Delivery Of Breast Cancer Care Research Articles

Interventions to reduce racial/ethnic disparities across the breast cancer care continuum.

160 Background: In the United States, racial/ethnic disparities in adoption of breast cancer evidence-based practices (EBPs) persist along the cancer care continuum. This scoping review applied an implementation science lens to describe the current evidence base for interventions to reduce disparities, synthesizing evidence on effective interventions while highlighting gaps in the literature. Methods: A formalized search strategy identified USA-based interventional studies aiming to improve adoption of an EBP along the breast cancer care continuum among racially/ethnically minoritized patients. Relevant articles from 1/2010 - 8/2022 (Medline, Embase, Cochrane, and Scopus) were included. For each article, two reviewers screened and extracted data, with a third resolving discrepancies. The PRISMA-ScR checklist and JBO Manual for Evidence Synthesis framework were followed. Results: Our search strategy yielded 45,215 articles. After applying inclusion/exclusion criteria, 59 articles were retained, targeting screening (85%, 50 of 59), treatment (12%, 7 of 59), and survivorship (5%, 3 of 59) (2 targeted multiple areas). No articles targeted end-of-life care. Of these, 49% (29 of 59) were randomized controlled trials (RCTs). Among 24 screening RCTs, the most common interventions—and fraction with statistically significant improved screening uptake—were patient navigation (100%, 11 of 11) and patient education (80%, 4 of 5). Among 4 treatment RCTs, 3 targeted adjuvant chemotherapy uptake. Of these, 1 had significant improvements and used patient navigation. The 2 studies without significant improvements used a patient tracking tool/alert system or patient education. Among 2 survivorship RCTs, one used email interventions, resulting in significantly improved physical activity and dietary health. A second used a nurse-facilitated internet support group, resulting in significantly improved physical/psychological symptoms. Early to mid-stage implementation outcomes (acceptability, adoption, appropriateness, feasibility, or fidelity) were commonly measured (81%, 48 of 59). No study measured later stage implementation outcomes (sustainability or costs). Conclusions: In multiple studies, patient navigation and education improved breast cancer screening among racially/ethnically minoritized populations. In one study, patient navigation improved completion of adjuvant treatment. Despite these studies, patient navigation is not reimbursed for cancer screening, and adoption has not been widespread. Future studies should focus on evaluating and improving later stage implementation outcomes (sustainability and costs). Based on these results, insurance reimbursement mechanisms for screening-related navigation may be warranted. Future breast cancer care delivery disparities research should also be expanded to include treatment, survivorship, and end-of-life care.

Investigating the Salience of Clinical Meaningfulness and Clinically Meaningful Outcomes in Metastatic Breast Cancer Care Delivery

PURPOSE As metastatic breast cancer (mBC) treatment evolves, there is a need to understand how clinical meaningfulness, or a meaningful change in a patient's daily life, and clinically meaningful outcomes inform patient-centered care. Partnering with key stakeholders ensures patient-centered research incorporates the knowledge and expertise of advisors with lived experience. We describe a multistakeholder engagement approach to examine how people living with mBC (PLWmBC), caregivers, and health care providers interpret clinical meaningfulness and clinically meaningful outcomes and their influence on mBC treatment decision making and care. METHODS Qualitative focus groups with PLWmBC, caregivers, and health care providers were conducted and analyzed along three overarching themes: interpretations of clinical meaningfulness and clinically meaningful outcomes; treatment recommendations, preferences, and decisions; and implications for clinical practice. Patient-led and professional organizations served as research partners in study design, implementation, and interpretation of findings. RESULTS Partnerships were established with four patient-led and three professional organizations representing diverse constituencies throughout the United States. Twenty-two focus groups were conducted with 50 PLWmBC, 24 caregivers, and 41 health care providers (oncologists, n = 11; advanced practice providers, n = 13; oncology nurses, n = 17) between March and June 2023. PLWmBC and caregivers were unfamiliar with the concepts of clinical meaningfulness and clinically meaningful outcomes. Although health care providers were familiar, they did not use the terms when discussing treatment with PLWmBC. Across groups, participants emphasized the importance of meaningful outcomes beyond overall survival, including quality of life and improvement in symptoms and functioning. Participants noted that outcomes considered meaningful are individualized and dynamic. CONCLUSION This study offers insight into how partnering with patient advocacy and professional organizations can enhance research quality and aid translation of findings to clinical practice, thereby supporting patient-centered care.

Advocate-BREAST: advocates and patients’ advice to enhance breast cancer care delivery, patient experience and patient centered research by 2025

PurposeThe aims of the Advocate-BREAST project are to study and improve the breast cancer (BC) patient experience through education and patient-centered research.MethodsIn December 2021, an electronic REDCap survey was circulated to 6,918 BC survivors (stage 0–4) enrolled in the Mayo Clinic Breast Disease Registry. The questionnaire asked about satisfaction with BC care delivery, and education and support receive(d) regarding BC linked concerns. Patients also ranked Quality Improvement (QI) proposals.ResultsThe survey received 2,437 responses. 18% had Ductal Carcinoma in Situ, 81% had early breast cancer (EBC), i.e. stage 1–3, and 2% had metastatic breast cancer (MBC). Mean age was 64 (SD 11.8), and mean time since diagnosis was 93 months (SD 70.2). 69.3% of patients received all care at Mayo Clinic. The overall experience of care was good (> 90%). The main severe symptoms recalled in year 1 were alopecia, eyebrow/eyelash thinning, hot flashes, sexual dysfunction, and cognitive issues. The main concerns recalled were fear of BC recurrence/spread; loved ones coping; fear of dying, and emotional health. Patients were most dissatisfied with information regarding sexual dysfunction, eyebrow/eyelash thinning, peripheral neuropathy, and on side effects of immunotherapy/targeted therapies. Top ranking QI projects were: i) Lifetime access to concise educational resources; ii) Holistic support programs for MBC and iii) Wellness Programs for EBC and MBC.ConclusionsPatients with early and advanced BC desire psychological support, concise educational resources, and holistic care.ImplicationsFocused research and QI initiatives in these areas will improve the BC patient experience.

Advocate-BREAST80+: A Comprehensive Patient and Advocate-Led Study to Enhance Breast Cancer Care Delivery and Patient-Centered Research in Women Aged ≥80 Years.

There are limited evidence-based data to guide treatment recommendations for breast cancer (BC) patients ≥80 years (P80+). Identifying and addressing unmet needs are critical. Advocate-BREAST80+ compared the needs of P80+ vs. patients < 80 years (P80-). In 12/2021, a REDCap survey was electronically circulated to 6918 persons enrolled in the Mayo Clinic Breast Disease Registry. The survey asked about concerns and satisfaction with multiple aspects of BC care. Overall, 2437 participants responded (35% response rate); 202 (8.3%) were P80+. P80+ were less likely to undergo local regional and systemic therapies vs. P80- (p < 0.01). Notably, P80+ were significantly less satisfied with information about the short and long-term side effects of BC therapies and managing toxicities. P80+ were also less likely to have participated in a clinical trial (p < 0.001) or to want to do so in the future (p = 0.0001). Although P80+ experienced less anxiety and symptom-related distress compared with P80-, they were significantly less satisfied with information regarding the side effects of BC therapies and their management. P80+ were significantly less likely to have participated in a clinical trial or be open to considering this option. Future studies should address educational needs pertaining to side effects and barriers to research participation in P80+.

Abstract PO3-11-02: Characterizing Breast Cancer Care Fragmentation Among Young Black Women Diagnosed with Breast Cancer

Abstract Introduction Fragmented cancer care is defined as receiving care across multiple institutions. The National Academy of Medicine has identified cancer care fragmentation as a priority area for cost reduction. However, little is known about the role of fragmented care on receipt of guideline-recommended care patient-reported outcomes, particularly among populations affected by health inequities like Black women. The objective of this study was to characterize breast cancer care fragmentation among a population-based cohort of young Black women with breast cancer. Methods Study participants were a population-based sample of self-identified Black women diagnosed with invasive breast cancer at or below age 50, recruited since 2017 through the Florida and Tennessee state cancer registries. As part of the study, participants completed baseline questionnaires about their cancer care delivery experiences. Participants were eligible if they self-reported the locations where they received their cancer treatment (i.e., diagnosis, surgery, chemotherapy, and radiation). Indicator variables for care fragmentation were created to identify participants who received their diagnosis, surgery, chemotherapy, and radiation within the same health system and those who received their cancer care across multiple health systems. Chi-squared tests were used to assess the relationship between care fragmentation, receipt of guideline-recommended genetic testing, and self-rated health. Self-rated health was dichotomized into Excellent/Very Good/Good and Fair/Poor. Results A total of 183 Black women diagnosed breast cancer ≤ age 50 were included in the analysis. Among the included participants, 11% (n=20) only had surgery, 15% (n=27) had surgery and radiation, 17% (n=31) had surgery and chemotherapy, and 57% (n=105) had surgery, chemotherapy, and radiation. Among the 105 women who had surgery, chemotherapy, and radiation, 17% (n=17) received all cancer treatment within the same health system of diagnosis, 21% (n=21) received all cancer treatment within the same health system but were diagnosed within a different health system, and the remaining 62% of participants received their cancer treatment across different health systems, representing care fragmentation. In chi-squared analyses, fragmented care was not associated with lower receipt of genetic testing(p=0.33) or self-rated health (p=0.28). Conclusion In this population-based study, most participants had fragmented breast cancer care, however fragmentation was not associated with lower self-rated health or receipt of guideline-recommended germline genetic testing. Current approaches for assessing care fragmentation are often too coarse to capture the complexity of breast cancer care delivery and service availability. Patient-centered conceptual models of what drives cancer care fragmentation and the specific aspects of fragmentation that have the potential to drive adverse outcomes are critical. Citation Format: Mya Roberson, Jordyn Brown, Brianna Taffe, Anne Weidner, Lindsay Venton, Sonya Reid, Tuya Pal. Characterizing Breast Cancer Care Fragmentation Among Young Black Women Diagnosed with Breast Cancer [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 PO3-11-02.

Re-imagining metastatic breast cancer care delivery: a patient-partnered qualitative study

PurposeWhile significant progress in metastatic breast cancer (MBC) treatment has prolonged survival and improved prognosis, there remain substantial gaps in providing patient-centered supportive care. The specific care delivery needs for metastatic cancer differ from that of early-stage cancer due to the incurable nature and lifelong duration of the condition. The objective of this study was to assess how patients living with MBC would re-imagine cancer care delivery.MethodsThis qualitative study was conducted in partnership with patient-led organizations Guiding Researchers and Advocates to Scientific Partnerships (GRASP) and Project Life, a nonprofit, online wellness community founded by patients with MBC for patients living with MBC. Virtual semi-structured interviews (n = 36) were conducted with Project Life members purposively sampled from the groups’ overall membership. The interview guide contained items surrounding patients’ lived experiences of MBC, greatest unmet needs related to care, and perspectives on virtual wellness community involvement. Interviews were coded using two-stage deductive and inductive analysis.ResultsThree major themes for re-imagining cancer care delivery were identified, including holistic care, information needs, and conceptual shifts. Within these several subthemes emerged with patients re-imagining referrals to non-oncological services, caregiver support, acceptance of integrative medicine, streamlined clinical trial enrollment, curated quality patient resources, MBC-specific terminology and approaches, long-term life and goal-of-care planning, and patient-centered voice throughout.ConclusionPeople living with metastatic cancers have specific supportive care needs. These findings highlight patient-driven areas for re-imagination that are most salient for individuals with MBC.

An exploration of facilitators and barriers to patient navigator core functions with breast cancer patients: Implications for the development of a human-centered mHealth app

ObjectivesTo understand the barriers to core functions and workflow among patient navigators (PN) who navigate people diagnosed with breast cancer (BC). To identify how a mobile health (mHealth) app could assist PNs in providing care to BC patients. MethodsThis qualitative research study used purposive sampling to recruit stakeholders (N = 33) from January to August 2021. We conducted individual semi-structured interviews with PNs (n = 11), oncology care providers (n = 12), and BC patients (n = 10). We used conventional content analysis to analyze the interview data. ResultsParticipants identified the following sociotechnical systems barriers in PN workflows that negatively impact BC patient care: 1) resources, 2) insurance coverage, 3) communication challenges, and 4) impact of logistical tasks. Participants identified the user experience, app features, and interoperability customizations to enhance PNs' provision of patient care as important design elements to include in a mHealth app. ConclusionFeedback from stakeholders provided valuable insights into key design considerations, functions, and content areas for developing a mHealth app for PN use in BC care delivery. InnovationThis is one of the first studies to incorporate the human-centered design and sociotechnical systems frameworks to understand barriers to PN workflow and provision of BC patient care across the cancer care continuum.

Feasibility of implementing patient-reported outcome measures into routine breast cancer care delivery using a novel collection and reporting platform.

imPROVE is a new Health Information Technology platform that enables systematic patient-reported outcome measure (PROM) collection through a mobile phone application. The purpose of this study is to describe our initial experience and approach to implementing imPROVE among breast cancer patients treated in breast and plastic surgery clinics. We describe our initial implementation in 4 phases between June 2021 and February 2022: preimplementation, followed by 3 consecutive implementation periods (P1, P2, P3). The Standards for Reporting Implementation Studies statement guided this study. Iterative Plan-Do-Study-Act (PDSA) cycles supported implementation, and success was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Qualitative interviews conducted during the preimplementation phase elicited 4 perceived implementation barriers. Further feedback collected during each phase of implementation resulted in the development of brochures, posters in clinic spaces, and scripts for clinic staff to streamline discussions with patients, and the resolution of technical issues concerning patient login capabilities, such as compatibility with cell phone software and barriers to downloading imPROVE. Feedback also generated ideas for facilitating provider interpretation of PROM results. By the end of P3, 2961 patients were eligible, 1375 (46.4%) downloaded imPROVE, and 1070 (36.1% of those eligible, 78% of those who downloaded) completed at least 1 PROM. Implementation efforts across 2 surgical departments at 2 academic teaching hospitals enabled collaboration across clinical specialties and longitudinal PROM reporting for patients receiving breast cancer care; the implementation effort also highlighted patient difficulties with mobile app-based PROM collection, particularly around initial engagement.

Was Unstable Medicaid Coverage Among Older Medicare Beneficiaries Associated With Worse Clinical Outcomes? Evidence From the Delivery of Breast Cancer Care.

Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes. Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries. Population-based cohort study. A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database. We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups. Duals had poorer outcomes than those who were "never dual." Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support. These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.

Abstract P6-05-41: Advocate-BREAST: Advocates and Patients’ Advice to Enhance Breast Cancer Care Delivery, Patient Experience and Patient Centered Research by 2025

Abstract Background: The high-level aims of the Advocate-BREAST study are to study and improve the overall experience of patients with breast cancer (BC) through education, shared decision making, and patient-centered clinical trials. Assessing areas of unmet need in care delivery and research as identified by patients with BC will direct future research and help us improve the patient experience. Methods: In April 2022, an electronic RedCap survey was circulated to 6,918 BC survivors (stage 0-4 disease) enrolled in the prospectively consented Mayo Clinic Breast Disease Registry (MCBDR), which includes rural-dwelling women often underrepresented in cancer care delivery research. The questionnaire asked about satisfaction with multiple aspects of cancer care delivery and the education and support patients receive(d) regarding practical, financial, emotional, societal and spiritual concerns linked to BC. Patients were also asked to rank potential Quality Improvement (QI) projects in order of the likelihood the proposal could improve quality of life for BC patients and their families. Questions regarding clinical trial participation, use of integrative medicine and perspectives on medical second opinions were also included. Responses were collected via anonymous local language questionnaires. Results: The survey received 2,451 responses from MCBDR enrollees. 13% of respondents had Ductal Carcinoma in Situ (DCIS), 83% had early breast cancer (EBC) (Stage 1-3) and 4% had metastatic breast cancer (MBC). Mean age was 64 (SD 11.9), and mean time in months since diagnosis was 93 (SD 1.42). 69.3 % of patients received all care at Mayo Clinic; 24.7% at Mayo and another healthcare organization, and 6% at a non-Mayo site. Although the overall experience of care was generally good/excellent (&amp;gt; 90 %), gaps were perceived in terms of information provision, continuity of care (including survivorship care after 5 years), navigating care transitions, and timely access to mental health resources. The main severe symptoms patients recalled in year 1 were hair loss, eyebrow/eyelash thinning, hot flashes, sexual dysfunction and cognitive issues. The main concerns patients recalled in the first year following diagnosis were fear of BC recurrence and spread as well as of dying, practical and emotional concerns for family members if they were to die of BC, and their emotional health. Patients were most dissatisfied with information and support related to management of lymphedema, sexual dysfunction, eyebrow/eyelash thinning, and peripheral neuropathy. Respondents overwhelmingly voiced the need for the following QI projects: i) lifetime access to online patient educational resources: including summary “cheat sheets”; ii) educational, practical, emotional and holistic support programs for MBC patients, and iii) BC Wellness Programs for EBC and MBC patients (endorsed by 82.6%; 82.4% and 81.9% of respondents, respectively). Predictors in terms of age, time since diagnosis, and cancer stage that may account for satisfaction with care, concerns, or QI preferences will be reported at the meeting. Of 20% of patients who saw an Integrative Medicine provider, 85% were satisfied/very satisfied with the care received. Of ~40% of patients who received a second opinion regarding their BC diagnosis and treatment plan, 96% found this beneficial. 47% of respondents had participated in a clinical trial, which is higher than seen in the general population such that conclusions may not be generalizable. Of those who had not participated in a study, 30% reported that they were unsure if they would participate in a trial if offered, and 9% reported that they would decline same. Conclusion: Understanding the lived experiences of persons with BC is essential to improve quality of care. Patients with early and advanced BC desire holistic care, continuity of care, concise educational resources and early psychological support. Citation Format: Kathryn Ruddy, Ciara C. O’Sullivan, Nicole Larson, Robert A. Vierkant, Mary Lou Smith, Cynthia Chauhan, Fergus J. Couch, Janet Olson. Advocate-BREAST: Advocates and Patients’ Advice to Enhance Breast Cancer Care Delivery, Patient Experience and Patient Centered Research by 2025 [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 P6-05-41.

Patient Satisfaction With Breast Cancer Care Delivery at the National Cancer Institute of Sri Lanka: Does Language Play a Role?

This study sought to examine whether there was an association between language barriers and patient satisfaction with breast cancer care in Sri Lanka. A telephone-based survey was conducted in the three official languages (Sinhala, Tamil, or English) among adult women (older than 18 years) who had been treated for breast cancer within 6-12 months of diagnosis at the National Cancer Institute of Sri Lanka. The European Organisation for Research and Treatment of Cancer Satisfaction with Cancer Care core questionnaire was adapted to assess three main domains (physicians, allied health care professionals, and the organization). All scores were linearly transformed to a 0-100 scale, and subscores for domains were summarized using means and standard deviations. These were also calculated for the Sinhalese and Tamil groups and compared. The study included 72 participants (32 ethnically Tamil and 40 Sinhalese, with 100% concordance with preferred language). The most commonly reported best aspect of care (n = 25) involved affective behaviors of the physicians and nurses. Ease of access to the hospital performed poorest overall, with a mean satisfaction score of 54 (30.5). Clinic-related concerns were highlighted as the worst aspect of the care (n = 10), including long waiting times during clinic visits. Sixty-three percent of Tamil patients reported receiving none of their care in Tamil and 18% reported experiencing language barriers during their care. Tamil patients were less satisfied overall and reported lower satisfaction with care coordination (P = .005) and higher financial burden (P = 0.014). Ethnically Tamil patients were significantly less satisfied than their Sinhalese counterparts and experienced more language barriers, suggesting there is a need to improve access to language-concordant care in Sri Lanka.

Evaluation of facilitators and barriers of timely breast cancer care in North Carolina (NC): A qualitative study.

134 Background: Early detection and timely treatment of breast cancer using multi-disciplinary therapies often contributes to a goal of curative intent along with improved overall outcomes. In prior studies, Black women compared to non-Black women are at a higher chance of treatment delay (&gt; 60 days) in NC. The care team factors that contribute to these treatment delays are unclear. Methods: This qualitative study utilized content analysis. The 30 participants included community stakeholders involved in breast cancer care delivery, including breast cancer clinicians and community resource providers. Participants were selected through purposive sampling. Three Area Health Education Centers (AHEC) regions (Northwest, Charlotte, and Area L) that represent the diversity of the state of NC were selected as sites for data collection. Each participant completed a one-time semi-structured interview which was audio-recorded and transcribed. Inductively derived codes were created from the previously established interview guide leading to the production of the codebook with each code conceptually defined. Transcripts were coded by 7 coders through the method of consensus coding leading to the identification of emergent themes. Code reports were generated from each code leading to the production of a narrative summary. Results: All participants identified perceived both facilitators and barriers to the timely initiation of breast cancer treatment. Barriers fell into several categories: geographical, financial, healthcare system related, and patient related (non-financial). Most barriers were perceived as more common among Black patients. Additionally, participants emphasized incidents of historical racism in medical care that limited Black patients from having trust in the healthcare system. Facilitators identified included: outreach through community partners, healthcare navigation, supportive healthcare providers, provision of social support services, transportation, integrative services, and raising the overall quality of cancer care. Conclusions: Despite the diversity of participants regarding region, years of employment, and role, stakeholders identified important common themes when reviewing the perceived facilitators and barriers of breast cancer care delivery. Perceived barriers were largely related to patients’ social determinants of health, and participants perceived that Black patients had more adverse social determinants impacting their care timeliness, highlighting that structural racism contributes to delayed cancer care delivery. Future initiatives aimed at improving the delivery of timely breast cancer care must focus on evaluating marginalized communities’ overall access to adequate care along with effective community engagement to build a higher level of trust from such patients and target the social determinants of health.

Measuring geographic variation in quality and equity of breast cancer care.

139 Background: Persistent higher breast cancer mortality among Black Americans is partly due to treatment disparities. There is a paucity of surveillance data quantifying racial disparities at local levels, and the relationship of geography to racial disparities in treatment is poorly understood. We sought to develop and apply a claims-based set of breast cancer quality measures, stratified by race, across regions of North Carolina. Methods: We created a retrospective cohort (n = 37,021) of stage I-III breast cancers from 2004-2017 using linked cancer registry and multi-payer claims data. We assessed 4 quality measures derived from ASCO/NCCN and Commission on Cancer including chemotherapy (CT) for hormone receptor negative disease, radiation (RT) after breast conserving surgery (BCS), RT for N2-3 disease, and adjuvant endocrine therapy (ET). Each measure was limited to the ages and tumor features eligible by the ASCO/NCCN/CoC guideline. We estimated age-adjusted overall performance (%) on each measure, and the Black-White gap, at the state level and across 9 geographic sub-regions. We used multivariable Poisson regression to estimate Risk Ratios (RR) comparing quality performance for Black vs. White patients overall and across regions. Exploratory analyses adjusted for patient- and neighborhood-level social determinants of health (SDOH). Results: Median age of the cohort was 68 years and 19% of patients were Black. At the state level, the % of eligible patients meeting quality measures ranged from 73% for adjuvant ET to 95% for RT after BCS. There was significant inter-region variation on all 4 measures. Black patients were less likely to receive adjuvant CT (RR = 0.92, CI 0.87-0.96), post-BCS RT (RR = 0.98, CI 0.97-0.99) and ET (RR = 0.95, CI 0.93-0.98). There was no racial disparity in RT for N2-3 disease. Both overall performance and the magnitude of disparity varied widely across regions and geographic patterns were not consistent across measures. For example, the Charlotte region had the top quality performance for RT for N+ (90%), but worst for ET (70%). Similarly, the Wake region had no racial disparities in CT or RT, but the largest disparity of any region for ET (RR = 0.90, CI 0.84-0.96). Adjustment for SDOH modestly attenuated the relationship between race and quality performance, but significant disparities persisted in the regions with the largest racial gaps. Conclusions: Racial disparities persist in breast cancer care delivery, but with non-uniformity of performance across measures and varying local patterns of disparities. Our findings suggest that cross-cutting interventions spanning the care continuum, and/or interventions adapted to local challenges, may be needed to effectively address racial disparities. The contributions of local resources, structural, and institutional barriers to these patterns remain to be explored. Community-engaged work to share and interpret these findings is ongoing.

Reimaging metastatic breast cancer care delivery: A patient-partnered qualitative investigation.

259 Background: Treatment advances for metastatic breast cancer (MBC) have markedly increased survival over the last several decades. Despite the clinical innovation that has occurred, there remains substantial fragmentation of care and lack of focused attention on MBC survivorship care. This study partnered with Project Life, an MBC-survivor led patient wellness community to assess MBC patient experiences with treatment experiences and social support services. Methods: We conducted, virtual, in-depth semi-structured qualitative interviews among people who were members of the Project Life Wellness community. The interview guide and study materials were developed in collaboration with Project Life leadership. A study flyer was distributed by Project Life to members that included a link to an eligibility survey. Participants were eligible if they self-identified as having MBC, were a member of the Project Life community, and could complete the interview in English. As part of the interview, we asked, “How would you re-imagine medical care for people with metastatic breast cancer?” We then systematically processed responses with phronetic iterative analysis, using the mixed-methods research software MAXQDA, to uncover contextually grounded, emergent themes through synthetic coding. Results: We interviewed 36 women with MBC who were members of the Project Life Wellness Community in Spring 2022. In terms of age, 8 (22%) participants were 30-45, 15 (42%) were 46-59, and 13 (36%) were 60+. Overall, 22% of participants identified as people of color (Black, Latina, or Asian). In response to how they would reimagine MBC care delivery, all participants touched upon dimensions of care coordination. Aspects of care coordination that participants specifically raised included 1) Organized referral processes for non-oncology care like mental health services, sexual health care, and palliative care; 2) The need for MBC-specific support services within the care setting; 3)Patient connection to psychosocial aspects of care including social work and patient navigation; 4) Streamlined processes for identifying and enrolling in clinical trials. Conclusions: In our investigation, when asked how they would reimagine MBC care delivery, participants overwhelmingly endorsed the need for more care coordination along several key domains. Responses highlighted the unique needs of care coordination specific to MBC patients. Future care innovations should center patient voices to ensure optimal impact.

Overuse of Axillary Surgery in Patients with Ductal Carcinoma In Situ: Opportunity for De-escalation.

Ductal carcinoma in situ (DCIS) is noninvasive breast cancer and therefore nodal staging is not routinely recommended. We evaluated the use of and factors associated with axillary surgery in DCIS in the National Cancer Database (NCDB). DCIS cases were identified from the NCDB 2012-2018. Use of axillary surgery was evaluated over time, and factors associated with axillary surgery were assessed for breast-conserving surgery (BCS) and mastectomy groups. We identified 178,762 patients, median age of 60 years. Majority of DCIS (87%) was ER-positive, and 14% low, 43% intermediate, and 44% high grade. Median DCIS size was 1.1 cm. BCS was performed in 72%, whereas 28% had mastectomy. Overall axillary surgery was performed in 38% and was higher in patients undergoing mastectomy compared with patients undergoing BCS (88% vs. 19%, p < 0.001). At axillary surgery, the vast majority (92%) had 1-5 nodes examined, whereas 8% had >5 nodes examined. Over time, axillary surgery decreased in BCS patients (21%in 2012 to17%in 2018, p < 0.001) but increased slightly in mastectomy patients (86% in 2012 to90%in 2018, p < 0.001). On multivariable analysis, factors significantly associated with axillary surgery were younger patient age, larger tumor size, higher grade, and ER-negative status. Factors associated with axillary surgery reflect higher risk disease for upstage to invasive cancer, indicating surgeon judgment. However, despite axillary surgery being overtreatment of DCIS, it is common in mastectomy and is performed for one in five patients undergoing BCS. This provides opportunity for improvement in breast cancer care delivery.

Breast reconstruction during the COVID-19 pandemic: Single institution experience from the pandemic's epicenter in the United States

IntroductionThe coronavirus disease-19 (COVID-19) pandemic dramatically changed the delivery of breast cancer care. The objective of this study was to quantify the effect of the pandemic on breast cancer screening, treatment, and reconstruction at a single institution in New York City.MethodsA retrospective chart review was conducted to determine the number of mammograms, lumpectomies, mastectomies, and breast reconstruction operations performed between January 1, 2019 and June 30, 2021. Outcomes analyzed included changes in mammography, oncologic surgery, and breast reconstruction surgery volume before, during and after the start of the pandemic.ResultsMammography volume declined by 11% in March–May of 2020. Oncologic breast surgeries and reconstructive surgeries similarly declined by 6.8% and 11%, respectively, in 2020 compared with 2019, reaching their lowest levels in April 2020. The volume of all procedures increased during the summer of 2020. Mammography volumes in June and July 2020 were found to be at pre-COVID levels, and in October–December 2020 were 15% higher than in 2019. Oncologic breast surgeries saw a similar rebound in May 2020, with 24.6% more cases performed compared with May 2019. Breast reconstruction volumes increased, though changes in the types of reconstruction were noted. Oncoplastic closures were more common during the pandemic, while two-stage implant reconstruction and immediate autologous reconstruction decreased by 27% and 43%, respectively. All procedures are on track to increase in volume in 2021 compared to that in 2020.ConclusionThe COVID-19 pandemic reduced the volume of breast cancer surveillance, surgical treatment, and reconstruction procedures. While it is reassuring that volumes have rebounded in 2021, efforts must be made to emphasize screening and treatment procedures in the face of subsequent surges, such as that recently attributable to the Delta and Omicron variants.

Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care

Considerable gaps in knowledge remain regarding the intersectionality between race, insurance status, rurality, and community-level socioeconomic status that contribute in concert to disparities in breast cancer care delivery. Women age 18-64 y old with either private, Medicaid, or no insurance coverage and a diagnosis of breast cancer from the North Carolina Central Cancer Registry (2010-2015) were identified and reviewed. Logistic regression models examined the impact of race, insurance status, rurality, and the Social Deprivation Index (SDI) on advanced stage disease at diagnosis (III, IV) and receipt of cancer directed surgery (CDS). Models tested two-way interactions between race, insurance status, rurality, and SDI. Of the study population (n=23,529), 14.6% were diagnosed with advanced stage disease (III, IV), and 97.1% of women with non-metastatic breast cancer (n=22,438) received cancer directed surgery (CDS). Twenty percent of women were non-Hispanic Black (NHB), 3.0% Hispanic, 10.9% Medicaid insured, 5.9% uninsured, 20.0% of women resided in rural areas, and 20.0% resided in communities of the highest quartile SDI. NHB race, Medicaid or uninsured status, and residence in rural or socially deprived areas were associated with advanced stage breast cancer at diagnosis. NHB and Medicaid or uninsured women were significantly less likely to receive CDS. There were no statistically significant interactions found influencing stage at diagnosis or receipt of cancer directed surgery. In a heterogeneous population across the state of North Carolina, non-Hispanic Black race, Medicaid or uninsured status, and residence in rural or high social deprivation communities are independently associated with advanced stage breast cancer at diagnosis, while non-Hispanic Black race and Medicaid or uninsured status are associated with lower odds to receive cancer directed surgery.

Identifying opportunities to improve equity in breast cancer care for uninsured Hispanic patients in underserved communities.

132 Background: Enhancing equitable oncologic care is an increasingly emphasized priority. Our study aims to identify aspects of breast cancer (BC) care in which differences exist based on insurance coverage. Methods: We performed a retrospective, case control study, (from 2014-2020); 39 Hispanic ethnicity uninsured patients (UP) from underserved communities with newly diagnosed BC and 119 insured patients (IP) diagnosed at Mayo Clinic Arizona (MCA). Patients were matched 3:1 for age, stage, year of diagnosis, estrogen receptors and HER-2 status. Demographic information, clinical variables, and zip code level specific socioeconomic information were compared. Continuous variables were compared by Wilcoxon rank-sum test and categorical variables by chi-square test. All patients were treated at MCA. Results: Similar treatment patterns with radiotherapy, chemotherapy and surgery were observed between groups. Primary language was Spanish for 94% of UP and English for 97.5% of IP. The majority of UP were of Hispanic ethnicity (97.4%); IP were 83.2% non-Hispanic White, 9.2% Hispanic, 3.4% African American. Zip code level information reflected more unemployment with a median of 10.6% versus 6.9% p &lt; 0.001, percent of high school or lower (53.0 % v 23.2 %, p &lt; 0.001), and lower income for UP (33733.5 v 64728.0 p values &lt; 0.001).BMI was significantly higher for UP (30.6 V 24.7, p = 0.005), with presence of more co-morbidities; diabetes (28.2% v 5.0%, p &lt; 0.001), hypertension (35.9 % v 20.2%, p = 0.046), dyslipidemia (28.2% v 12.6%, p = 0.023), metabolic syndrome (p 23.7% v 8.5, p = 0.013), and tobacco use (17.9% v 2.5%, p &lt; 0.001). Genetics consultation was performed for 62.2% IP versus 35.9% UP (p = 0.004), lower acceptance of nutrition consultation for UP (29.4% vs 7.4%, p = 0.024). Median time from mammogram to biopsy (25.5 days vs. 14 days, p = 0.056), and interval from diagnosis to treatment (62 days vs. 39 days) (p = 0.001) were less favorable for UP compared to IP. Conclusions: In comparing the status of UP and IP with newly diagnosed BC, we identified greater prevalence of co-morbidities and adverse social determinants of health in the former group. We identified access to genetic counseling, nutrition consultation, and timeliness of diagnostic biopsy and initiation of treatment as disparate features in the care pathway. These observations allowed development of tailored interventions to achieve greater equity in delivery of BC care at Mayo Clinic.

Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis.

IntroductionSystemic treatment for breast cancer in sub‐Saharan Africa (SSA) is cost effective. However, there are limited real‐world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline‐concordant care at Princess Marina Hospital (PMH) in Botswana.Materials and MethodsThe Consolidated Framework for Implementation Research was used to conduct one‐on‐one semistructured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size was determined by thematic saturation. Transcribed interviews were double‐coded and analyzed in NVivo using an integrated analysis approach.ResultsForty‐one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government‐funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention, lack of relative priority compared with HIV/AIDS, suboptimal interdepartmental communication, and lack of a clearly defined national cancer control policy. Community‐level barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy‐in, expansion of multidisciplinary tumor boards, leveraging nongovernmental and academic partnerships, and setting up monitoring, evaluation, and feedback processes.DiscussionThe study identified complex, multilevel factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes.Implications for PracticeTo address the increasing cancer burden in low‐ and middle‐income countries, resource‐stratified guidelines have been developed by multiple international organizations to promote high‐quality guideline‐concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they are intended to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource‐stratified guidelines in sub‐Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country‐level and facility‐level resources, cancer care accessibility, and community‐level barriers and facilitators.

Time-Driven Activity-Based Costing in Breast Cancer Care Delivery.

Accurate measurement of healthcare costs is required to assess and improve the value of oncology care. We aimed to determine the cost of breast cancer care provision across collaborating health care organizations. We used time-driven activity-based costing (TDABC) to calculate the complete cost of breast cancer care-initial treatment planning, chemotherapy, radiation therapy, surgical resection and reconstruction, and ancillary services (e.g., psychosocial oncology, physical therapy)-across multiple hospital sites. Data were collected between December 2019 and February 2020. TDABC steps involved (1) developing process maps for care delivery pathways; (2) determine capacity cost rates for staff, medical equipment, and hospital space; (3) measure the time required for each process step, both manually through clinic observation and using data from the Real-Time Location System (RTLS); and (4) calculate the total cost of care delivery. Surgical care costs ranged from $1431 for a lumpectomy to $12,129 for a mastectomy with prepectoral implant reconstruction. Radiation therapy was costed at $1224 for initial simulation and patient education, and $200 for each additional treatment. Base costs for chemotherapy delivery were $382 per visit, with additional costs driven by chemotherapy agent(s) administered. Personnel expenses were the greatest contributor to the cost of surgical care, except in mastectomy with implant reconstruction, where device costs equated to up to 60% of the cost of surgery. The cost of complete breast cancer care depended on (1) treatment protocols; (2) patient choice of reconstruction; and (3) the need for ancillary services (e.g., physical therapy). Understanding the actual costs and cost drivers of breast cancer care delivery may better inform resource utilization to lower the cost and improve thequality of care.