To evaluate the financial experiences of a racially and ethnically diverse cohort of long-term breast cancer survivors (17% African American, 40% Latina) identified through population-based ...registries.
Longitudinal study of women diagnosed with nonmetastatic breast cancer in 2005 to 2007 and reported to the SEER registries of metropolitan Los Angeles and Detroit. We surveyed 3,133 women approximately 9 months after diagnosis and 4 years later. Multivariable models evaluated correlates of self-reported decline in financial status attributed to breast cancer and of experiencing at least one type of privation (economically motivated treatment nonadherence and broader hardships related to medical expenses).
Among 1,502 patients responding to both surveys, median out-of-pocket expenses were ≤ $2,000; 17% of respondents reported spending > $5,000; 12% reported having medical debt 4 years postdiagnosis. Debt varied significantly by race: 9% of whites, 15% of blacks, 17% of English-speaking Latinas, and 10% of Spanish-speaking Latinas reported debt (P = .03). Overall, 25% of women experienced financial decline at least partly attributed to breast cancer; Spanish-speaking Latinas had significantly increased odds of this decline relative to whites (odds ratio OR, 2.76; P = .006). At least one privation was experienced by 18% of the sample; blacks (OR, 2.6; P < .001) and English-speaking Latinas (OR, 2.2; P = .02) were significantly more likely to have experienced privation than whites.
Racial and ethnic minority patients appear most vulnerable to privations and financial decline attributable to breast cancer, even after adjustment for income, education, and employment. These findings should motivate efforts to control costs and ensure communication between patients and providers regarding financial distress, particularly for vulnerable subgroups.
To report interim cosmetic results and toxicity from a prospective study evaluating accelerated partial-breast irradiation (APBI) administered using a highly conformal external beam approach.
We ...enrolled breast cancer patients in an institutional review board-approved prospective study of APBI using beamlet intensity-modulated radiotherapy (IMRT) at deep-inspiration breath-hold. Patients received 38.5 Gy in 3.85 Gy fractions twice daily. Dosimetric parameters in patients who maintained acceptable cosmesis were compared with those in patients developing unacceptable cosmesis in follow-up, using t-tests.
Thirty-four patients were enrolled; 2 were excluded from analysis because of fair baseline cosmesis. With a median follow-up of 2.5 years, new unacceptable cosmesis developed in 7 patients, leading to early study closure. We compared patients with new unacceptable cosmesis with those with consistently acceptable cosmesis. Retrospective analysis demonstrated that all but one plan adhered to the dosimetric requirements of the national APBI trial. The mean proportion of a whole-breast reference volume receiving 19.25 Gy (V50) was lower in patients with acceptable cosmesis than in those with unacceptable cosmesis (34.6% vs. 46.1%; p = 0.02). The mean percentage of this reference volume receiving 38.5 Gy (V100) was also lower in patients with acceptable cosmesis (15.5% vs. 23.0%; p = 0.02).
The hypofractionated schedule and parameters commonly used for external beam APBI and prescribed by the ongoing national trial may be suboptimal, at least when highly conformal techniques such as IMRT with management of breathing motion are used. The V50 and V100 of the breast reference volume seem correlated with cosmetic outcome, and stricter limits may be appropriate in this setting.
ABSTRACT
BACKGROUND
Leaders in academic medicine are often selected from the ranks of physician-researchers, whose demanding careers involve multiple professional commitments that must also be ...balanced with demands at home.
OBJECTIVE
To gain a more nuanced understanding of work–life balance issues from the perspective of a large and diverse group of faculty clinician-researchers and their mentors.
DESIGN
A qualitative study with semi-structured, in-depth interviews conducted from 2010 to 2011, using inductive analysis and purposive sampling.
PARTICIPANTS
One hundred former recipients of U.S. National Institutes of Health (NIH) K08 or K23 career development awards and 28 of their mentors.
APPROACH
Three researchers with graduate training in qualitative methods conducted the interviews and thematically coded verbatim transcripts.
KEY RESULTS
Five themes emerged related to work–life balance: (1) the challenge and importance of work–life balance for contemporary physician-researchers, (2) how gender roles and spousal dynamics make these issues more challenging for women, (3) the role of mentoring in this area, (4) the impact of institutional policies and practices intended to improve work–life balance, and (5) perceptions of stereotype and stigma associated with utilization of these programs.
CONCLUSIONS
In academic medicine, in contrast to other fields in which a lack of affordable childcare may be the principal challenge, barriers to work–life balance appear to be deeply rooted within professional culture. A combination of mentorship, interventions that target institutional and professional culture, and efforts to destigmatize reliance on flexibility (with regard to timing and location of work) are most likely to promote the satisfaction and success of the new generation of clinician-researchers who desire work–life balance.
Contralateral prophylactic mastectomy (CPM) use is increasing among women with unilateral breast cancer, but little is known about treatment decision making or physician interactions in diverse ...patient populations.
To evaluate patient motivations, knowledge, and decisions, as well as the impact of surgeon recommendations, in a large, diverse sample of patients who underwent recent treatment for breast cancer.
A survey was sent to 3631 women with newly diagnosed, unilateral stage 0, I, or II breast cancer between July 2013 and September 2014. Women were identified through the population-based Surveillance Epidemiology and End Results registries of Los Angeles County and Georgia. Data on surgical decisions, motivations for those decisions, and knowledge were included in the analysis. Logistic and multinomial logistic regression of the data were conducted to identify factors associated with (1) CPM vs all other treatments combined, (2) CPM vs unilateral mastectomy (UM), and (3) CPM vs breast-conserving surgery (BCS). Associations between CPM receipt and surgeon recommendations were also evaluated. All statistical models and summary estimates were weighted to be representative of the target population.
Receipt of CPM was the primary dependent variable for analysis and was measured by a woman's self-report of her treatment.
Of the 3631 women selected to receive the survey, 2578 (71.0%) responded and 2402 of these respondents who did not have bilateral disease and for whom surgery type was known constituted the final analytic sample. The mean (SD) age was 61.8 (12) years at the time of the survey. Overall, 1301 (43.9%) patients considered CPM (601 24.8% considered it very strongly or strongly); only 395 (38.1%) of them knew that CPM does not improve survival for all women with breast cancer. Ultimately, 1466 women (61.6%) received BCS, 508 (21.2%) underwent UM, and 428 (17.3%) received CPM. On multivariable analysis, factors associated with CPM included younger age (per 5-year increase: odds ratio OR, 0.71; 95% CI, 0.65-0.77), white race (black vs white: OR, 0.50; 95% CI, 0.34-0.74), higher educational level (OR, 1.69; 95% CI, 1.20-2.40), family history (OR, 1.63; 95% CI, 1.22-2.17), and private insurance (Medicaid vs private insurance: OR, 0.47; 95% CI, 0.28-0.79). Among 1569 patients (65.5%) without high genetic risk or an identified mutation, 598 (39.3%) reported a surgeon recommendation against CPM, of whom only 12 (1.9%) underwent CPM, but among the 746 (46.8%) of these women who received no recommendation for or against CPM from a surgeon, 148 (19.0%) underwent CPM.
Many patients consider CPM, but knowledge about the procedure is low and discussions with surgeons appear to be incomplete. Contralateral prophylactic mastectomy use is substantial among patients without clinical indications but is low when patients report that their surgeon recommended against it. More effective physician-patient communication about CPM is needed to reduce potential overtreatment.
In this phase 2 multicenter study, we evaluated the incorporation of autologous stem cell transplantation (ASCT) into a carfilzomib-lenalidomide-dexamethasone (KRd) regimen for patients with newly ...diagnosed multiple myeloma (NDMM). Transplant-eligible patients with NDMM received 4 cycles of KRd induction, ASCT, 4 cycles of KRd consolidation, and 10 cycles of KRd maintenance. The primary end point was rate of stringent complete response (sCR) after 8 cycles of KRd with a predefined threshold of ≥50% to support further study. Seventy-six patients were enrolled with a median age of 59 years (range, 40-76 years), and 35.5% had high-risk cytogenetics. The primary end point was met, with an sCR rate of 60% after 8 cycles. Depth of response improved over time. On intent-to-treat (ITT), the sCR rate reached 76%. The rate of minimal residual disease (MRD) negativity using modified ITT was 70% according to next-generation sequencing (<10-5 sensitivity). After median follow-up of 56 months, 5-year progression-free survival (PFS) and overall survival (OS) rates were 72% and 84% for ITT, 85% and 91% for MRD-negative patients, and 57% and 72% for patients with high-risk cytogenetics. For high-risk patients who were MRD negative, 5-year rates were 77% and 81%. Grade 3 to 4 adverse events included neutropenia (34%), lymphopenia (32%), infection (22%), and cardiac events (3%). There was no grade 3 to 4 peripheral neuropathy. Patients with NDMM treated with KRd with ASCT achieved high rates of sCR and MRD-negative disease at the end of KRd consolidation. Extended KRd maintenance after consolidation contributed to deepening of responses and likely to prolonged PFS and OS. Safety and tolerability were manageable. This trial was registered at www.clinicaltrials.gov as #NCT01816971.
Understanding the careers of recent career development awardees is essential to guide interventions to ensure gender equity and success in academic medicine.
In 2010-2011 (T1) and 2014 (T2), 1,719 ...clinician-researchers who received new K08 and K23 awards in 2006-2009 were longitudinally surveyed. Multivariable analyses evaluated the influence of factors on success, including demographics, job characteristics, work environment, priorities, and domestic responsibilities.
Of 1,275 respondents at T1, 1,066 (493 women; 573 men) responded at T2. Men and women differed in job characteristics, work environment, priorities, and domestic responsibilities. By T2, women had less funding (mean $780,000 vs. $1,120,000, P = .002) and published fewer papers (mean 33 vs. 45). Using a composite measure that considered funding, publications, or leadership to define success, 53.5% (264/493) of women and 67.0% (384/573) of men were successful. Gender differences in success persisted after accounting for other significant predictors-K award type, specialty, award year, work hours, funding institute tier, feeling responsible for participating in department/division administration, importance of publishing prolifically, feeling responsible for contributing to clinical care, importance of publishing high-quality research, collegiality of the mentoring relationship, adequacy of research equipment, and departmental climate. A significant interaction existed between K award type and gender; the gender difference in success was most pronounced among K23 researchers (among whom the odds ratio for females = 0.32).
Men and women continue to have different experiences and career outcomes, with important implications for the design of interventions to promote equity and success.
Understanding the goals and aspirations of the physician-scientist workforce can inform policies to promote retention. The authors explored gender differences therein, given women's increasing ...representation.
In 2010-2011, the authors qualitatively analyzed interviews with 100 former recipients of National Institutes of Health career development awards and 28 of their mentors. They also compared survey responses of 1,267 clinician-investigators who received these awards from 2006 to 2009, using logistic regression to evaluate gender differences after adjusting for other characteristics.
Interview participants described relatively consistent career goals, including scientific contribution and desire to positively affect lives through research, clinical care, and teaching. For many, the specific ways they sought to achieve and measure goal attainment evolved over time. Survey respondents endorsed a goal of publishing high-quality research with highest frequency (97.3%, no significant gender difference). Women were more likely to endorse the importance of balancing work and other activities (95.5% vs. 90.5%, P < .001). There were no significant gender differences in the importance of patient care (86.6%), teaching (71.6%), or publishing prolifically (64.9%). Men were more likely than women to consider salary (49.4% vs. 41.8%, P < .001), reputation (84.2% vs. 77.6%, P = .004), and leadership positions (38.9% vs. 34.3%, P = .03) important.
In an elite research-oriented sample, gender differences in initial aspirations were generally limited. Gender differences in career outcomes in such groups are unlikely to exclusively result from different baseline aspirations. Goals appear to evolve in response to challenges experienced.
Purpose To inform the evolving implementation of CancerLinQ and other rapid-learning systems for oncology care, we sought to evaluate perspectives of patients with cancer regarding ethical issues. ...Methods Using the GfK Group online research panel, representative of the US population, we surveyed 875 patients with cancer; 621 (71%) responded. We evaluated perceptions of appropriateness (scored from 1 to 10; 10, very appropriate) using scenarios and compared responses by age, race, and education. We constructed a scaled measure of comfort with secondary use of deidentified medical information and evaluated its correlates in a multivariable model. Results Of the sample, 9% were black and 9% Hispanic; 38% had completed high school or less, and 59% were age ≥ 65 years. Perceptions of appropriateness were highest when consent was obtained and university researchers used data to publish a research study (weighted mean appropriateness, 8.47) and lowest when consent was not obtained and a pharmaceutical company used data for marketing (weighted mean appropriateness, 2.7). Most respondents (72%) thought secondary use of data for research was very important, although those with lower education were less likely to endorse this (62% v 78%; P < .001). Overall, 35% believed it was necessary to obtain consent each time such research was to be performed; this proportion was higher among blacks/Hispanics than others (48% v 33%; P = .02). Comfort with the use of deidentified information from medical records varied by scenario and overall was associated with distrust in the health care system. Conclusion Perceptions of patients with cancer regarding secondary data use depend on the user and the specific use of the data, while also frequently differing by patient sociodemographic factors. Such information is critical to inform ongoing efforts to implement oncology learning systems.
To evaluate preferences for and experiences with genetic testing in a diverse cohort of patients with breast cancer identified through population-based registries, with attention to differences by ...race/ethnicity.
We surveyed women diagnosed with nonmetastatic breast cancer from 2005 to 2007, as reported to the SEER registries of metropolitan Los Angeles and Detroit, about experiences with hereditary risk evaluation. Multivariable models evaluated correlates of a strong desire for genetic testing, unmet need for discussion with a health care professional, and receipt of testing.
Among 1,536 patients who completed the survey, 35% expressed strong desire for genetic testing, 28% reported discussing testing with a health care professional, and 19% reported test receipt. Strong desire for testing was more common in younger women, Latinas, and those with family history. Minority patients were significantly more likely to have unmet need for discussion (failure to discuss genetic testing with a health professional when they had a strong desire for testing): odds ratios of 1.68, 2.44, and 7.39 for blacks, English-speaking Latinas, and Spanish-speaking Latinas compared with whites, respectively. Worry in the long-term survivorship period was higher among those with unmet need for discussion (48.7% v 24.9%; P <.001). Patients who received genetic testing were younger, less likely to be black, and more likely to have a family cancer history.
Many patients, especially minorities, express a strong desire for genetic testing and may benefit from discussion to clarify risks. Clinicians should discuss genetic risk even with patients they perceive to be at low risk, as this may reduce worry.
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