Oluwadamilola M. Fayanju

Perceived barriers to mammography among underserved women in a Breast Health Center Outreach Program

BACKGROUND To investigate perceived barriers to mammography among underserved women, we asked participants in the Siteman Cancer Center Mammography Outreach Registry-developed in 2006 to evaluate mobile mammographys effectiveness among the underserved-why they believed women did not get mammograms. METHODS The responses of approximately 9,000 registrants were analyzed using multivariable logistic regression. We report adjusted odds ratios (OR) and 95% confidence intervals (CI) significant at 2-tailed P values less than .05. RESULTS Fears of cost (40%), mammogram-related pain (13%), and bad news (13%) were the most commonly reported barriers. Having insurance was associated with not perceiving cost as a barrier (OR .44, 95% CI .40 to .49), but with perceiving fear of both mammogram-related pain (OR 1.39, 95% CI 1.21 to 1.60) and receiving bad news (OR 1.38, 95% CI 1.19 to 1.60) as barriers. CONCLUSION Despite free services, underserved women continue to report experiential and psychological obstacles to mammography, suggesting the need for more targeted education and outreach in this population.

Value-Based Breast Cancer Care: A Multidisciplinary Approach for Defining Patient-Centered Outcomes

PurposeValue in healthcare—i.e., patient-centered outcomes achieved per healthcare dollar spent—can define quality and unify performance improvement goals with health outcomes of importance to patients across the entire cycle of care. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution.MethodsContemporary breast cancer literature on treatment options, expected outcomes, and potential complications was extensively reviewed. Patient perspective was obtained via focus groups. Multidisciplinary physician teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration.ResultsOutcomes were divided into 3 tiers that reflect the entire cycle of care: (1) health status achieved, (2) process of recovery, and (3) sustainability of health. Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria and specifications for reporting. Patient data sources will include the Epic Systems EHR and validated patient-reported outcome questionnaires administered via our institution’s patient portal.ConclusionsAs healthcare costs continue to rise in the United States and around the world, a value-based approach with explicit, transparently reported patient outcomes will not only create opportunities for performance improvement but will also enable benchmarking across providers, healthcare systems, and even countries. Similar value-based breast cancer care frameworks are also being pursued internationally.

Measures of Appropriateness and Value for Breast Surgeons and Their Patients: The American Society of Breast Surgeons Choosing Wisely® Initiative

BackgroundCurrent breast cancer care is based on high-level evidence from randomized, controlled trials. Despite these data, there continues to be variability of breast cancer care, including overutilization of some tests and operations. To reduce overutilization, the American Board of Internal Medicine Choosing Wisely® Campaign recommends that professional organizations provide patients and providers with a list of care practices that may not be necessary. Shared decision making regarding these services is encouraged.MethodsThe Patient Safety and Quality Committee of the American Society of Breast Surgeons (ASBrS) solicited candidate measures for the Choosing Wisely® Campaign. The resulting list of “appropriateness” measures of care was ranked by a modified Delphi appropriateness methodology. The highest-ranked measures were submitted to and later approved by the ASBrS Board of Directors. They are listed below.Results(1) Don’t routinely order breast magnetic resonance imaging in new breast cancer patients. (2) Don’t routinely excise all the lymph nodes beneath the arm in patients having lumpectomy for breast cancer. (3) Don’t routinely order specialized tumor gene testing in all new breast cancer patients. (4) Don’t routinely reoperate on patients with invasive cancer if the cancer is close to the edge of the excised lumpectomy tissue. (5) Don’t routinely perform a double mastectomy in patients who have a single breast with cancer.ConclusionsThe ASBrS list for the Choosing Wisely® campaign is easily accessible to breast cancer patients online. These measures provide surgeons and their patients with a starting point for shared decision making regarding potentially unnecessary testing and operations.

Withdrawal of care in a potentially curable patient.

ordance with ACCME regulations, the American College of ns, as the accredited provider of this journal CME, must that anyone in a position to control the content of the tional activity has disclosed all relevant financial relationships ny commercial interest. The editor and author(s) of this article were required to complete disclosures and any reported conflicts have been managed to our satisfaction. However, if you perceive a bias within the article, please advise us of the circumstances on the evaluation form.

The American Society of Breast Surgeons and Quality Payment Programs: Ranking, Defining, and Benchmarking More Than 1 Million Patient Quality Measure Encounters

BackgroundTo identify and remediate gaps in the quality of surgical care, the American Society of Breast Surgeons (ASBrS) developed surgeon-specific quality measures (QMs), built a patient registry, and nominated itself to become a Center for Medicare and Medicaid Services (CMS) Qualified Clinical Data Registry (QCDR), thereby linking surgical performance to potential reimbursement and public reporting. This report provides a summary of the program development.MethodsUsing a modified Delphi process, more than 100 measures of care quality were ranked. In compliance with CMS rules, selected QMs were specified with inclusion, exclusion, and exception criteria, then incorporated into an electronic patient registry. After surgeons entered QM data into the registry, the ASBrS provided real-time peer performance comparisons.ResultsAfter ranking, 9 of 144 measures of quality were chosen, submitted, and subsequently accepted by CMS as a QCDR in 2014. The measures selected were diagnosis of cancer by needle biopsy, surgical-site infection, mastectomy reoperation rate, and appropriateness of specimen imaging, intraoperative specimen orientation, sentinel node use, hereditary assessment, antibiotic choice, and antibiotic duration. More than 1 million patient-measure encounters were captured from 2010 to 2015. Benchmarking functionality with peer performance comparison was successful. In 2016, the ASBrS provided public transparency on its website for the 2015 performance reported by our surgeon participants.ConclusionsIn an effort to improve quality of care and to participate in CMS quality payment programs, the ASBrS defined QMs, tracked compliance, provided benchmarking, and reported breast-specific QMs to the public.

Breast cancer patients' experiences within and outside the safety net.

BACKGROUND Following reforms to the breast-cancer referral process for our citys health Safety Net (SN), we compared the experiences from first abnormality to definitive diagnosis of breast-cancer patients referred to Siteman Cancer Center from SN and non-SN (NSN) providers. MATERIALS AND METHODS SN-referred patients with any stage (0-IV) and NSN-referred patients with late-stage (IIB-IV) breast cancer were prospectively identified after diagnosis during cancer center consultations conducted between September 2008 and June 2010. Interviews were taped and transcribed verbatim; transcripts were independently coded by two raters using inductive methods to identify themes. RESULTS Of 82 eligible patients, 57 completed interviews (33/47 SN [70%] and 24/35 NSN [69%]). Eighteen SN-referred patients (52%) had late-stage disease at diagnosis, as did all NSN patients (by design). A higher proportion of late-stage SN patients (67%) than either early-stage SN (47%) or NSN (33%) patients reported feelings of fear and avoidance that deterred them from pursuing care for concerning breast findings. A higher proportion of SN late-stage patients than NSN patient reported behaviors concerning for poor health knowledge or behavior (33% versus 8%), but reported receipt of timely, consistent communication from health care providers once they received care (50% versus 17%). Half of late-stage SN patients reported improper clinical or administrative conduct by health care workers that delayed referral and/or diagnosis. CONCLUSIONS Although SN patients reported receipt of compassionate care once connected with health services, they presented with higher-than-expected rates of late-stage disease. Psychological barriers, life stressors, and provider or clinic delays affected access to and navigation of the health care system and represent opportunities for intervention.

Surgical Education and Health Care Reform: Defining the Role and Value of Trainees in an Evolving Medical Landscape.

Objective: Health care reform and surgical education are often separated functionally. However, especially in surgery, where resident trainees often spend twice as much time in residency and fellowship than in undergraduate medical education, one must consider their contributions to health care. Summary Background Data: In this short commentary, we briefly review the status of health care in the United States as well as some of the recent and current changes in graduate medical education that pertain to surgical trainees. Methods: This is a perspective piece that draws on the interests and varied background of the multiinstitutional and international group of authors. Results: The authors propose 3 main areas of focus for research and practice— (1) accurately quantifying the care provided currently by trainees, (2) determining impact to trainees and hospital systems of training parameters, focusing on long-term outcomes rather than short-term outcomes, and (3) determining practice models of education that work best for both health care delivery and trainees. Conclusions: The authors propose that surgical education must align itself with rather than separate itself from overall health care reform measures and even individual hospital financial pressures. This should not be seen as additional burden of service, but rather practical education in training as to the pressures trainees will face as future employees. Rethinking the contributions and training of residents and fellows may also synergistically work to impress to hospital administrators that providing better, more focused and applicable education to residents and fellows may have long-term, strategic, positive impacts on institutions.

Contralateral Prophylactic Mastectomy: Aligning Patient Preferences and Provider Recommendations.

The rising rate of contralateral prophylactic mastectomy (CPM) performed in the United States is a source of increasing concern for breast oncologists. Several studies using a variety of methodologic approaches have now definitively demonstrated negligible to no overall survival benefit associated with CPM even among women with a family history of breast cancer or a genetic mutation that confers an increased risk of breast cancer.1-3 In addition, studies that have demonstrated improved breast cancer–specific or overall mortality cite selection bias as the reason for this perceived benefit; that is, healthier and often more advantaged patients who are more likely to live longer after a diagnosis of breast cancer are also more likely to choose CPM than are less-advantaged women with more comorbidities.4-6 Although CPM is not associated with improved survival, it reduces the risk of contralateral breast cancer, and the significance of this fact to some patients should not be minimized. As we move toward an ever-more personalized, patientcentered approach to care, we must thoughtfully weigh the balance between respecting patients’ preferences and leaving them with the long-term consequences associated with an “unnecessary” operation. For many women who choose CPM, the peace of mind associated with a reduced—albeit not eliminated—likelihood of subsequent cancer justifies the additional surgery and the potential attendant complications, even if the avoided cancer might not have actually shortened their lives. Furthermore, concerns about postsurgical cosmesis and symmetry can significantly affect the self-esteem of young women with breast cancer and affect their quality of life as much as, if not more than, concerns surrounding mortality and risk reduction. The reasons underlying the overall and differential uptake of CPM have been ascribed to many causes, but as Jagsi et al7 describe in this issue of JAMA Surgery, as well as the reports of other investigators, surgeon recommendation plays an important part in patients’ decisions about CPM. In addition, although more educated patients are consistently more likely to choose CPM, patients who understood the nonexistent or minimal survival benefit conferred by CPM were less likely to do so. Thus, the association between overall educational level and condition-specific knowledge is complex and may be modified by the input of a trusted surgeon. Therefore, what is the surgeon’s responsibility, and how does he or she educate without condescension and empower without misdirection? Clearly, not all patients should be discouraged from undergoing CPM. However, surgeons must be engaged in patients’ decision-making and remain invested in providing accurate information about the risks of CPM, including sequelae such as decreased or absent chest wall sensation, chronic pain, and altered body image. Although patients should be supported to make their own value-based medical decisions, the medical community must continue to do our part to educate patients on the negligible benefits of this procedure and help to overcome some of the fear and misperception that often drive this decision.

A Method for Achieving Reciprocity of Funding in Community-Based Participatory Research

Background: The St. Louis Komen Project was conceived to address disparities in breast cancer treatment and outcomes between African-American and White women in St. Louis, Missouri. Our goal was to apportion tasks and funding through a process to which all researcher partners had input and to which all could agree, thus eliminating institutionalized inequalities.Methods: This paper describes the collaborative process and resulting division of responsibilities, determination of costs, and ultimate allocation of funds and resources, as well as the documentation employed to achieve funding reciprocity and equal accountability.Results: Both communication and documentation are critical. Although the Memoranda of Understanding employed are not a panacea, they codify roles and expectations and promote trust. The process of developing financial transparency set the tone for subsequent steps in the research process.Conclusions: The exhaustive planning process and project-specific procedures developed by its partners have helped the project foster reciprocity, facilitate participation, and equitably distribute resources.

Surgical Procedures for Advanced Local and Regional Malignancies of the Breast

Abstract Surgery remains an integral part of the therapeutic plan for locally advanced breast cancer. Advances in systemic therapies have transformed the role of surgery for this population of patients from palliation to largely curative intent. Further, in the last decade, the integration of surgical care into the management algorithm of locally advanced breast cancer patients has also changed substantially with increasing use of neoadjuvant chemotherapy and more recently neoadjuvant endocrine therapy and targeted therapies for HER2-positive disease. Such neoadjuvant strategies have provided new opportunities to downsize the tumor burden and scope of surgical intervention. Advances in reconstructive techniques have also provided new opportunities to improve on quality of life of these heavily treated patients, although the need for radiation therapy in patients with locally advanced breast cancer remains an area of particular challenge for optimal timing of reconstruction.