Breast Cancer

SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.

In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.

The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.

“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”

She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”

Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.

They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).

The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.

The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.

Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.

“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.

In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.

When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).

Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).

“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”

But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.

The investigator had no disclosures.

SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.

In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.

The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.

“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”

She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”

Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.

They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).

The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.

The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.

Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.

“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.

In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.

When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).

Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).

“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”

But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.

The investigator had no disclosures.

SEATTLE – Sentinel lymph node biopsy is widely used in patients with early-stage breast cancer for staging the axilla, but it can be safely omitted in some patients, according to new research presented at the annual Society of Surgical Oncology Cancer Symposium.

In women aged 70 years and older with hormone receptor (HR)–positive invasive breast cancer, the risk of nodal involvement is 14%-15%, which adds support to the premise that sentinel lymph node surgery could be avoided in many of the women deemed to be low risk.

The Choosing Wisely campaign was initiated to reduce excess cost and expenditures in health care. The Society of Surgical Oncology recently released five Choosing Wisely guidelines that included specific tests or procedures commonly ordered but not always necessary in surgical oncology, explained study author Jessemae Welsh, MD, of the Mayo Clinic, Rochester, Minn. One of the recommendations was to avoid routine sentinel node biopsy in clinically node-negative women over age 70 years with hormone receptor–positive invasive breast cancer.

“Their rationale is that hormone therapy is the standard of care in these women and sentinel node surgery has shown no impact on local regional recurrence or breast cancer mortality,” said Dr. Welsh. “Therefore it would be safe to treat this population without any axillary node staging.”

She noted that the average 70-year-old woman may live another 14-16 years. “So the question is, how should we be applying the Choosing Wisely guidelines?”

Dr. Welsh and her colleagues evaluated the factors that might be impacting nodal positivity in this population, and in particular, they looked at T stage and tumor grade.

They used two large databases to identify all women over the age of 70 years with HR+ cN0 invasive disease in the institutional breast surgery database (IBSD, 2008-2016) from the Mayo Clinic and the National Cancer Database (NCDB, 2004-2013).

The rates of patients who were node positive (pN+) were based on those who had undergone axillary surgery.

The researchers then stratified patients by clinical T stage and tumor grade to compare risk of pN+ across strata.

Of 705 selected patients in the IBSD, 191 or 14.3% were pN+ and a similar rate was observed in the NCDB; 15.2% (19,607/129,216). Tumor grade and clinical T stage were associated with pN+.

“The overall rates were about 14% for both databases, and when we stratified this by T stage, we could see increasing node positivity with increasing T stage,” said Dr. Welsh.

In similar fashion, the researchers observed comparable increases when they stratified it by grade. “Increasing grades were associated with increasing rates, especially for grade 2 and higher,” said Dr. Welsh.

When the two factors were combined, the researchers were able to define low-risk criteria as clinical T1a-b, grade 1-2 or clinical T1c, grade 1. The low-risk group accounted for 54.3% (IBSD) and 43.2% (NCDB) of patients, and pN+ rates within this group were 7.6% (IBSD) and 7.4% (NCDB).

Patients outside of this subcohort had pN+ rates of 22.4% (IBSD) and 23.0% (NCDB), which extrapolated to a relative risk of 2.95 (95% CI: 1.97-4.42) and 3.11 (95% CI: 2.99-3.23), respectively (each P less than .001).

“Women in the high-risk group had three times the risk of node positivity as the low-risk group,” she said. “Based on our data, we can say that for grade 1 T1a-c we can omit sentinel node surgery, and also for grade 2 T1 a-b.”

But for grade 3, T2 or higher, or any grade 2 Tc tumors, clinicians should continue to consider sentinel node surgery, taking into account individual patient factors.

The investigator had no disclosures.

ORLANDO – Accumulating experience is showing the benefits of various models of care for cancer survivors in terms of health care use and costs, while also suggesting that some provide higher-quality care than others, according to a pair of studies reported at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Initiative for breast cancer survivors

“In 2011, Cancer Care Ontario did a quick environmental scan of our 14 regional cancer centers and found that the transition of breast cancer survivors from oncologists to primary care was very variable, and that centers often didn’t transition patients very frequently,” said Nicole Mittmann, PhD, first author on one of the studies, chief research officer for Cancer Care Ontario, and an investigator at Sunnybrook Research Institute, Toronto.

The advisory organization therefore implemented the Well Follow-Up Care Initiative to facilitate appropriate transition of breast cancer survivors. Each regional center was given a $100,000 incentive to roll out a model of the initiative.

Dr. Mittmann and her coinvestigators used provincial administrative databases to compare health care use and associated costs between 2,324 breast cancer survivors who were transitioned with the initiative and 2,324 propensity-matched control survivors who were not. The survivors were about 5 years out from their breast cancer diagnosis at baseline and had median follow-up of 2 years.

Study results reported at the symposium showed that the mean annual total cost of care per patient paid for by the provincial health ministry was $6,575 for the transitioned group and $10,832 for the nontransitioned group, a difference of $4,257 (39%). The main drivers were reduced costs of long-term care and cancer clinic visits.

Findings were similar for median annual costs, which amounted to $2,261 for the transitioned group and $2,903 for the control group, a difference of $638.

Compared with the nontransitioned group, the transitioned group had significantly fewer annual visits to medical oncologists (0.39 vs. 1.29) and radiation oncologists (0.16 vs. 0.36), while visits to general or family practitioners were statistically indistinguishable (7.35 and 7.91), Dr. Mittmann reported. There was also a trend toward fewer emergency department visits.

The transitioned group had fewer bone scans, CT and MRI scans, and radiographs annually, but differences were not significant.

Reassuringly, Dr. Mittmann said, survivors who were transitioned did not fare worse than their nontransitioned counterparts in overall survival; if anything, they tended to live longer. “We think that because the individual cancer centers enrolled patients that they thought were very well that this is a very well and highly selected and maybe a biased group,” Dr. Mittmann acknowledged. “But we certainly see that they are not doing worse than the control group.”

“About $1.4 million was distributed to the cancer centers” for the initiative, she noted. “That generated a savings for the health system of $1.5 million, if you are looking at median costs, to $9.9 million, if you are looking at mean costs.

“The transition of appropriate breast cancer survivors to the community appears to be safe and effective outside of a clinical trial, at least based on this particular retrospective analysis using databases,” she said. “The overall costs are not increased, and they may actually be decreased based on our data, and certainly these results will inform policy.”

The investigators plan several next steps, such as encouraging senior leadership at Cancer Care Ontario and the Ministry of Health to endorse the findings, according to Dr. Mittmann. In addition, “[we plan to] engage with both oncology and primary care leadership and think about how we can potentially roll out a program like this, and develop tools, whether those are letters or information packages, and education, to … appropriately transition individuals.”

Considerations in interpreting the study’s findings include the quality of the matching of survivors, according to invited discussant Monika K. Krzyzanowska, MD, a medical oncologist at Princess Margaret Cancer Centre, an associate professor at the University of Toronto, and a clinical lead of Quality Care and Access, Systemic Treatment Program, at Cancer Care Ontario. “The quality of that match depends on what’s in the model, so there could be potential for residual confounding, and administrative data may not have all of the elements that you would need to get a perfect match.”

Comparison of survivorship care models

Two-thirds of the large and growing population of cancer survivors are at least 5 years out from diagnosis, stimulating considerable discussion in the oncology community about how to best address their needs, according to Sarah Raskin, PhD, senior author on the second study and a research scientist at the Institute for Patient-Centered Initiatives and Health Equity at George Washington University Cancer Center, Washington.

“Yet, for a lack of cancer survivorship–specific guidelines from research or practice, cancer centers are increasingly developing survivorship care in a variety of ways, many of which are ad hoc or unproven as yet,” she said.

Dr. Raskin and her colleagues compared three emerging models of survivorship care: a specialized consultative model and a specialized longitudinal model – whereby patients have a single or multiple formalized survivorship visits, respectively, with care typically led by an oncology nurse-practitioner – and an oncology-embedded model – whereby survivorship is addressed as a part of ongoing oncology follow-up care, typically by the oncologist.

The investigators worked with survivors to develop the Patient-Prioritized Measure of High-Quality Survivorship Care, a 46-question scale assessing nine components of survivorship care that capture the health care priorities and needs that matter most to patients. Each component is rated on a scale from 0 (not at all met) to 1 (somewhat met) to 2 (definitely met).

Analyses were based on responses of 827 survivors of breast, colorectal, and prostate cancer who received care at 28 U.S. institutions using one of the above models and who were surveyed by telephone about the care received 1 week after their initial survivorship visit.

Results showed that survivors cared for under the three models differed significantly with respect to scores for seven of the nine components of quality of care, Dr. Raskin reported. The exceptions were practical life support, where the mean score was about 0.6-0.8 across the board, and having a medical home, where the mean score was about 1.8-1.9 across the board.

The specialized consult model of care had the highest scores for mental health and social support, information and resources, and supportive and prepared clinicians. The specialized longitudinal model of care had the highest scores for empowered and engaged patients, open patient-clinician communication, care coordination and transitions, and access to full spectrum of care. The oncology-embedded model had the lowest scores. Analysis of the tool’s 46 individual questions showed that patients cared for at institutions using the oncology-embedded model were significantly less likely than were counterparts cared for at institutions using the specialized models to report that the institution performed various activities such as offering a treatment summary, inquiring about the patient’s biggest worries or problems, and explaining the reasons why tests were needed (P less than .05 for each).

For some metrics, the overall proportion reporting that an activity was performed was low, regardless of the model being used. For example, only 48% of all patients reported being helped to set goals or make short-term plans to manage follow-up care and improve health, merely 24% reported being provided emotional and social support to deal with changes in relationships, and just 19% reported being referred to special providers for other medical problems.

“Overall, all three models are performing highly in terms of providing survivors with a medical home and communicating with patients. However, all three are performing quite low in terms of providing mental health and social support, as well as practical life support,” said Dr. Raskin.

“By model, we see that the embedded ongoing care model is significantly underperforming compared with both specialized models on seven of nine components, and we have some hypotheses from our early work with [Commission on Cancer]–accredited centers to explain this,” she added. “Embedded survivorship models have a lot of variability – many are high performers but others are low performers as compared with specialized programs. Embedded survivorship care models are typically led by the treating oncologist, who historically has focused on treating sick patients and less so on providing social supports for follow-up of well patients or ‘well-er’ patients. At the same time, specialized models focus predominantly on survivorship care and providing services and referrals for survivors, which may explain their high scores.

“We know that the higher quality of care measures presented here do not necessarily translate to better patient outcomes, and that’s actually going to be the next phase of our analysis,” she concluded.

The study sample may have had some selection bias, and it is unclear how well validated the tool was, according to Dr. Krzyzanowska, the discussant. Another issue was its assessment of quality of care at only a single time point.

Nonetheless, the findings show “that measuring quality of survivorship care from a patient perspective is feasible and valuable. We have already heard about [need for] survivorship plans in survivorship care, so certainly the work that was just presented is extremely important to help to fill some of these gaps,” she said.

“I’m not sure that we yet know what the optimal model of survivorship care is without the information of the other outcomes. Furthermore, there’s different survivor populations and different ways that health care is organized, so perhaps there isn’t really one optimal model, but the model has to fit with the context,” Dr. Krzyzanowska concluded. “That being said … the tool that they have created can be a great tool for existing survivorship care programs to assess and improve the quality of their care.”

Dr. Mittmann and Dr. Raskin had no disclosures to report.

ORLANDO – Accumulating experience is showing the benefits of various models of care for cancer survivors in terms of health care use and costs, while also suggesting that some provide higher-quality care than others, according to a pair of studies reported at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Initiative for breast cancer survivors

“In 2011, Cancer Care Ontario did a quick environmental scan of our 14 regional cancer centers and found that the transition of breast cancer survivors from oncologists to primary care was very variable, and that centers often didn’t transition patients very frequently,” said Nicole Mittmann, PhD, first author on one of the studies, chief research officer for Cancer Care Ontario, and an investigator at Sunnybrook Research Institute, Toronto.

The advisory organization therefore implemented the Well Follow-Up Care Initiative to facilitate appropriate transition of breast cancer survivors. Each regional center was given a $100,000 incentive to roll out a model of the initiative.

Dr. Mittmann and her coinvestigators used provincial administrative databases to compare health care use and associated costs between 2,324 breast cancer survivors who were transitioned with the initiative and 2,324 propensity-matched control survivors who were not. The survivors were about 5 years out from their breast cancer diagnosis at baseline and had median follow-up of 2 years.

Study results reported at the symposium showed that the mean annual total cost of care per patient paid for by the provincial health ministry was $6,575 for the transitioned group and $10,832 for the nontransitioned group, a difference of $4,257 (39%). The main drivers were reduced costs of long-term care and cancer clinic visits.

Findings were similar for median annual costs, which amounted to $2,261 for the transitioned group and $2,903 for the control group, a difference of $638.

Compared with the nontransitioned group, the transitioned group had significantly fewer annual visits to medical oncologists (0.39 vs. 1.29) and radiation oncologists (0.16 vs. 0.36), while visits to general or family practitioners were statistically indistinguishable (7.35 and 7.91), Dr. Mittmann reported. There was also a trend toward fewer emergency department visits.

The transitioned group had fewer bone scans, CT and MRI scans, and radiographs annually, but differences were not significant.

Reassuringly, Dr. Mittmann said, survivors who were transitioned did not fare worse than their nontransitioned counterparts in overall survival; if anything, they tended to live longer. “We think that because the individual cancer centers enrolled patients that they thought were very well that this is a very well and highly selected and maybe a biased group,” Dr. Mittmann acknowledged. “But we certainly see that they are not doing worse than the control group.”

“About $1.4 million was distributed to the cancer centers” for the initiative, she noted. “That generated a savings for the health system of $1.5 million, if you are looking at median costs, to $9.9 million, if you are looking at mean costs.

“The transition of appropriate breast cancer survivors to the community appears to be safe and effective outside of a clinical trial, at least based on this particular retrospective analysis using databases,” she said. “The overall costs are not increased, and they may actually be decreased based on our data, and certainly these results will inform policy.”

The investigators plan several next steps, such as encouraging senior leadership at Cancer Care Ontario and the Ministry of Health to endorse the findings, according to Dr. Mittmann. In addition, “[we plan to] engage with both oncology and primary care leadership and think about how we can potentially roll out a program like this, and develop tools, whether those are letters or information packages, and education, to … appropriately transition individuals.”

Considerations in interpreting the study’s findings include the quality of the matching of survivors, according to invited discussant Monika K. Krzyzanowska, MD, a medical oncologist at Princess Margaret Cancer Centre, an associate professor at the University of Toronto, and a clinical lead of Quality Care and Access, Systemic Treatment Program, at Cancer Care Ontario. “The quality of that match depends on what’s in the model, so there could be potential for residual confounding, and administrative data may not have all of the elements that you would need to get a perfect match.”

Comparison of survivorship care models

Two-thirds of the large and growing population of cancer survivors are at least 5 years out from diagnosis, stimulating considerable discussion in the oncology community about how to best address their needs, according to Sarah Raskin, PhD, senior author on the second study and a research scientist at the Institute for Patient-Centered Initiatives and Health Equity at George Washington University Cancer Center, Washington.

“Yet, for a lack of cancer survivorship–specific guidelines from research or practice, cancer centers are increasingly developing survivorship care in a variety of ways, many of which are ad hoc or unproven as yet,” she said.

Dr. Raskin and her colleagues compared three emerging models of survivorship care: a specialized consultative model and a specialized longitudinal model – whereby patients have a single or multiple formalized survivorship visits, respectively, with care typically led by an oncology nurse-practitioner – and an oncology-embedded model – whereby survivorship is addressed as a part of ongoing oncology follow-up care, typically by the oncologist.

The investigators worked with survivors to develop the Patient-Prioritized Measure of High-Quality Survivorship Care, a 46-question scale assessing nine components of survivorship care that capture the health care priorities and needs that matter most to patients. Each component is rated on a scale from 0 (not at all met) to 1 (somewhat met) to 2 (definitely met).

Analyses were based on responses of 827 survivors of breast, colorectal, and prostate cancer who received care at 28 U.S. institutions using one of the above models and who were surveyed by telephone about the care received 1 week after their initial survivorship visit.

Results showed that survivors cared for under the three models differed significantly with respect to scores for seven of the nine components of quality of care, Dr. Raskin reported. The exceptions were practical life support, where the mean score was about 0.6-0.8 across the board, and having a medical home, where the mean score was about 1.8-1.9 across the board.

The specialized consult model of care had the highest scores for mental health and social support, information and resources, and supportive and prepared clinicians. The specialized longitudinal model of care had the highest scores for empowered and engaged patients, open patient-clinician communication, care coordination and transitions, and access to full spectrum of care. The oncology-embedded model had the lowest scores. Analysis of the tool’s 46 individual questions showed that patients cared for at institutions using the oncology-embedded model were significantly less likely than were counterparts cared for at institutions using the specialized models to report that the institution performed various activities such as offering a treatment summary, inquiring about the patient’s biggest worries or problems, and explaining the reasons why tests were needed (P less than .05 for each).

For some metrics, the overall proportion reporting that an activity was performed was low, regardless of the model being used. For example, only 48% of all patients reported being helped to set goals or make short-term plans to manage follow-up care and improve health, merely 24% reported being provided emotional and social support to deal with changes in relationships, and just 19% reported being referred to special providers for other medical problems.

“Overall, all three models are performing highly in terms of providing survivors with a medical home and communicating with patients. However, all three are performing quite low in terms of providing mental health and social support, as well as practical life support,” said Dr. Raskin.

“By model, we see that the embedded ongoing care model is significantly underperforming compared with both specialized models on seven of nine components, and we have some hypotheses from our early work with [Commission on Cancer]–accredited centers to explain this,” she added. “Embedded survivorship models have a lot of variability – many are high performers but others are low performers as compared with specialized programs. Embedded survivorship care models are typically led by the treating oncologist, who historically has focused on treating sick patients and less so on providing social supports for follow-up of well patients or ‘well-er’ patients. At the same time, specialized models focus predominantly on survivorship care and providing services and referrals for survivors, which may explain their high scores.

“We know that the higher quality of care measures presented here do not necessarily translate to better patient outcomes, and that’s actually going to be the next phase of our analysis,” she concluded.

The study sample may have had some selection bias, and it is unclear how well validated the tool was, according to Dr. Krzyzanowska, the discussant. Another issue was its assessment of quality of care at only a single time point.

Nonetheless, the findings show “that measuring quality of survivorship care from a patient perspective is feasible and valuable. We have already heard about [need for] survivorship plans in survivorship care, so certainly the work that was just presented is extremely important to help to fill some of these gaps,” she said.

“I’m not sure that we yet know what the optimal model of survivorship care is without the information of the other outcomes. Furthermore, there’s different survivor populations and different ways that health care is organized, so perhaps there isn’t really one optimal model, but the model has to fit with the context,” Dr. Krzyzanowska concluded. “That being said … the tool that they have created can be a great tool for existing survivorship care programs to assess and improve the quality of their care.”

Dr. Mittmann and Dr. Raskin had no disclosures to report.

ORLANDO – Accumulating experience is showing the benefits of various models of care for cancer survivors in terms of health care use and costs, while also suggesting that some provide higher-quality care than others, according to a pair of studies reported at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Initiative for breast cancer survivors

“In 2011, Cancer Care Ontario did a quick environmental scan of our 14 regional cancer centers and found that the transition of breast cancer survivors from oncologists to primary care was very variable, and that centers often didn’t transition patients very frequently,” said Nicole Mittmann, PhD, first author on one of the studies, chief research officer for Cancer Care Ontario, and an investigator at Sunnybrook Research Institute, Toronto.

The advisory organization therefore implemented the Well Follow-Up Care Initiative to facilitate appropriate transition of breast cancer survivors. Each regional center was given a $100,000 incentive to roll out a model of the initiative.

Dr. Mittmann and her coinvestigators used provincial administrative databases to compare health care use and associated costs between 2,324 breast cancer survivors who were transitioned with the initiative and 2,324 propensity-matched control survivors who were not. The survivors were about 5 years out from their breast cancer diagnosis at baseline and had median follow-up of 2 years.

Study results reported at the symposium showed that the mean annual total cost of care per patient paid for by the provincial health ministry was $6,575 for the transitioned group and $10,832 for the nontransitioned group, a difference of $4,257 (39%). The main drivers were reduced costs of long-term care and cancer clinic visits.

Findings were similar for median annual costs, which amounted to $2,261 for the transitioned group and $2,903 for the control group, a difference of $638.

Compared with the nontransitioned group, the transitioned group had significantly fewer annual visits to medical oncologists (0.39 vs. 1.29) and radiation oncologists (0.16 vs. 0.36), while visits to general or family practitioners were statistically indistinguishable (7.35 and 7.91), Dr. Mittmann reported. There was also a trend toward fewer emergency department visits.

The transitioned group had fewer bone scans, CT and MRI scans, and radiographs annually, but differences were not significant.

Reassuringly, Dr. Mittmann said, survivors who were transitioned did not fare worse than their nontransitioned counterparts in overall survival; if anything, they tended to live longer. “We think that because the individual cancer centers enrolled patients that they thought were very well that this is a very well and highly selected and maybe a biased group,” Dr. Mittmann acknowledged. “But we certainly see that they are not doing worse than the control group.”

“About $1.4 million was distributed to the cancer centers” for the initiative, she noted. “That generated a savings for the health system of $1.5 million, if you are looking at median costs, to $9.9 million, if you are looking at mean costs.

“The transition of appropriate breast cancer survivors to the community appears to be safe and effective outside of a clinical trial, at least based on this particular retrospective analysis using databases,” she said. “The overall costs are not increased, and they may actually be decreased based on our data, and certainly these results will inform policy.”

The investigators plan several next steps, such as encouraging senior leadership at Cancer Care Ontario and the Ministry of Health to endorse the findings, according to Dr. Mittmann. In addition, “[we plan to] engage with both oncology and primary care leadership and think about how we can potentially roll out a program like this, and develop tools, whether those are letters or information packages, and education, to … appropriately transition individuals.”

Considerations in interpreting the study’s findings include the quality of the matching of survivors, according to invited discussant Monika K. Krzyzanowska, MD, a medical oncologist at Princess Margaret Cancer Centre, an associate professor at the University of Toronto, and a clinical lead of Quality Care and Access, Systemic Treatment Program, at Cancer Care Ontario. “The quality of that match depends on what’s in the model, so there could be potential for residual confounding, and administrative data may not have all of the elements that you would need to get a perfect match.”

Comparison of survivorship care models

Two-thirds of the large and growing population of cancer survivors are at least 5 years out from diagnosis, stimulating considerable discussion in the oncology community about how to best address their needs, according to Sarah Raskin, PhD, senior author on the second study and a research scientist at the Institute for Patient-Centered Initiatives and Health Equity at George Washington University Cancer Center, Washington.

“Yet, for a lack of cancer survivorship–specific guidelines from research or practice, cancer centers are increasingly developing survivorship care in a variety of ways, many of which are ad hoc or unproven as yet,” she said.

Dr. Raskin and her colleagues compared three emerging models of survivorship care: a specialized consultative model and a specialized longitudinal model – whereby patients have a single or multiple formalized survivorship visits, respectively, with care typically led by an oncology nurse-practitioner – and an oncology-embedded model – whereby survivorship is addressed as a part of ongoing oncology follow-up care, typically by the oncologist.

The investigators worked with survivors to develop the Patient-Prioritized Measure of High-Quality Survivorship Care, a 46-question scale assessing nine components of survivorship care that capture the health care priorities and needs that matter most to patients. Each component is rated on a scale from 0 (not at all met) to 1 (somewhat met) to 2 (definitely met).

Analyses were based on responses of 827 survivors of breast, colorectal, and prostate cancer who received care at 28 U.S. institutions using one of the above models and who were surveyed by telephone about the care received 1 week after their initial survivorship visit.

Results showed that survivors cared for under the three models differed significantly with respect to scores for seven of the nine components of quality of care, Dr. Raskin reported. The exceptions were practical life support, where the mean score was about 0.6-0.8 across the board, and having a medical home, where the mean score was about 1.8-1.9 across the board.

The specialized consult model of care had the highest scores for mental health and social support, information and resources, and supportive and prepared clinicians. The specialized longitudinal model of care had the highest scores for empowered and engaged patients, open patient-clinician communication, care coordination and transitions, and access to full spectrum of care. The oncology-embedded model had the lowest scores. Analysis of the tool’s 46 individual questions showed that patients cared for at institutions using the oncology-embedded model were significantly less likely than were counterparts cared for at institutions using the specialized models to report that the institution performed various activities such as offering a treatment summary, inquiring about the patient’s biggest worries or problems, and explaining the reasons why tests were needed (P less than .05 for each).

For some metrics, the overall proportion reporting that an activity was performed was low, regardless of the model being used. For example, only 48% of all patients reported being helped to set goals or make short-term plans to manage follow-up care and improve health, merely 24% reported being provided emotional and social support to deal with changes in relationships, and just 19% reported being referred to special providers for other medical problems.

“Overall, all three models are performing highly in terms of providing survivors with a medical home and communicating with patients. However, all three are performing quite low in terms of providing mental health and social support, as well as practical life support,” said Dr. Raskin.

“By model, we see that the embedded ongoing care model is significantly underperforming compared with both specialized models on seven of nine components, and we have some hypotheses from our early work with [Commission on Cancer]–accredited centers to explain this,” she added. “Embedded survivorship models have a lot of variability – many are high performers but others are low performers as compared with specialized programs. Embedded survivorship care models are typically led by the treating oncologist, who historically has focused on treating sick patients and less so on providing social supports for follow-up of well patients or ‘well-er’ patients. At the same time, specialized models focus predominantly on survivorship care and providing services and referrals for survivors, which may explain their high scores.

“We know that the higher quality of care measures presented here do not necessarily translate to better patient outcomes, and that’s actually going to be the next phase of our analysis,” she concluded.

The study sample may have had some selection bias, and it is unclear how well validated the tool was, according to Dr. Krzyzanowska, the discussant. Another issue was its assessment of quality of care at only a single time point.

Nonetheless, the findings show “that measuring quality of survivorship care from a patient perspective is feasible and valuable. We have already heard about [need for] survivorship plans in survivorship care, so certainly the work that was just presented is extremely important to help to fill some of these gaps,” she said.

“I’m not sure that we yet know what the optimal model of survivorship care is without the information of the other outcomes. Furthermore, there’s different survivor populations and different ways that health care is organized, so perhaps there isn’t really one optimal model, but the model has to fit with the context,” Dr. Krzyzanowska concluded. “That being said … the tool that they have created can be a great tool for existing survivorship care programs to assess and improve the quality of their care.”

Dr. Mittmann and Dr. Raskin had no disclosures to report.

Up to two-thirds of the mutations that drive human cancers may be due to DNA replication errors in normally dividing stem cells, not by inherited or environmentally induced mutations, according to a mathematical modeling study.

The proportion of replication error-driven mutations varied widely among 17 cancers analyzed, but the overall attributable risk of these errors was remarkably consistent among 69 countries included in the study, said Cristian Tomasetti, PhD, a coauthor of the paper and a biostatistician at Johns Hopkins University, Baltimore.

The findings should be a game-changer in the cancer field, Dr. Tomasetti said during a press briefing sponsored by the American Association for the Advancement of Science. Research dogma has long held that most cancers are related to lifestyle and environmental exposure, with a few primarily due to genetic factors.

“We have now determined that there is a third factor, and that it causes most of the mutations that drive cancer,” Dr. Tomasetti said. “We cannot ignore it and pretend it doesn’t exist. This is a complete paradigm shift in how we think of cancer and what causes it.”

The finding that 66% of cancer-driving mutations are based on unavoidable replication errors doesn’t challenge well-established epidemiology, said Dr. Tomasetti and his coauthor, Bert Vogelstein, MD. Rather, it fits perfectly with several key understandings of cancer: that about 40% of cases are preventable, that rapidly dividing tissues are more prone to develop cancers, and that cancer incidence rises exponentially as humans age.

“If we have as our starting point the assumption that 42% of cancers are preventable, we are completely consistent with that,” in finding that about 60% of cancers are unavoidable, Dr. Tomasetti said. “Those two numbers go perfectly together.”

The study also found that replication-error mutations (R) were most likely to drive cancers in tissues with rapid turnover, such as colorectal tissue. This makes intuitive sense, given that basal mutation rates hover at about three errors per cell replication cycle regardless of tissue type.

“The basal mutation rate in all cells is pretty even,” said Dr. Vogelstein, the Clayton Professor of Oncology and Pathology at John Hopkins University, Baltimore. “The difference is the number of stem cells. The more cells, the more divisions, and the more mistakes.”

R-mutations also contribute to age-related cancer incidence. As a person ages, more cell divisions accumulate, thus increasing the risk of a cancer-driving R-error. But these mutations also occur in children, who have rapid cell division in all their tissues. In fact, the colleagues suspect that R-errors are the main drivers of almost all pediatric cancers.

The new study bolsters the duo’s controversial 2015 work.

Courtesy Dr. Cristian Tomasetti and Dr. Bert Vogelstein

[email protected]

On Twitter @Alz_gal

Up to two-thirds of the mutations that drive human cancers may be due to DNA replication errors in normally dividing stem cells, not by inherited or environmentally induced mutations, according to a mathematical modeling study.

The proportion of replication error-driven mutations varied widely among 17 cancers analyzed, but the overall attributable risk of these errors was remarkably consistent among 69 countries included in the study, said Cristian Tomasetti, PhD, a coauthor of the paper and a biostatistician at Johns Hopkins University, Baltimore.

The findings should be a game-changer in the cancer field, Dr. Tomasetti said during a press briefing sponsored by the American Association for the Advancement of Science. Research dogma has long held that most cancers are related to lifestyle and environmental exposure, with a few primarily due to genetic factors.

“We have now determined that there is a third factor, and that it causes most of the mutations that drive cancer,” Dr. Tomasetti said. “We cannot ignore it and pretend it doesn’t exist. This is a complete paradigm shift in how we think of cancer and what causes it.”

The finding that 66% of cancer-driving mutations are based on unavoidable replication errors doesn’t challenge well-established epidemiology, said Dr. Tomasetti and his coauthor, Bert Vogelstein, MD. Rather, it fits perfectly with several key understandings of cancer: that about 40% of cases are preventable, that rapidly dividing tissues are more prone to develop cancers, and that cancer incidence rises exponentially as humans age.

“If we have as our starting point the assumption that 42% of cancers are preventable, we are completely consistent with that,” in finding that about 60% of cancers are unavoidable, Dr. Tomasetti said. “Those two numbers go perfectly together.”

The study also found that replication-error mutations (R) were most likely to drive cancers in tissues with rapid turnover, such as colorectal tissue. This makes intuitive sense, given that basal mutation rates hover at about three errors per cell replication cycle regardless of tissue type.

“The basal mutation rate in all cells is pretty even,” said Dr. Vogelstein, the Clayton Professor of Oncology and Pathology at John Hopkins University, Baltimore. “The difference is the number of stem cells. The more cells, the more divisions, and the more mistakes.”

R-mutations also contribute to age-related cancer incidence. As a person ages, more cell divisions accumulate, thus increasing the risk of a cancer-driving R-error. But these mutations also occur in children, who have rapid cell division in all their tissues. In fact, the colleagues suspect that R-errors are the main drivers of almost all pediatric cancers.

The new study bolsters the duo’s controversial 2015 work.

Courtesy Dr. Cristian Tomasetti and Dr. Bert Vogelstein

[email protected]

On Twitter @Alz_gal

Up to two-thirds of the mutations that drive human cancers may be due to DNA replication errors in normally dividing stem cells, not by inherited or environmentally induced mutations, according to a mathematical modeling study.

The proportion of replication error-driven mutations varied widely among 17 cancers analyzed, but the overall attributable risk of these errors was remarkably consistent among 69 countries included in the study, said Cristian Tomasetti, PhD, a coauthor of the paper and a biostatistician at Johns Hopkins University, Baltimore.

The findings should be a game-changer in the cancer field, Dr. Tomasetti said during a press briefing sponsored by the American Association for the Advancement of Science. Research dogma has long held that most cancers are related to lifestyle and environmental exposure, with a few primarily due to genetic factors.

“We have now determined that there is a third factor, and that it causes most of the mutations that drive cancer,” Dr. Tomasetti said. “We cannot ignore it and pretend it doesn’t exist. This is a complete paradigm shift in how we think of cancer and what causes it.”

The finding that 66% of cancer-driving mutations are based on unavoidable replication errors doesn’t challenge well-established epidemiology, said Dr. Tomasetti and his coauthor, Bert Vogelstein, MD. Rather, it fits perfectly with several key understandings of cancer: that about 40% of cases are preventable, that rapidly dividing tissues are more prone to develop cancers, and that cancer incidence rises exponentially as humans age.

“If we have as our starting point the assumption that 42% of cancers are preventable, we are completely consistent with that,” in finding that about 60% of cancers are unavoidable, Dr. Tomasetti said. “Those two numbers go perfectly together.”

The study also found that replication-error mutations (R) were most likely to drive cancers in tissues with rapid turnover, such as colorectal tissue. This makes intuitive sense, given that basal mutation rates hover at about three errors per cell replication cycle regardless of tissue type.

“The basal mutation rate in all cells is pretty even,” said Dr. Vogelstein, the Clayton Professor of Oncology and Pathology at John Hopkins University, Baltimore. “The difference is the number of stem cells. The more cells, the more divisions, and the more mistakes.”

R-mutations also contribute to age-related cancer incidence. As a person ages, more cell divisions accumulate, thus increasing the risk of a cancer-driving R-error. But these mutations also occur in children, who have rapid cell division in all their tissues. In fact, the colleagues suspect that R-errors are the main drivers of almost all pediatric cancers.

The new study bolsters the duo’s controversial 2015 work.

Courtesy Dr. Cristian Tomasetti and Dr. Bert Vogelstein

[email protected]

On Twitter @Alz_gal

ORLANDO – Women with breast cancer who look for well-rounded information about treatment on the websites of prominent U.S. cancer centers are likely to come up short, suggests a study presented at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Research has shown that nearly all women with breast cancer search the Internet for information about its treatment, and two-thirds report that what they find has a strong influence on their decision-making process (J Cancer Educ. 2013;28[4]:662-8).

But the analysis of content on the websites of 63 National Cancer Institute–designated comprehensive cancer centers or clinical cancer centers found that, on average, they addressed only 21% of a set of key concepts that women need to understand to make informed decisions about surgery, radiation therapy, chemotherapy, hormone therapy, and breast reconstruction. This contrasted starkly with 85% for the National Cancer Institute’s own website (cancer.gov) and 88% for the Susan G. Komen Foundation’s website (komen.org).

Susan London/Frontline Medical News

Study details

For the study, the investigators developed a list of 33 decision-specific knowledge questions about breast cancer treatment by drawing on decision quality instruments that assess how informed a woman’s decision-making process is. The primary outcome was whether the website provided sufficient information to answer each question. The researchers assessed seven measures of accessibility as secondary outcomes.

Results showed that websites contained sufficient content to address only 21% of the decision-specific knowledge questions, Dr. Dulaney reported in a poster session. The value was 17% for questions pertaining to breast surgery and radiation therapy, 18% for those pertaining to chemotherapy and hormone therapy, and 21% for those pertaining to breast reconstruction.

In addition, “a lot of websites put the information in silos,” he noted. “You can read about mastectomy, you can read about lumpectomy, you can read about chemo. But you can’t really get the big picture, which is how do these compare to each other, and which treatment is best for me.”

Even the most commonly addressed single question – what type of reconstruction is most likely to require more than one surgery or procedure – was addressed by only 51% of sites. Proportions were similar for questions pertaining to the type of tumors against which hormone therapy works best (48%) and the schedule for radiation therapy after lumpectomy (47%).

At the other extreme, however, very small proportions of sites addressed questions pertaining to how many women with treated early breast cancer will die from the disease (7%), how many undergoing breast reconstruction will experience complications requiring hospitalization or an unplanned procedure (4%), how skipping chemotherapy and hormone therapy influences risk of death (2%), and whether waiting several weeks to decide about those therapies affects survival (2%). These topics are more negative, Dr. Dulaney observed, “but these are things women need to know.”

None of the websites provided sufficient information to answer all 33 knowledge questions. But perhaps more worrisome, 16% did not provide sufficient information to answer any of them, he said.

When it came to accessibility of information, 94% of sites clearly had a breast cancer–specific page, 87% had information about breast cancer–specific trials, and 86% showed members of the center’s breast cancer team. But only 59% were mobile device friendly as assessed with a Google tool, and merely 24% had obvious links to view information in Spanish.

“A lot of minorities and people of lower socioeconomic status exclusively access the Internet via mobile devices, so they may not have a computer or [other] access to the Internet. But they have a cell phone that is probably a smartphone, and they can get online and search for information that way,” Dr. Dulaney said.

Many oncologists may not have had any say regarding the content and accessibility features of their institution’s website, he acknowledged.

“So we should maybe, number one, try to have more involvement in what information goes on to the website, and two, take a look at our own websites to see what’s on there, because patients are going to look for you, and they are going to associate this information with you,” he said. “If you are at a big institution and you really can’t make a change on your website, you can use alternatives such as social media platforms, things like that, to try and get information out to people.”

From a larger perspective, oncologists have often simply counseled patients that they can’t rely on information they have found online, according to Dr. Dulaney.

“But in this day and age, that can’t really be an answer,” he concluded. “Information on the web is ubiquitous, and there is good information out there. We need to do a better job of speaking up in the conversation. We have the answers to a lot of these questions, we just need to make our voices heard and also direct patients to reliable sources of information.”

ORLANDO – Women with breast cancer who look for well-rounded information about treatment on the websites of prominent U.S. cancer centers are likely to come up short, suggests a study presented at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Research has shown that nearly all women with breast cancer search the Internet for information about its treatment, and two-thirds report that what they find has a strong influence on their decision-making process (J Cancer Educ. 2013;28[4]:662-8).

But the analysis of content on the websites of 63 National Cancer Institute–designated comprehensive cancer centers or clinical cancer centers found that, on average, they addressed only 21% of a set of key concepts that women need to understand to make informed decisions about surgery, radiation therapy, chemotherapy, hormone therapy, and breast reconstruction. This contrasted starkly with 85% for the National Cancer Institute’s own website (cancer.gov) and 88% for the Susan G. Komen Foundation’s website (komen.org).

Susan London/Frontline Medical News

Study details

For the study, the investigators developed a list of 33 decision-specific knowledge questions about breast cancer treatment by drawing on decision quality instruments that assess how informed a woman’s decision-making process is. The primary outcome was whether the website provided sufficient information to answer each question. The researchers assessed seven measures of accessibility as secondary outcomes.

Results showed that websites contained sufficient content to address only 21% of the decision-specific knowledge questions, Dr. Dulaney reported in a poster session. The value was 17% for questions pertaining to breast surgery and radiation therapy, 18% for those pertaining to chemotherapy and hormone therapy, and 21% for those pertaining to breast reconstruction.

In addition, “a lot of websites put the information in silos,” he noted. “You can read about mastectomy, you can read about lumpectomy, you can read about chemo. But you can’t really get the big picture, which is how do these compare to each other, and which treatment is best for me.”

Even the most commonly addressed single question – what type of reconstruction is most likely to require more than one surgery or procedure – was addressed by only 51% of sites. Proportions were similar for questions pertaining to the type of tumors against which hormone therapy works best (48%) and the schedule for radiation therapy after lumpectomy (47%).

At the other extreme, however, very small proportions of sites addressed questions pertaining to how many women with treated early breast cancer will die from the disease (7%), how many undergoing breast reconstruction will experience complications requiring hospitalization or an unplanned procedure (4%), how skipping chemotherapy and hormone therapy influences risk of death (2%), and whether waiting several weeks to decide about those therapies affects survival (2%). These topics are more negative, Dr. Dulaney observed, “but these are things women need to know.”

None of the websites provided sufficient information to answer all 33 knowledge questions. But perhaps more worrisome, 16% did not provide sufficient information to answer any of them, he said.

When it came to accessibility of information, 94% of sites clearly had a breast cancer–specific page, 87% had information about breast cancer–specific trials, and 86% showed members of the center’s breast cancer team. But only 59% were mobile device friendly as assessed with a Google tool, and merely 24% had obvious links to view information in Spanish.

“A lot of minorities and people of lower socioeconomic status exclusively access the Internet via mobile devices, so they may not have a computer or [other] access to the Internet. But they have a cell phone that is probably a smartphone, and they can get online and search for information that way,” Dr. Dulaney said.

Many oncologists may not have had any say regarding the content and accessibility features of their institution’s website, he acknowledged.

“So we should maybe, number one, try to have more involvement in what information goes on to the website, and two, take a look at our own websites to see what’s on there, because patients are going to look for you, and they are going to associate this information with you,” he said. “If you are at a big institution and you really can’t make a change on your website, you can use alternatives such as social media platforms, things like that, to try and get information out to people.”

From a larger perspective, oncologists have often simply counseled patients that they can’t rely on information they have found online, according to Dr. Dulaney.

“But in this day and age, that can’t really be an answer,” he concluded. “Information on the web is ubiquitous, and there is good information out there. We need to do a better job of speaking up in the conversation. We have the answers to a lot of these questions, we just need to make our voices heard and also direct patients to reliable sources of information.”

ORLANDO – Women with breast cancer who look for well-rounded information about treatment on the websites of prominent U.S. cancer centers are likely to come up short, suggests a study presented at a symposium on quality care sponsored by the American Society of Clinical Oncology.

Research has shown that nearly all women with breast cancer search the Internet for information about its treatment, and two-thirds report that what they find has a strong influence on their decision-making process (J Cancer Educ. 2013;28[4]:662-8).

But the analysis of content on the websites of 63 National Cancer Institute–designated comprehensive cancer centers or clinical cancer centers found that, on average, they addressed only 21% of a set of key concepts that women need to understand to make informed decisions about surgery, radiation therapy, chemotherapy, hormone therapy, and breast reconstruction. This contrasted starkly with 85% for the National Cancer Institute’s own website (cancer.gov) and 88% for the Susan G. Komen Foundation’s website (komen.org).

Susan London/Frontline Medical News

Study details

For the study, the investigators developed a list of 33 decision-specific knowledge questions about breast cancer treatment by drawing on decision quality instruments that assess how informed a woman’s decision-making process is. The primary outcome was whether the website provided sufficient information to answer each question. The researchers assessed seven measures of accessibility as secondary outcomes.

Results showed that websites contained sufficient content to address only 21% of the decision-specific knowledge questions, Dr. Dulaney reported in a poster session. The value was 17% for questions pertaining to breast surgery and radiation therapy, 18% for those pertaining to chemotherapy and hormone therapy, and 21% for those pertaining to breast reconstruction.

In addition, “a lot of websites put the information in silos,” he noted. “You can read about mastectomy, you can read about lumpectomy, you can read about chemo. But you can’t really get the big picture, which is how do these compare to each other, and which treatment is best for me.”

Even the most commonly addressed single question – what type of reconstruction is most likely to require more than one surgery or procedure – was addressed by only 51% of sites. Proportions were similar for questions pertaining to the type of tumors against which hormone therapy works best (48%) and the schedule for radiation therapy after lumpectomy (47%).

At the other extreme, however, very small proportions of sites addressed questions pertaining to how many women with treated early breast cancer will die from the disease (7%), how many undergoing breast reconstruction will experience complications requiring hospitalization or an unplanned procedure (4%), how skipping chemotherapy and hormone therapy influences risk of death (2%), and whether waiting several weeks to decide about those therapies affects survival (2%). These topics are more negative, Dr. Dulaney observed, “but these are things women need to know.”

None of the websites provided sufficient information to answer all 33 knowledge questions. But perhaps more worrisome, 16% did not provide sufficient information to answer any of them, he said.

When it came to accessibility of information, 94% of sites clearly had a breast cancer–specific page, 87% had information about breast cancer–specific trials, and 86% showed members of the center’s breast cancer team. But only 59% were mobile device friendly as assessed with a Google tool, and merely 24% had obvious links to view information in Spanish.

“A lot of minorities and people of lower socioeconomic status exclusively access the Internet via mobile devices, so they may not have a computer or [other] access to the Internet. But they have a cell phone that is probably a smartphone, and they can get online and search for information that way,” Dr. Dulaney said.

Many oncologists may not have had any say regarding the content and accessibility features of their institution’s website, he acknowledged.

“So we should maybe, number one, try to have more involvement in what information goes on to the website, and two, take a look at our own websites to see what’s on there, because patients are going to look for you, and they are going to associate this information with you,” he said. “If you are at a big institution and you really can’t make a change on your website, you can use alternatives such as social media platforms, things like that, to try and get information out to people.”

From a larger perspective, oncologists have often simply counseled patients that they can’t rely on information they have found online, according to Dr. Dulaney.

“But in this day and age, that can’t really be an answer,” he concluded. “Information on the web is ubiquitous, and there is good information out there. We need to do a better job of speaking up in the conversation. We have the answers to a lot of these questions, we just need to make our voices heard and also direct patients to reliable sources of information.”

The Food and Drug Administration has approved ribociclib, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with an aromatase inhibitor as initial endocrine-based therapy for the treatment of postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer.

Overall survival data is immature but approval was based on improvement in progression-free survival (PFS) among 334 women randomized to receive ribociclib plus letrozole compared to 334 women randomized to receive placebo plus letrozole in phase III MONALEESA-2 (hazard ratio, 0.556; 95% CI: 0.429, 0.720; P less than .0001).

[email protected]

On Twitter @NikolaidesLaura

The Food and Drug Administration has approved ribociclib, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with an aromatase inhibitor as initial endocrine-based therapy for the treatment of postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer.

Overall survival data is immature but approval was based on improvement in progression-free survival (PFS) among 334 women randomized to receive ribociclib plus letrozole compared to 334 women randomized to receive placebo plus letrozole in phase III MONALEESA-2 (hazard ratio, 0.556; 95% CI: 0.429, 0.720; P less than .0001).

[email protected]

On Twitter @NikolaidesLaura

The Food and Drug Administration has approved ribociclib, a cyclin-dependent kinase (CDK) 4/6 inhibitor, in combination with an aromatase inhibitor as initial endocrine-based therapy for the treatment of postmenopausal women with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer.

Overall survival data is immature but approval was based on improvement in progression-free survival (PFS) among 334 women randomized to receive ribociclib plus letrozole compared to 334 women randomized to receive placebo plus letrozole in phase III MONALEESA-2 (hazard ratio, 0.556; 95% CI: 0.429, 0.720; P less than .0001).

[email protected]

On Twitter @NikolaidesLaura

MIAMI BEACH – Often people living with cancer hesitate to ask their providers about sensitive and important issues surrounding sexuality and fertility. At the same time, some clinicians remain uncomfortable raising questions regarding sexual function or simply lack the time to appropriately address the issues during a patient encounter.

A new online resource aims to solve both problems simultaneously, giving both patients and providers the tools to meaningfully address sexuality and fertility issues, Leslie R. Schover, PhD, said in a video interview at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

The Will2love.com site features first-person patient account videos from women and men who faced similar concerns, said Dr. Schover, founder of the Will2Love digital health company based in Houston. In addition, vignettes with actors inform patients and also model how oncologists, oncology nurses, and other staff could effectively communicate with concerned patients. A professional portal offers online skills training for clinicians.

[email protected]

MIAMI BEACH – Often people living with cancer hesitate to ask their providers about sensitive and important issues surrounding sexuality and fertility. At the same time, some clinicians remain uncomfortable raising questions regarding sexual function or simply lack the time to appropriately address the issues during a patient encounter.

A new online resource aims to solve both problems simultaneously, giving both patients and providers the tools to meaningfully address sexuality and fertility issues, Leslie R. Schover, PhD, said in a video interview at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

The Will2love.com site features first-person patient account videos from women and men who faced similar concerns, said Dr. Schover, founder of the Will2Love digital health company based in Houston. In addition, vignettes with actors inform patients and also model how oncologists, oncology nurses, and other staff could effectively communicate with concerned patients. A professional portal offers online skills training for clinicians.

[email protected]

MIAMI BEACH – Often people living with cancer hesitate to ask their providers about sensitive and important issues surrounding sexuality and fertility. At the same time, some clinicians remain uncomfortable raising questions regarding sexual function or simply lack the time to appropriately address the issues during a patient encounter.

A new online resource aims to solve both problems simultaneously, giving both patients and providers the tools to meaningfully address sexuality and fertility issues, Leslie R. Schover, PhD, said in a video interview at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

The Will2love.com site features first-person patient account videos from women and men who faced similar concerns, said Dr. Schover, founder of the Will2Love digital health company based in Houston. In addition, vignettes with actors inform patients and also model how oncologists, oncology nurses, and other staff could effectively communicate with concerned patients. A professional portal offers online skills training for clinicians.

[email protected]

MIAMI BEACH – The Food and Drug Administration has accepted pathological complete response rate (pCR) as a surrogate endpoint for disease-free and overall survival in clinical trials for neoadjuvant therapy of breast cancer.

Yet the specimen collection and histopathologic methods used to measure pCR have differed considerably across major neoadjuvant trials for breast cancer, said Michael F. Press, MD, PhD, of the USC/Norris Comprehensive Cancer Center at the University of California, Los Angeles.

In a video interview conducted at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource, Dr. Press outlined the problems associated with a lack of standardization of outcomes measures, and described how residual cancer burden may be a more effective, validated measures for comparing outcomes across clinical trials.

MIAMI BEACH – The Food and Drug Administration has accepted pathological complete response rate (pCR) as a surrogate endpoint for disease-free and overall survival in clinical trials for neoadjuvant therapy of breast cancer.

Yet the specimen collection and histopathologic methods used to measure pCR have differed considerably across major neoadjuvant trials for breast cancer, said Michael F. Press, MD, PhD, of the USC/Norris Comprehensive Cancer Center at the University of California, Los Angeles.

In a video interview conducted at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource, Dr. Press outlined the problems associated with a lack of standardization of outcomes measures, and described how residual cancer burden may be a more effective, validated measures for comparing outcomes across clinical trials.

MIAMI BEACH – The Food and Drug Administration has accepted pathological complete response rate (pCR) as a surrogate endpoint for disease-free and overall survival in clinical trials for neoadjuvant therapy of breast cancer.

Yet the specimen collection and histopathologic methods used to measure pCR have differed considerably across major neoadjuvant trials for breast cancer, said Michael F. Press, MD, PhD, of the USC/Norris Comprehensive Cancer Center at the University of California, Los Angeles.

In a video interview conducted at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource, Dr. Press outlined the problems associated with a lack of standardization of outcomes measures, and described how residual cancer burden may be a more effective, validated measures for comparing outcomes across clinical trials.

MIAMI BEACH – Growing evidence continues to point to a widening separation between female and male breast cancers, particularly with discoveries suggesting different pathways to disease and important genetic distinctions.

Therefore, the traditional practice of extrapolating findings from female breast cancer research to men with breast cancer no longer makes sense, Patrick I. Borgen, MD, said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

The incidence of male breast cancer is increasing. At the same time, fewer men with breast cancer get referred for and undergo genetic testing for their disease, said Dr. Borgen, chair of the department of surgery at Maimonides Medical Center in Brooklyn, N.Y.

Dr. Borgen explained in a video interview that both maternal and paternal inheritance of breast cancer are important, and they tie the lineage into a hypothesis for why BRCA mutations – which can predispose people to worse survival – have persisted through generations.

MIAMI BEACH – Growing evidence continues to point to a widening separation between female and male breast cancers, particularly with discoveries suggesting different pathways to disease and important genetic distinctions.

Therefore, the traditional practice of extrapolating findings from female breast cancer research to men with breast cancer no longer makes sense, Patrick I. Borgen, MD, said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

The incidence of male breast cancer is increasing. At the same time, fewer men with breast cancer get referred for and undergo genetic testing for their disease, said Dr. Borgen, chair of the department of surgery at Maimonides Medical Center in Brooklyn, N.Y.

Dr. Borgen explained in a video interview that both maternal and paternal inheritance of breast cancer are important, and they tie the lineage into a hypothesis for why BRCA mutations – which can predispose people to worse survival – have persisted through generations.

MIAMI BEACH – Growing evidence continues to point to a widening separation between female and male breast cancers, particularly with discoveries suggesting different pathways to disease and important genetic distinctions.

Therefore, the traditional practice of extrapolating findings from female breast cancer research to men with breast cancer no longer makes sense, Patrick I. Borgen, MD, said at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

The incidence of male breast cancer is increasing. At the same time, fewer men with breast cancer get referred for and undergo genetic testing for their disease, said Dr. Borgen, chair of the department of surgery at Maimonides Medical Center in Brooklyn, N.Y.

Dr. Borgen explained in a video interview that both maternal and paternal inheritance of breast cancer are important, and they tie the lineage into a hypothesis for why BRCA mutations – which can predispose people to worse survival – have persisted through generations.

MIAMI BEACH – The remarkable progress seen with immune checkpoint inhibitors in metastatic melanoma, non–small-cell lung cancer, and other tumors has yet to be replicated in breast cancer, but it’s early days yet, and breast cancer researchers need more time before the ultimate clinical benefits of immunotherapy in breast cancer can be ascertained, said Adam M. Brufsky, MD, PhD, of the University of Pittsburgh.

Early studies with inhibitors of programmed death-1 (PD-1) and its ligand PD-L1 in patients with advanced triple-negative breast cancer have yielded only minimal response rates to date, but it it’s far too early to give up on the concept, Dr. Brufsky cautioned at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

In a video interview, he discussed the challenges of treating breast cancers, which may be less immunogenic and have a lower tumor mutational burden than other malignancies that respond more readily to PD-1 inhibition. Several large, phase III clinical trials of checkpoint inhibitors combined with cytotoxic chemotherapy are underway, he said, and those eventual findings may shed light on the optimal approach to using immunotherapy to treat patients with refractory metastatic breast cancers.

MIAMI BEACH – The remarkable progress seen with immune checkpoint inhibitors in metastatic melanoma, non–small-cell lung cancer, and other tumors has yet to be replicated in breast cancer, but it’s early days yet, and breast cancer researchers need more time before the ultimate clinical benefits of immunotherapy in breast cancer can be ascertained, said Adam M. Brufsky, MD, PhD, of the University of Pittsburgh.

Early studies with inhibitors of programmed death-1 (PD-1) and its ligand PD-L1 in patients with advanced triple-negative breast cancer have yielded only minimal response rates to date, but it it’s far too early to give up on the concept, Dr. Brufsky cautioned at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

In a video interview, he discussed the challenges of treating breast cancers, which may be less immunogenic and have a lower tumor mutational burden than other malignancies that respond more readily to PD-1 inhibition. Several large, phase III clinical trials of checkpoint inhibitors combined with cytotoxic chemotherapy are underway, he said, and those eventual findings may shed light on the optimal approach to using immunotherapy to treat patients with refractory metastatic breast cancers.

MIAMI BEACH – The remarkable progress seen with immune checkpoint inhibitors in metastatic melanoma, non–small-cell lung cancer, and other tumors has yet to be replicated in breast cancer, but it’s early days yet, and breast cancer researchers need more time before the ultimate clinical benefits of immunotherapy in breast cancer can be ascertained, said Adam M. Brufsky, MD, PhD, of the University of Pittsburgh.

Early studies with inhibitors of programmed death-1 (PD-1) and its ligand PD-L1 in patients with advanced triple-negative breast cancer have yielded only minimal response rates to date, but it it’s far too early to give up on the concept, Dr. Brufsky cautioned at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

In a video interview, he discussed the challenges of treating breast cancers, which may be less immunogenic and have a lower tumor mutational burden than other malignancies that respond more readily to PD-1 inhibition. Several large, phase III clinical trials of checkpoint inhibitors combined with cytotoxic chemotherapy are underway, he said, and those eventual findings may shed light on the optimal approach to using immunotherapy to treat patients with refractory metastatic breast cancers.

MIAMI BEACH – Driven by efficacy demonstrated in ovarian cancer, a number of PARP inhibitors are in development and hold promise for treatment of breast cancer as well, including patients positive for the BRCA mutation.

Interestingly, early evidence suggests these agents could also treat BRCA-negative women, potentially expanding their future clinical utility, Kimberly L. Blackwell, MD, said in a video interview at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

MIAMI BEACH – Driven by efficacy demonstrated in ovarian cancer, a number of PARP inhibitors are in development and hold promise for treatment of breast cancer as well, including patients positive for the BRCA mutation.

Interestingly, early evidence suggests these agents could also treat BRCA-negative women, potentially expanding their future clinical utility, Kimberly L. Blackwell, MD, said in a video interview at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.

MIAMI BEACH – Driven by efficacy demonstrated in ovarian cancer, a number of PARP inhibitors are in development and hold promise for treatment of breast cancer as well, including patients positive for the BRCA mutation.

Interestingly, early evidence suggests these agents could also treat BRCA-negative women, potentially expanding their future clinical utility, Kimberly L. Blackwell, MD, said in a video interview at the annual Miami Breast Cancer Conference, held by Physicians’ Education Resource.