Quality Of Breast Cancer Care Research Articles

Association of Delay in Breast Cancer Diagnosis With Survival in Addis Ababa, Ethiopia: A Prospective Cohort Study.

There are limited data on the association between delay in breast cancer diagnosis after breast symptom recognition and survival, particularly in sub-Saharan Africa. The recently launched Global Breast Cancer Initiative by WHO includes measuring delay as the core indicator for quality of breast cancer care. Herein, we examined the association between delay in breast cancer diagnosis with overall survival among women in Addis Ababa, Ethiopia. A total of 439 women diagnosed with breast cancer from January 1, 2017, to June 30, 2018, in Addis Ababa were followed for survival to the end of 2019. Survival rates were estimated using the Kaplan-Meier method. The association between delay in diagnosis (>3 months after symptom recognition) and overall survival was computed using the multivariable Cox regression model after adjusting for demographic and clinical factors. Nearly 70% (303/439) of women with breast cancer were delayed in diagnosis of their cancer. During a median follow-up period of 25.1 months, 2-year overall survival rate was 73.5% (95% CI, 68.0 to 78.2) in women with diagnosis delay compared with 79.1% (95% CI, 71.2 to 85.1) in those women without diagnosis delay. In the multivariable Cox regression model, the risk of death was 73% higher (hazard ratio, 1.73; 95% CI, 1.09 to 2.74) in women with diagnosis delay compared with those without diagnosis delay. Delay in diagnostic confirmation of breast cancer after recognition of breast symptoms was negatively associated with overall survival in Addis Ababa, Ethiopia, underscoring the need to increase awareness about the importance of prompt presentation for clinical evaluation and referral for diagnostic confirmation to mitigate the undue high burden of the disease.

Timeliness of Breast Diagnostic Imaging and Biopsy in Practice: 15 Years of Collecting, Comparing, and Defining Quality Breast Cancer Care

BackgroundThe literature lacks well-established benchmarks for expected time between screening mammogram to diagnostic imaging and then to core needle breast biopsy.MethodsTimeliness of diagnostic imaging workup was evaluated using aggregate data from 2005 to 2019 submitted to The National Quality Measures for Breast Centers (NQMBC).ResultsA total of 419 breast centers submitted data for 1,805,515 patients on the time from screening mammogram to diagnostic imaging. The overall time was 7 days with 75th, 25th, and 10th percentile values of 5, 10, and 13.5 days, respectively. The average time in business days decreased from 9.1 to 7.1 days (p < 0.001) over the study period with the greatest gains in poorest-performing quartiles. Screening centers and centers in the Midwest had significantly shorter time to diagnostic imaging. Time from diagnostic imaging to core needle biopsy was submitted by 406 facilities representing 386,077 patients. The average time was 6 business days, with 75th, 25th, and 10th percentiles of 4, 9, and 13.7 days, respectively. Time to biopsy improved from a mean of 9.0 to 6.3 days (p < 0.001) with the most improvement in the poorest-performing quartiles. Screening centers, centers in the Midwest, and centers in metropolitan areas had significantly shorter time to biopsy.ConclusionsIn a robust dataset, the time from screening mammogram to diagnostic imaging and from diagnostic imaging to biopsy decreased from 2005 to 2019. On average, patients could expect to have diagnostic imaging and biopsies within 1 week of abnormal results. Monitoring and comparing performance with reported data may improve quality in breast care.

Comparing quality of breast cancer care in the Netherlands and Norway by federated propensity score analytics

PurposeThe aim of the study was to benchmark and compare breast cancer care quality indicators (QIs) between Norway and the Netherlands using federated analytics preventing transfer of patient-level data.MethodsBreast cancer patients (2017–2018) were retrieved from the Netherlands Cancer Registry and the Cancer Registry of Norway. Five European Society of Breast Cancer Specialists (EUSOMA) QIs were assessed: two on magnetic resonance imaging (MRI), two on surgical approaches, and one on postoperative radiotherapy. The QI outcomes were calculated using ‘Vantage 6’ federated Propensity Score Stratification (PSS). Likelihood of receiving a treatment was expressed in odds ratios (OR).ResultsIn total, 39,163 patients were included (32,786 from the Netherlands and 6377 from Norway). PSS scores were comparable to the crude outcomes of the QIs. The Netherlands scored higher on the QI ‘proportions of patients preoperatively examined with breast MRI’ [37% vs.17.5%; OR 2.8 (95% CI 2.7–2.9)], the ‘proportions of patients receiving primary systemic therapy examined with breast MRI’ [83.3% vs. 70.8%; OR 2.3 (95% CI 1.3–3.3)], and ‘proportion of patients receiving a single breast operation’ [95.2% vs. 91.5%; OR 1.8 (95% CI 1.4–2.2)]. Country scores for ‘immediate breast reconstruction’ and ‘postoperative radiotherapy after breast-conserving surgery’ were comparable. The EUSOMA standard was achieved in both countries for 4/5 indicators.ConclusionBoth countries achieved high scores on the QIs. Differences were observed in the use of MRI and proportion of patients receiving single surgery. The federated approach supports future possibilities on benchmark QIs without transfer of privacy-sensitive data.

360 Health Analysis (H360)-A Comparison of Key Performance Indicators in Breast Cancer Management across Health Institution Settings in Portugal.

The increased focus on quality indicators (QIs) and the use of clinical registries in real-world cancer studies have increased compliance with therapeutic standards and patient survival. The European Society of Breast Cancer Specialists (EUSOMA) established QIs to assess compliance with current standards in breast cancer care. This retrospective study is part of H360 Health Analysis and aims to describe compliance with EUSOMA QIs in breast cancer management in different hospital settings (public vs. private; general hospitals vs. oncology centers). A set of key performance indicators (KPIs) was selected based on EUSOMA and previously identified QIs. Secondary data were retrieved from patients' clinical records. Compliance with target KPIs in different disease stages was compared with minimum and target EUSOMA standards. A total of 259 patient records were assessed. In stages I, II, and III, 18 KPIs met target EUSOMA standards, 5 met minimum standards, and 8 failed to meet minimum standards. Compliance with KPIs varied according to the type of hospital (particularly regarding diagnosis) and disease stage. Although small differences were found in KPI compliance among institutions, several statistical differences were found among treatment KPIs according to disease stage, particularly in stage III. This study represents the first assessment of the quality of breast cancer care in different hospital settings in Portugal and shows that, although most QIs meet EUSOMA standards, there is room for improvement. Differences have been found across institutions, particularly between oncology centers and general hospitals, in diagnosis and compliance with KPIs among disease stages. Stage III showed the greatest variability in compliance with treatment KPIs, probably related to the lower specificity of the guidelines in this disease stage.

Stakeholders' Experiences and Perspectives Regarding Care Quality for Women With Breast Cancer: A Systematic Review.

The considerable growth in the number of patients with breast cancer leads to substantial pressure on healthcare services; however, the main measures that will evaluate what is important to the key stakeholders in improving the quality of breast cancer care are not well defined. This study aimed to synthesize providers' and patients' experiences and perspectives regarding barriers and quality breast cancer care in health services. PubMed, Scopus, MEDLINE, Web of Knowledge, and the Cochrane Library databases were searched, and articles published in English up to August 2020 were screened. Two reviewers independently screened all articles. Data were obtained directly from different stakeholder groups including patients, health providers, and professionals. The search strategy identified 21 eligible articles that met inclusion criteria and reported perspectives of 847 health providers and 24 601 patients regarding healthcare quality. Health providers and patients with breast cancer noted information needs, psychosocial support, responsibility for care, and coordination of care as important quality improvement characteristics of the healthcare system. Shifting to high-quality breast cancer care would likely be a complicated process, and there is a need for the cancer care services to consider important characteristics of quality cancer care as a care priority, that is, to be responsive. Breast cancer survivorship care programs and interventions may need to consider the barriers or common challenges to care noted in this review, especially regarding information sharing and the need for social support and care cooperation.

Breast Cancer Disparities and the Digital Divide.

Socioeconomically disadvantaged populations and minority groups suffer from high breast cancer mortality, a disparity caused by decreased access to specialty care, lower treatment adherence, co-morbidities, and genetic predisposition for biologically aggressive breast tumor subtypes. Telehealth has the potential to mitigate breast cancer disparities by increasing access to specialty care and health information. However, unequal access to high-speed/broadband internet service and telehealth itself magnifies breast cancer disparities in vulnerable populations. This review evaluates the impact of the digital divide on breast cancer outcomes, as well as strategies for leveraging telehealth to reduce breast cancer disparities. There is a paucity of research specific to employing telehealth to address breast cancer disparities. Previous studies provide examples of telehealth utilization for increasing screening mammography, in addition to improving access to breast cancer care, including breast cancer specialist, nurse navigators, and clinical trials. Telehealth can also be used as an approach to risk reduction, with strategies to support weight management and genetic testing. Eliminating the digital divide holds enormous potential for mitigating breast cancer disparities through an intentional focus on improving access to telehealth. With increased accessibility, resource allocation, and improved digital infrastructure, telehealth can be used to address disparities in early detection, quality of breast cancer care, treatment adherence, and risk assessment. Further research is essential to elucidate best practices in breast cancer telehealth approaches in underserved communities.

The impact of the SARS-COV-2 pandemic on the quality of breast cancer care in EUSOMA-certified breast centres

AimsWe analysed the impact of the SARS-CoV-2 pandemic (COVID-19) on the quality of breast cancer care in certified EUSOMA (European Society of Breast Cancer Specialists) breast centres. Materials and methodsThe results of the EUSOMA quality indicators were compared, based on pseudonymised individual records, for the periods 1 March 2020 till 30 June 2020 (first COVID-19 peak in most countries in Europe) and 1 March 2019 till 30 June 2019. In addition, a questionnaire was sent to the participating Centres for investigating the impact of the COVID-19 pandemic on the organisation and the quality of breast cancer care. ResultsForty-five centres provided data and 31 (67%) responded to the questionnaire. The total number of new cases dropped by 19% and there was a small significant higher tumour (p = 0.003) and lymph node (p = 0.011) stage at presentation. Comparing quality indicators (12,736 patients) by multivariable analysis showed mostly non-significant differences. Surgery could be performed in a COVID-free zone in 94% of the centres, COVID testing was performed before surgery in 96% of the centres, and surgical case load was reduced in 55% of the centres. Modifications of the indications for neoadjuvant endocrine therapy, chemotherapy, and targeted therapy were necessary in 23%, 23%, and 10% of the centres; changes in indications for adjuvant endocrine, chemo-, targeted, immune, and radiotherapy in 3%, 19%, 3%, 6%, and 10%, respectively. ConclusionQuality of breast cancer care was well maintained in EUSOMA breast centres during the first wave of the COVID-19 pandemic. A small but significantly higher tumour and lymph node stage at presentation was observed.

Abstract 3656: Breast cancer care quality in Peru

Abstract Although many studies indicate that the use of complementary medicine by cancer patients is common and widespread, few studies focused on patients' quality of care using complementary therapies. The overall health care quality perception of patients in Lima, the capital of Peru, was reported to be 68.9% according to the SERVQUAL questionnaire, which grades as acceptable. Breast cancer is the most common cancer in Peru. This study aims to determine the perception of health care quality for breast cancer patients in Lima. This is a cross-sectional study. The perspectives of 182 breast cancer patients about the quality of care at the largest hospital in Lima were assessed. One hundred seventeen patients (64.29%) were only seen at the Oncology Department, and 65 patients (35.71%) were seen at both the Oncology Department and Complementary Medicine Department. The quality perception is based on five dimensions: Reliability, responsiveness, assurance, empathy, and tangibility. The percentage has to be 60 to be an acceptable level. The average age was 58.81 years. The overall and oncology-only groups quality perceptions were not acceptable, 57.32%, and 53.65%, respectively. The oncology and the complementary patient group reported adequate general perception (63.92%). Perception of empathy and assurance were at acceptable levels for both groups. Reliability and tangibility did not receive a satisfactory grade in any group. The responsiveness level was only adequate in the complimentary and oncology group. The breast cancer patients’ perception of the health care quality who received Complementary Medicine services was significantly higher than the oncology-only group. We did not find a significant difference between the dimensions of quality and educational level, type of insurance, and the professional who attended the patient. In conclusion, the patients who were seen at the oncology and complementary medicine reported a better perception of the quality of healthcare. More studies are needed to improve healthcare in breast cancer patients. Citation Format: Andrea Anampa-Guzman, Rushmely Gaby Perez-Mendez, Juan Huaccho-Rojas, Martha Villar-Lopez, Elsy Mini-Diaz. Breast cancer care quality in Peru [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3656.

Monitoring Breast Cancer Care Quality at National and Local Level Using the French National Cancer Cohort

PurposeThe French National Cancer Institute has developed, in partnership with the French National Authority for Health, breast cancer-specific Care Quality, and Safety Indicators (BC QIs). With regard to the most common form of cancer, our aim is to support local and national quality initiatives, to improve BC pathways and outcomes, reduce heterogeneity of practice and regional inequities. In this study, we measure the BC QIs available in the French National medico-administrative cancer database, the French Cancer Cohort, for 2018. Materials and MethodsBC QIs are developed according to the RAND method. QIs are based on good clinical practice and care pathway recommendations. QI computation should be automatable without any additional workload for data collection. They will be published annually for all stakeholders, and especially hospitals. ResultsFinally, ten feasible and pertinent QIs were selected. In France, BC care was found to be close to compliance with most QIs: proportion of patients undergoing biopsy prior to first treatment (94.5%), proportion of patients undergoing adjuvant radiotherapy after breast-conserving surgery for BC (94.5%), proportion of women undergoing radiotherapy within 12 weeks after surgery and without chemotherapy (86.2%), proportion of DCIS patients undergoing immediate breast reconstruction (54.3%) and proportion of women with NMIBC undergoing breast reintervention (14.4%). However, some are still far from their recommended rate. In particular, some QIs vary considerably from one region, or one patient, to another. ConclusionEach result needs to be analyzed locally to find care quality leverage. This will strengthen transparency actions aimed at the public.

Initial Point of Entry to the Health Care System May Affect Downstream Quality of Breast Cancer Care.

Structural racism refers to the manner in which the structures of our society are generally set up to advantage White people while disadvantaging people of color. As an example, underresourced and nonaccredited facilities are more likely to be situated within racial or ethnic minority neighborhoods, which produces inequities at the initial point of entry into the health care system. In the case of breast cancer, resources and accreditation status of the first medical practice or facility that is encountered not only could determine aspects of initial screening but also could have other downstream implications on the timing and quality of diagnostic care (eg, breast imaging fellowship-trained imagers, access to stereotactic breast biopsy) and treatment (eg, on-site access to radiation, chemotherapy, hormone therapy, and targeted therapies; review by a multidisciplinary tumor board) [1].

Institutions Treating Breast Cancer Patients of a Low Socioeconomic Status Achieve Multidisciplinary Quality Standards at Lower Rates.

The National Accreditation Program of Breast Centers (NAPBC) certifies institutions that provide quality breast care. Whereas low socioeconomic status (SES) has a negative impact on patient outcomes, it is unknown whether an institution's patient SES mix is associated with meeting NAPBC standards. All institutions submitting at least 100 breast cancer patients to the National Cancer Database (2006-2017) were ranked based on the patients' insurance status, income, and education. The 10% treating the largest proportion of low-SES patients were termed low-SES institutions (LSES). Patient cohorts were created based on the 2018 NAPBC standards. Uni- and multivariate comparisons of patient, tumor, and treatment factors were made to calculate adjusted odds of meeting each standard between low- and non-low-SES institutions. The analysis included 1319 institutions. Both the LSES and non-LSES reached the benchmark rate of 50% lumpectomies (61.2 vs 62.9%; p < 0.001), but the unadjusted and adjusted rates of lumpectomy were lower in LSES. The rate for sentinel lymphadenectomy was lower for LSES (49.2 vs 53.7%; p < 0.001). Similarly, the unadjusted and adjusted rates of adjuvant chemotherapy and endocrine therapy were lower at LSES. Although the unadjusted rate of adjuvant radiation was higher at LSES, adjusted odds demonstrated that patients treated at LSES were less likely to undergo adjuvant radiation when appropriate. Small but significant differences in achieving multidisciplinary standards for quality breast cancer care exist between LSES and non-LSES and may exacerbate disparities already faced by patients of low SES.

Breast Cancer Care Quality Indicators in Spain: A Systematic Review.

Breast cancer (BC) management care requires an increment in quality. An initiative to improve the BC quality care is registered, and quality indicators (QIs) are studied. We appraised the appearance of QIs and their standards systematically in Spain. A prospective systematic search (Prospero no: CRD42021228867) for clinical pathways and integrated breast cancer care processes was conducted through databases and the World Wide Web in February 2021. Duplicate data extraction was performed with 98% reviewer agreement. Seventy-four QIs (QI per document mean: 11; standard deviation: 10.59) were found in 15 documents. The Catalonian document had the highest number of QIs (n = 30). No QI appeared in all the documents. There were 9/74 QIs covering structure (12.16%), 53/74 covering process (71.62%), and 12/74 covering outcome (16.22%). A total of 22/66 (33.33%) process and outcome QIs did not set a minimum standard of care. QIs related to primary care, patient satisfaction, and shared decision making were deficient. Most of the documents established a BC QI standard for compliance, but the high variability hinders the comparison of outcomes. Establishing a consensus-based set of QIs needs urgent attention.

The process of EUSOMA certification improves the quality of breast cancer care: the experience of an Italian EUSOMA certificated Breast Unit (BU) according to the results of a cross-sectional study.

The adherence to recognized guidelines and the constant monitoring of performance throughout quality indicators (QIs) are strategic tools to improve the quality of care. The study is aimed to assess the effect of the EUSOMA (European Society of Breast Cancer Specialists) certification process on the quality of breast cancer care of an EUSOMA certified Breast Unit (BU) of Northern Italy. Seventeen mandatory and recommended EUSOMA QIs, based on 594, were analysed for the years 2015-2018. Univariate logistic regression models were performed to compare QIs performance in the years before and after obtaining the EUSOMA certification (2015-6 vs. 2017-8). Compared to the years 2015-6, the second period of BU activity showed a higher number of QIs achieving both the minimum standard (15 vs. 11) and the 100% of completeness (6 vs. 1). There was a significant improvement of the two QIs evaluating the proportion of Ductal Carcinoma in situ receiving just an operation (from 76% to 95.2%; p=0.033) and the completeness of the prognostic characterisation of invasive cancers (from 94.6% to 99.5%; p=0.022). Conversely, the QI related to the endocrine-sensitive invasive carcinoma receiving adjuvant hormonal therapy dropped from 92.1% to 85.9% (p=0.042) and was significantly lower for patients over 74 compared to those aged ≤54 (73.8% vs. 94.7%; p<0.0001 Fisher's exact test). The EUSOMA certification process enhanced the clinical practice, promoting a tailored-patient primary systemic or adjuvant therapy and avoiding unnecessary invasive surgical and local-regional treatments.

Self-Efficacy for Coping with Breast Cancer Treatment Among Spanish-Speaking Latinas.

Background: Cancer-related self-efficacy, a multidimensional construct, is the confidence that one can overcome challenges associated with cancer and its treatment; higher levels have been associated with better psychosocial outcomes of breast cancer survivors. Little is known about factors that influence it among Latina breast cancer survivors.Purpose: Assess associations of several aspects of health care processes and of spirituality with self-efficacy for coping with breast cancer treatment among primarily Spanish-speaking Latina breast cancer survivors.Methods: We analyzed baseline data from a randomized controlled trial of a cognitive–behavioral stress management intervention that enrolled 151 Spanish-speaking Latinas within 1 year of breast cancer diagnosis. Multivariate linear regression models examined associations of health care processes (quality of breast cancer care and information, participating in medical care, difficulty engaging with doctors) and spirituality (meaning/peace, faith, acceptance) with self-efficacy for coping with breast cancer treatment.Results: Mean age was 51 (standard deviation [SD]=11), 66% completed high school or less, and most reported financial hardship in the past year (78%). Average time since diagnosis was 3.8 months (SD=2.7). In bivariate analyses, all six determinants were significantly associated with self-efficacy for coping with breast cancer treatment; participating in medical care (B=0.56, p<0.001) and having a sense of meaning/peace (B=0.76; p<0.001) were independently associated, controlling for sociodemographic and treatment characteristics.Discussion: Interventions that promote participation in treatment decisions and sense of meaning and peace could improve confidence in coping with breast cancer treatment, and potentially quality of life, among Latinas living with breast cancer (Trial Registration Number: NCT01383174 [ClinicalTrials.gov]).

The importance of patient engagement to quality of breast cancer care and health-related quality of life: a cross-sectional study among Latina breast cancer survivors in rural and urban communities

BackgroundCompared to their white counterparts, Latina breast cancer survivors experience poorer quality of care and worse health-related quality of life. Limited English proficiency (LEP) and patient engagement in cancer care could help explain these disparities. We assessed associations between LEP status and difficulty engaging with physicians, with self-reported quality of breast cancer care and health-related quality of life (physical and emotional well-being) among rural and urban Latina breast cancer survivors.MethodsAnalyses used cross-sectional baseline survey data from two studies that tested a stress management program among rural and urban Latina breast cancer survivors in California. Medical information was collected through medical records review. Linear regression models examined bivariate and multivariable associations of LEP status (yes or no), difficulty engaging with doctors (asking questions and participating in treatment decisions) (1–4; higher score = greater difficulty), and rural versus urban site, with three outcomes: (1) quality of breast cancer care and information; (2) physical well-being; and (3) and emotional well-being, controlling for demographic and medical factors.ResultsThe total sample included 304 women (151 from urban and 153 from rural sites). Mean age was 52.7 years (SD 10.9). Most were limited English proficient (84.5%) and had less than a high school education (67.8%). Difficulty engaging with doctors was inversely associated with patient ratings of quality of breast cancer care and information (B = − 0.190, p = 0.014), emotional well-being (B = − 1.866, p < 0.001), and physical well-being (B = − 1.272, p = 0.002), controlling for demographic and treatment factors. LEP (vs. not; B = 1.987, p = 0.040) was independently associated with physical well-being only. Rural/urban status was not related independently to any outcome.ConclusionsRural and urban Latina breast cancer survivors who report greater difficulty engaging with physicians experienced worse quality of breast cancer care and health-related quality of life. Promoting greater engagement of Latina breast cancer survivors in cancer care and providing medical interpreters when needed could improve patient outcomes among this vulnerable group.Trial registration: http://www.ClinicalTrials.gov identifier NCT02931552 and NCT01383174.

Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process.

PURPOSEThe burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings.METHODSTo identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda.RESULTSOur systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda.CONCLUSIONA modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.

Effect of Case-Mix and Random Variation on Breast Cancer Care Quality Indicators and Their Rankability.

Hospital comparisons to improve quality of care require valid and reliable quality indicators. We aimed to test the validity and reliability of 6 breast cancer indicators by quantifying the influence of case-mix and random variation. The nationwide population-based database included 79 690 patients with breast cancer from 91 Dutch hospitals between 2011 and 2016. The indicator-scores calculated were: (1) irradical breast-conserving surgery (BCS) for invasive disease, (2) irradical BCS for ductal carcinoma-in-situ, (3) breast contour-preserving treatment, (4) magnetic resonance imaging (MRI) before neo-adjuvant chemotherapy, (5) radiotherapy for locally advanced disease, and (6) surgery within 5 weeks from diagnosis. Case-mix and random variation adjustments were performed by multivariable fixed and random effect logistic regression models. Rankability quantified the between-hospital variation, representing unexplained differences that might be the result of the level of quality of care, as low (<50%), moderate (50%-75%), or high (>75%). All of the indicators showed between-hospital variation with wide (interquartile) ranges. Case-mix adjustment reduced variation in indicators 1 and 3 to 5. Random variation adjustment (further) reduced the variation for all indicators. Case-mix and random variation adjustments influenced the indicator-scores of individual hospitals and their ranking. Rankability was poor for indicator 1, 2, and 5, and moderate for 3, 4, and6. The 6 indicators lacked validity and/or reliability to a certain extent. Although measuring quality indicators may stimulate quality improvement in general, comparisons and judgments of individual hospital performance should be made with caution if based on indicators that have not been tested or adjusted for validity and reliability, especially in benchmarking.

Abstract A136: Racial disparities in delayed initiation of adjuvant endocrine therapy among patients with breast cancer

Abstract Adjuvant endocrine therapy (AET) is associated with significant improvements in disease-free and overall survival for patients with hormone receptor positive (HR+) breast cancer and guidelines recommend initiation of AET within 12 months of diagnosis. Black women with HR+ breast cancer have poorer overall survival than their white counterparts and breast cancer is the leading cause of cancer death for Hispanic women. We aim to describe the relationship between race/ethnicity and prolonged time to AET and identify other predictors of delayed AET. This is a retrospective, population-based cohort study using the National Cancer Database, which captures more than 70% of incident cancer cases in the US. We examined 249,761 women who were diagnosed with invasive stage IB to III, HR+, HER2- breast cancer between 2004 and 2014, had cancer-directed surgery, and who were prescribed AET. Time to AET was defined as time from breast cancer diagnosis to initiation of AET. Delayed AET was defined as more than 12 months from date of breast cancer diagnosis. Multivariable logistic regression models were used to identify predictors of delayed AET. Eighty percent (186,197) of women were white, ~10% (22,841) were black, and 5% (12,101) were Hispanic. Among all patients, mean age at diagnosis was 58.5 years, 29% were diagnosed with stage IB, 43% with stage II, and 27% with stage III cancer, and median time to initiation of AET was 6.1 months. Mean age of black and Hispanic women at diagnosis was 56.4 and 53.9 years respectively, compared to 59.2 years for white women. Fourteen and 20% of black and Hispanic patients were insured by Medicaid, respectively, versus 4.4% of white women. Black and Hispanic women had almost twice the odds of delayed time from diagnosis to surgery compared to white women (OR 1.78, 95% 1.73-1.83 and OR 1.93, 95% CI 1.86-2.01, respectively). In univariate analyses, factors associated with delayed AET were black and Hispanic race/ethnicity, being uninsured or having Medicaid, older age (categorized as &amp;gt; 70 years¬), higher tumor grade or stage, receipt of chemotherapy or radiation therapy, and delayed time to surgery or chemotherapy. Our final multivariable model adjusted for these significant factors, as well as comorbidities, urban/rural residence, and income and education (based on zip-code). In this model, being uninsured was no longer positively associated with delay in AET. Black patients had a 19% higher odds of delayed AET (OR 1.19, 95% CI 1.14-1.24) and Hispanic patients had 57% higher odds of delay compared to their white counterparts (OR 1.57, 95% CI 1.49-1.65). There are racial disparities in the quality of breast cancer care provided to patients in this study. Being of black or Hispanic race/ethnicity was associated with increased odds of delayed time to initiating AET beyond the recommended time frame of 12 months after diagnosis. Medicaid enrollment was also a predictor of delayed time to AET. Future efforts should be focused on improving delivery of quality breast cancer care measures to vulnerable populations. Citation Format: Kimberley T Lee, Vered Stearns, Lisa K Jacobs. Racial disparities in delayed initiation of adjuvant endocrine therapy among patients with breast cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A136.

Enhancing the Electronic Health Record to Improve the Quality of Breast Cancer Care in Eastern North Carolina

Enhancing the Electronic Health Record to Improve the Quality of Breast Cancer Care in Eastern North Carolina

How structural racism can kill cancer patients: Black patients with breast cancer and other malignancies face historical inequities that are ingrained but not inevitable. In this article, the second of a 2-part series, we explore the consequences of and potential solutions to racism and inequality in cancer care.

How structural racism can kill cancer patients: Black patients with breast cancer and other malignancies face historical inequities that are ingrained but not inevitable. In this article, the second of a 2-part series, we explore the consequences of and potential solutions to racism and inequality in cancer care.