Background
Breast cancer mortality is higher for Black and younger women. This study evaluated 2 possible contributors to disparities—time to treatment and treatment duration—by race and age.
Methods
...Among 2841 participants with stage I‐III disease in the Carolina Breast Cancer Study, we identified groups of women with similar patterns of socioeconomic status (SES), access to care, and tumor characteristics using latent class analysis. We then evaluated latent classes in association with treatment delay (initiation >60 days after diagnosis) and treatment duration (in quartiles by treatment modality).
Results
Thirty‐two percent of younger Black women were in the highest quartile of treatment duration (versus 22% of younger White women). Black women experienced a higher frequency of delayed treatment (adjusted relative frequency difference RFD, 5.5% 95% CI, 3.2%‐7.8%) and prolonged treatment duration (RFD, 8.8% 95% CI, 5.7%‐12.0%). Low SES was significantly associated with treatment delay among White women (RFD, 3.5% 95% CI, 1.1%‐5.9%), but treatment delay was high at all levels of SES in Black women (eg, 11.7% in high SES Black women compared with 10.6% and 6.7% among low and high SES White women, respectively). Neither SES nor access to care classes were significantly associated with delayed initiation among Black women, but both low SES and more barriers were associated with treatment duration across both groups.
Conclusions
Factors that influence treatment timeliness persist throughout the care continuum, with prolonged treatment duration being a sensitive indicator of differences by race, SES, and care barriers.
Economic and other barriers to care appear to compound across the continuum, with treatment duration representing a sensitive indicator of barriers to care. By developing an integrated view of multiple patient factors that contribute to duration, appropriate multidimensional interventions can be conceptualized to reduce racial mortality disparities.
Racial disparities in breast cancer mortality have been widely documented for several decades and persist despite advances in receipt of mammography across racial groups. This persistence leads to ...questions about the roles of biological, social, and health system determinants of poor outcomes. Cancer outcomes are a function not only of innate biological factors but also of modifiable characteristics of individual behavior and decision making as well as characteristics of patient‐health system interaction and the health system itself. Attempts to explain persistent racial disparities have mostly been limited to discussion of differences in insurance coverage, socioeconomic status, tumor stage at diagnosis, comorbidity, and molecular subtype of the tumor. This article summarizes existing literature exploring reasons for racial disparities in breast cancer mortality, with an emphasis on treatment disparities and opportunities for future research. Because breast cancer care requires a high degree of multidisciplinary team collaboration, ensuring that guideline recommended treatment (such as endocrine therapy for hormone receptor positive patients) is received by all racial/ethnic groups is critical and requires coordination across multiple providers and health care settings. Recognition that variation in cancer care quality may be correlated with race (and socioeconomic and health system factors) may assist policy makers in identifying strategies to more equally distribute clinical expertise and health infrastructure across multiple user populations.
This article summarizes existing literature exploring reasons for racial disparities in breast cancer mortality, with an emphasis on treatment disparities and opportunities for future research. Recognition that variation in cancer care quality may be correlated with race (and socioeconomic and health system factors) may assist policy makers in identifying strategies to more equally distribute clinical expertise and health infrastructure across multiple user populations.
Background
Recent clinical trials support adding ovarian suppression (OS) to oral endocrine therapy (ET) for premenopausal women with early breast cancer. The adoption of OS among real‐world ...populations and the impact of OS on ET adherence have not been evaluated.
Methods
This study examined a retrospective, observational cohort of women under the age of 50 years with incident early breast cancer from 2001 to 2016. The IBM MarketScan Commercial insurance claims database was used to identify new users of ET with or without OS and to track discontinuation of or adherence to ET. In all, 21,948 women filled at least 1 prescription for ET within 12 months of their diagnosis after a washout period of 12 months with no prior claims. Patients who received an aromatase inhibitor without a synchronous OS drug were excluded.
Results
Use of OS increased over time and reached 11.3% in 2016. In an unadjusted analysis, 40.2% of ET+OS users discontinued ET early, whereas 48.8% of tamoxifen‐alone users did. In adjusted analyses, ET+OS users had a similar likelihood of discontinuing ET in comparison with tamoxifen‐alone users (hazard ratio, 0.92; 95% confidence interval, 0.83‐1.03). Approximately 30% of women had low adherence over the first year of use. The likelihood of high adherence was similar, regardless of OS exposure.
Conclusions
The use of OS among young, commercially insured patients with breast cancer increased over time in agreement with recent clinical trial results but remained relatively low. Nonadherence to ET was common, but the use of OS was not associated with lower adherence to ET in this observational, nonrandomized cohort. These findings may reassure oncologists that use of OS does not endanger ET adherence, although prospective studies are needed for confirmation.
This study examines how ovarian suppression (OS) is being incorporated into endocrine therapy (ET) for early breast cancer after recent confirmatory clinical trials. Results show that use of OS is not associated with lower adherence to ET.
Background
Treatment delays affect breast cancer survival and constitute poor‐quality care. Black patients experience more treatment delay, but the relationship of geography to these disparities is ...poorly understood.
Methods
We studied a population‐based, retrospective, observational cohort of patients with breast cancer in North Carolina between 2004 and 2017 from the Cancer Information and Population Health Resource, which links cancer registry and sociodemographic data to multipayer insurance claims. We included patients >18 years with Stage I–III breast cancer who received surgery or chemotherapy as their first treatment. Delay was defined as >60 days from diagnosis to first treatment. Counties were aggregated into nine Area Health Education Center regions. Race was dichotomized as Black versus non‐Black.
Results
Among 32,626 patients, 6190 (19.0%) were Black. Black patients were more likely to experience treatment delay >60 days (15.0% of Black vs. 8.0% of non‐Black). Using race‐stratified modified Poisson regression, age‐adjusted relative risk of delay in the highest risk region was approximately twice that in the lowest risk region among Black (relative risk, 2.1; 95% CI, 1.6–2.6) and non‐Black patients (relative risk, 1.9; 95% CI, 1.5–2.3). Adjustment for clinical and sociodemographic features only slightly attenuated interregion differences. The magnitude of the racial gap in treatment delay varied by region, from 0.0% to 9.4%.
Conclusions
Geographic region was significantly associated with risk of treatment delays for both Black and non‐Black patients. The magnitude of racial disparities in treatment delay varied markedly between regions. Future studies should consider both high‐risk geographic regions and high‐risk patient groups for intervention to prevent delays.
This study found that geographic region was significantly associated with risk of cancer treatment delays for both Black and non‐Black patients, but the magnitude of racial disparities in treatment delay varied markedly between regions. Future studies should consider both high‐risk geographic regions and high‐risk patient groups for targeted intervention to prevent delays in cancer treatment.
Background
The objective of the current study was to estimate productivity costs due to metastatic breast cancer (mBC) via productive time lost among survivors and potential life‐years lost from ...premature mortality among 3 age groups: younger (aged 18‐44 years), midlife (aged 45‐64 years), and older (aged ≥65 years) women.
Methods
The authors estimated the number of work and home productivity days missed due to mBC by age group using data from the 2000 to 2016 National Health Interview Survey. Years of potential life lost (YPLL) due to mBC were calculated for each age group using 2015 National Vital Statistics System data. The authors valued both sources of lost productivity time using the Current Population Survey and prior studies.
Results
The per‐woman value of lost productive days (work and home) due to mBC ranged from $680 for older women to $5169 for younger women. In 2015, the value of lost work and home productivity days associated with mBC nationally was $67 million for younger women, $246 million for midlife women, and $66 million for older women. YPLL were highest among midlife women (403,786 life‐years), followed by older women (248,522 life‐years) and younger women (95,943 life‐years). Midlife women were found to have the highest market value of YPLL ($4.1 billion), followed by younger women ($1.6 billion) and older women ($527 million).
Conclusions
The results of the current study demonstrated that mBC generates a high economic burden through lost productivity, especially among midlife women.
Herein, the authors report that metastatic breast cancer was associated with $18.2 billion in lost productivity nationally in 2015. The results of the current study highlight the potential benefit of supportive resources to help women with metastatic breast cancer guard against potentially severe cancer‐related financial losses for themselves and others within their households.
Background
After controlling for baseline disease factors, researchers have found that black women have worse breast cancer survival, and this suggests that treatment differences may contribute to ...poorer outcomes. Delays in initiating and completing treatment are one proposed mechanism.
Methods
Phase 3 of the Carolina Breast Cancer Study involved a large, population‐based cohort of women with incident breast cancer. For this analysis, we included black women (n = 1328) and white women (n = 1331) with stage I to III disease whose treatment included surgery with or without adjuvant therapies. A novel treatment pathway grouping was used to benchmark the treatment duration (surgery only, surgery plus chemotherapy, surgery plus radiation, or all 3). Models controlled for the treatment pathway, age, and tumor characteristics and for demographic factors related to health care access. Exploratory analyses of the association between delays and cancer recurrence were performed.
Results
In fully adjusted analyses, blacks had 1.73 times higher odds of treatment initiation more than 60 days after their diagnosis in comparison with whites (odds ratio OR, 1.73; 95% confidence interval CI, 1.04‐2.90). Black race was also associated with a longer treatment duration. Blacks were also more likely to be in the highest quartile of treatment duration (OR, 1.69; 95% CI, 1.41‐2.02), even after adjustments for demographic and tumor characteristics (OR, 1.31; 95% CI, 1.04‐1.64). A nonsignificant trend toward a higher recurrence risk was observed for patients with delayed initiation (hazard ratio, 1.44; 95% CI, 0.89‐2.33) or the longest duration (hazard ratio, 1.17; 95% CI, 0.87‐1.59).
Conclusions
Black women more often had delayed treatment initiation and a longer duration than whites receiving similar treatment. Interventions that target access barriers may be needed to improve timely delivery of care.
Black women more often have delays across the breast cancer treatment continuum than whites receiving similar treatment. Interventions that target access barriers may be needed to improve timely delivery of care.
The disparity in outcomes of breast cancer for Black compared with White women in the U.S. is well known and persistent over time, with the largest disparities appearing among women with hormone ...receptor‐positive (HR+) cancers. The racial gap in breast cancer survival first emerged in the 1980s, a time of significantmen treatment advances in early‐stage breast cancer, including the introduction of adjuvant endocrine therapy. Since that time, the gap has continued to widen despite steady advances in treatment and survival of breast cancer overall. Although advanced stage at presentation and unfavorable biology undoubtedly contribute to racial differences in survival of HR+ breast, treatment disparities are increasingly acknowledged to play a key role as well. The recent recognition of racial differences in endocrine therapy use may be a key explanatory factor in the persistent racial gap in mortality of HR+ disease, and may be a key focus of intervention to improve breast cancer outcomes for Black women.
Implications for Practice
Black women with hormone receptor–positive breast cancer experience the greatest racial disparity in survival among all breast cancer subtypes. This survival gap appears consistently across studies and is not entirely explained by differences in presenting stage, tumor biology as assessed by genomic risk scores, or receipt of chemotherapy. Recent research highlights lower adherence to endocrine therapy (ET) for Black women. Health systems and individual providers should focus on improving communication about the importance of ET use, sharing decisions around ET, providing appropriate support for side effects and other ET‐related concerns, and equitably delivering survivorship care, including ET adherence assessment.
The disparity in outcomes of breast cancer for Black compared to White women in the United States is well‐known. This article examines the factors contributing to these persistent disparities, including biological and access‐related determinants.
Background
This study explores the incidence of patient‐reported major toxicity—symptoms rated “moderate,” “severe,” or “very severe”—for chemotherapy regimens commonly used in early breast cancer.
...Patients and Methods
Female patients aged 21 years or older completed a validated Patient‐Reported Symptom Monitoring instrument and rated 17 symptoms throughout adjuvant or neoadjuvant chemotherapy. Fisher's exact tests compared differences in percentages in symptom ratings, and general linear regression was used to model the incidence of patient‐reported major toxicity.
Results
In 152 patients, the mean age was 54 years (range, 24–77), and 112 (74%) were white; 51% received an anthracycline‐based regimen. The proportion of patients rating fatigue, constipation, myalgia, diarrhea, nausea, peripheral neuropathy, and swelling of arms or legs as a major toxicity at any time during chemotherapy varied significantly among four chemotherapy regimens (p < .05). The mean (SD) number of symptoms rated major toxicities was 6.3 (3.6) for anthracycline‐based and 4.4 (3.5) for non‐anthracycline‐based regimens (p = .001; possible range, 0–17 symptoms). Baseline higher body mass index (p = .03), patient‐reported Karnofsky performance status ≤80 (p = .0003), and anthracycline‐based regimens (p = .0003) were associated with greater total number of symptoms rated major toxicities (alternative model: chemotherapy duration, p < .0001). Twenty‐six percent of dose reductions (26 of 40), 75% of hospitalizations (15 of 20), and 94% of treatment discontinuations (15 of 16) were in anthracycline‐based regimens.
Conclusion
Capturing multiple toxicity outcomes throughout chemotherapy enables oncologists and patients to understand the range of side effects as they discuss treatment efficacies. Continuous symptom monitoring may aid in the timely development of interventions that minimize toxicity and improve outcomes.
Implications for Practice
This study investigated patient‐reported toxicities for 17 symptoms recorded prospectively during adjuvant and neoadjuvant chemotherapy regimens for early breast cancer. An analysis of four commonly used chemotherapy regimens identified significant differences among regimens in both individual symptoms and total number of symptoms rated moderate, severe, or very severe. Longer chemotherapy regimens, such as anthracycline‐based regimens followed by paclitaxel, had higher proportions of symptoms rated major toxicities. The inclusion of patient perspectives on multiple toxicity outcomes at the same time at multiple time points during chemotherapy has the potential for improving patient‐provider communication regarding symptom management, patient satisfaction, and long‐term clinical outcomes.
摘要
背景。本研究探索了在常用于治疗早期乳腺癌的化疗方案中患者报告的主要毒性(即被评为“中度”、“重度”或“极重度”的症状)的发生率。
患者和方法。年满 21 岁或以上的女性患者填写一份经验证的患者报告的症状监测文件并对辅助或新辅助化疗期间的 17 个症状进行评级。Fisher's精确检验对症状评级百分比之间的差异进行比较，一般线性回归用于模拟患者报告的主要毒性的发生率。
结果。在 152 名患者中，平均年龄为 54 岁(范围介于 24–77 岁之间)，112 名患者 (74%) 为白种人；51% 的患者接受蒽环类方案治疗。在化疗期间的任何时间将疲劳、便秘、肌痛、腹泻、恶心、周围神经病变以及手臂或腿部肿胀评为主要毒性的患者的比例在 4 个化疗方案中显著不同 (p < 0.05)。在蒽环类方案和非蒽环类方案中，被评为主要毒性的症状的平均数 (SD) 分别为 6.3 (3.6) 和 4.4 (3.5)(p = 0.001；可能的范围，0–17 个症状)。基线较高的体质量指数 (p = 0.03)、患者报告的 Karnofsky 体力状态 ≤80 (p = 0.000 3) 以及蒽环类方案 (p = 0.000 3) 与被评为主要毒性的症状的总数较高相关(替代模式:化疗持续时间，p < 0.000 1)。在蒽环类方案中，剂量减少占 26%(40 名患者中的 26 名患者)，住院治疗占 75%(20 名患者中的 15 名患者)，治疗中断占 94%(16 名患者中的 15 名患者)。
结论。获取化疗过程中的多种毒性结果，可令肿瘤学家和患者在讨论治疗有效性时了解副作用的范围。持续的症状监测可能有助于及时地制定可以最大限度地减少毒性并改进预后的干预措施。
《肿瘤学家》
实践意义:本研究调查了患者报告的早期乳腺癌辅助和新辅助化疗方案中前瞻性记录的 17 个症状的毒性。针对 4 个常用化疗方案的分析在单项症状和被评为“中度”、“重度”或“极重度”的症状的总数方面确定了方案之间的显著差异。在较长的化疗方案中，如后续采用紫杉醇治疗的蒽环类方案，被评为主要毒性的症状占有较高的比例。同时，在化疗期间的多个时间点加入患者关于多种毒性结果的看法，这可能会改进患者和医疗服务提供者之间有关症状管理、患者满意度以及长期临床预后的沟通。
This article focuses on the incidence of patient‐reported major toxicity for chemotherapy regimens commonly used in breast cancer, especially considering the need for patient‐centered assessments of treatment tolerability as an important complement to the NCI's CTCAE.
Background
The National Cancer Institute's Patient‐Reported Outcomes Version of the Common Terminology Criteria for Adverse Events, collected alongside the clinician‐reported Common Terminology ...Criteria for Adverse Events, enables comparisons of patient and clinician reports on treatment toxicity.
Methods
In a multisite study of women receiving chemotherapy for early‐stage breast cancer, symptom reports were collected on the same day from patients and their clinicians for 17 symptoms; their data were not shared with each other. The proportions of moderate, severe, or very severe patient‐reported symptom severity were compared with the proportions of clinician‐rated grade 2, 3, or 4 toxicity. Patient‐clinician agreement was assessed via κ statistics. Chi‐square tests investigated whether patient characteristics were associated with patient‐clinician agreement.
Results
Among 267 women, the median age was 58 years (range, 24‐83 years), and 26% were nonwhite. There was moderate scoring agreement (κ = 0.413‐0.570) for 53% of symptoms, fair agreement for 41% (κ = 0.220‐0.378), and slight agreement for 6% (κ = 0.188). For example, patient‐reported and clinician‐rated percentages were 22% and 8% for severe or very severe fatigue, 41% and 46% for moderate fatigue, 32% and 39% for mild fatigue, and 6% and 7% for none. Clinician severity scores were lower for nonwhite patients in comparison with white patients for peripheral neuropathy, nausea, arthralgia, and dyspnea.
Conclusions
Although clinician reporting of symptoms is common practice in oncology, there is suboptimal agreement with the gold standard of patient self‐reporting. These data provide further evidence supporting the integration of patient‐reported outcomes into oncological clinical research and clinical practice to improve monitoring of symptoms as well as timely interventions for symptoms.
Although clinician reporting of symptoms is common practice in oncology, there is suboptimal agreement with the gold standard of patient self‐reporting. These data provide further evidence supporting the integration of patient‐reported outcomes into oncological clinical research and clinical practice to improve monitoring of symptoms as well as timely interventions for symptoms.
Patients with HER2-positive breast cancer predominantly received TCHP (docetaxel, carboplatin, trastuzumab, and pertuzumab), which has shown a similar pathological complete response rate in other ...trials and population-based studies.4,5 Most patients with triple-negative breast cancer were treated with AC+T (doxorubicin and cyclophosphamide followed by paclitaxel), which yielded substantially lower pathological complete response rates of 31–42% in previous randomised trials.6,7 Patients with triple-negative breast cancer in this trial1 might represent a highly selected group for chemotherapy responsiveness. Capecitabine and trastuzumab emtansine have proven efficacy in terms of event-free survival in patients with residual disease.8,9 When discussing surgery-omitting approaches, we must consider that false-negative pathological complete response assessment might result in inappropriate de-escalation of adjuvant therapy, with downstream effects on cancer survival. Ultimately, the ability to accurately predict residual disease status and show the feasibility of such techniques across multiple practice settings will be needed to incorporate surgery-sparing approaches into breast cancer treatment paradigms.
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