AK, Hamilton AS, Ward KC, Jagsi R, Katz SJ, Hawley ST, Wallner LP. Provider Involvement in Care During Initial Cancer Treatment and Patient Preferences for Provider Roles After Initial Treatment. J Oncol Pract 2019; 15:e328-e337. [PMID: 30856036 PMCID: PMC6550057 DOI: 10.1200/jop.18.00497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Patients report strong preferences regarding which provider-oncologist or primary care provider (PCP)-handles their primary care after initial cancer treatment (eg, other cancer screenings, preventive care, comorbidity management). Little is known about associations between provider involvement during initial cancer treatment and patient preferences for provider roles after initial treatment. METHODS Women who received a diagnosis of early-stage breast cancer in 2014 to 2015 were identified from the Georgia and Los Angeles County SEER registries and surveyed (N = 2,502; 68% response rate). Women reported the level of their providers' involvement in their care during initial cancer treatment. Associations between level of medical oncologist's participation and PCP's engagement during initial cancer treatment and patient preferences for oncologist led ( v PCP led) other cancer screenings after initial treatment were examined using multivariable logistic regression models. RESULTS During their initial cancer treatment, 20% of women reported medical oncologists participated substantially in delivering primary care and 66% reported PCPs were highly engaged in their cancer care. Two-thirds (66%) of women preferred medical oncologists to handle other cancer screenings after initial treatment. Women who reported substantial medical oncologist participation in primary care were more likely (adjusted odds ratio, 1.42; 95% CI, 1.05 to 1.91) and those who reported high PCP engagement in cancer care were less likely (adjusted odds ratio, 0.41; 95% CI, 0.31 to 0.53) to prefer oncologist-led other cancer screenings after initial treatment. CONCLUSIONS Providers' involvement during initial cancer treatment may affect patient preferences regarding provision of follow-up primary care. Clarifying provider roles as early as during cancer treatment may help to better delineate their roles throughout survivorship.
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Affiliation(s)
| | - Yun Li
- University of Michigan, Ann Arbor, MI
| | | | | | | | | | | | - Sarah T. Hawley
- University of Michigan, Ann Arbor, MI
- Ann Arbor VA Center of Excellence in Health Services Research & Development, Ann Arbor, MI
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43
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Katz SJ, Morrow M, Kurian AW. Guidelines Do Not Proscribe Surgeons Performing Genetic Testing-Reply. JAMA Surg 2019; 154:269-270. [PMID: 30540358 DOI: 10.1001/jamasurg.2018.4885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Steven J Katz
- Department of Medicine, University of Michigan, Ann Arbor.,Department of Health Management and Policy, University of Michigan, Ann Arbor
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Comprehensive Cancer Center, New York, New York
| | - Allison W Kurian
- Department of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University, Stanford, California
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44
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Resnicow K, Patel MR, Mcleod MC, Katz SJ, Jagsi R. Physician attitudes about cost consciousness for breast cancer treatment: differences by cancer sub-specialty. Breast Cancer Res Treat 2019; 173:31-36. [PMID: 30259283 PMCID: PMC8968296 DOI: 10.1007/s10549-018-4976-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/20/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE High costs of cancer care place considerable burden on patients and society. Despite increasing recognition that providers should play a role in reducing care costs, how physicians across cancer specialties differ in their cost-consciousness has not been reported. We examined cost-consciousness regarding breast cancer care among medical oncologists, surgeons, and radiation oncologists. METHODS We identified 514 cancer surgeons, 504 medical oncologists, and 251 radiation oncologists by patient report through the iCanCare study. iCanCare identified newly diagnosed women with breast cancer through the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles. We queried providers on three dimensions of cost-consciousness: (1) perceived importance of cost saving for society, patients, practice, and payers; (2) awareness of patient out-of-pocket expenses; and (3) discussion of financial burden. RESULTS We received responses from 376 surgeons (73%), 304 medical oncologists (60%), and 169 radiation oncologists (67%). Overall levels of cost-consciousness were moderate, with scores ranging from 2.5 to 3.0 out of 5. After adjusting for covariates, surgeons had the lowest scores on all three cost-consciousness measures; medical oncologists had the highest scores. Pairwise contrasts showed surgeons had significantly lower scores than medical oncologists for all three measures and significantly lower scores than radiation oncologists for two of the three cost-consciousness variables: importance of cost saving and discussion of financial burden. CONCLUSIONS How cost-consciousness impacts medical decision-making across specialty and how policy, structural, and behavioral interventions might sensitize providers regarding cost-related matters merit further examination.
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Affiliation(s)
- Ken Resnicow
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 109 Observatory, Ann Arbor, MI, 48109, USA.
| | - Minal R Patel
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 109 Observatory, Ann Arbor, MI, 48109, USA
| | - M Chandler Mcleod
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
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Katz SJ, Ward KC, Hamilton AS, Abrahamse P, Hawley ST, Kurian AW. Association of Germline Genetic Test Type and Results With Patient Cancer Worry After Diagnosis of Breast Cancer. JCO Precis Oncol 2018; 2018:PO.18.00225. [PMID: 30656245 PMCID: PMC6333469 DOI: 10.1200/po.18.00225] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND There are concerns that multigene panel testing compared with BRCA1/ 2-only testing after diagnosis of breast cancer may lead to unnecessary patient worry about cancer because of more ambiguous results. METHODS Patients with breast cancer diagnosed from 2013 to 2015 and accrued from SEER registries in Georgia and Los Angeles were surveyed (n = 5,080; response rate, 70%), and responses were merged with SEER data and germline genetic testing and results. We examined patient reports of cancer worry by test type and results in 1,063 women who linked to a genetic test and reported undergoing testing. RESULTS More than half of the sample (n = 640; 60.2%) received BRCA1/2-only testing versus 423 patients (39.8%) who had a multigene panel. A minority of tested patients reported substantial cancer worry after treatment: 11.1% (n = 130) reported higher impact of cancer worry, and 15.1% (n = 162) reported a high frequency of cancer worry (worrying often or almost always) in the past month. Impact of cancer worry did not substantively differ by test type, test result outcomes, or clinical or treatment factors. The odds ratio for higher impact of cancer worry was 0.81 (95% CI, 0.51 to 1.28) for multigene versus BRCA1/2-only testing. In a separate model, the odds ratios were 1.21 (95% CI, 0.54 to 2.68) and 0.90 (95% CI, 0.50 to 1.62) for pathogenic variant and variant of uncertain significance, respectively, versus a negative test (the reference group). CONCLUSION Compared with BRCA1/2 testing alone, multigene panel testing was not associated with increased cancer worry after diagnosis of breast cancer.
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Affiliation(s)
- Steven J. Katz
- Steven J. Katz, Paul Abrahamse, and Sarah T. Hawley, University of Michigan; Sarah T. Hawley, Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; Kevin C. Ward, Emory University, Atlanta, GA; Ann S. Hamilton, University of Southern California, Los Angeles; and Allison W. Kurian, Stanford University, Stanford, CA
| | - Kevin C. Ward
- Steven J. Katz, Paul Abrahamse, and Sarah T. Hawley, University of Michigan; Sarah T. Hawley, Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; Kevin C. Ward, Emory University, Atlanta, GA; Ann S. Hamilton, University of Southern California, Los Angeles; and Allison W. Kurian, Stanford University, Stanford, CA
| | - Ann S. Hamilton
- Steven J. Katz, Paul Abrahamse, and Sarah T. Hawley, University of Michigan; Sarah T. Hawley, Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; Kevin C. Ward, Emory University, Atlanta, GA; Ann S. Hamilton, University of Southern California, Los Angeles; and Allison W. Kurian, Stanford University, Stanford, CA
| | - Paul Abrahamse
- Steven J. Katz, Paul Abrahamse, and Sarah T. Hawley, University of Michigan; Sarah T. Hawley, Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; Kevin C. Ward, Emory University, Atlanta, GA; Ann S. Hamilton, University of Southern California, Los Angeles; and Allison W. Kurian, Stanford University, Stanford, CA
| | - Sarah T. Hawley
- Steven J. Katz, Paul Abrahamse, and Sarah T. Hawley, University of Michigan; Sarah T. Hawley, Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; Kevin C. Ward, Emory University, Atlanta, GA; Ann S. Hamilton, University of Southern California, Los Angeles; and Allison W. Kurian, Stanford University, Stanford, CA
| | - Allison W. Kurian
- Steven J. Katz, Paul Abrahamse, and Sarah T. Hawley, University of Michigan; Sarah T. Hawley, Ann Arbor VA Center for Clinical Management Research, Ann Arbor, MI; Kevin C. Ward, Emory University, Atlanta, GA; Ann S. Hamilton, University of Southern California, Los Angeles; and Allison W. Kurian, Stanford University, Stanford, CA
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Kurian AW, Katz SJ. Cancer Risk Estimates for Study of Multiple-Gene Testing After Diagnosis of Breast Cancer-Reply. JAMA Oncol 2018; 4:1788. [PMID: 30383131 DOI: 10.1001/jamaoncol.2018.4959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Allison W Kurian
- Department of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, Stanford University, Stanford, California
| | - Steven J Katz
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor.,Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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Hawley ST, An L, Li Y, Jagsi R, Katz SJ. Improving informed breast cancer systemic treatment decision-making. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
225 Background: Decision making for adjuvant chemotherapy is increasingly complicated for women with a new diagnosis of early stage breast cancer. Few decision tools are designed to help support informed systemic treatment decision-making, by improving knowledge and decision quality. Methods: We conducted a randomized controlled trial (RCT) of a tailored, comprehensive (locoregional and systemic treatment) and interactive decision tool (iCanDecide), compared with static online information. 537 newly diagnosed, early stage breast cancer patients were enrolled from 22 surgical practices. Participants were surveyed 5 weeks (N = 496; RR 92%) and those eligible for systemic treatment (N = 358) again at 9 months (N = 307; RR 88%). The main outcome for this analysis was knowledge about systemic treatment using 4 true/false items, categorized into high (3- 4 correct) vs. low (0-2 correct). We also assessed subjective decision quality (SDQ) for chemotherapy on a 5-point scale and dichotomized into high (4-5) vs. low (1-3) We evaluated the distribution of participants in each arm, and assessed the association between the study arm and the outcomes using bivariate and multivariable approaches. Results: Of the 358 respondents, 201 did not receive or intend to have chemotherapy. Significantly more intervention than control patients had high knowledge about systemic treatment (52.9% vs. 39.9%, p = 0.012). Overall SDQ for chemotherapy was slightly higher in intervention than control subjects (mean 4.8 vs. 4.6, p = 0.08). However, among women who did not receive chemotherapy, significantly more intervention subjects reported high SDQ than controls (87.1% vs. 75.2%, p = 0.06). Values significantly related to chemotherapy use included avoiding side effects, continuing to work, and being most extensive possible. Conclusions: We found that the interactive decision tool contributed significantly to higher knowledge about systemic treatment among eligible patients. We further found the tool shows promise for improving subjective decision quality, particularly in patients who choose not to have chemotherapy. Further work to integrate tools into the oncology clinical setting is needed. Clinical trial information: NCT01840163.
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Affiliation(s)
| | - Larry An
- University of Michigan - CHCR, Ann Arbor, MI
| | - Yun Li
- University of Michigan, Ann Arbor, MI
| | - Reshma Jagsi
- University of Michigan Health System, Ann Arbor, MI
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Gornick MC, Kurian AW, An LC, Fagerlin A, Jagsi R, Katz SJ, Hawley ST. Knowledge regarding and patterns of genetic testing in patients newly diagnosed with breast cancer participating in the iCanDecide trial. Cancer 2018; 124:4000-4009. [DOI: 10.1002/cncr.31731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/22/2018] [Accepted: 07/13/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Michele C. Gornick
- Department of Internal MedicineUniversity of Michigan Medical School Ann Arbor Michigan
| | - Allison W. Kurian
- Department of MedicineStanford University Stanford California
- Department of Health Research and PolicyStanford University Stanford California
| | - Lawrence C. An
- Department of Internal MedicineUniversity of Michigan Medical School Ann Arbor Michigan
| | - Angela Fagerlin
- Department of Population Health SciencesUniversity of Utah School of Medicine Salt Lake City Utah
| | - Reshma Jagsi
- Department of Radiation OncologyUniversity of Michigan Medical School Ann Arbor Michigan
| | - Steven J. Katz
- Department of Internal MedicineUniversity of Michigan Medical School Ann Arbor Michigan
| | - Sarah T. Hawley
- Department of Internal MedicineUniversity of Michigan Medical School Ann Arbor Michigan
- Ann Arbor VA Center for Clinical Management Research Ann Arbor Michigan
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Jagsi R, Ward KC, Abrahamse P, Wallner LP, Kurian AW, Hamilton AS, Katz SJ, Hawley ST. Unmet need for clinician engagement regarding financial toxicity after diagnosis of breast cancer. Cancer 2018; 124:3668-3676. [PMID: 30033631 PMCID: PMC6553459 DOI: 10.1002/cncr.31532] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Little is known regarding whether growing awareness of the financial toxicity of a cancer diagnosis and its treatment has increased clinician engagement or changed the needs of current patients. METHODS The authors surveyed patients with early-stage breast cancer who were identified through population-based sampling from 2 Surveillance, Epidemiology, and End Results (SEER) regions and their physicians. The authors described responses from approximately 73% of surgeons (370 surgeons), 61% of medical oncologists (306 medical oncologists), 67% of radiation oncologists (169 radiation oncologists), and 68% of patients (2502 patients). RESULTS Approximately one-half (50.9%) of responding medical oncologists reported that someone in their practice often or always discusses financial burden with patients, as did 15.6% of surgeons and 43.2% of radiation oncologists. Patients indicated that financial toxicity remains common: 21.5% of white patients and 22.5% of Asian patients had to cut down spending on food, as did 45.2% of black and 35.8% of Latina patients. Many patients desired to talk to providers about the financial impact of cancer (15.2% of whites, 31.1% of blacks, 30.3% of Latinas, and 25.4% of Asians). Unmet patient needs for engagement with physicians about financial concerns were common. Of 945 women who worried about finances, 679 (72.8%) indicated that physicians and their staff did not help. Of 523 women who desired to talk to providers regarding the impact of breast cancer on employment or finances, 283 (55.4%) reported no relevant discussion. CONCLUSIONS Many patients report inadequate clinician engagement in the management of financial toxicity, even though many providers believe that they make services available. Clinician assessment and communication regarding financial toxicity must improve; cure at the cost of financial ruin is unacceptable. Cancer 2018;000:000-000. © 2018 American Cancer Society.
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Affiliation(s)
- Reshma Jagsi
- University of Michigan, Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine
| | - Kevin C. Ward
- Emory University, Rollins School of Public Health, Department of Epidemiology
| | | | - Lauren P. Wallner
- University of Michigan, Department of Internal Medicine
- University of Michigan, Department of Epidemiology
| | | | - Ann S. Hamilton
- Keck School of Medicine, University of Southern California, Department of Preventive Medicine
| | - Steven J. Katz
- University of Michigan, Department of Internal Medicine
- University of Michigan, Department of Health Management and Policy
| | - Sarah T. Hawley
- University of Michigan, Department of Internal Medicine
- University of Michigan, Department of Health Management and Policy
- Ann Arbor VA Center of Excellence in Health Services Research & Development
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50
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Shumway DA, Griffith KA, Hawley ST, Wallner LP, Ward KC, Hamilton AS, Morrow M, Katz SJ, Jagsi R. Patient views and correlates of radiotherapy omission in a population-based sample of older women with favorable-prognosis breast cancer. Cancer 2018; 124:2714-2723. [PMID: 29669187 PMCID: PMC7537366 DOI: 10.1002/cncr.31378] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/26/2018] [Accepted: 02/20/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The omission of radiotherapy (RT) after lumpectomy is a reasonable option for many older women with favorable-prognosis breast cancer. In the current study, we sought to evaluate patient perspectives regarding decision making about RT. METHODS Women aged 65 to 79 years with AJCC 7th edition stage I and II breast cancer who were reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results registries were surveyed (response rate, 70%) regarding RT decisions, the rationale for omitting RT, decision-making values, and understanding of disease recurrence risk. We also surveyed their corresponding surgeons (response rate, 77%). Patient characteristics associated with the omission of RT were evaluated using multilevel, multivariable logistic regression, accounting for patient clustering within surgeons. RESULTS Of 999 patients, 135 omitted RT (14%). Older age, lower tumor grade, and having estrogen receptor-positive disease each were found to be strongly associated with omission of RT in multivariable analyses, whereas the number of comorbidities was not. Non-English speakers were more likely to omit RT (adjusted odds ratio, 5.9; 95% confidence interval, 1.4-24.5). The most commonly reported reasons for RT omission were that a physician advised the patient that it was not needed (54% of patients who omitted RT) and patient choice (41%). Risk of local disease recurrence was overestimated by all patients: by approximately 2-fold among those who omitted RT and by approximately 8-fold among those who received RT. The risk of distant disease recurrence was overestimated by approximately 3-fold on average. CONCLUSIONS To some extent, decisions regarding RT omission are appropriately influenced by patient age, tumor grade, and estrogen receptor status, but do not appear to be optimally tailored according to competing comorbidities. Many women who are candidates for RT omission overestimate their risk of disease recurrence. Cancer 2018;124:2714-2723. © 2018 American Cancer Society.
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Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, Ann Arbor VA Health Care System, Ann Arbor, Michigan
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Ann S Hamilton
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Monica Morrow
- Breast Surgical Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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