Purpose
Although racial disparities in health-related quality of life (HRQOL) among women with breast cancer (BC) are well documented, less is known about HRQOL changes over time among women of ...different races. Our objective was to assess racial differences in HRQOL during active treatment and survivorship phases of BC care.
Methods
We used data from the third phase of the Carolina Breast Cancer Study (CBCS-III). CBCS-III enrolled 3000 women in North Carolina aged 20–74 years diagnosed with BC between 2008 and 2013. HRQOL assessments occurred 5 and 25 months post diagnosis, representing distinct phases of care. HRQOL measures included the Functional Assessment of Cancer Therapy for BC and Functional Assessment of Chronic Illness Therapy for Spiritual Well-Being. Analysis of covariance models were employed to assess racial differences in changes in HRQOL.
Results
The cohort included 2142 Non-Hispanic White (
n
= 1105) and Black women (
n
= 1037) who completed both HRQOL assessments. During active treatment, Whites reported physical and functional scores 2–2.5 points higher than Blacks (
p
< 0.0001). Spiritual HRQOL was 2.1 points higher for Blacks (
p
< 0.0001). During survivorship, differences persisted. After adjusting for demographic, socioeconomic, tumor, and treatment characteristics, physical and functional HRQOL gaps narrowed, but spiritual HRQOL gaps widened.
Conclusions
Racial differences in physical and functional HRQOL during active treatment and survivorship may be largely mediated by socioeconomic factors. However, our results suggest that among Black women, spiritual HRQOL is well supported throughout the BC care continuum. These results inform opportunities for improving the quality and equity of supportive services for women with BC.
Background:
Patients with advanced cancer who have dependent children are an important population with a life-limiting illness and high levels of psychological distress. Few studies have addressed ...the experience of being a parent with advanced cancer and their potential palliative needs.
Aim:
To describe the experience of living with advanced cancer as a parent, including illness experience, parental concerns, and treatment decision making and to explore whether these experiences differ by their functional status.
Design:
We conducted a cross-sectional, qualitative study using in-depth, semi-structured interviews. Data were analyzed using thematic content analysis.
Setting and participants:
A total of 42 participants with metastatic cancer and with at least one child under the age of 18 years were recruited from a comprehensive cancer center. 25 participants were rated as having high functional status (the Eastern Cooperative Oncology Group (ECOG) Performance Status Scale = 0–1) and 17 with low functional status (ECOG=2–4).
Results:
We identified four themes regarding the experience of being a parent with advanced cancer: (1) parental concerns about the impact of their illness and death on their children, (2) “missing out” and losses of parental role and responsibilities, (3) maintaining parental responsibilities despite life-limiting illness, and (4) parental identity influencing decision making about treatment. Parental functional status influenced not only physical responsibilities but also intensified parenting psychological concerns.
Conclusion:
Parents with metastatic cancer may have unique palliative care needs as they experience parenting concerns while managing the psychological and physical demands of advanced cancer.
Background
Breast cancer chemotherapy utilization not only may differ by race and age, but also varies by genomic risk, tumor characteristics, and patient characteristics. Studies in demographically ...diverse populations with both clinical and genomic data are necessary to understand potential disparities by race and age.
Methods
In the Carolina Breast Cancer Study Phase 3 (2008–2013), chemotherapy receipt (yes/no) and regimen type were assessed in association with age and race among hormone receptor (HR) positive and HER2-negative tumors (
n
= 1862). Odds ratios were estimated for the association between demographic factors and chemotherapy receipt.
Results
Monotonic decreases in frequency of adjuvant chemotherapy receipt were observed over time during the study period, while neoadjuvant chemotherapy was stable. Younger age was associated with chemotherapy receipt (OR 95% CI: 2.9 2.4, 3.6) and with anthracycline-based regimens (OR 95% CI: 1.7 1.3, 2.4). Participants who had Medicaid (OR 95% CI: 1.8 1.3, 2.5), lived in rural settings (OR 95% CI: 1.4 1.0, 2.0), or were Black (OR 95% CI: 1.5 1.2, 1.8) had slightly higher odds of chemotherapy, but these associations were non-significant with adjustment for stage and grade. Associations between younger age and chemotherapy receipt were strongest among women who did not receive genomic testing.
Conclusions
While race was not strongly associated with chemotherapy receipt, younger age remains a strong predictor of chemotherapy receipt, even with adjustment for clinical factors and among women who receive genomic testing.
Background
Though randomized clinical trials have demonstrated a reduction in second breast events with endocrine therapy among women with ductal carcinoma in situ (DCIS), use of these therapies ...remains highly variable. The purpose of this study was to evaluate patient and treatment‐related factors associated with endocrine therapy initiation and medical oncology specialty utilization after DCIS.
Materials and Methods
We identified women with a DCIS diagnosis during 2006–2010 in the North Carolina Central Cancer Registry with linked public and private insurance claims in the University of North Carolina Integrated Cancer Information Surveillance System data resource. Multivariable generalized linear regression models were used to estimate risk ratios (RR) and 95% confidence intervals (CI) for endocrine therapy initiation in the year following DCIS diagnosis.
Results
Among 2,090 women with a DCIS diagnosis, 37% initiated endocrine therapy. Initiation was less common among women aged 75+ at diagnosis (RR = 0.79; 95% CI: 0.64–0.97 vs. age 45–54) and women treated with breast‐conserving surgery (BCS) who did not receive radiation (RR = 0.63; 95% CI: 0.50–0.78 vs. BCS plus radiation). Consultation with a medical oncologist was strongly associated with endocrine therapy initiation (RR = 1.40; 95% CI: 1.23–1.61). Women who saw a medical oncologist more often had private insurance, higher census tract‐level income, hormone receptor positive disease, and treatment with BCS and radiation.
Conclusion
Treatment strategies for DCIS remain controversial. Our data suggest that endocrine therapy is more often used in addition to standard therapies such as BCS plus radiation, rather than as an alternative to radiation.
Implications for Practice
Randomized trials have demonstrated a reduction in second breast cancer events with use of endocrine therapy for ductal carcinoma in situ (DCIS). However, notable variation exists in the uptake of these therapies among DCIS patients. In this study, factors associated with endocrine therapy initiation in the year following a DCIS diagnosis included consultation with a medical oncologist and treatment with breast‐conserving surgery with radiation. Our findings help to explain the wide variation in endocrine therapy initiation and suggest the need for clear guidelines in the treatment of DCIS.
Ductal carcinoma in situ accounts for over 20% of all breast cancer diagnoses. The purpose of this study was to evaluate characteristics associated with endocrine therapy initiation in the year after a diagnosis of ductal carcinoma in situ and to investigate factors associated with receiving medical oncology consultation among women with ductal carcinoma in situ.
Introduction
As the cost of cancer treatment continues to rise, many patients are faced with significant emotional and financial burden. Oncology navigators guide patients through many aspects of ...care and therefore may be especially aware of patients’ financial distress. Our objective was to explore navigators’ perception of their patients’ financial burden and their role in addressing financial needs.
Materials and methods
We conducted a real-time online survey of attendees at an oncology navigators’ association conference. Participants included lay navigators, oncology nurse navigators, community health workers, and social workers. Questions assessed perceived burden in their patient population and their role in helping navigate patients through financial resources. Answers to open-ended questions are reported using identified themes.
Results
Seventy-eight respondents participated in the survey, reporting that on average 75% of their patients experienced some degree of financial toxicity related to their cancer. Only 45% of navigators felt the majority of these patients were able to get some financial assistance, most often through assistance with medical costs (73%), subsidized insurance (36%), or non-medical expenses (31%). Commonly identified barriers for patients obtaining assistance included lack of resources (50%), lack of knowledge about resources (46%), and complex/duplicative paperwork (20%).
Conclusion
Oncology navigators reported a high burden of financial toxicity among their patients but insufficient knowledge or resources to address this need. This study underscores the importance of improved training and coordination for addressing financial burden, and the need to address community and system-level barriers.
Purpose
Little is known about racial variations in the financial impact of cancer care. Using data from a national survey of racially diverse patients with metastatic breast cancer, we examined ...racial/ethnic patterns in employment and cost-management (i.e., financial coping) behaviors.
Methods
We conducted an online survey of patients with metastatic breast cancer. Participants reported on socio-demographic characteristics, employment, and financial coping behaviors. We employed adjusted modified Poisson regressions to evaluate racial/ethnic differences in changes in work for pay and financial coping.
Results
Our analysis included 1052 respondents from 41 states, including Non-Hispanic Blacks (NHB, 9%), Hispanics (7%), Asians/Pacific Islanders/Native Hawaiians (API/NH, 10%), American Indians/Alaskan Natives (AI/AN, 8%), and Non-Hispanic Whites (NHW, 66%). In adjusted analyses comparing NHWs with patients of color, patients of color were more likely to take unpaid leave (NHB Adjusted Risk Ratio ARR = 2.27; 95% CI 1.54, 3.34), take paid leave (Hispanic ARR = 2.27; 95% CI 1.54, 1.29), stop work (AI/AN ARR = 1.22; 95% CI 1.05, 1.41), and reduce work hours (AI/AN ARR = 1.33; 95% CI 1.14, 1.57). Patients of color were more likely than NHWs to stop treatment (NHB ARR = 1.22; 95% CI 1.08, 1.39), borrow money from friends/family (Hispanic ARR = 1.75; 95% CI 1.25, 2.44), skip other medical bills (API/NH ARR = 2.02; 95% CI 1.54, 2.63), and skip non-medical bills (AI/AN ARR = 1.67 95% CI 1.06, 2.63). Non-Hispanic Whites more commonly reported using savings or skipping a vacation to help manage costs.
Conclusions
Racial/ethnic differences exist in employment changes and financial coping among metastatic breast cancer patients, with patients of color experiencing worse consequences. Equity must be a guiding principle in strategies addressing financial burden during cancer care.
Abstract
Background
Almost half of the patients with cancer report cancer-related financial hardship, termed “financial toxicity” (FT), which affects health-related quality of life, care retention, ...and, in extreme cases, mortality. This increasingly prevalent hardship warrants urgent intervention. Financial navigation (FN) targets FT by systematically identifying patients at high risk, assessing eligibility for existing resources, clarifying treatment cost expectations, and working with patients and caregivers to develop a plan to cope with cancer costs. This trial seeks to (1) identify FN implementation determinants and implementation outcomes, and (2) evaluate the effectiveness of FN in improving patient outcomes.
Methods
The Lessening the Impact of Financial Toxicity (LIFT) study is a multi-site Phase 2 clinical trial. We use a pre-/post- single-arm intervention to examine the effect of FN on FT in adults with cancer. The LIFT trial is being conducted at nine oncology care settings across North Carolina in the United States. Sites vary in geography (five rural, four non-rural), size (21–974 inpatient beds), and ownership structure (governmental, non-profit). The study will enroll 780 patients total over approximately 2 years. Eligible patients must be 18 years or older, have a confirmed cancer diagnosis (any type) within the past 5 years or be living with advanced disease, and screen positive for cancer-related financial distress. LIFT will be delivered by full- or part-time financial navigators and consists of 3 components: (1) systematic FT screening identification and comprehensive intake assessment; (2) connecting patients experiencing FT to financial support resources via trained oncology financial navigators; and (3) ongoing check-ins and electronic tracking of patients’ progress and outcomes by financial navigators. We will measure intervention effectiveness by evaluating change in FT (via the validated Comprehensive Score of Financial Toxicity, or COST instrument) (primary outcome), as well as health-related quality of life (PROMIS Global Health Questionnaire), and patient-reported delayed or forgone care due to cost. We also assess patient- and stakeholder-reported implementation and service outcomes post-intervention, including uptake, fidelity, acceptability, cost, patient-centeredness, and timeliness.
Discussion
This study adds to the growing evidence on FN by evaluating its implementation and effectiveness across diverse oncology care settings.
Trial registration
ClinicalTrials.gov
NCT04931251. Registered on June 18, 2021.
Purpose
We estimated average medical costs due to metastatic breast cancer (mBC) among younger (aged 18–44), midlife (aged 45–64), and older women (aged 65 and older) by phase of care: initial, ...continuing, and terminal.
Methods
We used 2003–2014 North Carolina cancer registry data linked with administrative claims from public and private payers. We developed a claims-based algorithm to identify breast cancer patients who progressed to metastatic disease. We matched breast cancer patients (mBC and earlier stage) to non-cancer patients on age group, county of residence, and insurance plan. Outcomes were average monthly medical expenditures and expected medical expenditures by phase. We used regression to estimate excess costs attributed to mBC as the difference in mean payments between patients with mBC (
N
= 4806) and patients with each earlier-stage breast cancer (stage 1, stage 2, stage 3, and unknown stage;
N
= 21,772) and non-cancer controls (
N
= 109,631) by treatment phase and age group.
Results
Adjusted monthly costs for women with mBC were significantly higher than for women with earlier-stage breast cancer and non-cancer controls for all age groups and treatment phases except the initial treatment among women with stage 3 breast cancer at diagnosis. The largest expected total costs were for women aged 18–44 with mBC during the continuing phase ($209,961 95% Confidence Interval $165,736–254,186).
Conclusions
We found substantial excess costs for mBC among younger women and during the continuing and terminal phases of survivorship. It is important to assess whether this care is high value for these women.
OncotypeDx is a prognostic and predictive genomic assay used in early-stage hormone receptor-positive, HER2- (HR+/HER2-) breast cancer. It is used to inform adjuvant chemotherapy decisions, but not ...all eligible women receive testing. We aimed to assess variation in testing by demographics and geography, and to determine whether testing was associated with chemotherapy.
For 1,615 women in the Carolina Breast Cancer Study with HR+/HER2-, Stage I-II tumors, we estimated prevalence differences (PD) and 95% confidence intervals (CI) for receipt of OncotypeDx genomic testing in association with and sociodemographic characteristics. We assessed associations between testing and chemotherapy receipt overall and by race. Finally, we calculated the proportion of eligible women receiving OncotypeDx by county-level rurality, census tract-level socioeconomic status, and Area Health Education Center regions.
38% (N = 609) of potentially eligible women were tested, with lower testing prevalences in Black (31%; PD, -11%; 95% CI, -16%-6%) and low-income women (24%; PD, -20%; 95% CI, -29% to -11%) relative to non-Black and higher income women. Urban participants were less likely to be tested than rural participants, though this association varied by region. Among women with low genomic risk tumors, tested participants were 29% less likely to receive chemotherapy than untested participants (95% CI, -40% to -17%). Racial differences in chemotherapy were restricted to untested women.
Both individual and area-level socioeconomics predict likelihood of OncotypeDx testing.
Variable adoption of OncotypeDx by socioeconomics and across geographic settings may contribute to excess chemotherapy among patients with HR+/HER2- cancers. See related In the Spotlight, p. 635.
Response to Strassels and Durham Check, Devon K; Winn, Aaron N; Fergestrom, Nicole ...
JNCI : Journal of the National Cancer Institute,
12/2020, Letnik:
112, Številka:
12
Journal Article
PDF
