Preserving Fertility in Breast Cancer Care: Options and Considerations

The Impact of COVID-19 on Breast Cancer Care: A Qualitative Analysis of Surgeons’ Perspectives

Introduction: Black women are more likely to be diagnosed at later stages of breast cancer compared with White women due to lower frequency of screening and lack of timely follow-up after abnormal screening results. Disparities in breast cancer screening, risk, and mortality are present within both Black women and sexual minority communities; however, there exists limited research concerning breast cancer care among Black sexual minority women. Materials and Methods: This scoping review examines the literature from 1990 to 2017 of the breast cancer care continuum among Black sexual minority women, including behavioral risk factors, screening, treatment, and survivorship. A total of 91 articles were identified through PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. Fifteen articles were selected for data extraction, which met the criteria for including Black/African American women, discussing breast cancer care among both racial and sexual minorities, and being a peer-reviewed article. Results: The 15 articles were primarily within urban contexts, and defined sexual minorities as lesbian or bisexual women. Across all the studies, Black sexual minority women were highly under-represented, and key conclusions are not fully applicable to Black sexual minority women. Sexual minority women had a higher prevalence of breast cancer risk factors (i.e., nulliparity, fewer mammograms, higher alcohol intake, and lower oral contraceptive use). Furthermore, some studies noted homophobia from health providers as potential barriers to engagement in care for sexual minority women. Conclusions: The lack of studies concerning Black sexual minority women in breast cancer care indicates the invisibility of a group that experiences multiple marginalized identities. More research is needed to capture the dynamics of the breast cancer care continuum for Black sexual minority women.

Implementation science and breast cancer control: A Breast Health Global Initiative (BHGI) perspective from the 2010 Global Summit

Introduction A major barrier to timely breast cancer diagnosis and care in Nigeria is attributable to the out-of-pocket cost of accessing healthcare services, despite the presence of a National Health Insurance Scheme (NHIS). Excessive out-of-pocket payments are often associated with a catastrophic health care expenditure (CHE). Despite the rising incidence of breast cancer in Nigeria, there is a paucity of economic data on the cost of care and the impact healthcare expenditure may have on a household. This study provides a comprehensive, prospective analysis of out-of-pocket spending for breast cancer care at a single tertiary care institution in South West Nigeria. Methods Consecutive patients undergoing curative intent surgery for a new diagnosis of breast cancer at Obafemi Awolowo University Teaching Hospital (OAUTH) between August 2019-April 2022 were approached for enrolment. A novel, context specific questionnaire was developed for this study and administered by trained personnel. The questionnaire was delivered to patients and caregivers during hospital admission and again during six-month follow-up. Participants were asked to estimate monthly household income and expenditures. Out-of-pocket direct and indirect expenses for breast cancer diagnosis and care were elicited. Where feasible, hospital accounting records and individual receipts were used to minimize recall bias. Sequelae of the out-of-pocket costs were also elicited, such as the use of debt financing and important forgone expenditures, such as childhood education. Capacity-to-pay was calculated for each household from the provided data as the sum of annual non-food expenditures. A CHE was defined as an aggregate healthcare expenditure that exceeded 40% of a household’s capacity-to-pay. All monetary figures were collected in the local currency (Naira) and converted to USD using the Nigerian Central Bank conversion rate of 415.83N to 1USD. Research ethics board approval was obtained for this study from OAUTH. Results Data were collected from 57 eligible patients with a mean age of 49.8 years (SD 12). The median household size was five (range 1-10) and the majority (75.4%) had completed at least secondary education. Seventy four percent (73.6%) of patients had ≥ Stage III disease at presentation and 89.5% received systemic chemotherapy. Only seven percent (4/received adjuvant radiotherapy. The mean annual capacity-to-pay for the cohort was $2,840.8 ($2,913.6). The mean cost of care, including direct and indirect expenditure was $3,379.7 (SD $3032.2). Excluding indirect costs, such as the cost of travel and self-reported lost income, the mean cost of direct expenditures associated with diagnosis and treatment was $1,705.3 (SD $1,236.6). Out of the 57 patients enrolled in the study 52 (91.2%) experienced a CHE as a result of their breast cancer treatment. As a result, 56% of households had to borrow money and seven percent withdrew children from school. Sixty-three percent of patients had no form of health insurance. Conclusions Over 90% of breast cancer patients at a tertiary care facility in Nigeria experience a CHE as a result of out-of-pocket costs associated with accessing care. This limits access to costly evidence-based adjuncts (i.e. radiotherapy) and has a negative impact on the wellbeing of the broader household. There is a need for national and global initiatives to ensure financial protection from the cost of breast cancer care. Citation Format: Funmilola Wuraola, Chloe Blackman, Israel Adeyemi Owoade, Adeoluwa Oluwaseyi Adeleye, Peter Kingham, Olusegun Alatise, Gregory Knapp. The Out-of-Pocket Cost of Breast Cancer Care in Nigeria: A Prospective Analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-46.

202 Background: The global BC Care and Outcomes Report revealed ample differences in BC care and outcomes exist across continents, exposing the need for regionally focused studies. Aim: Provide an overview of the burden of BC and of BC care and outcomes in LAC and identify the major challenges Methods: Review of literature (PubMed, LILACS, SCIELO), public databases (Globocan 2002 and 2008, CEPALSTAT, DIRAC, PAHO, WHOSYS, etc) and conference presentations (ASCO, ISPOR). Local experts and patient organizations were surveyed. Current BC epidemiology in LAC, countries’ risk profiles and future trends, disease burden and available resources, patterns of care and treatment access (case studies), and outcomes (such as mortality-to-incidence ratios - MIRs) were analyzed and compared (Sweden as benchmark). Results: BC exhibits the highest annual incidence (114,900 cases) and mortality (37,000 deaths) of all cancers in LAC and is expected to double by 2030. Age is the main risk factor. Heavy burden is due to younger age at diagnosis. Poor outcomes are partly due to late diagnosis. Availability of specialized surgeons, waiting times, node clearance policy and access to breast reconstruction vary widely across countries and between public and private settings. Radiotherapy equipment is insufficient, except in Uruguay, Chile, and Venezuela. All modern systemic therapies are available, but some not widely diffused due to their costs. Palliative care is developing but, despite great efforts, problems persist. BC MIRs have improved, albeit unevenly, over time. Conclusions: Inequalities in access to diagnosis and treatment, fragmented organization and management of BC care and poor uptake of evidence-based best practices result in high morbidity and associated societal costs. [Table: see text]

BACKGROUND In Mexico, 71% of the population is covered by public health insurance, while 2% are privately insured and 27% are uninsured. Previous studies have demonstrated differences in breast cancer (BC) care according to type of healthcare coverage in the United States and Latin America. Most studies have observed that privately insured patients are diagnosed at earlier stages, have less symptom-to-diagnosis and treatment delays, and have better overall outcomes. The aim of this analysis was to evaluate whether differences in BC care exist among young women with breast cancer (YWBC), ≤40 years at diagnosis, depending on their insurance status in Mexico. METHODS Data was collected from the Mexican prospective cohort of YWBC Joven & Fuerte. Patient surveys and researcher follow-ups were used to collect data related to clinicopathologic features, time from symptom onset to seeking medical assistance and treatment, and perceived quality of information received and medical staff support. Results were analyzed using SPSS. RESULTS Information about health insurance status was available for 608 patients: 565 (93%) had public coverage and 43 (7%) had private coverage. Table 1 describes the clinicopathologic characteristics of both groups. Patients with private insurance were diagnosed at earlier stages, 0-II vs. III-IV (81% vs. 16%), than those with public insurance (50% vs. 45%) (p< 0.001). No difference was found on the distribution of BC subtypes among both groups. A total of 573 (94%) patients had registered information regarding the time from symptom onset to contacting a medical professional. Only 18 (3%) were diagnosed with imaging studies (5% and 3% with private and public coverage, respectively). More privately insured patients (95%) contacted a healthcare professional during the first 3 months since symptom onset than publicly insured patients (74%) (p=0.003). Information regarding the time from contacting a healthcare professional to treatment start was available for 472 (78%) patients. There was no difference in the proportion of patients who started treatment ≤3 months after arriving with a healthcare professional according to type of health insurance (76% private vs. 67% public coverage; p=0.2). The majority of patients (96%) considered having adequate support from the medical staff (100% private vs. 94% public). Compared to those with public coverage, more privately insured patients perceived receiving adequate information about their treatment (79% private vs. 50% public; p< 0.001). There were no differences between groups regarding the perceived quality of information regarding their diagnosis (p=0.06) and continuous BC care (p=0.6). CONCLUSION Patients with private coverage were diagnosed at earlier stages, reported contacting a healthcare professional earlier, and perceived receiving adequate information regarding their treatment more often than patients with public coverage. These results coincide with previously reported differences between patients with private and public health insurance. Interestingly, there were no differences between the delays from the first visit to treatment initiation and perceived support from the medical staff depending on type of healthcare coverage. Given the observed differences between privately and publicly insured patients, population-based interventions to increase awareness of alarm signs for BC and widespread access to quality patient education resources could help decrease the disparities between these groups. Table 1. Clinicopathologic features of BC depending on insurance status Citation Format: David G Gonzalez-Sanchez, Arantxa Ramirez-Cisneros, Alejandra Platas, Alejandra Platas, Daniela Vazquez-Juarez, Fernanda Mesa-Chavez, Ana Ferrigno, Alejandro Mohar, Alan Fonseca, Cynthia Villarreal-Garza. Relationship Between Insurance Status and Breast Cancer Care in Young Mexican Women [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-10-03.

BackgroundThe main study objectives were: to establish a nationwide voluntary collaborative network of breast centres with independent data analysis; to define suitable quality indicators (QIs) for benchmarking the quality of breast cancer (BC) care; to demonstrate existing differences in BC care quality; and to show that BC care quality improved with benchmarking from 2003 to 2007.MethodsBC centres participated voluntarily in a scientific benchmarking procedure. A generic XML-based data set was developed and used for data collection. Nine guideline-based quality targets serving as rate-based QIs were initially defined, reviewed annually and modified or expanded accordingly. QI changes over time were analysed descriptively.ResultsDuring 2003–2007, respective increases in participating breast centres and postoperatively confirmed BCs were from 59 to 220 and from 5,994 to 31,656 (> 60% of new BCs/year in Germany). Starting from 9 process QIs, 12 QIs were developed by 2007 as surrogates for long-term outcome. Results for most QIs increased. From 2003 to 2007, the most notable increases seen were for preoperative histological confirmation of diagnosis (58% (in 2003) to 88% (in 2007)), appropriate endocrine therapy in hormone receptor-positive patients (27 to 93%), appropriate radiotherapy after breast-conserving therapy (20 to 79%) and appropriate radiotherapy after mastectomy (8 to 65%).ConclusionNationwide external benchmarking of BC care is feasible and successful. The benchmarking system described allows both comparisons among participating institutions as well as the tracking of changes in average quality of care over time for the network as a whole. Marked QI increases indicate improved quality of BC care.

e18718 Background: COVID-19-related physical distancing restrictions impacted the delivery of close-contact healthcare care in the initial months of the pandemic. To ascertain the effect of these changes on breast cancer (BC) care at Gundersen Health System (GHS), we compared stage at diagnosis (dx), interval between dx and initiation of treatment (tx), and modality of first tx offered to pts (pts) diagnosed with BC before, during, and after pandemic-related restrictions. Methods: We performed a retrospective review of the electronic health records of approximately 904 pts with a new BC dx at GHS. Based on the timing of COVID-19-related restrictions at GHS, we designated any date from January 1, 2019 - March 31, 2020 as “Pre-COVID”, April 1, 2020 - December 31, 2020 as “COVID”, and January 1, 2021 - March 31, 2022 as “Post-COVID”. The median time to first tx for each modality of tx was compared using Kruskal-Wallis tests. Cox proportional hazard models were used to investigate patterns in the time to tx for various tx modalities in the three time periods of interest while accounting for clinical stage at dx. Changes in the distribution of modality of first tx, cancer stage at dx, type of surgery, and mode of disease detection across the three time periods of interest were assessed using Chi-square tests of association. Results: The median time to surgery for pts with surgery as first tx modality was significantly different between time periods (p < 0.001) with time to surgery shortest pre-COVID and longest post-COVID. Significant differences in time to first chemotherapy tx were noted for clinical stage 2 pts (p = 0.002), but not for pts diagnosed at other stages. No differences were noted in times to first hormone therapy tx (p = 0.28). There were significant differences in the distribution of modality of first tx (p < 0.001), the clinical stage at dx (p = 0.01), and the mode of detection (p = 0.04) across the three time periods. These differences reveal a shift in the typical paradigm of BC care due to the pandemic; with a delay in detection and tx, change in clinical stage at dx, and a change in the modality of the first tx. Conclusions: Our data illustrate the effect the pandemic had on routine BC care during and after the pandemic-related restrictions regarding time to first tx, clinical stage at the time of dx, and initial tx modality. Furthermore, these pandemic changes are ongoing with the time to first tx longer in the post-pandemic period as compared to pre-pandemic period. This delay in return to pre-pandemic standards may be due to continued issues with supply chain and staffing shortages. Identifying differences attributable to the pandemic will help guide future decisions regarding BC care should conditions necessitate the reimplementation of strict infection-prevention measures. Identifying issues that continue post-COVID will help determine strategies to close those care gaps.

101 Background: Collaborative care between cancer specialists and primary care providers (PCP) ensures high quality cancer care. Yet, little is known about patient’s perspectives about the level of PCP engagement in and communication about breast cancer (BC) care during treatment. Methods: A weighted random sample of newly diagnosed breast cancer patients in the Georgia and Los Angeles SEER registries were surveyed approximately 6 months after diagnosis (expected final N = 2600, 70% current response rate). PCP BC engagement and communication were defined using 2 outcome measures (categorized as less (never/rarely) vs. more (sometimes/often/always)): how informed the respondent’s PCP was about BC treatment and how often respondents talked with their PCP about their BC care visits. Overall PCP quality was assessed by averaging patient responses (5 categories, never to always) to 5 questions: ease of access to PCP (3 questions) and PCP’s awareness of patient values (2 questions) and categorized as high ( ≥ 4), moderate (3) and low ( < 3). The associations between patient factors and PCP quality with BC engagement and communication were evaluated using multivariable logistic regression. Results: In a preliminary sample (N = 2054), the majority of women reported high PCP quality (63%), high PCP BC engagement (65%) and communication (68%). (Table) Women who reported less PCP BC engagement were more likely to report low PCP quality (OR: 15.7, 95%CI: 9.5, 25.9;) and chemotherapy use (OR: 1.3, 95%CI: 1.1, 1.6), adjusting for age, race, insurance, comorbidities and PCP continuity. The results were similar for PCP communication. Conclusions: Patient perceptions of PCP quality, engagement and communication during BC treatment are high for most women with BC. However, there remains opportunity for improvement in both, as many women report poor engagement and communication despite perceiving high quality primary care. Targeting these patients and their clinicians may be particularly effective in interventions to improve collaborative care in cancer. [Table: see text]

Anyone who has been diagnosed with breast cancer or is acquainted with someone who has been diagnosed with breast cancer knows that cancer raises a host of questions concerning its nature, how we know it, and how we treat it. Such questions frame the difficult decisions that patients must make about their treatment, care, and mortality. Thinking Though Breast Cancer: A Philosophical Exploration of Diagnosis, Treatment, and Survival is a philosophical investigation of the second leading cause of cancer death among women. It is a study of how breast cancer is described, explained, evaluated, and socialized in medicine. Further, it is an investigation of the ethical implications of understanding breast cancer. These include the extent to which informed consent is secured, patient harms are minimized, patient benefits are maximized, and access to appropriate breast cancer care is made possible. The inquiry draws on clinical information as well as philosophical advice and provides suggestions about how to navigate the complex and, at times, uncertain terrain of breast cancer knowledge and care. In this way, the book is not simply an academic overview of what we know about breast cancer. It is a personal search for guidance about managing the complex, confusing, and scary terrain of breast cancer diagnosis, prognosis, and treatment.

In this review of current pertinent literature from the fields of cancer epidemiology, oncology, health services research, and geriatrics, we describe the epidemiology and unique features of breast cancer and its victims in old age. In addition, we review the current evidence regarding treatment efficacy (i.e., beneficial under ideal circumstances) and effectiveness (i.e., beneficial under usual circumstances) in relation to primary tumor management and the use of adjuvant therapy in early stage disease and outline the challenges associated with studying breast cancer care in older women (> or = 65 years of age). Comorbidity, impaired functional status, lack of social support, and differences in host physiology are among the many factors that influence treatment efficacy and effectiveness, making extrapolation of study findings from younger to older women questionable. Indeed, with the exception of studies of adjuvant tamoxifen therapy, none of the clinical trials supporting the 1990 National Institutes of Health Consensus Development Conference on Treatment of Early-Stage Breast Cancer guidelines have included women over the age of 70 years. Because (a) breast cancer is becoming increasingly common in old age and (b) health-related quality of life is frequently more important to older women than is risk of recurrence or death, all three aspects (surgical management of the primary tumor, postoperative irradiation, and axillary lymph node dissection) of recommended primary treatment deserve fresh scrutiny. The value of adjuvant chemotherapy has yet to be defined. Substantial variations in breast cancer diagnosis, treatment, and care exist, and these differences become greater with increasing age of the patient. However, evidence regarding the reasons for these variations and their relationships with subsequent outcomes is lacking. Challenges for investigators in studies of older women include recruitment into studies, collection of reliable data from interviews or surveys, measurement of disease severity and comorbidity, and selection of relevant outcomes. Given current uncertainty about optimal treatment, clinicians can best serve older patients with early stage breast cancer by involving them in decision-making, taking into account available efficacy data, and individualizing care on the basis of such factors as comorbidity, social support, functional status, and patient preferences for outcomes. Future studies of treatment efficacy in older women should examine the roles of radiation therapy and axillary lymph node dissection that follow breast-conserving therapy and should focus on quality of life in addition to recurrence and mortality. Less aggressive treatments, tamoxifen therapy, and adjuvant chemotherapy should also be evaluated.

229 (PB-053) Poster - COVID-19, breast cancer care, and social determinants of health: a cross-sectional study to investigate the impact of a pandemic on health and health care

A voluntary, external, science-based benchmarking program was established in Germany in 2003 to analyze and improve the quality of breast cancer (BC) care. Based on recent data from 2009, we aim to show that such analyses can also be performed for individual interdisciplinary specialties, such as radiation oncology (RO). Breast centers were invited to participate in the benchmarking program. Nine guideline-based quality indicators (QIs) were initially defined, reviewed annually, and modified, expanded, or abandoned accordingly. QI changes over time were analyzed descriptively, with particular emphasis on relevance to radiation oncology. During the 2003-2009 study period, there were marked increases in breast center participation and postoperatively confirmed primary BCs. Starting from 9 process QIs, 15 QIs were developed by 2009 as surrogate indicators of long-term outcome. During 2003-2009, 2/7 RO-relevant QIs (radiotherapy after breast-conserving surgery or after mastectomy) showed considerable increases (from 20 to 85% and 8 to 70%, respectively). Another three, initially high QIs practically reached the required levels. The current data confirm proof-of-concept for the established benchmarking program, which allows participating institutions to be compared and changes in quality of BC care to be tracked over time. Overall, marked QI increases suggest that BC care in Germany improved from 2003-2009. Moreover, it has become possible for the first time to demonstrate improvements in the quality of BC care longitudinally for individual breast centers. In addition, subgroups of relevant QIs can be used to demonstrate the progress achieved, but also the need for further improvement, in specific interdisciplinary specialties.

BackgroundUnderstanding the cost of delivering breast cancer (BC) care in low‐ and middle‐income countries (LMICs) is critical to guide effective care delivery strategies. This scoping review summarizes the scope of literature on the costs of BC care in LMICs and characterizes the methodological approaches of these economic evaluations.Materials and MethodsA systematic literature search was performed in five databases and gray literature up to March 2020. Studies were screened to identify original articles that included a cost outcome for BC diagnosis or treatment in an LMIC. Two independent reviewers assessed articles for eligibility. Data related to study characteristics and methodology were extracted. Study quality was assessed using the Drummond et al. checklist.ResultsNinety‐one articles across 38 countries were included. The majority (73%) of studies were published between 2013 and 2020. Low‐income countries (2%) and countries in Sub‐Saharan Africa (9%) were grossly underrepresented. The majority of studies (60%) used a health care system perspective. Time horizon was not reported in 30 studies (33%). Of the 33 studies that estimated the cost of multiple steps in the BC care pathway, the majority (73%) were of high quality, but studies varied in their inclusion of nonmedical direct and indirect costs.ConclusionThere has been substantial growth in the number of BC economic evaluations in LMICs in the past decade, but there remain limited data from low‐income countries, especially those in Sub‐Saharan Africa. BC economic evaluations should be prioritized in these countries. Use of existing frameworks for economic evaluations may help achieve comparable, transparent costing analyses.Implications for PracticeThere has been substantial growth in the number of breast cancer economic evaluations in low‐ and middle‐income countries (LMICs) in the past decade, but there remain limited data from low‐income countries. Breast cancer economic evaluations should be prioritized in low‐income countries and in Sub‐Saharan Africa. Researchers should strive to use and report a costing perspective and time horizon that captures all costs relevant to the study objective, including those such as direct nonmedical and indirect costs. Use of existing frameworks for economic evaluations in LMICs may help achieve comparable, transparent costing analyses in order to guide breast cancer control strategies.

e18324 Background: Understanding clinic-based resource utilization among breast cancer (BC) patients is critical for the development of bundled payment models, and redesigning efficient value based systems of care delivery. BC outpatient visits (OVs) are costly from a time and human resource perspective and warrant investigation. Methods: This observational study included patients who were diagnosed with BC (Stages 0 to 3) in 2012 and were followed within our health network. Frequencies of OVs were compared between years 1, 2 and 3 of follow-up across subgroups, using one-sample Kolmogorov-Smirnov test; p < 0.05 was considered significant. Results: Of 643 patients identified, 83% were Caucasian and 99.5 % were females. 99.4% had breast surgery, 60% received radiation, and 42% received chemotherapy. 66% of patients who had mastectomy had reconstruction (73% implants, 27% tissue flap). The average duration of follow-up was 3.2 yrs. The frequency of OVs was highest in the 1st year after diagnosis across all groups in the Table (all p < 0.001). Breast reconstruction was associated with high clinic resource utilization; tissue flap procedures were associated with significantly more OVs than implant procedures during the 3 years (median of 16 vs.14 visits, p < 0.001). Conclusions: Outpatient visits represent a significant resource requirement associated with breast cancer care. These data are an important baseline as we design improved models of care and bundled payment models, and can be used to set expectations among breast cancer patients and care teams. [Table: see text]