Karen Hiotis

A Tracking and Feedback Registry to Reduce Racial Disparities in Breast Cancer Care

BACKGROUND Black and Hispanic women with early-stage breast cancer are more likely than white women to experience fragmented care and less likely to see medical oncologists to get effective adjuvant treatment. We implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists. METHODS We compared completed oncology consultations and use of adjuvant treatment among a group of 639 women with newly diagnosed stage I or II breast cancer who had undergone surgery at one of six New York City hospitals from 1999 to 2000 with the same outcomes for a different group of 300 women with breast cancer whose surgeries occurred in 2004-2006, after the implementation of the tracking registry. Underuse of adjuvant treatment was defined as no radiotherapy after breast-conserving surgery, no chemotherapy for estrogen receptor (ER)-negative tumors, or no hormonal therapy for ER-positive tumors 1 cm or larger. We used hierarchical modeling to adjust for clustering within hospital and surgeon practice. Odds ratios were converted to adjusted relative risks (aRRs). All statistical tests were two-sided. RESULTS Implementation of the tracking and feedback registry was accompanied by a statistically significant increase in oncology consultations (83% before vs 97% after the intervention; difference = 14%; 95% confidence interval [CI] = 11% to 18%; P < .001) and decrease in underuse of adjuvant treatment (23% before vs 14% after the intervention; difference = -9%, 95% CI = -12% to -6%; P < .001). Underuse declined from 34% to 14% among black women, from 23% to 13% among Hispanic women, and from 17% to 14% among white women (chi-square of change in underuse from before to after among the three racial groups; P = .001). In multivariable models adjusting for clustering by hospital and surgeon, the intervention was associated with increased rates of oncology consultation (aRR = 1.6, 95% CI = 1.3 to 1.8), and reduced underuse of adjuvant treatment (aRR = 0.75, 95% CI = 0.6 to 0.9). Compared with the preintervention findings, minority race was no longer a risk factor for low rates of oncology consultation (aRR = 1.0, 95% CI = 0.7 to 1.3) or for underuse of adjuvant therapy (aRR = 1.0, 95% CI = 0.8 to 1.3). CONCLUSIONS A tracking and feedback registry that enhances completed oncology consultations between surgeons and oncologists also appears to reduce rates of adjuvant treatment underuse and to eliminate the racial disparity in treatment.

Colocolonic intussusception of a giant pseudopolyp in a patient with ulcerative colitis. A case report and review of the literature

Adult intussusception in the setting of inflammatory bowel disease (IBD) is a rare phenomenon. Giant pseudopolyps, while generally considered benign, may function as lead points for intussusception. Diagnosis and management of intussusception in the setting of IBD can be fraught with hazards. We report the case of a 27-year-old male, recently diagnosed with ulcerative colitis and giant pseudopolyps, who presented with colocolonic intussusception and obstruction. Diagnosis was confirmed using CT imaging and the patient underwent resection of the colocolonic intussusception without reduction. The following case underscores the challenges in managing adult intussusception in the setting of IBD and allows for a review of the literature to date. Resection of non-reduced intussusception, rather than endoscopic or enema reduction, should continue to be definitive treatment of patients presenting with this unusual problem.

Indigent breast cancer patients among all racial and ethnic groups present with more advanced disease compared withnationally reported data

BACKGROUND This study examines the epidemiologic and pathologic characteristics of indigent breast cancer patients followed up in a public city hospital in comparison to national standards. METHODS A prospective oncology database was queried to identify all patients presenting with primary breast cancer. Medical records of 188 patients identified between March 1997 and May 2002 were retrospectively reviewed. Pathologic and epidemiologic data were compared with 1998 data reported by the Surveillance, Epidemiology, and End Results (SEER) program. RESULTS Among the patient population 10% were Caucasian, 13% African-American, 49% Hispanic, 25% Chinese, and 6% were of other background. The majority of patients were uninsured. Indigent patients within each ethnic group presented with more advanced disease when compared with patients reported by SEER. CONCLUSIONS Indigent patients among all ethnic and racial backgrounds present with more advanced disease when compared with national statistics reported by SEER. The majority of these patients is uninsured and would benefit from more aggressive education, screening, detection methods, and follow-up.

Cervical Adenocarcinoma in a Patient With Lynch Syndrome, Muir-Torre Variant

Introduction Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer syndrome, is the most common form of hereditary colorectal cancer. Patients with Lynch syndrome are at high risk of developing colorectal cancer at an early age (mean, age 45 years), in addition to extracolonic cancers. The most common extracolonic cancer in Lynch syndrome is endometrial carcinoma. Other extracolonic cancers seen in Lynch syndrome include carcinoma of the ovary, stomach, small bowel, pancreas, hepatobiliary, brain, and upper genitourinary tract. Patients with Lynch syndrome may also have skin tumors, which is consistent with the Muir-Torre variant of Lynch syndrome. We report the case of a 39-year-old woman with Lynch syndrome who was found to have endocervical adenocarcinoma and later developed carcinoma of the skin, making her disease a Muir-Torre variant of Lynch syndrome. To our knowledge, there has been only one other case report of cervical carcinoma in a patient with Lynch syndrome.

Receptor Status and Ethnicity of Indigent Patients With Breast Cancer in New York City

Previous studies have suggested racial differences in breast cancer hormonal receptor status, reflecting possible differences in tumor biology. However, racial differences in socioeconomic status and reproductive risk factors may influence receptor status. We investigated this issue, studying a racially diverse but socioeconomically homogeneous cohort of 215 patients with breast cancer at a New York public hospital from January 1, 1999, through December 31, 2003. We analyzed positive findings for estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) (HER2/neu) receptors, considering patients in racial groups by cancer stage and overall. No difference was found in rates of estrogen, progesterone, or HER2/neu positivity among Asian, black, Hispanic, or white patients presenting with ductal carcinoma in situ or with invasive cancer.

Volume-outcome relationships in breast cancer

A significant effect of hospital case volume on perioperative mortality has been documented for a variety of malignancies that require technically challenging operative procedures and complex perioperative management. The effect of case volume on outcome is less clear for the more common cancers, such as breast and colon cancers, that are less technically challenging and require little in the way of specialized care in the postoperative period. For these cancers perioperative mortality is minimal and one must look at other end points such as long-term survival and functional results. The literature demonstrating improved outcomes in terms of mammographical sensitivity, breast-conservation rates, specimen to tumour volume ratios in breast-conserving surgery, sentinel node biopsy success rates, and 5-year survival is reviewed.

Usability and feasibility of health IT interventions to enhance Self-Care for Lymphedema Symptom Management in breast cancer survivors

Purpose The-Optimal-Lymph-Flow health IT system (TOLF) is a patient-centered, web-and-mobile-based educational and behavioral health IT system focusing on safe, innovative, and pragmatic self-care strategies for lymphedema symptom management. The purpose of this study was to evaluate usability, feasibility, and acceptability of TOLF among the end-user of breast cancer survivors. Methods Two types of usability testing were completed with 30 breast cancer survivors: heuristic evaluation and end-user testing. Each participant was asked to think aloud while completing a set of specified tasks designed to explicate and freely explore the system features. A heuristic evaluation checklist, the Perceived Ease of Use and Usefulness Questionnaire, and The Post Study System Usability Questionnaire were used to evaluate usability of the system. Open-ended questions were used to gather qualitative data. Quantitative data were analyzed using descriptive statistics and qualitative data were summarized thematically. Results Breast cancer survivors were very satisfied with the system: 90% (n = 27) rated the system having no usability problems; 10% (n = 3) noted minor cosmetic problems: spelling errors or text font size. The majority of participants 96.6% (n = 29) strongly agreed that the system was easy to use and effective in helping to learn about lymphedema, symptoms and self-care strategies. Themes from the qualitative data included empowerment, high quality information, loving avatar simulation videos, easy accessibility, and user-friendliness. Conclusions This usability study provided evidence on breast cancer survivors acceptance and highly positive evaluation of TOLFs usability as well as feasibility of using technologically-driven delivery model to enhance self-care strategies for lymphedema symptom management.

Race, Oncotype DX, and other characteristics in a highly screened population.

32 Background: Oncotype DX breast cancer 21 gene assay recurrence score (RS) is used to predict disease recurrence and response to chemotherapy in order to offer patients the highest treatment benefit to risk ratio. There is a dearth of literature on the relationship of Oncotype RS and race in women with hormone receptor positive and node negative/positive disease. The purpose of this study was to investigate the relationship of race and clinical characteristics (including Oncotype RS) in an insured population of highly screened women with newly diagnosed breast cancer. METHODS The Breast Cancer Database of our institution was queried for patients who were newly diagnosed with breast cancer. We looked at demographics, risk factors, tumor characteristics, and Oncotype RS. Statistical analyses included Pearsons Chi-Square and Fishers Exact Tests. RESULTS A total of 1,767 women were diagnosed with breast cancer from 1/2010 to 4/2014. The median age was 59 years. There was a total of 1327 (75%) Whites, 162 (9%) Blacks, 163 (9%) Asians, and 108 (6%) Hispanics. Majority of patients had a college-level education (83%), had annual/biannual screening mammography (78%), and clinical breast exams (89%). Majority of patients had invasive ductal carcinoma (61%), early stage (0, I, II) tumors (94%), ER+ (85%), PR+ (72%), Her2-negative (86%), and node-negative disease (80%). Compared to Whites, there was a significantly higher proportion of later stage disease among Blacks (p = 0.001) and Asians (p = 0.003), more triple negative breast cancers among Blacks (p < 0.0001) and higher Ki-67 scores among Blacks (p < 0.001) and Asians (p < 0.001). Oncotype RS was not significantly different among the race categories and a majority of patients had a low Oncotype RS (57%). These results did not change after stratifying for nodal status. CONCLUSIONS In a population of women who had health insurance and were highly screened, we found clinical differences among races with respect to tumor histology. However, we did not find a statistically significant difference among race and Oncotype RS, even after stratifying for nodal status. Further studies are warranted to determine which tumor proliferation markers are contributing to ethnic differences in breast cancer mortality.

A Decade of Change: An Institutional Experience with Breast Surgery in 1995 and 2005

Introduction With the adoption of routine screening mammography, breast cancers are being diagnosed at earlier stages, with DCIS now accouting for 22.5% of all newly diagnosed breast cancers. This has been attributed to both increased breast cancer awareness and improvements in breast imaging techniques. How have these changes, including the increased use of image-guided sampling techniques, influenced the clinical practice of breast surgery? Methods The institutional pathology database was queried for all breast surgeries, including breast reconstruction, performed in 1995 and 2005. Cosmetic procedures were excluded. The results were analysed utilizing the Chi-square test. Results Surgical indications changed during 10-year study period, with an increase in preoperatively diagnosed cancers undergoing definitive surgical management. ADH, and to a lesser extent, ALH, became indications for surgical excision. Fewer surgical biopsies were performed for indeterminate abnormalities on breast imaging, due to the introduction of stereotactic large core biopsy. While the rate of benign breast biopsies remained constant, there was a higher percentage of precancerous and DCIS cases in 2005. The overall rate of mastectomy decreased from 36.8% in 1995 to 14.5% in 2005. With the increase in sentinel node procedures, the rate of ALND dropped from 18.3% to 13.7%. Accompanying the increased recognition of early-stage cancers, the rate of positive ALND also decreased, from 43.3% to 25.0%. Conclusions While the rate of benign breast biopsies has remained constant over a recent 10-year period, fewer diagnostic surgical image-guided biopsies were performed in 2005. A greater percentage of patients with breast cancer or preinvasive disease have these diagnoses determined before surgery. More preinvasive and Stage 0 cancers are undergoing surgical management. Earlier stage invasive cancers are being detected, reflected by the lower incidence of axillary nodal metastases.

Abstract A29: Mathematical models are not the be-all and end-all for breast cancer risk assessment

Purpose: Well-established risk factors for breast cancer include family history (FH), BRCA mutations and biopsies with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS). Several mathematical models, including the Gail and Tyrer-Cuzick models, have been developed to quantify a patient9s risk for developing breast cancer. These models all differ in the list of variables and risk factors that are included in risk calculations. As a result, there is no single model that best estimates the risk for all high risk patients. The purpose of this study is to examine the application of the Gail and Tyrer-Cuzick models in a contemporary cohort of women who are enrolled in a comprehensive high-risk breast cancer database. Methods: The institutional High Risk Breast Cancer Consortium (HRBCC) was established in January 2011. Patients who were at high risk for developing breast cancer based on family history (maternal and paternal), BRCA mutations, AH and LCIS were eligible to enroll in the database. The following variables were included in this analysis: age, family history, genetic testing results, reproductive history, AH, LCIS, Gail and Tyrer-Cuzick scores, risk reduction strategies, and outcomes. All clinical data are obtained from detailed questionnaires filled out by patients who consent to the database studies and from a review of electronic medical records. Descriptive statistics were performed. Results: A total of 604 women were enrolled between 1/2011-2/2016. The median age was 51 years (range 20-87). The majority of women were Caucasian (83%). 52% had a strong FH, 13% were BRCA1 and 2 positive, 48% had AH, and 22% had LCIS. 47% of patients in our high risk program were not eligible for Gail model analysis (age 84 years. For patients who were eligible for Gail model analysis, 26 (8%) women did not meet criteria (5-year risk ≥1.7%) for being designated as high risk for breast cancer. 34 (6%) of our patients did not have Tyrer-Cuzick scores over 20% (criterion for high risk). Notably, majority of the patients (69%) who were not defined as high-risk based on Gail scores ≥1.7% or Tyrer-Cuzick scores ≥20%, had a strong family history of breast cancer. Only 14 (2%) patients developed breast cancer during our study period, and the majority (93%) of the cancers were early stage (stage 0,I). Conclusions: Our institutional high-risk database includes women who are at high risk based on well-established risk factors for developing breast cancer (FH, BRCA mutations, AH, LCIS). Current mathematical models including the Gail and Tyrer-Cuzick models did not capture the increased risk of breast cancer in 8% of our population. While the models are helpful, in clinical practice they are not necessarily the be-all and end-all. Using heuristic risk factors is more time efficient and comprehensive risk assessment allows the clinicians and patients to better understand risk. Identifying patients as high risk and enrolling them in a high-risk database and program allow us to capture long term follow up, recommend surveillance for early detection, and better understand the effectiveness of different risk reduction and management strategies for this population. Citation Format: Freya Schnabel, Jennifer Chun, Shira Schwartz, Amber Guth, Deborah Axelrod, Richard Shapiro, Karen Hiotis, Julia Smith. Mathematical models are not the be-all and end-all for breast cancer risk assessment. [abstract]. In: Proceedings of the AACR Special Conference: Improving Cancer Risk Prediction for Prevention and Early Detection; Nov 16-19, 2016; Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(5 Suppl):Abstract nr A29.