Cleo A. Samuel

Racial Disparities in Cancer Care in the Veterans Affairs Health Care System and the Role of Site of Care

OBJECTIVES We assessed cancer care disparities within the Veterans Affairs (VA) health care system and whether between-hospital differences explained disparities. METHODS We linked VA cancer registry data with VA and Medicare administrative data and examined 20 cancer-related quality measures among Black and White veterans diagnosed with colorectal (n = 12,897), lung (n = 25,608), or prostate (n = 38,202) cancer from 2001 to 2004. We used logistic regression to assess racial disparities for each measure and hospital fixed-effects models to determine whether disparities were attributable to between- or within-hospital differences. RESULTS Compared with Whites, Blacks had lower rates of early-stage colon cancer diagnosis (adjusted odds ratio [AOR] = 0.80; 95% confidence interval [CI] = 0.72, 0.90), curative surgery for stage I, II, or III rectal cancer (AOR = 0.57; 95% CI = 0.41, 0.78), 3-year survival for colon cancer (AOR = 0.75; 95% CI = 0.62, 0.89) and rectal cancer (AOR = 0.61; 95% CI = 0.42, 0.87), curative surgery for early-stage lung cancer (AOR = 0.50; 95% CI = 0.41, 0.60), 3-dimensional conformal or intensity-modulated radiation (3-D CRT/IMRT; AOR = 0.53; 95% CI = 0.47, 0.59), and potent antiemetics for highly emetogenic chemotherapy (AOR = 0.87; 95% CI = 0.78, 0.98). Adjustment for hospital fixed-effects minimally influenced racial gaps except for 3-D CRT/IMRT (AOR = 0.75; 95% CI = 0.65, 0.87) and potent antiemetics (AOR = 0.95; 95% CI = 0.82, 1.10). CONCLUSIONS Disparities in VA cancer care were observed for 7 of 20 measures and were primarily attributable to within-hospital differences.

National Trends in Nonoperative Management of Rectal Adenocarcinoma

PURPOSE Neoadjuvant chemoradiation for stage II/III rectal cancer results in up to 49% of patients with a clinical complete response. As a result, many have questioned whether surgery can be omitted for this group of patients. Currently, there is insufficient evidence for chemoradiation only, or nonoperative management (NOM), to support its adoption. Despite this, anecdotal evidence suggests there is a trend toward increased use of NOM. Our objective was to examine the use of NOM for rectal cancer over time, as well as the patient- and facility-level factors associated with its use. METHODS We included all incident cases of invasive, nonmetastatic rectal adenocarcinoma reported to the National Cancer Database from 1998 to 2010. We performed univariate and multivariate analyses to assess for NOM use over time, as well as associated patient- and facility-level factors. RESULTS A total of 146,135 patients met the inclusion criteria: 5,741 had NOM and 140,394 had surgery with or without additional therapy. From 1998 to 2010, NOM doubled, from 2.4% to 5% of all cases annually. Patients who were black (adjusted odds ratio [AOR], 1.71; 95% CI, 1.57 to 1.86), uninsured (AOR, 2.35; 95% CI, 2.08 to 2.65) or enrolled in Medicaid (AOR, 2.10; 95% CI, 1.90 to 2.33), or treated at low-volume facilities (AOR, 1.53; 95% CI, 1.42 to 1.64) were more likely to receive NOM than were patients who were white, privately insured, and treated at a high-volume facility, respectively. CONCLUSION NOM demonstrates promise for the treatment of rectal cancer; currently, however, the most appropriate strategy is to pursue this approach with well-informed patients in the context of a clinical trial. We observed evidence of increasing NOM use, with this increase occurring more frequently in black and uninsured/Medicaid patients, raising concern that increased NOM use may actually represent increasing disparities in rectal cancer care rather than innovation. Further studies are needed to assess survival differences by treatment strategy.

Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer

PURPOSE Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care. METHODS We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death). RESULTS The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities. CONCLUSION We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.

Developing and Evaluating Composite Measures of Cancer Care Quality.

Background:Composite measures are useful for distilling quality data into summary scores; yet, there has been limited use of composite measures for cancer care. Objective:Compare multiple approaches for generating cancer care composite measures and evaluate how well composite measures summarize dimensions of cancer care and predict survival. Study Design:We computed hospital-level rates for 13 colorectal, lung, and prostate cancer process measures in 59 Veterans Affairs hospitals. We computed 4 empirical-factor (based on an exploratory factor analysis), 3 cancer-specific (colorectal, lung, prostate care), and 3 care modality–specific (diagnosis/evaluation, surgical, nonsurgical treatments) composite measures. We assessed correlations among all composite measures and estimated all-cause survival for colon, rectal, non–small cell lung, and small cell lung cancers as a function of composite scores, adjusting for patient characteristics. Results:Four factors emerged from the factor analysis: nonsurgical treatment, surgical treatment, colorectal early diagnosis, and prostate treatment. We observed strong correlations (r) among composite measures comprised of similar process measures (r=0.58–1.00, P<0.0001), but not among composite measures reflecting different care dimensions. Composite measures were rarely associated with survival. Conclusions:The empirical-factor domains grouped measures variously by cancer type and care modality. The evidence did not support any single approach for generating cancer care composite measures. Weak associations across different care domains suggest that low-quality and high-quality cancer care delivery may coexist within Veterans Affairs hospitals.

Examining health-related quality of life patterns in women with breast cancer

PurposeWe aimed to identify subgroups of women with breast cancer who experience different health-related quality of life (HRQOL) patterns during active treatment and survivorship and determine characteristics associated with subgroup membership.MethodsWe used data from the third phase of the population-based Carolina Breast Cancer Study and included 2142 women diagnosed with breast cancer from 2008 to 2013. HRQOL was measured, on average, 5 and 25 months post diagnosis. Latent profile analysis was used to identify HRQOL latent profiles (LPs) at each time point. Latent transition analysis was used to determine probabilities of women transitioning profiles from 5 to 25 months. Multinomial logit models estimated adjusted odds ratios (aORs) and 95% confidence intervals for associations between patient characteristics and LP membership at each time point.ResultsWe identified four HRQOL LPs at 5 and 25 months. LP1 had the poorest HRQOL and LP4 the best. Membership in the poorest profile at 5 months was associated with younger age aOR 0.95; 0.93–0.96, White race aOR 1.48; 1.25–1.65, being unmarried aOR 1.50; 1.28–1.65 and having public aOR 3.09; 1.96–4.83 or no insurance aOR 6.51; 2.12–20.10. At 25 months, Black race aOR 1.75; 1.18–1.82 was associated with the poorest profile membership. Black race and smoking were predictors of deteriorating to a worse profile from 5 to 25 months.ConclusionsOur results suggest patient-level characteristics including age at diagnosis and race may identify women at risk for experiencing poor HRQOL patterns. If women are identified and offered targeted HRQOL support, we may see improvements in long-term HRQOL and better breast cancer outcomes.

Oncology navigators’ perceptions of cancer-related financial burden and financial assistance resources

IntroductionAs the cost of cancer treatment continues to rise, many patients are faced with significant emotional and financial burden. Oncology navigators guide patients through many aspects of care and therefore may be especially aware of patients’ financial distress. Our objective was to explore navigators’ perception of their patients’ financial burden and their role in addressing financial needs.Materials and methodsWe conducted a real-time online survey of attendees at an oncology navigators’ association conference. Participants included lay navigators, oncology nurse navigators, community health workers, and social workers. Questions assessed perceived burden in their patient population and their role in helping navigate patients through financial resources. Answers to open-ended questions are reported using identified themes.ResultsSeventy-eight respondents participated in the survey, reporting that on average 75% of their patients experienced some degree of financial toxicity related to their cancer. Only 45% of navigators felt the majority of these patients were able to get some financial assistance, most often through assistance with medical costs (73%), subsidized insurance (36%), or non-medical expenses (31%). Commonly identified barriers for patients obtaining assistance included lack of resources (50%), lack of knowledge about resources (46%), and complex/duplicative paperwork (20%).ConclusionOncology navigators reported a high burden of financial toxicity among their patients but insufficient knowledge or resources to address this need. This study underscores the importance of improved training and coordination for addressing financial burden, and the need to address community and system-level barriers.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer. DATA SOURCES Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer. CONCLUSION Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care. IMPLICATIONS FOR NURSING PRACTICE Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Establishing New Community-Based Participatory Research Partnerships using the Community-Based Participatory Research Charrette Model: Lessons from the Cancer Health Accountability for Managing Pain and Symptoms Study

Abstract:Background: Community-based participatory research (CBPR) is a collaborative and equitable approach to research inquiry; however, the process of establishing and maintaining CBPR partnerships can be challenging. There is an ongoing need for innovative strategies that foster partnership development and long-term sustainability. In 2010, the University of North Carolina at Chapel Hill developed a CBPR charrette model to facilitate stakeholder engagement in translational research.Objective: To describe how the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) Study leveraged the CBPR charrette process to develop and strengthen its CBPR partnership and successfully implement research objectives.Methods: Fourteen CHAMPS community, academic, and medical partners participated in the CBPR charrette. Two co-facilitators guided the charrette application process and in-person discussion of partnership strengths, needs, and challenges. Community experts (CEs) and academic experts (AEs) with extensive experience in CBPR and health disparities provided technical assistance and recommendations during the in-person charrette.Conclusions: Overall, the CHAMPS partnership benefited significantly from the charrette process. Specifically, the charrette process engendered greater transparency, accountability, and trust among CHAMPS partners by encouraging collective negotiation of project goals and implementation, roles and responsibilities, and compensation and communication structures. The process also allowed for the exploration of newly identified challenges and potential solutions with support from CEs and AEs. Furthermore, the charrette also functioned as a catalyst for capacity building among CHAMPS community, academic, and medical partners. Future studies should compare the impact of the CBPR charrette, relative to other approaches, on partnership development and process evaluation outcomes.

Investigating Associations Between Health-Related Quality of Life and Endocrine Therapy Underuse in Women With Early-Stage Breast Cancer

PURPOSE Endocrine therapy (ET) underuse puts women at increased risk for breast cancer (BC) recurrence. Our objective was to determine if health-related quality of life (HRQOL) subgroups were associated with underuse. METHODS Data came from the third phase of the Carolina Breast Cancer Study. We included 1,599 women with hormone receptor-positive BC age 20 to 74 years. HRQOL was measured, on average, 5 months postdiagnosis. Subgroups were derived using latent profile (LP) analysis. Underuse was defined as not initiating or adhering to ET by 36 months postdiagnosis. Multivariable logistic regression models estimated adjusted odds ratios (ORs) between HRQOL LPs and underuse. The best HRQOL LP was the reference. Chemotherapy- and race-stratified models were estimated, separately. RESULTS Initiation analyses included 953 women who had not begun ET by their 5-month survey. Of these, 154 never initiated ET. Adherence analyses included 1,114 ET initiators, of whom 211 were nonadherent. HRQOL was not significantly associated with noninitiation, except among nonchemotherapy users, with membership in the poorest LP associated with increased odds of noninitiation (adjusted OR, 5.5; 95% CI, 1.7 to 17.4). Membership in the poorest LPs was associated with nonadherence (LP1: adjusted OR, 2.2; 95% CI, 1.2 to 4.0 and LP2: adjusted OR,1.9; 95% CI, 1.1 to 3.6). Membership in the poorest LP was associated with nonadherence among nonchemotherapy users (adjusted OR, 2.1; 95% CI, 1.2 to 5.1). CONCLUSION Our results suggest women with poor HRQOL during active treatment may be at increased risk for ET underuse. Focusing on HRQOL, a modifiable factor, may improve targeting of future interventions early in the BC continuum to improve ET initiation and adherence and prevent BC recurrence.

Abstract B25: Understanding Racial Differences in Health-Related Quality of Life in a Diverse, Population-Based Cohort of Breast Cancer Survivors in North Carolina

Objective: There are over 3 million women in the United States living with breast cancer or who have a history of breast cancer. As the number of women undergoing treatments and surviving breast cancer grows, characterizing changes in health-related quality of life (HRQOL) is critical to ensuring patient-centered breast cancer care. Breast cancer risk and burden varies systemically between Black and White women. Black women are more likely to be diagnosed at younger ages and with more aggressive breast cancer tumors. Although racial disparities in HRQOL are well documented, less is known about differences in HRQOL at distinct phases of breast cancer care. Our objective was to assess racial disparities in HRQOL between active treatment and survivorship phases of the breast cancer care continuum. Methods: The study used data from the third phase of the Carolina Breast Cancer Study (CBCS-III). CBCS-III enrolled 3,000 women in North Carolina aged 20-74 years diagnosed with invasive, pathologically confirmed breast cancer between 2008 and 2013. HRQOL assessments occurred 5- and 25-months after diagnosis, respectively, representing distinct phases of care. The Functional Assessment of Cancer Therapy for Breast Cancer and the Functional Assessment of Chronic Illness Therapy for Spiritual Well-Being measured HRQOL. We implemented three approaches (Institute of Medicine, Residual Direct Effect and interactive effects of race and socioeconomic factors) to assessing racial disparities to better understand if racial disparities in HRQOL changes existed and to identify potential mediators of disparities in HRQOL. Analysis of covariance models assessed racial differences in changes in HRQOL between active treatment and survivorship. Adjusted models included demographic, socioeconomic, tumor and treatment characteristics. Results: The cohort included 2,142 Non-Hispanic White (52%) and Black (48%) women with breast cancer who completed both HRQOL assessments. During active treatment, White women reported significantly better physical and functional HRQOL than Black women, but spiritual HRQOL was 2 points higher for Black women. At 25-months post-diagnosis, White women reported HRQOL scores well above U.S norms across physical, social, emotional and functional well-being domains. Black women, however, continued to report physical well-being scores 1.2 points below the U.S norm and 2.3 points below their White breast cancer counterparts. Once demographic, socioeconomic, tumor and treatment characteristics were adjusted for, racial differences narrowed and were not considered clinically meaningful. Conclusions: Racial differences in physical and functional HRQOL may be mediated by socioeconomic factors. Psychosocial and spiritual HRQOL seem well supported, mitigating negative effects of breast cancer care, especially among Black women. These results inform opportunities for improving the quality and equity of supportive services for women with breast cancer. Citation Format: Laura C. Pinheiro, Cleo A. Samuel, Katherine E. Reeder-Hayes, Stephanie B. Wheeler, Andrew F. Olshan, Bryce B. Reeve. Understanding Racial Differences in Health-Related Quality of Life in a Diverse, Population-Based Cohort of Breast Cancer Survivors in North Carolina. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B25.