Breast Cancer

Editor’s Note: This is the fourth installment of a five-part monthly series that will discuss the biologic, genomic, and health system factors that contribute to the racial survival disparity in breast cancer. The series was adapted from an article that originally appeared in CA: A Cancer Journal for Clinicians,¹ a journal of the American Cancer Society. Eliminating racial disparities in cancer mortality through effective interventions has become an increasingly important imperative of federal, state, and community health care programs. This month’s column reviews interventions to close this survival gap.

Insurance

It has been posited that interventions aimed at providing insurance coverage to minority patients will be able to reduce racial health care disparities.² Studies have indicated that women without insurance present with more-advanced disease,^3,4 and are more likely to receive nonstandard treatment.⁵ However, outside of cancer care, a large study of Medicaid expansion in Oregon demonstrated that Medicaid coverage alone generated no significant improvement in measured physical health outcomes in the first 2 years.⁶ Thus, coverage alone does not ensure that patients will be able to navigate the health care system and that quality care will be provided.

In breast cancer, Hoffman et al.⁷ evaluated the effect of race and health insurance on diagnostic time, which was defined as the number of days from suspicious finding to diagnostic resolution (either no evidence of malignancy on diagnostic mammogram or definitive diagnosis by biopsy) in a large, urban setting. The authors’ hypothesis was that every insured patient would receive the same timely diagnosis as any other patient with equivalent insurance, regardless of race or ethnicity. The study found that non-Hispanic whites with government insurance had significantly shorter diagnostic times than did non-Hispanic African Americans with government insurance: The average diagnostic times were 12 and 39 days, respectively. In addition, privately insured non-Hispanic whites also had significantly shorter diagnostic times than did privately insured non-Hispanic African Americans (16 vs. 27 days). In addition, Short et al.⁸ demonstrated that when the health plan status was held constant in a retrospective study of 476 white patients and 99 African American patients with newly diagnosed breast cancer, African American patients had a higher mortality rate (8.1% vs. 3.6%) and were diagnosed at a later stage. Accordingly, interventions must go beyond just providing health insurance to minorities in order to have a significant impact on the mortality gap.

Patient education and physician communication

An underlying cause frequently cited for the delayed diagnosis and treatment of African American patients with breast cancer is a lack of patient education and physician communication. These elements are essential components of quality care. In a qualitative study of low-income, ethnically diverse women older than 40 years, Allen et al.⁹ identified salient themes differentiating women who received timely follow-up from those who did not. For the women who delayed follow-up, prominent themes were dissatisfaction with the communication of results, disrespect on the part of providers and clinical staff, logistical barriers to accessing services, anxiety and fear about a possible cancer diagnosis, and a lack of information about breast cancer screening and symptoms.

In another study, Masi and Gehlert¹⁰ employed focus group interviews of African American adults to characterize their perceptions of breast cancer treatment. The analysis revealed a core set of themes, including mistrust of the medical establishment and concern about the effect of racism on treatment quality; the researchers concluded that “in the eyes of many study participants, the issues of trust, race, and quality of care were closely intertwined.”¹⁰ Thus, this knot that is created by underlying issues of trust can be untied only by interventions that address improved physician communication and patient education.

Janz et al.¹¹ examined racial differences in the adequacy of information and support for women with breast cancer. The researchers used survey data from a population of 1,766 women diagnosed with nonmetastatic breast cancer and reported to the Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry. The study found that across treatment- and survivorship-related issues, African American women desired more information than white women did. One of the explanations for the unmet information needs posited by the authors is a failure to provide culturally appropriate information related to health issues. This breakdown in patient education and communication was demonstrated by Hawley et al. to hold across providers and locations.¹²

Hawley et al.¹² evaluated the association between minority patients’ knowledge of breast cancer treatment risks and benefits and provider characteristics and treatment locations. The provider characteristics included surgeon-level independent variables, such as breast cancer procedure volume and demographics (years in practice and sex). The treatment location variable was categorized into one of three groups: National Cancer Institute–designated cancer center, American College of Surgeons cancer program, or no specific cancer program. Provider characteristics and treatment locations are factors previously identified as being associated with high-quality care.

The study employed a multivariable regression to identify associations between patient, surgeon, and treatment-setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast-conserving surgery with radiation. The authors found that minority women were significantly less likely to have adequate knowledge and more likely to be uncertain about recurrence risk than were white patients. In the multivariate logistic regression model, neither provider characteristics nor treatment setting attenuated observed racial disparities in knowledge. Quality health care depends on the ability to make an informed treatment decision. As the authors concluded, this study underscores the need for providers to communicate information effectively to all patients, and effective communication relies on the cultural competency of providers.¹³ Without effective, culturally competent communication, there are treatment delays and omissions that result in poor-quality cancer care. Currently, the research has established that these communication deficits are found across providers and treatment center types.

Patient Navigation

Patient navigation has been championed as a method of improving care in breast cancer by enhancing patient communication and education, and removing barriers to timely care. Patient navigation empowers patients to become knowledgeable about their own health and supports them through the course of care.¹⁴ Patient navigation programs have been developed to address the patient communication breakdowns and underuse and misuse of treatment among vulnerable populations, which were detailed earlier in this series and are thought to contribute to the racial mortality gap.¹⁵

A benefit of patient navigation has been suggested in studies evaluating the time to diagnosis and follow-up from an abnormal screening. Markossian et al.¹⁶ evaluated the efficacy of a Chicago-based cancer patient navigation program developed to reduce the time from abnormal screening to definitive diagnostic testing. The majority of patients in this study were Hispanic (66%) and African American (32%). Compared with controls without navigation, the breast navigation group had a shorter time to diagnostic resolution. Hoffman et al.¹⁷ evaluated patient navigation in the District of Columbia to determine its ability to reduce the breast cancer diagnostic time (number of days from abnormal screening to a definitive diagnosis). African American women comprised 48% of the study population. The investigators found that women in the navigation group reached their diagnostic resolution significantly faster than did other women. Among women with breast cancer, there was a nearly fourfold reduction in time to diagnostic resolution for women in the navigation group versus women without a navigator.

In a national multicenter study, Ko et al.¹⁴ were the first to evaluate whether patient navigation can improve the quality of breast cancer care. The authors hypothesized that breast cancer patients assigned a navigator would be more likely to receive recommended standard treatment than were those without a navigator. Three separate quality measures of breast cancer care, including initiation of antiestrogen therapy, radiation therapy, and chemotherapy, were evaluated. Study participants were racially and ethnically diverse, with a plurality being African American (37.5%). The study produced mixed results: Patients in the navigation group had a statistically higher likelihood of receiving antiestrogen therapy than were non–navigated controls, but navigation patients eligible for radiation therapy were no more likely to receive it than were controls. The initiation of chemotherapy could not be accurately assessed because of a limited sample size. The study concluded that navigation alone does not remove all of the barriers to quality care for breast cancer patients, and barriers are diverse and potentially specific to the modality of treatment.

A study by Tejeda et al.¹⁸ used a systematic framework to characterize barriers faced by minority patients with breast and cervical cancer. The investigators categorized barriers as intrapersonal (defined by characteristics of the individual, such as knowledge, belief, attitudes, and transportation and financial barriers), interpersonal (defined by processes that involve other people, such as social support systems, child care, and employment issues), or institutional (defined by characteristics and policies of organizations). The authors found that although navigators were able to easily resolve intrapersonal barriers, ongoing navigation was needed to address institutional barriers. Thus, patient navigation in a vacuum does not work, and it is only in examining the entire health care system that changes can be implemented to eliminate barriers to quality care and close the racial mortality chasm.

System Change

To this effect, Clarke et al.¹⁹ performed a review of the disparities intervention literature to understand which interventions are being evaluated to improve minority health. The authors found that the majority of such interventions are focused on changing the patient rather than the system that serves her, with the most common strategy being education and training (37% of strategies studied). Interventions aimed at health care system improvements were surprisingly few, with the responsibility for change resting with the patient rather than the care delivery system. Interventions incorporating community involvement were also severely lacking and reflected only 6.5% of the reviewed intervention tactics. The majority of interventions failed to involve major stakeholders, including providers, health care institutions, community organizers, and policy makers, and accordingly, were unlikely to succeed in creating meaningful change.

In breast cancer, there have been examples of successful system-based approaches to reducing the racial mortality disparity. At New York area hospitals, Bickell et al.²⁰ implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists to decrease the underuse of valuable adjuvant treatments.

The intervention targeted important quality issues in both communication (the breakdown in dialogue among providers of different specialties and between providers and patients) and the underuse of adjuvant treatment in minorities. The approach was designed to address failures in the health care system through the involvement of leadership from pathology, surgery, and oncology. The intervention also incorporated technology, with tracking software prompting contact with patients who had failed to follow up. Among African American and Hispanic women, there were statistically significant decreases in the underuse of radiotherapy (23% before the intervention vs. 10% after the intervention), chemotherapy (26% vs. 6%), and hormonal therapy (27% vs. 11%). After the intervention, minority race was no longer a risk factor for low rates of oncology consultation or underuse of adjuvant therapy. Interestingly, four of the six hospitals involved in this study had a patient navigation system in place; however, as discussed, the navigation system alone was not enough to address the system failures that led to disparities in care.

Ansell et al.²¹ also described a system-based approach to reducing the breast cancer mortality disparity in Chicago. The Metropolitan Chicago Breast Cancer Task Force comprised 102 individuals and 74 Chicago area organizations to address the growing disparity in breast cancer mortality between African American and white patients. The task force identified a number of themes underlying the disparity gap, including a need for breast cancer education and outreach programs for African American women, a broken mammography process leading to quality differences between African American and white patients, and a number of barriers to diagnosis and treatment, including fear, a lack of primary care, the burden of insurance copays/deductibles, and the noncompletion of treatment for social and economic reasons. After identifying these underlying causes, the task force proposed that addressing one aspect of the health care system would not correct the problem, but rather quality improvement initiatives would have to occur across the continuum of care for breast cancer.

In Delaware, such a broad system-based intervention was implemented to eliminate health disparities in colorectal cancer.²² Delaware created a comprehensive statewide colorectal screening and treatment program, combining many of the interventions discussed previously, including insurance coverage, patient education and communication, and patient navigation, to address the entire health care system and its treatment of African Americans with colorectal cancer. The state also partnered with underserved community organizations to tailor programs locally and create targeted marketing campaigns.

The results of this system-based approach were impressive, with screening rates among African American increasing from 48% to 74% and equaling the rate among whites. In addition, among African American patients, the percentage diagnosed at advanced and regional stages declined from 79% to 40%, and the percentage diagnosed at a local stage increased from 16% to 50%. Most importantly, the mortality rate declined by 42% for African Americans, resulting in a rate almost equal to that among whites. Significantly, this program was also found to be economically viable, because the cost savings from reduced cancer incidence and the stage shift to cancers requiring less-aggressive treatment offset the program cost. As the authors concluded, this model of a comprehensive, system-wide approach to the racial mortality difference would lend itself to other cancers, and more research is needed to assess and build such an approach to breast cancer.

As discussed in the aforementioned studies, multifaceted interventions that address all stakeholders are needed to close the racial survival disparity in breast cancer. In the final installment of this series, we will address how the changing care models ushered in by the Patient Protection and Affordable Care Act have the potential to advance this agenda of creating an intervention that works across the breast cancer care continuum to reduce disparities.

Other installments of this column can be found in the Related Content box.

1. Daly B, Olopade OI. A perfect storm: How tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change. CA Cancer J Clin. 2015 May-Jun;65(3):221-38.

2. Lillie-Blanton M, Hoffman C. The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health Aff (Millwood). 2005 Mar-Apr;24(2):398-408.

3. Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993 Jul 29;329(5):326-31.

4. Coburn N, Fulton J, Pearlman DN, Law C, DiPaolo B, Cady B. Treatment variation by insurance status for breast cancer patients. Breast J. 2008 Mar-Apr;14(2):128-34.

5. Voti L, Richardson LC, Reis I, Fleming LE, Mackinnon J, Coebergh JW. The effect of race/ethnicity and insurance in the administration of standard therapy for local breast cancer in Florida. Breast Cancer Res Treat. 2006 Jan;95(1):89-95.

6. Baicker K, Taubman SL, Allen HL, et al. The Oregon experiment – effects of Medicaid on clinical outcomes. N Engl J Med. 2013 May 2;368(18):1713-22.

7. Hoffman HJ, LaVerda NL, Levine PH, et al. Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia. Cancer. 2011 Aug 15;117(16):3824-32.

8. Short LJ, Fisher MD, Wahl PM, et al. Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention. Cancer. 2010 Jan 1;116(1):193-202.

9. Allen JD, Shelton RC, Harden E, Goldman RE. Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. Patient Educ Couns. 2008 Aug;72(2):283-92.

10. Masi CM, Gehlert S. Perceptions of breast cancer treatment among African-American women and men: implications for interventions. J Gen Intern Med. 2009 Mar;24(3):408-14.

11. Janz NK, Mujahid MS, Hawley ST, Griggs JJ, Hamilton AS, Katz SJ. Racial/ethnic differences in adequacy of information and support for women with breast cancer. Cancer. 2008 Sep 1;113(5):1058-67.

12. Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res. 2008 Aug;43(4):1366-87.

13. Lannin DR, Mathews HF, Mitchell J, Swanson MS. Impacting cultural attitudes in African-American women to decrease breast cancer mortality. Am J Surg. 2002 Nov;184(5):418-23.

14. Ko NY, Darnell JS, Calhoun E, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol. 2014 Sep 1;32(25):2758-64.

15. Vargas RB, Ryan GW, Jackson CA, Rodriguez R, Freeman HP. Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer. Cancer. 2008 Jul 15;113(2):426-33.

16. Markossian TW, Darnell JS, Calhoun EA. Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program. Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1691-700.

17. Hoffman HJ, LaVerda NL, Young HA, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1655-63.

18. Tejeda S, Darnell JS, Cho YI, Stolley MR, Markossian TW, Calhoun EA. Patient barriers to follow-up care for breast and cervical cancer abnormalities. J Womens Health (Larchmt). 2013 Jun;22(6):507-17.

19. Clarke AR, Goddu AP, Nocon RS, et al. Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care? Med Care. 2013 Nov;51(11):1020-26.

20. Bickell NA, Shastri K, Fei K, et al. A tracking and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst. 2008 Dec 3;100(23):1717-23.

21. Ansell D, Grabler P, Whitman S, et al. A community effort to reduce the black/white breast cancer mortality disparity in Chicago. Cancer Causes Control. 2009 Nov;20(9):1681-88.

22. Grubbs SS, Polite BN, Carney J, Jr., et al. Eliminating racial disparities in colorectal cancer in the real world: it took a village. J Clin Oncol. 2013 Jun 1;31(16):1928-30.

Olufunmilayo Olopade, MD, FACP, OON, is the Walter L. Palmer Distinguished Service Professor of Medicine and Human Genetics, and director, Center for Global Health at the University of Chicago. She is adopting emerging high throughput genomic and informatics strategies to identify genetic and nongenetic risk factors for breast cancer in order to implement precision health care in diverse populations. This innovative approach has the potential to improve the quality of care and reduce costs while saving more lives.

Disclosures: Dr. Olopade serves on the Medical Advisory Board for CancerIQ. Dr. Daly serves as a director of Quadrant Holdings Corporation and receives compensation from this entity. Frontline Medical Communications is a subsidiary of Quadrant Holdings Corporation.

Published in conjunction with Susan G. Komen®.

Editor’s Note: This is the fourth installment of a five-part monthly series that will discuss the biologic, genomic, and health system factors that contribute to the racial survival disparity in breast cancer. The series was adapted from an article that originally appeared in CA: A Cancer Journal for Clinicians,¹ a journal of the American Cancer Society. Eliminating racial disparities in cancer mortality through effective interventions has become an increasingly important imperative of federal, state, and community health care programs. This month’s column reviews interventions to close this survival gap.

Insurance

It has been posited that interventions aimed at providing insurance coverage to minority patients will be able to reduce racial health care disparities.² Studies have indicated that women without insurance present with more-advanced disease,^3,4 and are more likely to receive nonstandard treatment.⁵ However, outside of cancer care, a large study of Medicaid expansion in Oregon demonstrated that Medicaid coverage alone generated no significant improvement in measured physical health outcomes in the first 2 years.⁶ Thus, coverage alone does not ensure that patients will be able to navigate the health care system and that quality care will be provided.

In breast cancer, Hoffman et al.⁷ evaluated the effect of race and health insurance on diagnostic time, which was defined as the number of days from suspicious finding to diagnostic resolution (either no evidence of malignancy on diagnostic mammogram or definitive diagnosis by biopsy) in a large, urban setting. The authors’ hypothesis was that every insured patient would receive the same timely diagnosis as any other patient with equivalent insurance, regardless of race or ethnicity. The study found that non-Hispanic whites with government insurance had significantly shorter diagnostic times than did non-Hispanic African Americans with government insurance: The average diagnostic times were 12 and 39 days, respectively. In addition, privately insured non-Hispanic whites also had significantly shorter diagnostic times than did privately insured non-Hispanic African Americans (16 vs. 27 days). In addition, Short et al.⁸ demonstrated that when the health plan status was held constant in a retrospective study of 476 white patients and 99 African American patients with newly diagnosed breast cancer, African American patients had a higher mortality rate (8.1% vs. 3.6%) and were diagnosed at a later stage. Accordingly, interventions must go beyond just providing health insurance to minorities in order to have a significant impact on the mortality gap.

Patient education and physician communication

An underlying cause frequently cited for the delayed diagnosis and treatment of African American patients with breast cancer is a lack of patient education and physician communication. These elements are essential components of quality care. In a qualitative study of low-income, ethnically diverse women older than 40 years, Allen et al.⁹ identified salient themes differentiating women who received timely follow-up from those who did not. For the women who delayed follow-up, prominent themes were dissatisfaction with the communication of results, disrespect on the part of providers and clinical staff, logistical barriers to accessing services, anxiety and fear about a possible cancer diagnosis, and a lack of information about breast cancer screening and symptoms.

In another study, Masi and Gehlert¹⁰ employed focus group interviews of African American adults to characterize their perceptions of breast cancer treatment. The analysis revealed a core set of themes, including mistrust of the medical establishment and concern about the effect of racism on treatment quality; the researchers concluded that “in the eyes of many study participants, the issues of trust, race, and quality of care were closely intertwined.”¹⁰ Thus, this knot that is created by underlying issues of trust can be untied only by interventions that address improved physician communication and patient education.

Janz et al.¹¹ examined racial differences in the adequacy of information and support for women with breast cancer. The researchers used survey data from a population of 1,766 women diagnosed with nonmetastatic breast cancer and reported to the Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry. The study found that across treatment- and survivorship-related issues, African American women desired more information than white women did. One of the explanations for the unmet information needs posited by the authors is a failure to provide culturally appropriate information related to health issues. This breakdown in patient education and communication was demonstrated by Hawley et al. to hold across providers and locations.¹²

Hawley et al.¹² evaluated the association between minority patients’ knowledge of breast cancer treatment risks and benefits and provider characteristics and treatment locations. The provider characteristics included surgeon-level independent variables, such as breast cancer procedure volume and demographics (years in practice and sex). The treatment location variable was categorized into one of three groups: National Cancer Institute–designated cancer center, American College of Surgeons cancer program, or no specific cancer program. Provider characteristics and treatment locations are factors previously identified as being associated with high-quality care.

The study employed a multivariable regression to identify associations between patient, surgeon, and treatment-setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast-conserving surgery with radiation. The authors found that minority women were significantly less likely to have adequate knowledge and more likely to be uncertain about recurrence risk than were white patients. In the multivariate logistic regression model, neither provider characteristics nor treatment setting attenuated observed racial disparities in knowledge. Quality health care depends on the ability to make an informed treatment decision. As the authors concluded, this study underscores the need for providers to communicate information effectively to all patients, and effective communication relies on the cultural competency of providers.¹³ Without effective, culturally competent communication, there are treatment delays and omissions that result in poor-quality cancer care. Currently, the research has established that these communication deficits are found across providers and treatment center types.

Patient Navigation

Patient navigation has been championed as a method of improving care in breast cancer by enhancing patient communication and education, and removing barriers to timely care. Patient navigation empowers patients to become knowledgeable about their own health and supports them through the course of care.¹⁴ Patient navigation programs have been developed to address the patient communication breakdowns and underuse and misuse of treatment among vulnerable populations, which were detailed earlier in this series and are thought to contribute to the racial mortality gap.¹⁵

A benefit of patient navigation has been suggested in studies evaluating the time to diagnosis and follow-up from an abnormal screening. Markossian et al.¹⁶ evaluated the efficacy of a Chicago-based cancer patient navigation program developed to reduce the time from abnormal screening to definitive diagnostic testing. The majority of patients in this study were Hispanic (66%) and African American (32%). Compared with controls without navigation, the breast navigation group had a shorter time to diagnostic resolution. Hoffman et al.¹⁷ evaluated patient navigation in the District of Columbia to determine its ability to reduce the breast cancer diagnostic time (number of days from abnormal screening to a definitive diagnosis). African American women comprised 48% of the study population. The investigators found that women in the navigation group reached their diagnostic resolution significantly faster than did other women. Among women with breast cancer, there was a nearly fourfold reduction in time to diagnostic resolution for women in the navigation group versus women without a navigator.

In a national multicenter study, Ko et al.¹⁴ were the first to evaluate whether patient navigation can improve the quality of breast cancer care. The authors hypothesized that breast cancer patients assigned a navigator would be more likely to receive recommended standard treatment than were those without a navigator. Three separate quality measures of breast cancer care, including initiation of antiestrogen therapy, radiation therapy, and chemotherapy, were evaluated. Study participants were racially and ethnically diverse, with a plurality being African American (37.5%). The study produced mixed results: Patients in the navigation group had a statistically higher likelihood of receiving antiestrogen therapy than were non–navigated controls, but navigation patients eligible for radiation therapy were no more likely to receive it than were controls. The initiation of chemotherapy could not be accurately assessed because of a limited sample size. The study concluded that navigation alone does not remove all of the barriers to quality care for breast cancer patients, and barriers are diverse and potentially specific to the modality of treatment.

A study by Tejeda et al.¹⁸ used a systematic framework to characterize barriers faced by minority patients with breast and cervical cancer. The investigators categorized barriers as intrapersonal (defined by characteristics of the individual, such as knowledge, belief, attitudes, and transportation and financial barriers), interpersonal (defined by processes that involve other people, such as social support systems, child care, and employment issues), or institutional (defined by characteristics and policies of organizations). The authors found that although navigators were able to easily resolve intrapersonal barriers, ongoing navigation was needed to address institutional barriers. Thus, patient navigation in a vacuum does not work, and it is only in examining the entire health care system that changes can be implemented to eliminate barriers to quality care and close the racial mortality chasm.

System Change

To this effect, Clarke et al.¹⁹ performed a review of the disparities intervention literature to understand which interventions are being evaluated to improve minority health. The authors found that the majority of such interventions are focused on changing the patient rather than the system that serves her, with the most common strategy being education and training (37% of strategies studied). Interventions aimed at health care system improvements were surprisingly few, with the responsibility for change resting with the patient rather than the care delivery system. Interventions incorporating community involvement were also severely lacking and reflected only 6.5% of the reviewed intervention tactics. The majority of interventions failed to involve major stakeholders, including providers, health care institutions, community organizers, and policy makers, and accordingly, were unlikely to succeed in creating meaningful change.

In breast cancer, there have been examples of successful system-based approaches to reducing the racial mortality disparity. At New York area hospitals, Bickell et al.²⁰ implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists to decrease the underuse of valuable adjuvant treatments.

The intervention targeted important quality issues in both communication (the breakdown in dialogue among providers of different specialties and between providers and patients) and the underuse of adjuvant treatment in minorities. The approach was designed to address failures in the health care system through the involvement of leadership from pathology, surgery, and oncology. The intervention also incorporated technology, with tracking software prompting contact with patients who had failed to follow up. Among African American and Hispanic women, there were statistically significant decreases in the underuse of radiotherapy (23% before the intervention vs. 10% after the intervention), chemotherapy (26% vs. 6%), and hormonal therapy (27% vs. 11%). After the intervention, minority race was no longer a risk factor for low rates of oncology consultation or underuse of adjuvant therapy. Interestingly, four of the six hospitals involved in this study had a patient navigation system in place; however, as discussed, the navigation system alone was not enough to address the system failures that led to disparities in care.

Ansell et al.²¹ also described a system-based approach to reducing the breast cancer mortality disparity in Chicago. The Metropolitan Chicago Breast Cancer Task Force comprised 102 individuals and 74 Chicago area organizations to address the growing disparity in breast cancer mortality between African American and white patients. The task force identified a number of themes underlying the disparity gap, including a need for breast cancer education and outreach programs for African American women, a broken mammography process leading to quality differences between African American and white patients, and a number of barriers to diagnosis and treatment, including fear, a lack of primary care, the burden of insurance copays/deductibles, and the noncompletion of treatment for social and economic reasons. After identifying these underlying causes, the task force proposed that addressing one aspect of the health care system would not correct the problem, but rather quality improvement initiatives would have to occur across the continuum of care for breast cancer.

In Delaware, such a broad system-based intervention was implemented to eliminate health disparities in colorectal cancer.²² Delaware created a comprehensive statewide colorectal screening and treatment program, combining many of the interventions discussed previously, including insurance coverage, patient education and communication, and patient navigation, to address the entire health care system and its treatment of African Americans with colorectal cancer. The state also partnered with underserved community organizations to tailor programs locally and create targeted marketing campaigns.

The results of this system-based approach were impressive, with screening rates among African American increasing from 48% to 74% and equaling the rate among whites. In addition, among African American patients, the percentage diagnosed at advanced and regional stages declined from 79% to 40%, and the percentage diagnosed at a local stage increased from 16% to 50%. Most importantly, the mortality rate declined by 42% for African Americans, resulting in a rate almost equal to that among whites. Significantly, this program was also found to be economically viable, because the cost savings from reduced cancer incidence and the stage shift to cancers requiring less-aggressive treatment offset the program cost. As the authors concluded, this model of a comprehensive, system-wide approach to the racial mortality difference would lend itself to other cancers, and more research is needed to assess and build such an approach to breast cancer.

As discussed in the aforementioned studies, multifaceted interventions that address all stakeholders are needed to close the racial survival disparity in breast cancer. In the final installment of this series, we will address how the changing care models ushered in by the Patient Protection and Affordable Care Act have the potential to advance this agenda of creating an intervention that works across the breast cancer care continuum to reduce disparities.

Other installments of this column can be found in the Related Content box.

1. Daly B, Olopade OI. A perfect storm: How tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change. CA Cancer J Clin. 2015 May-Jun;65(3):221-38.

2. Lillie-Blanton M, Hoffman C. The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health Aff (Millwood). 2005 Mar-Apr;24(2):398-408.

3. Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993 Jul 29;329(5):326-31.

4. Coburn N, Fulton J, Pearlman DN, Law C, DiPaolo B, Cady B. Treatment variation by insurance status for breast cancer patients. Breast J. 2008 Mar-Apr;14(2):128-34.

5. Voti L, Richardson LC, Reis I, Fleming LE, Mackinnon J, Coebergh JW. The effect of race/ethnicity and insurance in the administration of standard therapy for local breast cancer in Florida. Breast Cancer Res Treat. 2006 Jan;95(1):89-95.

6. Baicker K, Taubman SL, Allen HL, et al. The Oregon experiment – effects of Medicaid on clinical outcomes. N Engl J Med. 2013 May 2;368(18):1713-22.

7. Hoffman HJ, LaVerda NL, Levine PH, et al. Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia. Cancer. 2011 Aug 15;117(16):3824-32.

8. Short LJ, Fisher MD, Wahl PM, et al. Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention. Cancer. 2010 Jan 1;116(1):193-202.

9. Allen JD, Shelton RC, Harden E, Goldman RE. Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. Patient Educ Couns. 2008 Aug;72(2):283-92.

10. Masi CM, Gehlert S. Perceptions of breast cancer treatment among African-American women and men: implications for interventions. J Gen Intern Med. 2009 Mar;24(3):408-14.

11. Janz NK, Mujahid MS, Hawley ST, Griggs JJ, Hamilton AS, Katz SJ. Racial/ethnic differences in adequacy of information and support for women with breast cancer. Cancer. 2008 Sep 1;113(5):1058-67.

12. Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res. 2008 Aug;43(4):1366-87.

13. Lannin DR, Mathews HF, Mitchell J, Swanson MS. Impacting cultural attitudes in African-American women to decrease breast cancer mortality. Am J Surg. 2002 Nov;184(5):418-23.

14. Ko NY, Darnell JS, Calhoun E, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol. 2014 Sep 1;32(25):2758-64.

15. Vargas RB, Ryan GW, Jackson CA, Rodriguez R, Freeman HP. Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer. Cancer. 2008 Jul 15;113(2):426-33.

16. Markossian TW, Darnell JS, Calhoun EA. Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program. Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1691-700.

17. Hoffman HJ, LaVerda NL, Young HA, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1655-63.

18. Tejeda S, Darnell JS, Cho YI, Stolley MR, Markossian TW, Calhoun EA. Patient barriers to follow-up care for breast and cervical cancer abnormalities. J Womens Health (Larchmt). 2013 Jun;22(6):507-17.

19. Clarke AR, Goddu AP, Nocon RS, et al. Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care? Med Care. 2013 Nov;51(11):1020-26.

20. Bickell NA, Shastri K, Fei K, et al. A tracking and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst. 2008 Dec 3;100(23):1717-23.

21. Ansell D, Grabler P, Whitman S, et al. A community effort to reduce the black/white breast cancer mortality disparity in Chicago. Cancer Causes Control. 2009 Nov;20(9):1681-88.

22. Grubbs SS, Polite BN, Carney J, Jr., et al. Eliminating racial disparities in colorectal cancer in the real world: it took a village. J Clin Oncol. 2013 Jun 1;31(16):1928-30.

Olufunmilayo Olopade, MD, FACP, OON, is the Walter L. Palmer Distinguished Service Professor of Medicine and Human Genetics, and director, Center for Global Health at the University of Chicago. She is adopting emerging high throughput genomic and informatics strategies to identify genetic and nongenetic risk factors for breast cancer in order to implement precision health care in diverse populations. This innovative approach has the potential to improve the quality of care and reduce costs while saving more lives.

Disclosures: Dr. Olopade serves on the Medical Advisory Board for CancerIQ. Dr. Daly serves as a director of Quadrant Holdings Corporation and receives compensation from this entity. Frontline Medical Communications is a subsidiary of Quadrant Holdings Corporation.

Published in conjunction with Susan G. Komen®.

Editor’s Note: This is the fourth installment of a five-part monthly series that will discuss the biologic, genomic, and health system factors that contribute to the racial survival disparity in breast cancer. The series was adapted from an article that originally appeared in CA: A Cancer Journal for Clinicians,¹ a journal of the American Cancer Society. Eliminating racial disparities in cancer mortality through effective interventions has become an increasingly important imperative of federal, state, and community health care programs. This month’s column reviews interventions to close this survival gap.

Insurance

It has been posited that interventions aimed at providing insurance coverage to minority patients will be able to reduce racial health care disparities.² Studies have indicated that women without insurance present with more-advanced disease,^3,4 and are more likely to receive nonstandard treatment.⁵ However, outside of cancer care, a large study of Medicaid expansion in Oregon demonstrated that Medicaid coverage alone generated no significant improvement in measured physical health outcomes in the first 2 years.⁶ Thus, coverage alone does not ensure that patients will be able to navigate the health care system and that quality care will be provided.

In breast cancer, Hoffman et al.⁷ evaluated the effect of race and health insurance on diagnostic time, which was defined as the number of days from suspicious finding to diagnostic resolution (either no evidence of malignancy on diagnostic mammogram or definitive diagnosis by biopsy) in a large, urban setting. The authors’ hypothesis was that every insured patient would receive the same timely diagnosis as any other patient with equivalent insurance, regardless of race or ethnicity. The study found that non-Hispanic whites with government insurance had significantly shorter diagnostic times than did non-Hispanic African Americans with government insurance: The average diagnostic times were 12 and 39 days, respectively. In addition, privately insured non-Hispanic whites also had significantly shorter diagnostic times than did privately insured non-Hispanic African Americans (16 vs. 27 days). In addition, Short et al.⁸ demonstrated that when the health plan status was held constant in a retrospective study of 476 white patients and 99 African American patients with newly diagnosed breast cancer, African American patients had a higher mortality rate (8.1% vs. 3.6%) and were diagnosed at a later stage. Accordingly, interventions must go beyond just providing health insurance to minorities in order to have a significant impact on the mortality gap.

Patient education and physician communication

An underlying cause frequently cited for the delayed diagnosis and treatment of African American patients with breast cancer is a lack of patient education and physician communication. These elements are essential components of quality care. In a qualitative study of low-income, ethnically diverse women older than 40 years, Allen et al.⁹ identified salient themes differentiating women who received timely follow-up from those who did not. For the women who delayed follow-up, prominent themes were dissatisfaction with the communication of results, disrespect on the part of providers and clinical staff, logistical barriers to accessing services, anxiety and fear about a possible cancer diagnosis, and a lack of information about breast cancer screening and symptoms.

In another study, Masi and Gehlert¹⁰ employed focus group interviews of African American adults to characterize their perceptions of breast cancer treatment. The analysis revealed a core set of themes, including mistrust of the medical establishment and concern about the effect of racism on treatment quality; the researchers concluded that “in the eyes of many study participants, the issues of trust, race, and quality of care were closely intertwined.”¹⁰ Thus, this knot that is created by underlying issues of trust can be untied only by interventions that address improved physician communication and patient education.

Janz et al.¹¹ examined racial differences in the adequacy of information and support for women with breast cancer. The researchers used survey data from a population of 1,766 women diagnosed with nonmetastatic breast cancer and reported to the Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry. The study found that across treatment- and survivorship-related issues, African American women desired more information than white women did. One of the explanations for the unmet information needs posited by the authors is a failure to provide culturally appropriate information related to health issues. This breakdown in patient education and communication was demonstrated by Hawley et al. to hold across providers and locations.¹²

Hawley et al.¹² evaluated the association between minority patients’ knowledge of breast cancer treatment risks and benefits and provider characteristics and treatment locations. The provider characteristics included surgeon-level independent variables, such as breast cancer procedure volume and demographics (years in practice and sex). The treatment location variable was categorized into one of three groups: National Cancer Institute–designated cancer center, American College of Surgeons cancer program, or no specific cancer program. Provider characteristics and treatment locations are factors previously identified as being associated with high-quality care.

The study employed a multivariable regression to identify associations between patient, surgeon, and treatment-setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast-conserving surgery with radiation. The authors found that minority women were significantly less likely to have adequate knowledge and more likely to be uncertain about recurrence risk than were white patients. In the multivariate logistic regression model, neither provider characteristics nor treatment setting attenuated observed racial disparities in knowledge. Quality health care depends on the ability to make an informed treatment decision. As the authors concluded, this study underscores the need for providers to communicate information effectively to all patients, and effective communication relies on the cultural competency of providers.¹³ Without effective, culturally competent communication, there are treatment delays and omissions that result in poor-quality cancer care. Currently, the research has established that these communication deficits are found across providers and treatment center types.

Patient Navigation

Patient navigation has been championed as a method of improving care in breast cancer by enhancing patient communication and education, and removing barriers to timely care. Patient navigation empowers patients to become knowledgeable about their own health and supports them through the course of care.¹⁴ Patient navigation programs have been developed to address the patient communication breakdowns and underuse and misuse of treatment among vulnerable populations, which were detailed earlier in this series and are thought to contribute to the racial mortality gap.¹⁵

A benefit of patient navigation has been suggested in studies evaluating the time to diagnosis and follow-up from an abnormal screening. Markossian et al.¹⁶ evaluated the efficacy of a Chicago-based cancer patient navigation program developed to reduce the time from abnormal screening to definitive diagnostic testing. The majority of patients in this study were Hispanic (66%) and African American (32%). Compared with controls without navigation, the breast navigation group had a shorter time to diagnostic resolution. Hoffman et al.¹⁷ evaluated patient navigation in the District of Columbia to determine its ability to reduce the breast cancer diagnostic time (number of days from abnormal screening to a definitive diagnosis). African American women comprised 48% of the study population. The investigators found that women in the navigation group reached their diagnostic resolution significantly faster than did other women. Among women with breast cancer, there was a nearly fourfold reduction in time to diagnostic resolution for women in the navigation group versus women without a navigator.

In a national multicenter study, Ko et al.¹⁴ were the first to evaluate whether patient navigation can improve the quality of breast cancer care. The authors hypothesized that breast cancer patients assigned a navigator would be more likely to receive recommended standard treatment than were those without a navigator. Three separate quality measures of breast cancer care, including initiation of antiestrogen therapy, radiation therapy, and chemotherapy, were evaluated. Study participants were racially and ethnically diverse, with a plurality being African American (37.5%). The study produced mixed results: Patients in the navigation group had a statistically higher likelihood of receiving antiestrogen therapy than were non–navigated controls, but navigation patients eligible for radiation therapy were no more likely to receive it than were controls. The initiation of chemotherapy could not be accurately assessed because of a limited sample size. The study concluded that navigation alone does not remove all of the barriers to quality care for breast cancer patients, and barriers are diverse and potentially specific to the modality of treatment.

A study by Tejeda et al.¹⁸ used a systematic framework to characterize barriers faced by minority patients with breast and cervical cancer. The investigators categorized barriers as intrapersonal (defined by characteristics of the individual, such as knowledge, belief, attitudes, and transportation and financial barriers), interpersonal (defined by processes that involve other people, such as social support systems, child care, and employment issues), or institutional (defined by characteristics and policies of organizations). The authors found that although navigators were able to easily resolve intrapersonal barriers, ongoing navigation was needed to address institutional barriers. Thus, patient navigation in a vacuum does not work, and it is only in examining the entire health care system that changes can be implemented to eliminate barriers to quality care and close the racial mortality chasm.

System Change

To this effect, Clarke et al.¹⁹ performed a review of the disparities intervention literature to understand which interventions are being evaluated to improve minority health. The authors found that the majority of such interventions are focused on changing the patient rather than the system that serves her, with the most common strategy being education and training (37% of strategies studied). Interventions aimed at health care system improvements were surprisingly few, with the responsibility for change resting with the patient rather than the care delivery system. Interventions incorporating community involvement were also severely lacking and reflected only 6.5% of the reviewed intervention tactics. The majority of interventions failed to involve major stakeholders, including providers, health care institutions, community organizers, and policy makers, and accordingly, were unlikely to succeed in creating meaningful change.

In breast cancer, there have been examples of successful system-based approaches to reducing the racial mortality disparity. At New York area hospitals, Bickell et al.²⁰ implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists to decrease the underuse of valuable adjuvant treatments.

The intervention targeted important quality issues in both communication (the breakdown in dialogue among providers of different specialties and between providers and patients) and the underuse of adjuvant treatment in minorities. The approach was designed to address failures in the health care system through the involvement of leadership from pathology, surgery, and oncology. The intervention also incorporated technology, with tracking software prompting contact with patients who had failed to follow up. Among African American and Hispanic women, there were statistically significant decreases in the underuse of radiotherapy (23% before the intervention vs. 10% after the intervention), chemotherapy (26% vs. 6%), and hormonal therapy (27% vs. 11%). After the intervention, minority race was no longer a risk factor for low rates of oncology consultation or underuse of adjuvant therapy. Interestingly, four of the six hospitals involved in this study had a patient navigation system in place; however, as discussed, the navigation system alone was not enough to address the system failures that led to disparities in care.

Ansell et al.²¹ also described a system-based approach to reducing the breast cancer mortality disparity in Chicago. The Metropolitan Chicago Breast Cancer Task Force comprised 102 individuals and 74 Chicago area organizations to address the growing disparity in breast cancer mortality between African American and white patients. The task force identified a number of themes underlying the disparity gap, including a need for breast cancer education and outreach programs for African American women, a broken mammography process leading to quality differences between African American and white patients, and a number of barriers to diagnosis and treatment, including fear, a lack of primary care, the burden of insurance copays/deductibles, and the noncompletion of treatment for social and economic reasons. After identifying these underlying causes, the task force proposed that addressing one aspect of the health care system would not correct the problem, but rather quality improvement initiatives would have to occur across the continuum of care for breast cancer.

In Delaware, such a broad system-based intervention was implemented to eliminate health disparities in colorectal cancer.²² Delaware created a comprehensive statewide colorectal screening and treatment program, combining many of the interventions discussed previously, including insurance coverage, patient education and communication, and patient navigation, to address the entire health care system and its treatment of African Americans with colorectal cancer. The state also partnered with underserved community organizations to tailor programs locally and create targeted marketing campaigns.

The results of this system-based approach were impressive, with screening rates among African American increasing from 48% to 74% and equaling the rate among whites. In addition, among African American patients, the percentage diagnosed at advanced and regional stages declined from 79% to 40%, and the percentage diagnosed at a local stage increased from 16% to 50%. Most importantly, the mortality rate declined by 42% for African Americans, resulting in a rate almost equal to that among whites. Significantly, this program was also found to be economically viable, because the cost savings from reduced cancer incidence and the stage shift to cancers requiring less-aggressive treatment offset the program cost. As the authors concluded, this model of a comprehensive, system-wide approach to the racial mortality difference would lend itself to other cancers, and more research is needed to assess and build such an approach to breast cancer.

As discussed in the aforementioned studies, multifaceted interventions that address all stakeholders are needed to close the racial survival disparity in breast cancer. In the final installment of this series, we will address how the changing care models ushered in by the Patient Protection and Affordable Care Act have the potential to advance this agenda of creating an intervention that works across the breast cancer care continuum to reduce disparities.

Other installments of this column can be found in the Related Content box.

1. Daly B, Olopade OI. A perfect storm: How tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change. CA Cancer J Clin. 2015 May-Jun;65(3):221-38.

2. Lillie-Blanton M, Hoffman C. The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health Aff (Millwood). 2005 Mar-Apr;24(2):398-408.

3. Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993 Jul 29;329(5):326-31.

4. Coburn N, Fulton J, Pearlman DN, Law C, DiPaolo B, Cady B. Treatment variation by insurance status for breast cancer patients. Breast J. 2008 Mar-Apr;14(2):128-34.

5. Voti L, Richardson LC, Reis I, Fleming LE, Mackinnon J, Coebergh JW. The effect of race/ethnicity and insurance in the administration of standard therapy for local breast cancer in Florida. Breast Cancer Res Treat. 2006 Jan;95(1):89-95.

6. Baicker K, Taubman SL, Allen HL, et al. The Oregon experiment – effects of Medicaid on clinical outcomes. N Engl J Med. 2013 May 2;368(18):1713-22.

7. Hoffman HJ, LaVerda NL, Levine PH, et al. Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the District of Columbia. Cancer. 2011 Aug 15;117(16):3824-32.

8. Short LJ, Fisher MD, Wahl PM, et al. Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention. Cancer. 2010 Jan 1;116(1):193-202.

9. Allen JD, Shelton RC, Harden E, Goldman RE. Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. Patient Educ Couns. 2008 Aug;72(2):283-92.

10. Masi CM, Gehlert S. Perceptions of breast cancer treatment among African-American women and men: implications for interventions. J Gen Intern Med. 2009 Mar;24(3):408-14.

11. Janz NK, Mujahid MS, Hawley ST, Griggs JJ, Hamilton AS, Katz SJ. Racial/ethnic differences in adequacy of information and support for women with breast cancer. Cancer. 2008 Sep 1;113(5):1058-67.

12. Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res. 2008 Aug;43(4):1366-87.

13. Lannin DR, Mathews HF, Mitchell J, Swanson MS. Impacting cultural attitudes in African-American women to decrease breast cancer mortality. Am J Surg. 2002 Nov;184(5):418-23.

14. Ko NY, Darnell JS, Calhoun E, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol. 2014 Sep 1;32(25):2758-64.

15. Vargas RB, Ryan GW, Jackson CA, Rodriguez R, Freeman HP. Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer. Cancer. 2008 Jul 15;113(2):426-33.

16. Markossian TW, Darnell JS, Calhoun EA. Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program. Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1691-700.

17. Hoffman HJ, LaVerda NL, Young HA, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012 Oct;21(10):1655-63.

18. Tejeda S, Darnell JS, Cho YI, Stolley MR, Markossian TW, Calhoun EA. Patient barriers to follow-up care for breast and cervical cancer abnormalities. J Womens Health (Larchmt). 2013 Jun;22(6):507-17.

19. Clarke AR, Goddu AP, Nocon RS, et al. Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care? Med Care. 2013 Nov;51(11):1020-26.

20. Bickell NA, Shastri K, Fei K, et al. A tracking and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst. 2008 Dec 3;100(23):1717-23.

21. Ansell D, Grabler P, Whitman S, et al. A community effort to reduce the black/white breast cancer mortality disparity in Chicago. Cancer Causes Control. 2009 Nov;20(9):1681-88.

22. Grubbs SS, Polite BN, Carney J, Jr., et al. Eliminating racial disparities in colorectal cancer in the real world: it took a village. J Clin Oncol. 2013 Jun 1;31(16):1928-30.

Olufunmilayo Olopade, MD, FACP, OON, is the Walter L. Palmer Distinguished Service Professor of Medicine and Human Genetics, and director, Center for Global Health at the University of Chicago. She is adopting emerging high throughput genomic and informatics strategies to identify genetic and nongenetic risk factors for breast cancer in order to implement precision health care in diverse populations. This innovative approach has the potential to improve the quality of care and reduce costs while saving more lives.

Disclosures: Dr. Olopade serves on the Medical Advisory Board for CancerIQ. Dr. Daly serves as a director of Quadrant Holdings Corporation and receives compensation from this entity. Frontline Medical Communications is a subsidiary of Quadrant Holdings Corporation.

Published in conjunction with Susan G. Komen®.

Oncologists should take an individualized approach when making decisions about adjuvant endocrine therapies for premenopausal hormone receptor–positive, HER2-negative early breast cancer, suggests an analysis of a pair of randomized phase III trials published online in the Journal of Clinical Oncology.

Investigators led by Meredith M. Regan, Sc.D., of Dana-Farber Cancer Institute in Boston, analyzed data from the TEXT (Tamoxifen and Exemestane Trial) and SOFT (Suppression of Ovarian Function Trial) trials of adjuvant endocrine therapies, comprising a total of nearly 5,000 women.

Results suggested that the absolute improvement in the 5-year breast cancer–free interval rate with exemestane plus ovarian function suppression (OFS) versus tamoxifen with or without OFS ranged from less than 1% in women with a lowest recurrence risk based on clinicopathologic factors to 10%-15% in women with a highest risk.

“TEXT and SOFT demonstrated that premenopausal women with hormone receptor–positive disease benefit, on average, from exemestane plus OFS versus tamoxifen with or without OFS. However, individualized treatment decisions should weigh the benefits against the adverse effects and costs of these therapy options,” the investigators wrote.

“In the absence of predictive biomarkers, consideration of a patient’s prognosis, as illustrated by STEPP [Subpopulation Treatment Effect Pattern Plot] analysis of a composite measure of recurrence risk in the TEXT and SOFT populations, is integral to this decision making,” they added.

In the SOFT trial, women were randomized to 5 years of tamoxifen alone (as an active comparator), tamoxifen plus OFS, or exemestane (Aromasin) plus OFS. In the TEXT trial, women were randomized to 5 years of exemestane plus OFS or of tamoxifen plus OFS.

Dr. Regan and colleagues based their analyses on a total of 4,891 women. They assessed each patient’s composite recurrence risk from a Cox model that included a set of conventional clinicopathologic factors: age, nodal status, tumor size and grade, and estrogen receptor, progesterone receptor, and Ki-67 expression levels. And they used STEPP methodology to assess the impact of endocrine therapy across groups having different risk.

The median duration of follow-up was 5.6 years in the SOFT trial and 6 years in the TEXT trial. Results showed that the 5-year breast cancer–free interval rate was 90.8% for the study cohort as a whole. But it ranged considerably from 98.6% for patients with composite risk in the lowest quartile to 77.5% for patients with composite risk in the highest quartiles, the investigators reported (J Clin Oncol. 2016. doi: 10.1200/JCO.2015.64.3171).

In the SOFT population, patients who remained premenopausal after neoadjuvant or adjuvant chemotherapy had an absolute improvement of 5% or more in the 5-year breast cancer–free interval rate with exemestane plus OFS, compared with tamoxifen plus OFS or tamoxifen alone. The difference was 10%-15% for the subset at intermediate to high risk for recurrence.

In addition, a benefit of tamoxifen plus OFS over tamoxifen alone was evident in patients having the highest composite risk.

Among patients who were not given chemotherapy, who on average had the lowest composite recurrence risk, the 5-year breast cancer–free interval rate was excellent regardless of the endocrine therapy received.

In the TEXT trial population, the benefit of exemestane plus OFS over tamoxifen plus OFS in 5-year breast cancer–free interval rate ranged from 5% to 15%. Again, the patients who were not given chemotherapy, who had the lowest composite recurrence risk, fared well regardless of which endocrine therapy they received.

These findings should help guide clinical decisions in premenopausal women with hormone receptor–positive, HER2-negative breast cancer, both at the extremes of risk and in the scenario of intermediate risk, where factors such as patient preference, tolerance, and cost play a greater role, according to the investigators.

“Further follow-up of TEXT and SOFT patients is essential to guide patient care,” they concluded.

Oncologists should take an individualized approach when making decisions about adjuvant endocrine therapies for premenopausal hormone receptor–positive, HER2-negative early breast cancer, suggests an analysis of a pair of randomized phase III trials published online in the Journal of Clinical Oncology.

Investigators led by Meredith M. Regan, Sc.D., of Dana-Farber Cancer Institute in Boston, analyzed data from the TEXT (Tamoxifen and Exemestane Trial) and SOFT (Suppression of Ovarian Function Trial) trials of adjuvant endocrine therapies, comprising a total of nearly 5,000 women.

Results suggested that the absolute improvement in the 5-year breast cancer–free interval rate with exemestane plus ovarian function suppression (OFS) versus tamoxifen with or without OFS ranged from less than 1% in women with a lowest recurrence risk based on clinicopathologic factors to 10%-15% in women with a highest risk.

“TEXT and SOFT demonstrated that premenopausal women with hormone receptor–positive disease benefit, on average, from exemestane plus OFS versus tamoxifen with or without OFS. However, individualized treatment decisions should weigh the benefits against the adverse effects and costs of these therapy options,” the investigators wrote.

“In the absence of predictive biomarkers, consideration of a patient’s prognosis, as illustrated by STEPP [Subpopulation Treatment Effect Pattern Plot] analysis of a composite measure of recurrence risk in the TEXT and SOFT populations, is integral to this decision making,” they added.

In the SOFT trial, women were randomized to 5 years of tamoxifen alone (as an active comparator), tamoxifen plus OFS, or exemestane (Aromasin) plus OFS. In the TEXT trial, women were randomized to 5 years of exemestane plus OFS or of tamoxifen plus OFS.

Dr. Regan and colleagues based their analyses on a total of 4,891 women. They assessed each patient’s composite recurrence risk from a Cox model that included a set of conventional clinicopathologic factors: age, nodal status, tumor size and grade, and estrogen receptor, progesterone receptor, and Ki-67 expression levels. And they used STEPP methodology to assess the impact of endocrine therapy across groups having different risk.

The median duration of follow-up was 5.6 years in the SOFT trial and 6 years in the TEXT trial. Results showed that the 5-year breast cancer–free interval rate was 90.8% for the study cohort as a whole. But it ranged considerably from 98.6% for patients with composite risk in the lowest quartile to 77.5% for patients with composite risk in the highest quartiles, the investigators reported (J Clin Oncol. 2016. doi: 10.1200/JCO.2015.64.3171).

In the SOFT population, patients who remained premenopausal after neoadjuvant or adjuvant chemotherapy had an absolute improvement of 5% or more in the 5-year breast cancer–free interval rate with exemestane plus OFS, compared with tamoxifen plus OFS or tamoxifen alone. The difference was 10%-15% for the subset at intermediate to high risk for recurrence.

In addition, a benefit of tamoxifen plus OFS over tamoxifen alone was evident in patients having the highest composite risk.

Among patients who were not given chemotherapy, who on average had the lowest composite recurrence risk, the 5-year breast cancer–free interval rate was excellent regardless of the endocrine therapy received.

In the TEXT trial population, the benefit of exemestane plus OFS over tamoxifen plus OFS in 5-year breast cancer–free interval rate ranged from 5% to 15%. Again, the patients who were not given chemotherapy, who had the lowest composite recurrence risk, fared well regardless of which endocrine therapy they received.

These findings should help guide clinical decisions in premenopausal women with hormone receptor–positive, HER2-negative breast cancer, both at the extremes of risk and in the scenario of intermediate risk, where factors such as patient preference, tolerance, and cost play a greater role, according to the investigators.

“Further follow-up of TEXT and SOFT patients is essential to guide patient care,” they concluded.

Oncologists should take an individualized approach when making decisions about adjuvant endocrine therapies for premenopausal hormone receptor–positive, HER2-negative early breast cancer, suggests an analysis of a pair of randomized phase III trials published online in the Journal of Clinical Oncology.

Investigators led by Meredith M. Regan, Sc.D., of Dana-Farber Cancer Institute in Boston, analyzed data from the TEXT (Tamoxifen and Exemestane Trial) and SOFT (Suppression of Ovarian Function Trial) trials of adjuvant endocrine therapies, comprising a total of nearly 5,000 women.

Results suggested that the absolute improvement in the 5-year breast cancer–free interval rate with exemestane plus ovarian function suppression (OFS) versus tamoxifen with or without OFS ranged from less than 1% in women with a lowest recurrence risk based on clinicopathologic factors to 10%-15% in women with a highest risk.

“TEXT and SOFT demonstrated that premenopausal women with hormone receptor–positive disease benefit, on average, from exemestane plus OFS versus tamoxifen with or without OFS. However, individualized treatment decisions should weigh the benefits against the adverse effects and costs of these therapy options,” the investigators wrote.

“In the absence of predictive biomarkers, consideration of a patient’s prognosis, as illustrated by STEPP [Subpopulation Treatment Effect Pattern Plot] analysis of a composite measure of recurrence risk in the TEXT and SOFT populations, is integral to this decision making,” they added.

In the SOFT trial, women were randomized to 5 years of tamoxifen alone (as an active comparator), tamoxifen plus OFS, or exemestane (Aromasin) plus OFS. In the TEXT trial, women were randomized to 5 years of exemestane plus OFS or of tamoxifen plus OFS.

Dr. Regan and colleagues based their analyses on a total of 4,891 women. They assessed each patient’s composite recurrence risk from a Cox model that included a set of conventional clinicopathologic factors: age, nodal status, tumor size and grade, and estrogen receptor, progesterone receptor, and Ki-67 expression levels. And they used STEPP methodology to assess the impact of endocrine therapy across groups having different risk.

The median duration of follow-up was 5.6 years in the SOFT trial and 6 years in the TEXT trial. Results showed that the 5-year breast cancer–free interval rate was 90.8% for the study cohort as a whole. But it ranged considerably from 98.6% for patients with composite risk in the lowest quartile to 77.5% for patients with composite risk in the highest quartiles, the investigators reported (J Clin Oncol. 2016. doi: 10.1200/JCO.2015.64.3171).

In the SOFT population, patients who remained premenopausal after neoadjuvant or adjuvant chemotherapy had an absolute improvement of 5% or more in the 5-year breast cancer–free interval rate with exemestane plus OFS, compared with tamoxifen plus OFS or tamoxifen alone. The difference was 10%-15% for the subset at intermediate to high risk for recurrence.

In addition, a benefit of tamoxifen plus OFS over tamoxifen alone was evident in patients having the highest composite risk.

Among patients who were not given chemotherapy, who on average had the lowest composite recurrence risk, the 5-year breast cancer–free interval rate was excellent regardless of the endocrine therapy received.

In the TEXT trial population, the benefit of exemestane plus OFS over tamoxifen plus OFS in 5-year breast cancer–free interval rate ranged from 5% to 15%. Again, the patients who were not given chemotherapy, who had the lowest composite recurrence risk, fared well regardless of which endocrine therapy they received.

These findings should help guide clinical decisions in premenopausal women with hormone receptor–positive, HER2-negative breast cancer, both at the extremes of risk and in the scenario of intermediate risk, where factors such as patient preference, tolerance, and cost play a greater role, according to the investigators.

“Further follow-up of TEXT and SOFT patients is essential to guide patient care,” they concluded.

AMSTERDAM – Breast cancer patients who underwent chemotherapy or radiotherapy had about a two-fold increased prevalence of mild systolic cardiac dysfunction a median of 10 years after treatment, compared with age-matched controls in a study that included a total of 700 people.

But even longer follow-up of treated breast cancer patients is needed to determine whether the excess mild cardiac dysfunction seen in this analysis eventually progresses to more severe cardiac impairment, Liselotte M. Boerman said at the European Breast Cancer Conference.

Dr. Cecil Fox/National Cancer Institute

Data from the Breast Cancer Long-term Outcome of Cardiac Dysfunction (BLOC) study showed that 175 breast cancer patients who received chemotherapy (and may have also received radiotherapy) had a 2.5-fold higher prevalence of a left ventricular ejection fraction (LVEF) below 54% (95% confidence interval, 1.2-5.4) when measured by echocardiography a median of 10 years after treatment, compared with an equal number of age-matched individuals from the general population.

A separate group of 175 patients treated with radiotherapy only and evaluated by echocardiography a median of 10 years later had a 2.3-fold increased prevalence (1.1-4.7) of a LVEF below 54% when compared with an equal number of age-matched individuals, said Ms. Boerman, an epidemiology researcher at the University of Groningen (the Netherlands).

This degree of left-ventricular dysfunction was found in 15% of the chemotherapy patients and 6% of their controls, and in 16% of the radiotherapy patients and 8% of their controls.

Mitchel L. Zoler/Frontline Medical News

However, the treated breast cancer patients had no long-term increase in their prevalence of more significant systolic cardiac dysfunction, defined as a LVEF of less than 45%, compared with the controls, and the overall rate of systolic dysfunction of this severity was low, affecting fewer than 1% of patients.

Also, the chemotherapy and radiotherapy patients showed no significant increase in the prevalence of diastolic cardiac dysfunction, defined as delayed cardiac relaxation beyond the age-appropriate range. Treated patients did show, after 10 years, a suggestion of an increased prevalence of diagnosed cardiovascular disease, which was 2.3-fold higher (1.0-4.9) in the chemotherapy-receiving patients, compared with their controls; and 70% higher (0.9-3.4) among the patients treated with radiotherapy, compared with their controls, Ms. Boerman said.

The study used data collected from breast cancer patients younger than 80 years old treated after 1980 and controls seen by general practice Dutch physicians. The chemotherapy patients were diagnosed at an average age of 49 years old (range 26-66 years old). About 78% had received treatment with an anthracycline agent and 7% had received trastuzumab (Herceptin). Radiotherapy had also been administered to 70%, while 62% had also received hormonal therapy, and 7% either had a recurrence or developed a tumor in their contralateral breast.

None of the radiotherapy-only patients had received chemotherapy, but 21% had also received hormonal therapy. Their average age at diagnosis was 54 years old (range 32-79 years old), and 10% had a recurrence or a contralateral tumor.

Mitchel L. Zoler/Frontline Medical News

Follow-up echocardiography occurred 5-34 years after the index treatment, at a median age of 60 years old. Echocardiography follow-up occurred in 70% of the chemotherapy breast cancer patients contacted, and in 63% of those who received radiotherapy only. Among controls, about half of those selected by age matching, and contacted, agreed to participate.

Rates of cardiovascular-disease risk factors – dyslipidemia, hypertension, and diabetes – were at roughly similar levels in the cases and controls at the time of breast cancer diagnosis. But the rate of current smoking at the time of diagnosis appeared higher in the cases (30% among those who received chemotherapy and 33% among those on radiotherapy), compared with their respective control groups (22% and 30%). Ms. Boerman said that a multivariate analysis had not yet been run on the data but should occur soon.

“The prevalence of cardiac dysfunction was higher [in treated patients] than I would have expected, but there is potential bias as only 70% of invited patients actually participated,” commented Dr. Robert Mansel, a professor at the Institute of Cancer & Genetics at Cardiff University (Wales). He also noted the very low rate of patients who developed severe cardiac dysfunction.

Ms. Boerman and Dr. Mansel reported having no financial disclosures.

[email protected]

On Twitter @mitchelzoler

AMSTERDAM – Breast cancer patients who underwent chemotherapy or radiotherapy had about a two-fold increased prevalence of mild systolic cardiac dysfunction a median of 10 years after treatment, compared with age-matched controls in a study that included a total of 700 people.

But even longer follow-up of treated breast cancer patients is needed to determine whether the excess mild cardiac dysfunction seen in this analysis eventually progresses to more severe cardiac impairment, Liselotte M. Boerman said at the European Breast Cancer Conference.

Dr. Cecil Fox/National Cancer Institute

Data from the Breast Cancer Long-term Outcome of Cardiac Dysfunction (BLOC) study showed that 175 breast cancer patients who received chemotherapy (and may have also received radiotherapy) had a 2.5-fold higher prevalence of a left ventricular ejection fraction (LVEF) below 54% (95% confidence interval, 1.2-5.4) when measured by echocardiography a median of 10 years after treatment, compared with an equal number of age-matched individuals from the general population.

A separate group of 175 patients treated with radiotherapy only and evaluated by echocardiography a median of 10 years later had a 2.3-fold increased prevalence (1.1-4.7) of a LVEF below 54% when compared with an equal number of age-matched individuals, said Ms. Boerman, an epidemiology researcher at the University of Groningen (the Netherlands).

This degree of left-ventricular dysfunction was found in 15% of the chemotherapy patients and 6% of their controls, and in 16% of the radiotherapy patients and 8% of their controls.

Mitchel L. Zoler/Frontline Medical News

However, the treated breast cancer patients had no long-term increase in their prevalence of more significant systolic cardiac dysfunction, defined as a LVEF of less than 45%, compared with the controls, and the overall rate of systolic dysfunction of this severity was low, affecting fewer than 1% of patients.

Also, the chemotherapy and radiotherapy patients showed no significant increase in the prevalence of diastolic cardiac dysfunction, defined as delayed cardiac relaxation beyond the age-appropriate range. Treated patients did show, after 10 years, a suggestion of an increased prevalence of diagnosed cardiovascular disease, which was 2.3-fold higher (1.0-4.9) in the chemotherapy-receiving patients, compared with their controls; and 70% higher (0.9-3.4) among the patients treated with radiotherapy, compared with their controls, Ms. Boerman said.

The study used data collected from breast cancer patients younger than 80 years old treated after 1980 and controls seen by general practice Dutch physicians. The chemotherapy patients were diagnosed at an average age of 49 years old (range 26-66 years old). About 78% had received treatment with an anthracycline agent and 7% had received trastuzumab (Herceptin). Radiotherapy had also been administered to 70%, while 62% had also received hormonal therapy, and 7% either had a recurrence or developed a tumor in their contralateral breast.

None of the radiotherapy-only patients had received chemotherapy, but 21% had also received hormonal therapy. Their average age at diagnosis was 54 years old (range 32-79 years old), and 10% had a recurrence or a contralateral tumor.

Mitchel L. Zoler/Frontline Medical News

Follow-up echocardiography occurred 5-34 years after the index treatment, at a median age of 60 years old. Echocardiography follow-up occurred in 70% of the chemotherapy breast cancer patients contacted, and in 63% of those who received radiotherapy only. Among controls, about half of those selected by age matching, and contacted, agreed to participate.

Rates of cardiovascular-disease risk factors – dyslipidemia, hypertension, and diabetes – were at roughly similar levels in the cases and controls at the time of breast cancer diagnosis. But the rate of current smoking at the time of diagnosis appeared higher in the cases (30% among those who received chemotherapy and 33% among those on radiotherapy), compared with their respective control groups (22% and 30%). Ms. Boerman said that a multivariate analysis had not yet been run on the data but should occur soon.

“The prevalence of cardiac dysfunction was higher [in treated patients] than I would have expected, but there is potential bias as only 70% of invited patients actually participated,” commented Dr. Robert Mansel, a professor at the Institute of Cancer & Genetics at Cardiff University (Wales). He also noted the very low rate of patients who developed severe cardiac dysfunction.

Ms. Boerman and Dr. Mansel reported having no financial disclosures.

[email protected]

On Twitter @mitchelzoler

AMSTERDAM – Breast cancer patients who underwent chemotherapy or radiotherapy had about a two-fold increased prevalence of mild systolic cardiac dysfunction a median of 10 years after treatment, compared with age-matched controls in a study that included a total of 700 people.

But even longer follow-up of treated breast cancer patients is needed to determine whether the excess mild cardiac dysfunction seen in this analysis eventually progresses to more severe cardiac impairment, Liselotte M. Boerman said at the European Breast Cancer Conference.

Dr. Cecil Fox/National Cancer Institute

Data from the Breast Cancer Long-term Outcome of Cardiac Dysfunction (BLOC) study showed that 175 breast cancer patients who received chemotherapy (and may have also received radiotherapy) had a 2.5-fold higher prevalence of a left ventricular ejection fraction (LVEF) below 54% (95% confidence interval, 1.2-5.4) when measured by echocardiography a median of 10 years after treatment, compared with an equal number of age-matched individuals from the general population.

A separate group of 175 patients treated with radiotherapy only and evaluated by echocardiography a median of 10 years later had a 2.3-fold increased prevalence (1.1-4.7) of a LVEF below 54% when compared with an equal number of age-matched individuals, said Ms. Boerman, an epidemiology researcher at the University of Groningen (the Netherlands).

This degree of left-ventricular dysfunction was found in 15% of the chemotherapy patients and 6% of their controls, and in 16% of the radiotherapy patients and 8% of their controls.

Mitchel L. Zoler/Frontline Medical News

However, the treated breast cancer patients had no long-term increase in their prevalence of more significant systolic cardiac dysfunction, defined as a LVEF of less than 45%, compared with the controls, and the overall rate of systolic dysfunction of this severity was low, affecting fewer than 1% of patients.

Also, the chemotherapy and radiotherapy patients showed no significant increase in the prevalence of diastolic cardiac dysfunction, defined as delayed cardiac relaxation beyond the age-appropriate range. Treated patients did show, after 10 years, a suggestion of an increased prevalence of diagnosed cardiovascular disease, which was 2.3-fold higher (1.0-4.9) in the chemotherapy-receiving patients, compared with their controls; and 70% higher (0.9-3.4) among the patients treated with radiotherapy, compared with their controls, Ms. Boerman said.

The study used data collected from breast cancer patients younger than 80 years old treated after 1980 and controls seen by general practice Dutch physicians. The chemotherapy patients were diagnosed at an average age of 49 years old (range 26-66 years old). About 78% had received treatment with an anthracycline agent and 7% had received trastuzumab (Herceptin). Radiotherapy had also been administered to 70%, while 62% had also received hormonal therapy, and 7% either had a recurrence or developed a tumor in their contralateral breast.

None of the radiotherapy-only patients had received chemotherapy, but 21% had also received hormonal therapy. Their average age at diagnosis was 54 years old (range 32-79 years old), and 10% had a recurrence or a contralateral tumor.

Mitchel L. Zoler/Frontline Medical News

Follow-up echocardiography occurred 5-34 years after the index treatment, at a median age of 60 years old. Echocardiography follow-up occurred in 70% of the chemotherapy breast cancer patients contacted, and in 63% of those who received radiotherapy only. Among controls, about half of those selected by age matching, and contacted, agreed to participate.

Rates of cardiovascular-disease risk factors – dyslipidemia, hypertension, and diabetes – were at roughly similar levels in the cases and controls at the time of breast cancer diagnosis. But the rate of current smoking at the time of diagnosis appeared higher in the cases (30% among those who received chemotherapy and 33% among those on radiotherapy), compared with their respective control groups (22% and 30%). Ms. Boerman said that a multivariate analysis had not yet been run on the data but should occur soon.

“The prevalence of cardiac dysfunction was higher [in treated patients] than I would have expected, but there is potential bias as only 70% of invited patients actually participated,” commented Dr. Robert Mansel, a professor at the Institute of Cancer & Genetics at Cardiff University (Wales). He also noted the very low rate of patients who developed severe cardiac dysfunction.

Ms. Boerman and Dr. Mansel reported having no financial disclosures.

[email protected]

On Twitter @mitchelzoler

AMSTERDAM – A telephone-based system to monitor chemotherapy-induced symptoms when patients are home and facilitate interventions as needed led to significant cuts in symptom burden in a single-center, randomized trial with 152 breast cancer patients.

“Symptom care at home gives patients symptom care when and where they need it,” Kathi H. Mooney, Ph.D., said at the European Breast Cancer Conference. “Rarely is symptom monitoring extended to when patients are home, but that is when symptoms are most problematic for patients.”

The 30-day program was linked with significant cuts in the number of days with any of seven chemotherapy-induced symptoms. In addition, overall days with any severe symptom fell by 48% (P = .006) and the number of days with any moderate symptoms fell by 38% (P = .011), reported Dr. Mooney, professor of nursing at the University of Utah, Salt Lake City.

She and her associates designed a telephone-based system to address the usual reticence that chemotherapy patients have to report their symptoms. Prior study results had documented that patients with moderate or severe symptoms initiated calls for about 5% of episodes, even when explicitly told to report symptoms. This led the Utah researchers to develop an automated, interactive system that phoned patients daily.

The enrolled patients spanned the full spectrum of breast cancer stages; the average age was 53 years. All patients received a daily, automated call that prompted them to rate each of 11 chemotherapy symptoms on a scale of 0-10.

The calls also provided automated, self-management coaching for problematic symptoms. The investigational Symptom Care at Home intervention involved a nurse practitioner getting back to patients who reported poorly-controlled symptoms. These follow-up calls averaged just under 7 minutes in length, and on average each patient received 11 calls during the 30 days of the intervention.

After 30 days, the 83 patients in the Symptom Care at Home program had statistically-significant reductions in days with moderate or worse episodes for 7 of the 11 symptoms tallied: numbness or tingling, anxiety, nausea, pain, depressed mood, sore mouth, and fatigue. The most robust effects were a 72% drop in days with moderate or worse numbness or tingling, a 66% reduction in anxiety days, and a 61% cut in nausea days.

Mitchel L. Zoler/Frontline Medical News

“I like the intervention used in this study. I think it shows what can happen when you collect symptom information in a way that is patient friendly,” said Dr. Robert Mansel, professor at the Institute of Cancer & Genetics at Cardiff University, South Wales. “I was delighted to see that this intervention really made a difference. The findings show that patients often suffer a lot more from treatment than they are usually prepared to tell us.”

In addition to the efficacy of this intervention, “patients told us that they liked having someone to talk with about their symptoms,” Dr. Mooney said in an interview. “Patients are concerned about their symptoms.”

One aspect of the Symptom Care at Home program that has not yet been analyzed is its cost efficacy. The University of Utah’s Huntsman Cancer Institute, where the program was developed, is awaiting results from a cost-benefit analysis before deciding whether to make the telephone system part of routine practice, she said.

Dr. Mooney and Dr. Mansel reported having no financial disclosures.

[email protected]

On Twitter @mitchelzoler

AMSTERDAM – A telephone-based system to monitor chemotherapy-induced symptoms when patients are home and facilitate interventions as needed led to significant cuts in symptom burden in a single-center, randomized trial with 152 breast cancer patients.

“Symptom care at home gives patients symptom care when and where they need it,” Kathi H. Mooney, Ph.D., said at the European Breast Cancer Conference. “Rarely is symptom monitoring extended to when patients are home, but that is when symptoms are most problematic for patients.”

The 30-day program was linked with significant cuts in the number of days with any of seven chemotherapy-induced symptoms. In addition, overall days with any severe symptom fell by 48% (P = .006) and the number of days with any moderate symptoms fell by 38% (P = .011), reported Dr. Mooney, professor of nursing at the University of Utah, Salt Lake City.

She and her associates designed a telephone-based system to address the usual reticence that chemotherapy patients have to report their symptoms. Prior study results had documented that patients with moderate or severe symptoms initiated calls for about 5% of episodes, even when explicitly told to report symptoms. This led the Utah researchers to develop an automated, interactive system that phoned patients daily.

The enrolled patients spanned the full spectrum of breast cancer stages; the average age was 53 years. All patients received a daily, automated call that prompted them to rate each of 11 chemotherapy symptoms on a scale of 0-10.

The calls also provided automated, self-management coaching for problematic symptoms. The investigational Symptom Care at Home intervention involved a nurse practitioner getting back to patients who reported poorly-controlled symptoms. These follow-up calls averaged just under 7 minutes in length, and on average each patient received 11 calls during the 30 days of the intervention.

After 30 days, the 83 patients in the Symptom Care at Home program had statistically-significant reductions in days with moderate or worse episodes for 7 of the 11 symptoms tallied: numbness or tingling, anxiety, nausea, pain, depressed mood, sore mouth, and fatigue. The most robust effects were a 72% drop in days with moderate or worse numbness or tingling, a 66% reduction in anxiety days, and a 61% cut in nausea days.

Mitchel L. Zoler/Frontline Medical News

“I like the intervention used in this study. I think it shows what can happen when you collect symptom information in a way that is patient friendly,” said Dr. Robert Mansel, professor at the Institute of Cancer & Genetics at Cardiff University, South Wales. “I was delighted to see that this intervention really made a difference. The findings show that patients often suffer a lot more from treatment than they are usually prepared to tell us.”

In addition to the efficacy of this intervention, “patients told us that they liked having someone to talk with about their symptoms,” Dr. Mooney said in an interview. “Patients are concerned about their symptoms.”

One aspect of the Symptom Care at Home program that has not yet been analyzed is its cost efficacy. The University of Utah’s Huntsman Cancer Institute, where the program was developed, is awaiting results from a cost-benefit analysis before deciding whether to make the telephone system part of routine practice, she said.

Dr. Mooney and Dr. Mansel reported having no financial disclosures.

[email protected]

On Twitter @mitchelzoler

AMSTERDAM – A telephone-based system to monitor chemotherapy-induced symptoms when patients are home and facilitate interventions as needed led to significant cuts in symptom burden in a single-center, randomized trial with 152 breast cancer patients.

“Symptom care at home gives patients symptom care when and where they need it,” Kathi H. Mooney, Ph.D., said at the European Breast Cancer Conference. “Rarely is symptom monitoring extended to when patients are home, but that is when symptoms are most problematic for patients.”

The 30-day program was linked with significant cuts in the number of days with any of seven chemotherapy-induced symptoms. In addition, overall days with any severe symptom fell by 48% (P = .006) and the number of days with any moderate symptoms fell by 38% (P = .011), reported Dr. Mooney, professor of nursing at the University of Utah, Salt Lake City.

She and her associates designed a telephone-based system to address the usual reticence that chemotherapy patients have to report their symptoms. Prior study results had documented that patients with moderate or severe symptoms initiated calls for about 5% of episodes, even when explicitly told to report symptoms. This led the Utah researchers to develop an automated, interactive system that phoned patients daily.

The enrolled patients spanned the full spectrum of breast cancer stages; the average age was 53 years. All patients received a daily, automated call that prompted them to rate each of 11 chemotherapy symptoms on a scale of 0-10.

The calls also provided automated, self-management coaching for problematic symptoms. The investigational Symptom Care at Home intervention involved a nurse practitioner getting back to patients who reported poorly-controlled symptoms. These follow-up calls averaged just under 7 minutes in length, and on average each patient received 11 calls during the 30 days of the intervention.

After 30 days, the 83 patients in the Symptom Care at Home program had statistically-significant reductions in days with moderate or worse episodes for 7 of the 11 symptoms tallied: numbness or tingling, anxiety, nausea, pain, depressed mood, sore mouth, and fatigue. The most robust effects were a 72% drop in days with moderate or worse numbness or tingling, a 66% reduction in anxiety days, and a 61% cut in nausea days.

Mitchel L. Zoler/Frontline Medical News

“I like the intervention used in this study. I think it shows what can happen when you collect symptom information in a way that is patient friendly,” said Dr. Robert Mansel, professor at the Institute of Cancer & Genetics at Cardiff University, South Wales. “I was delighted to see that this intervention really made a difference. The findings show that patients often suffer a lot more from treatment than they are usually prepared to tell us.”

In addition to the efficacy of this intervention, “patients told us that they liked having someone to talk with about their symptoms,” Dr. Mooney said in an interview. “Patients are concerned about their symptoms.”

One aspect of the Symptom Care at Home program that has not yet been analyzed is its cost efficacy. The University of Utah’s Huntsman Cancer Institute, where the program was developed, is awaiting results from a cost-benefit analysis before deciding whether to make the telephone system part of routine practice, she said.

Dr. Mooney and Dr. Mansel reported having no financial disclosures.

[email protected]

On Twitter @mitchelzoler