Rebeca Franco

Racial disparities in the treatment of advanced epithelial ovarian cancer.

OBJECTIVE: To examine whether treatment with guideline-recommended care (surgery and chemotherapy) is associated with mortality differences between black and white women with advanced epithelial ovarian cancer. METHODS: We conducted an observational cohort study using the Surveillance, Epidemiology, and End Results (SEER) linked to Medicare claims for 1995–2007. We evaluated long-term survival for 4,695 black and white women with stage III or stage IV epithelial ovarian cancer with Kaplan-Meier analysis and Cox regression, and then in patients matched by propensity score to create two similar cohorts for comparison. We investigated the association between race, stage, and survival among women who were treated with guideline-recommended care and those who received incomplete treatment. RESULTS: Black women with advanced epithelial ovarian cancer were more likely to die than white women (unadjusted hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.10–1.46). Black women were less likely than white women to receive guideline-recommended care (54% compared with 68%; P<.001), and women who did not receive recommended treatment had lower survival rates than women who received recommended care. Cox proportional hazards models demonstrated no differences in black women compared with white women regarding mortality among women who were treated with guideline-recommended care (adjusted HR 1.04; 95% CI 0.85–1.26), or among women who received incomplete treatment (adjusted HR 1.09; 95% CI 0.89–1.34). The survival analysis of patients matched by propensity score confirmed these analyses. CONCLUSIONS: Differences in rates of treatment with guideline-recommended care are associated with black–white mortality disparities among women with advanced epithelial ovarian cancer. LEVEL OF EVIDENCE: III

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.

Ovarian Cancer Treatment and Survival Trends Among Women Older Than 65 Years of Age in the United States, 1995-2008.

OBJECTIVE: To evaluate whether overall survival is improving among women in the United States with advanced ovarian cancer. METHODS: This retrospective cohort study evaluated trends in treatment and overall survival for women older than 65 years diagnosed with stage III and IV epithelial ovarian cancer between 1995 and 2008 using Surveillance, Epidemiology, and End Results–Medicare data. Parametric and semiparametric multivariate survival analyses were used to assess comparative treatment survival rates and factors affecting survival and recurrence. RESULTS: Of 7,938 women who met study criteria, 2.9% received no treatment, 15.4% underwent surgery only, 24.8% received chemotherapy only, 41.8% underwent primary debulking surgery and chemotherapy in an optimal timeframe, and 15.1% had primary debulking surgery and chemotherapy, but the timing was not optimal or patients did not complete all six cycles of chemotherapy. Those who underwent surgery only had similar survival as those who received no treatment (2.2 compared with 1.7 months), whereas those who received chemotherapy only had a better overall survival (14.4 months). Optimal treatment was associated with the longest survival time (P<.001, median overall survival 39.0 months). Additionally, survival time associated with optimal treatment increased over the past decade. However, the proportion of women who received optimal treatment has decreased over the past decade. CONCLUSION: Elderly women with advanced ovarian cancer have the best survival with optimal therapy. When this is not offered or possible, chemotherapy alone offers better survival than surgery alone.

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

Metabolic syndrome and pre-diabetes contribute to racial disparities in breast cancer outcomes: hypothesis and proposed pathways.

Women with obesity and type 2 diabetes (T2D) are at greater risk of dying from breast cancer than women without these conditions. Obesity and T2D are associated with insulin resistance and endogenous hyperinsulinemia and are more common in Black women. There is increasing disparity in breast cancer mortality between Black and White women in the USA. We hypothesize that insulin resistance and endogenous hyperinsulinemia in Black women with breast cancer contribute to their greater breast cancer mortality and are associated with increased insulin receptor signalling in tumours.

Secondary Surgery Versus Chemotherapy for Recurrent Ovarian Cancer.

Objective: The best course of treatment for recurrent ovarian cancer is uncertain. We sought to determine whether secondary cytoreductive surgery for first recurrence of ovarian cancer improves overall survival compared with other treatments. Materials and Methods: We assessed survival using Surveillance, Epidemiology and End Results-Medicare data for advanced stage ovarian cancer cases diagnosed from January 1, 1997 to December 31, 2007 with survival data through 2010 using multinomial propensity weighted finite mixture survival regression models to distinguish true from misclassified recurrences. Of 35,995 women ages 66 years and older with ovarian cancer, 3439 underwent optimal primary debulking surgery with 6 cycles of chemotherapy; 2038 experienced a remission. Results: One thousand six hundred thirty-five of 2038 (80%) women received treatment for recurrence of whom 72% were treated with chemotherapy only, 16% with surgery and chemotherapy and 12% received hospice care. Median survival of women treated with chemotherapy alone, surgery and chemotherapy, or hospice care was 4.1, 5.4, and 2.2 years, respectively (P<0.001). Of those receiving no secondary treatments, 75% were likely true nonrecurrences with median survival of 15.9 years and 25% misclassified with 2.4 years survival. Survival among women with recurrence was greater for those treated with surgery and chemotherapy compared with chemotherapy alone (hazard ratio=1.67; 95% confidence interval, 1.13-2.47). Women who were older with more comorbidities and high-grade cancer had worse survival. Conclusions: Secondary surgery with chemotherapy to treat recurrent ovarian cancer increases survival by 1.3 years compared with chemotherapy alone and pending ongoing randomized trial results, may be considered a standard of care.

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.

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.

A Validation Study of Administrative Claims Data to Measure Ovarian Cancer Recurrence and Secondary Debulking Surgery

Objective: Administrative claims data offer an alternative to chart abstraction to assess ovarian cancer recurrence, treatment and outcomes. Such analyses have been hindered by lack of valid recurrence and treatment algorithms. In this study, we sought to develop claims-based algorithms to identify ovarian cancer recurrence and secondary debulking surgery, and to validate them against the gold-standard of chart abstraction. Methods: We conducted chart validation studies; 2 recurrence algorithms and 1 secondary surgery among 94 ovarian cancer patients treated at one hospital between 2003–2009. A new recurrence algorithm was based on treatment timing (≥6 months after primary treatment) and a previously validated algorithm was based on secondary malignancy codes. A secondary debulking surgery algorithm was based on surgical billing codes. Results: The new recurrence algorithm had: sensitivity=100% (95% confidence interval [CI]=87%-=100%), specificity=89% (95%CI=78%–95%), kappa=84% (SE=10%) while the secondary-malignancy-=code recurrence algorithm had: sensitivity=84% (95%CI=66%–94%), specificity=44% (95%CI=31%-=57%), kappa=23% (SE=8%). The secondary surgery algorithm had: sensitivity=77% (95%CI=50%–92%), = specificity= 92% (95%CI=83%–97%), kappa=66% (SE=10%).= Conclusions: A recurrence algorithm based on treatment timing accurately identified ovarian cancer =recurrence. If validated in other populations, such an algorithm can provide a tool to compare effectiveness of recurrent ovarian cancer treatments.