Katherine Y. Tossas-Milligan

Do hospitals in a large metropolitan area utilize published breast cancer care practices and guidelines

151 Background: Insufficient utilization of guideline and evidence based care practices contribute to the cancer crisis (IOM 2013). We examined utilization of published breast cancer (BC) care practices and guidelines at hospitals in a large metropolitan area. METHODS IRB approved web survey of all 35 hospitals in a large metro area that provide BC treatment. Using guidelines/recommendations (NCCN, NAPBC, ADA, IOM) and peer-reviewed literature (62 studies) we developed a survey on BC care practices. Results analyzed by simple frequencies and Fishers exact test. RESULTS Response rate: 91% (32/35 sites). Care practices, included in the table, are utilized by < 50% of sites. Radiation oncologist preoperative consults (53%, 8/15) and offering indicated pre-operative chemo* (67%, 10/15) are associated with 15 sites that have high volume (67+/year, Chen CS 2008) BC surgeons, compared to 17 sites without high volume BC surgeons (12%, 2/17) and (24%, 4/17) respectively, p=0.02, p=0.03. Indicated supportive services, such as a dental checkups (ADA 2008), are more likely at sites with patient-centered written treatment plans (IOM 2011) (58%, 7/12) than at sites without written treatment plans (10%, 2/20), p=0.006. CONCLUSIONS Low utilization of published care practices and guidelines is concerning and requires attention. Other metro areas and regions should be examined as our findings indicate that patients may have limited local choices of care that is up-to-date on published guidelines and practices. [Table: see text].

Abstract PR08: Tumor masking or tumor aggressiveness? A structural equations modeling approach to estimate the impact of breast density on breast cancer stage, overall and by race

Background: Non-Latina (nL) black women are diagnosed at later stages and with more aggressive forms of breast cancer than their nL white counterparts, including higher-grade tumors and those that lack estrogen and progesterone receptors (ER/PR negative). High breast density (HBD) is a strong risk factor for a late-stage breast cancer diagnosis among women undergoing mammography screening, yet nL black women are slightly less likely to have dense breasts according to the standard clinical classification method. We previously found that after adjusting for differences in obesity using body mass index (BMI), nL black women were substantially more likely to have dense breasts compared to nL white women. Dense breast tissue can mask tumors and cause them to go undetected at screening, only to arise later as a lump, discovered symptomatically when they later stage. It is also conceivable that dense breast tissue could predispose women to develop more aggressive breast cancers that grow more rapidly, are more likely to arise between screens as “true interval” cancers, and therefore might be detected with more frequent screening. We used path analysis (or structural equations modeling, SEM) to estimate the separate contributions of tumor masking and tumor aggressiveness in mediating HBD9s associations with later stage, overall and by race. Methods: We used data on 4691 women from the Metropolitan Chicago Breast Cancer Registry, aged 40-79, and diagnosed at stages 1 (early), 2,3 or 4 (later), between 2001 and 2013. Breast density was obtained from the screening mammogram preceding diagnosis. Mode of detection was defined dichotomously as symptomatic versus screen detected. Path analysis (conducted in Mplus) was used to estimate the age, race, and BMI adjusted, direct and indirect effects of HBD on stage at diagnosis. Because estimates can vary depending on model assumptions, we ran simultaneous linear regression models and also ran simultaneous ordered probit regression models. In both sets of models we estimated the relative contributions of tumor masking and tumor aggressiveness in transmitting the association of HBD with stage at diagnosis. Results: A one-unit increase in BD was associated with a 9-percentage-point increased prevalence of later stage (stage 2,3,4, vs. 1) at diagnosis. Roughly one third of the HBD, later-stage association could be explained by tumor masking, and virtually none of the association could be explained by tumor aggressiveness. Similar results were obtained for linear and ordered probit models. Results were broadly similar for nL black and nL white women. Conclusion: Ours is the first analysis we are aware of to formally confirm via mediation analyses that tumor masking is the primary process through which women with dense breasts are disproportionately diagnosed at later stages. To reduce opportunities for tumor masking, women with dense breasts are often referred for supplemental/advanced imaging with breast MRI, ultrasound, or (increasingly) tomosynthesis. We think it is likely that the current criteria for referring women for advanced imaging based on breast density may contribute to racial disparities because (1) they do not account for the greater prevalence of more aggressive breast cancer in nL black patients, and (2) they do not account for the disproportionate prevalence of obesity among nL black women, which may obscure the usefulness of the usual clinical classification method of BMI in making referrals for supplemental imaging. Citation Format: Katherine Y. Tossas-Milligan, Garth H. Rauscher, Richard Campbell, Victoria Seewaldt. Tumor masking or tumor aggressiveness? A structural equations modeling approach to estimate the impact of breast density on breast cancer stage, overall and by race [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR08.

Performance characteristics of digital vs film screen mammography in community practice

We compared the performance characteristics of 297 629 full field digital (FFDM) and 416 791 screen film mammograms (SFM). Sensitivity increased with age, decreased with breast density, and was lower for more aggressive and lobular tumors. While sensitivity did not differ significantly by modality, specificity was generally 1%‐2% points higher for FFDM than for SFM across age and breast density categories. The lower recall rate for FFDM vs SFM in our study may partially explain performance differences by modality. In this large health care organization, modest gains in performance were achieved with the introduction of FFDM as a replacement for SFM.

Abstract C43: Is the influence of high mammographic breast density on breast cancer incidence the same for non-Latina black and white women?

Background: Non-Latina Black (black) women, despite their lower BC incidence, are more likely to die from breast cancer compared to their nL White (white) counterparts. While differential access to care, comorbidities and BC aggressiveness are potential contributors to this difference, the potential impact of HMD on this disparity has rarely been explored. For example, nL black women are disproportionately diagnosed with more aggressive tumors that lack estrogen and progesterone receptors (ER and PR) and that are high grade. Therefore, if the association of HMD with breast cancer incidence varied by tumor subtype this could have implications for disparities in breast cancer aggressiveness and subsequent outcomes. Most of the conclusions establishing high mammographic breast density (HMD) as a risk factor for increased breast cancer incidence are derived from studies conducted primarily in whites, which jeopardizes generalizability. We sought to estimate the association between HMD and breast cancer incidence separately for white and black women and by tumor subtype, using data from a single, large healthcare organization. Methods: We used data from screening mammograms performed in women ages 18-100, between 2001 and 2010, probabilistically linked to incident BC cases recorded in the Illinois State Cancer Registry (ISCR) during 2001-2011. Each screening mammogram received a breast density score from the interpreting radiologist using the American College of Radiology Breast Imaging Reporting and Data System (BIRADS 1-4), defined as fatty (BIRADS 1), scattered fibroglandular (BIRADS 2), heterogeneously dense (BIRADS 3) or extremely dense (BIRADS 4). A mean BIRADS breast density score was calculated using available scores from both breasts at each exam. The mean was dichotomized as high (mean BIRADS score > 2.5) versus low (mean BIRADS score ≤2.5) and the dichotomous variable was modeled in logistic regression with generalized estimating equations (to account for multiple screens per woman) to estimate the association between breast density and the probability of a breast cancer diagnosis within 12 months of the screen. Models included age, race, family history, parity and exam year as covariates, and separate models were estimated for black and white women. Odds ratios were interpreted as rate ratios (RR) due to the rarity of the outcome ( Results: Included in this analysis were 616,466 screens on 201,348 white or black women during 2001-2010, and 4,104 BC in 3,706 women during 2001-2011 (overall rate of 6.7 per 1000 screens, 6.7 for whites and 6.5 for blacks, p=0.21). There were disparities in the distribution of tumor subtypes: breast cancers diagnosed in black women were more likely to be ER negative (23% vs. 15%, p Discussion: Our findings reiterate high breast density as a risk factor for breast cancer incidence. In addition, we found that the association was of roughly equal magnitude among white and black women, and of roughly equal magnitude for ER negative and ER positive tumors. The stronger association of HMD with high grade tumors, however, implies that HMD may be a more detrimental risk factor for black women who are more likely to experience higher grade tumors than white women. Citation Format: Katherine Y. Tossas-Milligan, Firas Dabbous, Garth Rauscher. Is the influence of high mammographic breast density on breast cancer incidence the same for non-Latina black and white women? [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C43.

Abstract PR03: A reverse, racial disparity with respect to interval breast cancer rates within a large healthcare organization has implications for eliminating disparities more generally

Background: It is well established that Non Latina (nL) Black patients are more likely than nL white (white) patients to be diagnosed with more aggressive forms of breast cancer. In addition, prior population-based research conducted in Chicago suggests that black women tend to be screened at lower resource facilities, and may also have screening images of lower quality and be more likely to have their breast cancer missed at interpretation. Consistent with all of these observations, black patients were more likely to report symptomatic awareness of their breast cancer despite a recent asymptomatic screening mammogram in the Breast Cancer Care in Chicago study. Therefore, black women may be more likely than their white counterparts to have a breast cancer diagnosis following a negative screen (so-called interval breast cancer). METHODS: The goal of the present study was to examine potential disparities in interval breast cancer (IBC) using data from approximately 30 mammography sites (including 8 hospital-based sites) within a single large health care organization in metropolitan Chicago. Methods: A screening mammogram was defined as a bilateral mammogram with a description of screening in the radiology database, in women without a prior history of breast cancer, mastectomy, or breast implants, and without any imaging in the 9 months prior to the screen. We linked 761,908 screening examinations conducted between 2001-2010 to breast cancer incidence data from the Illinois state cancer registry, using probabilistic methods. After excluding other race/ethnicities for this analysis, we identified 4829 breast cancers diagnosed between 2001 and 2011 and within 12 months of a screen. An interval breast cancer was defined as a breast cancer diagnosed within 12 months of a negative screening mammogram (BIRADS 1,2). IBC was modeled in logistic regression with generalized estimating equations (to account for multiple screens per woman) while adjusting for age, parity, breast density, race, family history, parity and exam year, ER status, tumor grade, and individual screening facility as covariates. Of the 31 facilities with data, 18 smaller screening facilities with less than 20 associated breast cancer diagnoses were collapsed into a single category. Model-based standardization (predictive margins) was used to estimate adjusted prevalence differences (PDs) in IBC from the logistic regression models, and 95% bias-corrected bootstrap confidence intervals were obtained (1000 replications). Results: Before adjusting for mammography site, black patients were, contrary to expectation, less likely to experience an IBC than white patients (1.36 vs. 1.83 per 1000 screens, adjusted Rate Difference or RD = - 0.47 per 1000 screens, p Conclusion: In this large healthcare organization, we observed a reverse disparity such that white patients were more likely than their black counterparts to experience an IBC, but the association disappeared when we took mammography site into account in the analysis. These results suggest that higher quality mammography screening resources are more widely accessible to black than white patients within this organization. Larger volume facilities within this organization tend to be located in urban areas with higher proportions of black women, whereas smaller standalone facilities tend to be located in the suburbs where there are a higher proportion of white women. These standalone facilities may be less likely to employ breast imaging specialists and less likely provide multimodality breast imaging in a multidisciplinary setting, and these differences may be contributing to differential access to quality screening that benefits black women. The larger implication of these findings is that at a population level, racial disparities in breast cancer could perhaps be ameliorated or even eliminated if resources were disproportionately made more available to black women. In order to overcome breast cancer disparities and create true equity in care, disproportionate resource allocation solutions may be necessary. This abstract is also presented as Poster C61. Citation Format: Garth H. Rauscher, Firas Dabbous, Terry Dolecek, Terry Macarol, Katherine Tossas-Milligan, Jenna Khan, Sarah Friedwald, Wm. Thomas Summerfelt. A reverse, racial disparity with respect to interval breast cancer rates within a large healthcare organization has implications for eliminating disparities more generally. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr PR03.

Abstract B84: Racial/ethnic and socioeconomic disparities in access to screening mammograms in a statewide sample of mammography facilities in Illinois

Purpose: The purpose of this study was to use data collected from a recent Metropolitan Chicago Breast Cancer Task Force (MCBCTF) survey to explore racial/ethnic and socioeconomic disparities in access to screening and diagnostic services for breast cancer in Illinois and to compare equitable access to services for Chicago versus the rest of the state. Methods: Facilities that performed mammography were recruited to participate in a quality improvement project that included completing a facility survey. Participants who completed surveys received an increased mammogram reimbursement for Medicaid patients to equal the Medicare rate from the Illinois Department of Healthcare and Family Service. The survey included the following data elements: number of digital and analog machines, number of radiologists dedicated (>75% of their time) to breast imaging and number of general radiologists, number of dedicated and general mammography technicians, monthly volumes of screening and diagnostic mammograms, and whether breast ultrasound, MRI, or image-guided biopsy services were available at the site. In addition, sites reported the percentage of patients who were African-American (AA) or Hispanic, and the percentage of patients who were uninsured and on Medicaid, in categories of >10, 10-25, 25-40, 40-60, 60-75, 75-90, and >90%. Within each patient group defined by ethnicity and health insurance status, we estimated the number of screening mammograms performed separately for facilities with none, partial and sole reliance on dedicated radiologists, and separately by facility availability of breast MRI and image-guided biopsy. In all, 156 out of 359 facilities accredited by the Food and Drug Administration completed the survey, representing approximately 8.2 million screening mammograms conducted in calendar year 2012 in Illinois. Results: Overall, about 3/4 of screening mammograms were performed in nH whites and 4/5 in privately insured patients. Within the city of Chicago, 47% and 30% were performed in ethnic minorities and those without private insurance, compared to 21% and 15% in the rest of the state. Within Chicago, mammograms were more than twice as likely to be performed at facilities relying solely on dedicated radiologists when compared to the rest of the state (39% vs. 17%). In Chicago, non-Hipanic Whites were more likely than their AA and Hispanic counterparts to be screened at facilities relying solely on dedicated radiologists (50% vs. 27% and 15%, respectively) and at facilities with MRI (90% vs. 57% and 71%) and biopsy services (92% vs. 63% and 79%). In a similar manner, privately insured patients were more likely than Medicaid and uninsured patients to be screened at facilities that relied solely on dedicated radiologists (44% vs. 13% and 18%, respectively). When examining equitable access to these services for the rest of the state as a whole, very little was noted in the way of disparities by race/ethnicity or insurance status. Conclusions: Disparities in equitable access to breast cancer screening and diagnostic services exist within Chicago that are generally absent outside of the city. The concentration of academic medical centers within Chicago, while increasing access to quality breast healthcare, has also introduced racial/ethnic and socioeconomic disparities due to unequal access to these academic medical centers. Citation Format: Bethliz Irizarry, Katherine Y. Tossas-Milligan, Garth Rauscher, Anne Marie Murphy. Racial/ethnic and socioeconomic disparities in access to screening mammograms in a statewide sample of mammography facilities in Illinois. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B84.

Abstract B79: Trends in mammography quality benchmarks met over time: Moving beyond the Mammography Quality Standards Act to address breast cancer disparities

Backround: In 2007, the Metropolitan Chicago Breast Cancer Taskforce (The Taskforce) was initiated to identify the reasons for an alarming Black/White breast cancer mortality gap in metropolitan Chicago and to propose solutions. One hypothesis raised was that unequal access to high quality breast cancer screening and treatment care may be a significant driver of Chicago9s breast cancer disparity. While there is growing interest in the role of breast cancer screening quality in explaining black/white breast cancer mortality gap, there is no research to our knowledge assessing quality measures about the breast cancer screening processes within facilities across the state of Illinois. We summarize data and report trends on 11 breast cancer screening metrics from 3 years of mammography quality data surveillance for facilities in Illinois. Methods: The Taskforce collected aggregate data on 11 breast cancer screening quality metrics for calendar years 2006, 2009, and 2011, including the number of screening mammograms that: received follow-up imaging within 30 days and 12 months; received a biopsy recommendation within 12 months of the screen; resulted in a biopsy recommendation within 12 months; resulted in a biopsy (following recommendation) within 60 days and 12 months of the screen, respectively. Finally, we requested the number of cancers diagnosed within 12 months of an abnormal screening mammogram and the number of these that were minimal and early stage cancers. Data were analyzed for the 32 facilities that submitted metrics across all 3 years. The change in the mean number of benchmarks met was estimated using linear regression using a generalized estimating equations approach with exchangeable correlation matrix and robust standard errors to account for clustering by site. At each time point 95% confidence intervals were estimated. Results: Out of 11 possible metrics, the average number of benchmarks met by each facility for 2006, 2009 and 2011 was 4.88, 7.06 and 8.09, respectively. This represented a 0.65 increase in the overall mean number of benchmarks met by calendar year (95%CI=0.44, 0.75) (or an overall 1.61 increase in the overall mean number of benchmarks met per time point, 95%CI=1.16, 1.97). With respect to individual benchmarks, the proportion of facilities able to show that they met the benchmarks increased substantially between 2006 and 2011 for many benchmarks including cancer detection rate (0.66 to 0.91, p=0.008), proportion of breast cancers diagnosed as minimal (0.28 to 0.88, p=0.0000) and early stage (0.22 to 0.66, p=0.000). Other benchmarks remained unmet by a majority of facilities despite showing substantial improvement over time. These included timely imaging within 30 days of the screen (0.28 to 0.44, p=0.077), and timely biopsy within 60 days of the screen (0.13 to 0.42, p=0.002). Discussion: The American College of Radiology recommends that facilities meet certain additional quality benchmarks above and beyond the audit requirements of the Mammography Quality Standards Act. These include measuring the proportion of abnormal screening mammograms, timeliness of follow-up, extent of screen-detection (i.e., cancer detection rate for screening mammograms), and ability to detect small and early stage tumors. To date, none of these recommendations have been incorporated into MQSA guidelines. The results of this quality improvement project show an overall improvement across time in the average number of quality benchmarks institutions can demonstrate that they meet. Much of this improvement likely stems from an increased ability to collect and report the data needed to construct these measures. Lack of timeliness of diagnostic imaging and biopsy services remain a clear shortcoming for many facilities. Citation Format: Katherine Y. Tossas-Milligan, Bethliz Irizarry, AnneMarie Murphy, Garth H. Rauscher. Trends in mammography quality benchmarks met over time: Moving beyond the Mammography Quality Standards Act to address breast cancer disparities. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B79.

Do breast cancer treatment and imaging providers follow hereditary breast and ovarian cancer risk screening guidelines

207 Background: Women with personal or family history suggestive of susceptibility to hereditary breast or ovarian cancer (HBOC) should be referred to genetic assessment (USPSTF, Ann Intern Med. 2005). Women with HBOC have a 50-85% lifetime risk of breast cancer, 30-50% of breast cancer before 50 years old,15-50% lifetime risk of ovarian cancer, and 40-60% chance of developing a second breast cancer (ASCO Cancer.net HBOC 8/2013). Our goal is to examine if this almost decade old guideline is followed in breast cancer treatment and breast cancer imaging centers in a large metropolitan area. METHODS We conducted an IRB approved web survey of all 35 breast cancer treatment sites (5 academic, 21 community, 9 public or safety net) and 58 breast imaging sites (5 academic, 27 community, 26 public or safety net) in Chicago. Results were analyzed using simple frequencies and Fishers exact test. RESULTS We achieved a response rate of 91% (32/35 treatment sites, 53/58 imaging sites). We found that 56% (18/32) of treatment sites have a hereditary cancer syndrome (HBOC) screening process for newly diagnosed breast cancer patients. Most of these sites, 83% (15/18), always use genetic test results in surgical decisions, as compared to 21% (3/14) of sites that do not have an HBOC screening process, p=0.0009. Only 8% (4/53) of breast imaging sites have an HBOC screening process and provide indicated patients genetic assessment information and/or referrals. While 38% (20/53) of imaging sites conduct daily internal staff discussions of hereditary risk, only 15% of them (3/20) provide genetic assessment information to indicated patients. We found no statistically significant difference between practices of academic, community, public and safety net sites. CONCLUSIONS Breast cancer treatment sites have partial adherence to HBOC risk screening guidelines; while breast imaging sites rarely adhere to HBOC risk assessment guidelines. Consistent HBOC risk screening protocols are needed in breast cancer treatment and breast cancer imaging sites that include providing indicated patients information about, and access to, genetic assessment.