Kezhen Fei

Underuse of Breast Cancer Adjuvant Treatment: Patient Knowledge, Beliefs, and Medical Mistrust

PURPOSE Little is known about why women with breast cancer who have surgery do not receive proven effective postsurgical adjuvant treatments. METHODS We surveyed 258 women who recently underwent surgical treatment at six New York City hospitals for early-stage breast cancer about their care, knowledge, and beliefs about breast cancer and its treatment. As per national guidelines, all women should have received adjuvant treatment. Adjuvant treatment data were obtained from inpatient and outpatient charts. Factor analysis was used to create scales scored to 100 of treatment beliefs and knowledge, medical mistrust, and physician communication about treatment. Bivariate and multivariate analyses assessed differences between treated and untreated women. RESULTS Compared with treated women, untreated women were less likely to know that adjuvant therapies increase survival (on a 100-point scale; 66 v 75; P < .0001), had greater mistrust (64 v 53; P = .001), and had less self-efficacy (92 v 97; P < .05); physician communication about treatment did not affect patient knowledge of treatment benefits (r = 0.8; P = .21). Multivariate analysis found that untreated women were more likely to be 70 years or older (adjusted relative risk [aRR], 1.11; 95% CI, 1.00 to 1.13), to have comorbidities (aRR, 1.10; 95% CI, 1.04 to 1.12), and to express mistrust in the medical delivery system (aRR, 1.003; 95% CI, 1.00 to 1.007), even though they were more likely to believe adjuvant treatments were beneficial (aRR, 0.99; 95% CI, 0.98 to 0.99; model c, 0.84; P < or = .0001). CONCLUSION Patient knowledge and beliefs about treatment and medical mistrust are mutable factors associated with underuse of effective adjuvant therapies. Physicians may improve cancer care by ensuring that discussions about adjuvant therapy include a clear presentation of the benefits, not just the risks of treatment, and by addressing patient trust in and concerns about the medical system.

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.

Utilization of Oncotype DX in an Inner City Population: Race or Place?

Oncotype DX, a 21-gene-array analysis, can guide chemotherapy treatment decisions for women with ER+ tumors. Of 225 ER+ women participating in a patient assistance trial, 23% underwent Oncotype DX testing: 31% of whites, 21% of blacks, and 14% of Hispanics (P = 0.04) were tested. Only 3 white women were treated at municipal hospitals and none was tested. 3% of women treated in municipal hospital as compared to 30% treated at tertiary referral centers were tested (P = 0.001). Within tertiary referral centers, there was no racial difference in testing: 32% of whites, 29% of blacks, and 19% of Hispanics (P = 0.25). Multivariate analysis (model c-statistic = 0.76; P < 0.0001) revealed that women who underwent testing were more likely to have stage 1B (RR = 1.70; 95% CI: 1.45–1.85) and to be treated after 2007 (RR = 1.34; 95% CI: 1.01–1.65) and less likely to be treated at a municipal hospital (RR = 0.20; 95% CI: 0.04–0.94). Women treated at municipal hospitals were less likely to undergo testing resulting in a misleading racial disparity that is driven by site of care. As Oncotype DX can reduce overuse of chemotherapy, it is imperative to expand testing to those who could benefit from yet experience underuse of this test, namely, women treated at safety net hospitals. This trial is registered with NCT00233077.

Understanding the Challenges of Adjuvant Treatment Measurement and Reporting in Breast Cancer Cancer Treatment Measuring and Reporting

Background:Healthcare accrediting organizations and insurers increasingly require reporting of clinical data, and cancer treatment is one area of enhanced scrutiny. Objectives:To compare rates of received versus reported adjuvant breast cancer treatments, and to assess barriers to measuring and reporting treatments to the tumor registry (TR) of a high-volume medical center with both hospital-based and community-based oncologists. Research Design:We calculated rates of received treatments using data collected using chart abstraction (N=115) and compared these with rates of reported treatments from the TR (N=535). We conducted 31 indepth interviews with clinical and administrative informants. Asking about perceptions of the TR, current reporting methods, and reporting barriers. Interviews were recorded, transcribed, and analyzed using deductive and inductive methods. Results:Rates of reported versus received treatments were radiation therapy after breast-conserving surgery 22% versus 84% (P < 0.0001); chemotherapy for stage 2 or 3: 17% versus 79% (P < 0.0001); hormonal therapy for stage 2 or 3: 1% versus 91% (P < 0.0001). Comparing community-based versus hospital-based oncologists’ rates reported to the TR, we found the following differences: radiation therapy post-breast conserving surgery 12% versus 32% (< 0.0001); chemotherapy 8% versus 29% (< 0.0001); and hormonal therapy 0% versus 3% (0.09). We found 4 key barriers to measuring and reporting poor understanding about the TR, limited information technology capabilities, poor communication, and mistrust. Conclusions:Efforts to improve cancer care quality by improved treatment reporting must overcome key barriers, especially those involving information exchange and mistrust. Communications between the TR and oncology practices must improve to facilitate better treatment measurement and reporting.

Breast cancer patients' recall of receiving patient assistance services.

BackgroundThe objective of this study was to assess factors that affect breast cancer patients’ recall of patient assistance services.MethodsWe surveyed newly-diagnosed breast cancer patients and compared recall of receiving patient assistance services at 2 weeks and 6 months in a patient-assistance randomized controlled trial aimed to connect women to such programs. The intervention group received information about assistance programs targeted to their practical, psychosocial, and/or informational needs; the control group received a Department of Health pamphlet about breast cancer and its treatment, including a list of patient assistance services.FindingsOf 333 women, 210 (63%) reported informational, 183 (55%) psychosocial and 177 (53%) practical needs. At 2 weeks, 96% (202/210) of women with informational needs reported receiving informational material but at 6 months, recall dropped to 69% (140/210). All women whose informational needs were met recalled receiving information, compared to 31% whose needs were unmet (p < 0.0001). Of 109 intervention patients with psychosocial or practical needs, 77% (79) contacted a program specified in their action plan at 2 weeks. However, at 6 months, only 39% (31/79) recalled contacting a program. Women without recall were less likely to report having their needs met (6% vs. 58%; p < 0.001).ConclusionsRecall of patient assistance services is strongly related to having needs met. Use of patient surveys to evaluate utilization or impact of such programs should be used with caution due to poor patient recall.Clinical Trials # NCT00233077http://www.clinicaltrials.gov/ct2/show/NCT00233077?term=Nina+Bickell&rank=2

Caution Ahead: Research Challenges of a Randomized Controlled Trial Implemented to Improve Breast Cancer Treatment at Safety-Net Hospitals

PURPOSE To implement and test a Web-based tracking and feedback (T&F) tool to close referral loops and reduce adjuvant breast cancer treatment underuse in safety-net hospitals (SNHs). PATIENT AND METHODS We randomly assigned 10 SNHs, identified patients with new stage 1 to stage 3 breast cancer, assessed their connection with the oncologist, and relayed this information to surgeons for follow-up. We interviewed key informants about the tools usefulness. We conducted intention-to-treat and pre- and poststudy analyses to assess the T&F tool and implementation effectiveness, respectively. RESULTS Between the study start and intervention implementation, several hospitals reorganized care delivery and 49% of patients scheduled to undergo breast cancer surgery were ineligible because they already were in contact with an oncologist. One high-volume hospital closed. Despite randomization of hospitals, intervention (INT) hospitals had fewer white patients (5% v 16%; P = .0005), and more underuse (28% v 15%; P = .002) compared with usual care (UC) hospitals. Over time, INT hospitals with poorer follow-up significantly reduced underuse compared with UC hospitals (INT hospitals, from 33% to 9%, P = .001 v UC hospitals, from 15% to 11%, P = .5). There was no difference in underuse (9% at INT hospitals, 11% at UC hospitals; P = .8). Hospitals with better follow-up (odds ratio, 0.85; 95% CI, 0.73 to 0.98) had less underuse. In settings with poor follow-up and tracking approaches, key informants found the tool useful. The rapidly changing delivery landscape posed significant challenges to this implementation research. CONCLUSION A T&F tool did not significantly reduce adjuvant underuse but may help reduce underuse in SNHs with poor follow-up capabilities. Inability to discern T&F effectiveness is likely due to encountered challenges that inform lessons for future implementation research.

Racial Disparities in Clinically Significant Prostate Cancer Treatment: The Potential Health Information Technology Offers

PURPOSE Black men are more likely to die as a result of prostate cancer than white men, despite effective treatments that improve survival for clinically significant prostate cancer. We undertook this study to identify gaps in prostate cancer care quality, racial disparities in care, and underlying reasons for poorer quality care. METHODS We identified all black men and random age-matched white men with Gleason scores ≥ 7 diagnosed between 2006 and 2013 at two urban hospitals to determine rates of treatment underuse. Underuse was defined as not receiving primary surgery, cryotherapy, or radiotherapy. We then interviewed treating physicians about the reasons for underuse. RESULTS Of 359 black and 282 white men, only 25 (4%) experienced treatment underuse, and 23 (92%) of these were black. Most (78%) cases of underuse were due to system failures, where treatment was recommended but not received; 38% of these men continued receiving care at the hospitals. All men with treatment underuse due to system failures were black. CONCLUSION Treatment rates of prostate cancer are high. Yet, racial disparities in rates and causes of underuse remain. Only black men experienced system failures, a type of underuse amenable to health information technology-based solutions. Institutions are missing opportunities to use their health information technology capabilities to reduce disparities in cancer care.

Patient and clinician perspectives on treatment decision-making for African American men with prostate cancer.

186 Background: Prostate cancer is the most common cancer for men in the US, yet the burden of this disease falls disproportionately on African Americans (AAs). The disparitys etiology is complex. Surgery and radiotherapy offer similar survival but historically have different rates of performance with younger and white men more likely to undergo surgery and AAs more likely to experience underuse. This study aims to examine treatment decision-making (TDM) processes for AA men from patient and physician perspectives. METHODS At 1 academic and 1 municipal urban hospital, pathology records and a tumor registry from 2007-2012 were used to identify 359 AA and 282 white men with locally advanced prostate cancer, a Gleason score of 7-10, and receipt of definitive treatment. 15/17 treating physicians of participating patients were interviewed. Underuse overall was 4%, AA had higher rate of underuse compared to whites (6% vs. 1% respectively, p = 0.0002). 14 patients with longer times between diagnosis and treatment were recruited for 4 focus groups & 2 interviews lasting 60-90 minutes eliciting perspectives on themes related to TDM. Transcripts were coded and analyzed using a grounded theory approach. RESULTS Preliminary analysis of patient interviews suggests that patients primarily base their treatment decisions on physician recommendations. Patients were often unaware of treatment side effects. However, some patients felt this deficit helped them decide to receive treatment, whereas if they had known about possible impotence and incontinence, they would have refused treatment. Physicians recognized that patient concerns about side effects were a critical TDM factor. Physicians attributed prolonged delays between diagnosis and treatment to waiting times for tests of possible tumor spread and medical comorbidities. CONCLUSIONS Understanding decision making and care processes for AA men with local advanced prostate cancer is critical to reducing the treatment and outcome disparities in this population. This study identifies several patient and physician/system factors that contribute to this process. These data can help inform interventions to improve prostate cancer care for AA men.

Patient perception of choice in decision-making for early stage breast cancer: does race and socioeconomic status matter?

To the Editor: It has recently been recognized that women with breast cancer who have a choice of surgical type have better short-term health status, suggesting that choice may help with recovery. However, women with a new diagnosis of breast cancer do not always have a clear understanding of surgical options, and the implication of these choices in terms of local recurrence and long-term survival. Among women recently diagnosed with early-stage breast cancer, only 16% knew that local recurrence rates were different for mastectomy (MT) and breastconserving surgery (BCS); 48% knew that survival rates were equivalent for these two treatments. Surgical options may not always be fully presented to the patients; only 33% of women eligible for either MT or BCS have reported their surgeon discussed postmastectomy reconstruction. This information-giving influences surgical choice, as women who reported this discussion were four times more likely to undergo mastectomy than those women who did not. Among older patients, those who reported that their surgeons mentioned more treatment options were more likely to perceive that they had a surgical choice, and to chose BCT. We undertook this study to determine which factors are associated with a woman’s sense of choice in her surgical treatment, among a racially and socioeconomically diverse cohort of women with earlystage breast cancer. Women with newly diagnosed stage I ⁄ II breast cancer during 2004–2006 were identified from pathology databases of six participating New York City hospitals (three Municipal hospitals, two Tertiary, one Community hospital). These patients were enrolled in an ongoing study to reduce disparities in breast cancer care. Patients were interviewed an average of 11 months from the time of surgery (range: 6–28 months). The survey assessed patients’ beliefs, attitudes, and knowledge about breast cancer and treatment, as well as their experiences with care. Patients treated with MT versus BCS were compared (Table 1). A separate analysis compared responses of patients who felt they had a choice of surgical treatment to those who did not (Table 2). Bivariate comparisons were conducted with t-tests and chi-squared test (Table 3). Cronbach’s alpha was used to evaluate the internal consistency

Abstract 5497: Breast cancer treatment decision-making: Are we asking too much of patients

Background. Physicians are mandated to offer treatment choices to breast cancer patients yet not all patients may want the responsibility that entails. Prior studies show that breast cancer patients who are not given enough responsibility for treatment decision-making have poorer treatment knowledge and report worse quality of care. In contrast, few studies explore potential adverse consequences for breast cancer patients who feel they are given too much responsibility for treatment decision-making. Methods. We sought to describe and compare women by degree of responsibility they felt they had for making decisions about their breast cancer treatment. Our sample includes women with early-stage breast cancer treated surgically at 8 NYC hospitals, recruited for an RCT of patient assistance to improve receipt of adjuvant treatment. In multivariable analyses, we explored the association between treatment decision-making responsibility and a) baseline knowledge of benefit of surgical and adjuvant treatments discussed with doctor and b) regret of treatment decisions after 6 months. Results. Of 368 women aged 28-89y enrolled at baseline, 72% reported a “reasonable amount,” 21% “too much,” and 7% “not enough” responsibility for treatment decision-making. The majority in the first group were White (53%), earned >