PURPOSE: COVID-19 has altered healthcare delivery. Previous work has focused on patients with cancer and COVID-19, but little has been reported on healthcare system changes among patients without COVID-19. METHODS: We performed a retrospective study of patients with breast cancer (BC) in New York City between February 1, 2020, and April 30, 2020. New patients were included as were patients scheduled to receive intravenous or injectable therapy. Patients with COVID-19 were excluded. Demographic and treatment information were obtained by chart review. Delays and/or changes in systemic therapy, surgery, radiation, and radiology related to the pandemic were tracked, along with the reasons for delay and/or change. Univariate and multivariable analysis were used to identify factors associated with delay and/or change. RESULTS: We identified 350 eligible patients, of whom 149 (42.6%) experienced a delay and/or change, and practice reduction (51.0%) was the most common reason. The patients who identified as Black or African American, Asian, or Other races were more likely to experience a delay and/or change compared with White patients (Black, 44.4%; Asian, 47.1%; Other, 55.6%; White, 31.4%; P = .001). In multivariable analysis, Medicaid compared with commercial insurance (odds ratio [OR], 3.04; 95% CI, 1.32 to 7.27) was associated with increased odds of a delay and/or change, whereas stage II or III BC compared with stage I (OR, 0.38; 95% CI, 0.15 to 0.95; and OR, 0.28; 95% CI, 0.08 to 0.092, respectively) was associated with decreased odds of a delay and/or change. CONCLUSION: Almost half of the patients with BC without COVID-19 had a delay and/or change. We found racial and socioeconomic disparities in the likelihood of a delay and/or change. Further studies are needed to determine the impact these care alterations have on BC outcomes.
Background/Aims Essential to bringing innovative cancer treatments to patients is voluntary participation in clinical trials but approximately 8% of American cancer patients are enrolled onto a trial. We used a domain-oriented framework to assess barriers to cancer clinical trial enrollment. Methods Physicians (MD, DO, fellows, residents) and research staff (physician assistants, nurse practitioners, staff and research nurses, clinical assistants, and program coordinators) involved in clinical research at a comprehensive cancer center completed an online survey in 2017; adult cancer patients not currently enrolled in a trial were interviewed in 2018. To inform the construct of our physician/staff and patient surveys and to assess barriers to clinical trial enrollment, we first conducted in-depth interviews among 14 key informants representing medical, hematologic, gynecologic, neurologic, radiation oncology, as well as members of the clinical research team (one clinical research coordinator, one research nurse practitioner). Perceived structural, provider- and patient-level barriers to clinical trial enrollment were assessed. Differences in perceptions, attitudes, and beliefs toward clinical trial enrollment between (1) physicians and staff, (2) patients by ethnicity, and (3) physicians/staff and patients were examined. Results In total, 120 physicians/staff involved in clinical research (39.2% physicians, 60.8% staff; 48.0% overall response rate) and 150 cancer patients completed surveys. Nearly three-quarters of physician/staff respondents reported difficulty in keeping track of the eligibility criteria for open studies but was more often cited by physicians than staff (84.4% vs 64.3%, p = 0.02). Physicians more often reported lack of time to present clinical trial information than did staff( p < 0.001); 44.0% of staff versus 18.2% of physicians reported patient family interaction as a clinical trial enrollment barrier ( p = 0.007). Hispanic patients more often stated they would join a trial, even if standard therapy was an option compared to non-Hispanic patients (47.7% vs 20.8%, p = 0.002). Comparing the beliefs and perceptions of physicians/staff to those of patients, patients more often reported negative beliefs about clinical trial enrollment (e.g. being in a trial does not help patients personally, 32.9% vs 1.8%, p < 0.001) but less often felt they had no other options when agreeing to join (38.1% vs 85.6%, p < 0.001), and less often refused clinical trial enrollment due to lack of understanding (9.1% vs 63.3%, p = 0.001) than reported by physicians/staff. Conclusion Our findings indicate a wide gap between physician/staff and patient attitudes and beliefs about clinical trial enrollment and highlight the importance of focusing future initiatives to raise awareness of this incongruency. Reconciling these differences will require tailored education to reduce implicit biases and dispel misperceptions. Strategies to improve the quality of patient–provider communication and address infrastructure and resource issues are also needed to improve patient enrollment onto cancer clinical trials.
PURPOSE: Adjuvant therapy is associated with improved survival for women with breast cancer, but not all women who could benefit initiate treatment. Women's belief systems are related to treatment initiation. It has been hypothesized that complementary and alternative (CAM) use is associated with decreased initiation of standard oncology treatments because patients may be exploring alternative treatment approaches. However, there are limited data on the association between CAM use and cancer treatment initiation. We examined the association between CAM use and initiation of adjuvant breast cancer chemotherapy in a prospective cohort of early stage breast cancer patients. PATIENTS AND METHODS: Subjects participated in a multi-center prospective cohort study of women with early stage invasive breast cancer (n=1,156). National Comprehensive Cancer Network guidelines were used to define groups based on whether chemotherapy was indicated. Three subgroups were created: chemotherapy indicated for subjects <70 years, chemotherapy discretionary for subjects <70 years, and chemotherapy discretionary for subjects ≥70 years. CAM use was assessed based upon self-reported use of 5 CAM modalities, including vitamin/mineral supplements, herbal supplements, other over-the-counter natural products, mind-body based approaches, and body/energy-based treatments. Psychosocial factors potentially related to chemotherapy initiation were assessed. Multivariable logistic regression models evaluated the associations between CAM use and chemotherapy initiation, adjusted for demographic, clinical and psychosocial factors. RESULTS: Current CAM use was reported by 87% of women and 38% reporting current use of ≥3 modalities. The most commonly used CAM modalities were mind body therapies (63%) and other natural products (41%). In bivariate analyses, among women <70 years where chemotherapy was indicated, women who reported current use of vitamins/minerals or current use of all 5 CAM modalities were less likely to initiate chemotherapy compared to non-users (P<.0001), but this was not observed among women for whom chemotherapy was discretionary. Psychosocial factors were also associated with high levels of current CAM use in this group, including higher expectations of adverse effects from chemotherapy, more concerns about the physical effects of chemotherapy, lower beliefs in the benefits of chemotherapy, and lower positive decision balance while making chemotherapy decisions (all P<.05). Among women age <70 years for whom chemotherapy was indicated, 89% initiated treatment, and current use of all 5 CAM modalities was inversely associated with initiation in multivariable analyses adjusted for demographic and clinical factors (OR=0.08, CI: 0.02-0.32). The association remained after separately adjusting for psychosocial factors (all P<.05), except for positive decision balance, which was no longer statistically significant. CONCLUSIONS: High use of CAM was associated with decreased chemotherapy initiation among women with breast cancer for whom chemotherapy was indicated. It is important for oncologists to discuss CAM use with their patients, especially since high CAM use is associated with negative expectations and beliefs about chemotherapy. Citation Format: Greenlee H, Neugut AI, Falci L, Hillyer GC, Buono D, Roh JM, Ergas IJ, Kwan ML, Lee M, Tsai WY, Shi Z, Lamerato L, Mandelblatt JS, Kushi LH, Hershman DL. Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-05.
Background: Non-adherence to adjuvant hormonal therapy among women with breast cancer is common, but little is known about how financial factors influence it. We investigated the relationship between prescription co-payment amount and compliance with adjuvant aromatase inhibitors (AI) therapy. Patients and Methods: Using de-identified, integrated pharmacy and medical claim database at Medco Health Solutions, Inc. women >50 years old on AIs for early breast cancer with at least 2 mail order prescription refills between 1/1/07 and 12/31/08 were identified. All data were pooled prior to the analysis. Variables that were evaluated included medical and demographic information, household income, number of other prescriptions, diagnostic codes, prescription refill dates, provider type and co-payment amounts. Age was classified as <63 or ≥63 to distinguish patients ever covered by Medicare. Copayment amount was categorized as <$30, between $30 and $89.99, and ≥$90. Non-persistence was defined as prescription supply gap of 45 days with no subsequent refill. Non-adherence was defined as a medication possession ratio ≥80% of eligible days. Logistic regressions and Cox proportional hazards modeling were used. Results: Of 8110 women age 50-62 years (mean=59.1), 1721(21.2%) were non-persistent and of those who continued, 863(10.3%) were non-adherent over the 2 year period. Among 14,050 women ≥63 years (mean=74.9), 3476(24.7%) were non-persistent and of those who continued, 1248(8.9%) were non-adherent. Ninety day co-payments ranged from $0 to $893.49. In a multivariate analysis, non-persistence (ever/never) in both age groups was associated with older age, having a primary care physician write the prescription, and higher number of co-prescriptions. Similar results were seen with non-adherence. Compared to a copayment of <$30, a 90 day copayment of $30-$89.99 was associated with time to non-persistence in women ≥63 (HR 1.34, 95%CI 1.24-1.46) but not among women <63, while a copayment ≥$90 was associated with time to non-persistence both in women <63 (HR 1.26, 95%CI 1.09–1.38) and women ≥63 (HR 1.33, 95%CI 1.22–1.46). Conclusions: We found that a higher prescription co-payment was associated with both early discontinuation and non-adherence to AIs. This relationship was stronger for older women. Because hormone therapy non-compliance is associated with worse survival outcomes, future public policy efforts should be directed towards reducing financial constraints as a means of increasing the use of these life-saving medications. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S6-4.
Background. Adjuvant hormonal therapy (HT) for hormone-sensitive breast cancer decreases risk of breast cancer recurrence and improves survival. However, some women are non-adherent to this life-saving treatment. Methods. In a cohort of women recruited at diagnosis of breast cancer in an integrated healthcare system, we investigated factors related to HT interruption (≥90 day gap). Serial interviews were conducted at baseline and during treatment to examine psychological factors as well as sociodemographic factors, tumor characteristics, and treatment factors. A series of multivariate models assessed potential predictors of HT interruptions. Results. Of the 569 women in our cohort who initiated HT, 137 (24%) interrupted it, including 18 (3%) who did so prior to the first follow-up interview. In a multivariate analysis of clinical and demographic factors, only household income remained associated with HT interruption (OR 0.42, 95%CI 0.24-0.76). At first follow-up, after controlling for income, race and age, lower scores on all quality of life subscales, lower scores on global treatment satisfaction, and poorer scores on the intrusive and avoidant thought subscales of the Impact of Events scale were associated with higher odds of HT interruptions (P<0.001 for all predictors). Scores on social support and on interpersonal processes of care measures were not associated with HT interruptions. However, a higher score on the single question "How often did your doctor speak too fast?" was associated with higher risk of HT interruptions (OR 1.32, p=0.02). Conclusions: Patients under greater duress and those with lower physical, functional, emotional or social quality of life appeared to be at the highest risk of HT interruption and thus received poorer quality care. A better understanding of psychological factors that can result in poor quality care may pave the way to targeted interventions to improve adherence. Citation Format: Hershman DL, Kushi LH, Hillyer GC, Coromilis E, Buono D, Lamerato LE, Bovbjerg DH, Mandelblatt8 JS, Tsai W-Y, Jacobson JS, Wright JD, Neugut AI. Psychosocial factors related to interruptions in adjuvant hormonal therapy among women with breast cancer: The breast cancer quality of care study (BQUAL). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-04.
Purpose: We examined the association between patient experience of care and utilization of hormone therapy (HT) in the treatment of non-metastatic hormone-receptor positive (HR+) breast cancer. Methods: Patients newly diagnosed with non-metastatic breast cancer were recruited from 2006 to 2010 for a longitudinal multisite cohort study in New York, NY, Detroit, MI, and Northern California. Of 1,145 patients surveyed, 797 had HR+ tumors eligible for HT and all necessary data. We assessed patient experience 4 to 8 weeks after recruitment using 6 subscales of the Interpersonal Processes of Care (IPC) survey: compassion, discrimination, and hurriedness in communication, as well as concern elicitation, result explanation, and patient-centered decision-making. Subscales ranged from 1 to 5 where higher values indicated better experiences. HT for 5 years is standard care for HR+ breast cancer so utilization was defined as time from diagnosis to HT initiation and time from HT initiation to early discontinuation before 5 years as calculated from follow-up survey responses. We evaluated the relationship between patient experience and utilization using Cox proportional hazard models, controlling for education, income, insurance, marital status, social support, site of care, age at diagnosis, stage, grade, tumor size, Charlson comorbidity index, and chemotherapy. Results: Median age at diagnosis was 59 years (interquartile range 51–66) with the majority diagnosed at clinical stage 1 (54%) and with low or moderate grade disease (78%). Less hurried communication was associated with increased probability of HT initiation (Hazards Ratio (HR) 1.15; 95% Confidence Interval (CI) 1.03, 1.30; p = 0.018). Conversely, more patient-centered decision-making was associated with increased probability of early discontinuation (HR 1.29; CI, 1.03, 1.63; p = 0.028). All other associations were null. Conclusion: While unhurried communication was associated with initiation of hormone therapy, patient-centered decision-making was associated with early discontinuation. Different aspects of patient experience may have vastly different relationships with patient utilization of health services. Actionable assessments of patient experience may require measurement along multiple dimensions.
Introduction: In patients with early stage breast cancer (BC) treated with curative intent, multidisciplinary teams (MDT) have emerged as a way to involve a wide range of specialists and encourage effective communication to formulate an optimal treatment strategy for patients. We sought to evaluate the frequency and predictors of MDT evaluation in patients with BC. Methods: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset to evaluate patients diagnosed with stages I and II breast cancer who underwent primary surgery from 2002-2007 and were followed through 2012. We evaluated claims for outpatient visits and characterized the treating physician as a surgeon, radiation oncologist (RO) or medical oncologist (MO). We defined MDT as having seen a physician in each of the three specialties within 12 months of diagnosis. We used multivariable logistic regression to evaluate factors associated with MDT. Results: A total of 35,484 stage I and II breast cancer patients were included in the analysis. Within the first year, 77.5% visited a medical oncologist, 57.8% visited a radiation oncologist, and 47% of women were seen by all 3 specialists. Prior to surgery, 4.9% of patients were seen by all 3 physicians, with 14.8% seen by a MO and 16.4% seen by a RO in addition to the surgeon. Evaluation by a MDT was more frequent in women who had a lumpectomy vs mastectomy (57.1% vs 28.4%, p<0.0001), Caucasian race as opposed to black and Hispanic (47.4% vs 42.1% vs 37.4%, p<0.0001), those that lived in an urban setting versus rural (48.1% vs 36.25%, p<0.0001), and those that were married versus unmarried (50.8% vs 43.1%, p<0.0001). As age increased, the number of patients who saw all three physicians decreased. As socioeconomic status improved, more patients saw all three physicians. In a multivariate model, evaluation by a MDT was higher in patients with Stage II disease (OR [95% CI] = 1.10 [1.04-1.18]), diagnosed in 2006-2007 (as compared to 2002-2005) (OR = 1.73 [1.63-1.85]), and those who received chemotherapy (OR = 1.51 [1.39-1.64]) and was less likely for older women (OR = 0.77 [0.71-0.84]), those who underwent mastectomy (OR = 0.73 [0.68-0.78]), and those in the lowest socioeconomic quintile (OR = 0.88 [0.80-0.97]). Of those seen by all 3 physicians in the first year, 20.4%, 10.1%, 6.1%, and 3.9% were seen by all 3 specialists in years 2, 3, 4 and 5 respectively. Only 2.2% of patients saw all three specialists all five years. Conclusions: Early stage breast cancer patients are evaluated by a medical oncologist, surgeon and radiation oncologist less than 50% of the time in the first year after diagnosis. Prior to surgery, where decision making may be most important, only 5% of patients were evaluated by all three specialties. Further research is needed to determine if MDT improves quality of care delivered, treatment adherence, patient satisfaction or breast cancer survival. Citation Format: Quyyumi F, Accordino MK, Buono DL, Neugut AI, Hillyer GC, Wright JD, Hershman DL. Factors associated with multidisciplinary care in the management of early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-14.
Introduction: In patients with early stage breast cancer treated with curative intent, optimal follow-up guidelines vary widely among national organizations. NCCN guidelines suggest patients should be followed by a medical oncologist (MO) every 3-6 months and by a radiation oncologist (RO) every 6-12 months for the first 5 years. These recommendations are not evidence based and have an unknown effect on cancer outcomes. We sought to evaluate the patterns of follow-up care and predictors of discontinuation of follow-up care. Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset, we evaluated patients diagnosed with stage I and II breast cancer who underwent surgery from 2002-2007 with follow-up to 2012. Patients who died in the 5-year period following diagnosis were excluded. We evaluated patterns of follow-up visits for the 5 years after diagnosis among surgeon, MO and RO. We defined discontinuation of follow-up care as >12 months without a visit claim from any of the three providers. We performed a Cox-proportional hazards multivariate analysis to determine factors associated with discontinuation of follow-up care. Patients were censored if a new cancer was diagnosed. Results: A total of 35,484 stage I and II breast cancer patients were included in the analysis. In addition to the surgeon, 77.5% saw a MO, and 57.8% saw RO in the first year. The mean number of total physician appointments for years 1-5 were 9.4, 3.3, 2.4, 2.0 and 1.7, respectively. During the 5 years, 13,908 (39.6%) patients discontinued follow-up visits. The discontinuation rate averaged about 12% per year for years 2-5. Discontinuing physician visits increased with increasing age. Patients who saw all 3 physicians in year 1 were less likely to discontinue follow-up visits (OR = 0.54, 0.51-0.57). Patients were more likely to discontinue physician visits if they were hormone receptor negative (HR = 1.41, 1.33-1.49), were black (HR = 1.14, 1.06-1.22) or Hispanic (HR = 1.36, 1.17-1.58) compared to white, lived in a rural as opposed to urban setting (HR 1.12, 1.05-1.18), were unmarried (HR = 1.16, 1.12-1.20), had a higher comorbidity score (HR = 1.15, 1.10-1.21), or were in a lower SES quintile (HR = 1.08, 1.02-1.15). Women who had a mastectomy (vs lumpectomy) (HR =0.83, 0.80-0.87) and those who were receiving chemotherapy (HR = 0.55, 0.52-0.59) or radiation therapy (OR = 0.60, 0.57-0.62) were less likely to discontinue physician visits. Conclusions: Clinical practice guidelines for surveillance of breast cancer after primary treatment are based on expert opinion and have an unclear effect on long-term outcomes. Coordination of follow-up care may reduce discontinuation. More research is needed to determine the optimal follow-up for maintaining adherence to therapy, reducing over-testing and encouraging secondary cancer screening guidelines. Citation Format: Hershman DL, Quyyumi F, Accordino MK, Buono DL, Neugut AI, Hillyer GC, Wright JD. Factors associated with follow up medical care among women with early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-06.
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