Radiation Oncology Care Research Articles

Impact of Head and Neck Multidisciplinary Clinic on Treatment Package Time During 2 Years of the COVID-19 Pandemic: A Single-Institution Experience.

Prolongation of treatment package time is strongly associated with inferior oncologic outcomes. We examine the effect of creation of a multidisciplinary head and neck clinic on treatment package times. This was a retrospective cohort study evaluating treatment package time in patients receiving adjuvant radiation through a multidisciplinary clinic compared with standard clinics at a single academic institution between 7/31/2020 and 7/31/2022. Adjuvant radiotherapy was administered to 23 patients in multidisciplinary clinic, 68 patients in standard clinic and 17 patients in satellite clinics. Patients seen in multidisciplinary clinic began adjuvant radiation sooner (median 35 vs 41 vs 48 days, p=0.01) with more compact treatment package times (median 78 vs 84 vs 86 days, p=0.003). Nine patient (13%) in standard clinics and 4 patients (24%) at the satellite clinics had adjuvant treatment package times exceeding 100 days. No patient seen in multidisciplinary clinic had treatment package times exceeding 100 days. Colocalization of radiation oncology and otolaryngology care in multidisciplinary clinic substantially improved time to postoperative radiotherapy and treatment package times. This is likely due to the identification of patients requiring adjuvant radiation earlier in their clinical presentation which in turn allowed for advanced planning and minimization of delays in initiation of adjuvant radiation.

A systems theory-based safety assessment of pre-treatment patient-specific quality assurance for intensity-modulated treatments in a single-vendor environment

Background and purposeWhile patient-specific quality assurance (PSQA) has been integral to intensity-modulated treatments, its value is debated. A systems approach to safety is essential for understanding complex systems like radiation oncology but is often overlooked in PSQA research. This study aims to elucidate PSQA’s fundamental value and identify opportunities for enhancing safety in intensity-modulated treatments. Materials and MethodsFirst, causal scenarios that could lead to patient harm were identified using a prospective safety assessment technique developed for complex systems. Second, PSQA’s ability to mitigate these scenarios was evaluated using standard stability and control principles. The analysis also included safeguards related to PSQA, such as daily linac QA, equipment commissioning, and equipment design. ResultsTen causal scenarios were identified, highlighting well-known issues like flawed algorithms, data corruption, and hardware errors. Mitigation is achieved through advanced dose calculation and optimization algorithms, software and data integration, and preconfigured beam data, which improve decision-making and system state determination. Modern linac control systems enhance all aspects of system stability and control. Commissioning, daily linac QA, and PSQA are effective in enhancing the determination of system states only when feedback is non-overlapping and unambiguous. ConclusionGiven equipment improvement and related safeguards, the feedback generated from PSQA has diminished in value. To better complement other safeguards, PSQA should evolve to provide automated, unambiguous detection of any potential catastrophic treatment deviations prior to treatment. This evolution would allow physicists to focus on more critical aspects of patient care in radiation oncology.

Beyond diagnosis: using a futurist approach to improve access to radiation oncology services in South Africa

Aim Radiation oncology is an integral aspect of comprehensive cancer treatment, with approximately 50% of patients requiring curative or palliative radiotherapy intervention. In the South African public sector, radiation oncology services are constrained by various factors including service coverage, equipment and staff shortages, causing consequent delays in access to care. The National Cancer Strategic Framework for South Africa (NCSF) (2017-2022) offers strategic direction for cancer services in the country. Methods Futurist causal layered analysis (CLA) provides a comprehensive approach to exploring the multifaceted factors that influence access to radiation oncology services. Using the established layers of CLA, namely, the litany, systemic, worldview and mythical layers, the NCSF, relevant literature, and expert perspectives, were used to explore the multiple levels of influence related to radiation oncology services in South Africa. Findings Considering litany, review of process flows and radiation oncology care models could offer strategic pathways for reducing waiting times and improving access to care. From the systemic layer analysis, health system strengthening should include improving clinical governance and access to available services within both the public and private sectors. This could simultaneously address the worldview of an unconstitutional lack of access to radiation oncology care within the public health sector. The final level considered myths related to radiation oncology in South Africa, including its perceived efficacy only in advanced cancer stages, and highlighted the importance of a business case for radiation oncology services to support enhanced planning and outcomes. Conclusions CLA methodology offers new insights into the challenges and opportunities facing radiation oncology services in South Africa. By comprehensively addressing the complex causal layers impacting radiation oncology services, policymakers and stakeholders can make more informed decisions to improve access to radiation oncology care in the country. The study recommends that the entire cascade of cancer care, including treatment pathways and multi-stakeholder perspectives, should be reviewed. Internal and external factors that delay the initiation of radiotherapy should be mapped and mitigated.

29 - Shaping patient care in Geriatric Radiation Oncology: Through the lens of an Advanced Practice Radiation Therapist

29 - Shaping patient care in Geriatric Radiation Oncology: Through the lens of an Advanced Practice Radiation Therapist

Peer-to-Peer Phone Calls and Letters Appealing Insurance Denials of Service: Practical Tips and Resources

The approval of radiation oncology care by insurance companies is burdensome for providers. In this topic discussion, we attempt to provide practical recommendations for how to deal with peer-to-peer phone calls as well as how to improve the timeliness and quality of subsequent letters of appeal.

Optimization of treatment workflow for 0.35T MR-Linac system.

This study presents a novel and comprehensive framework for evaluating magnetic resonance guided radiotherapy (MRgRT) workflow by integrating the Failure Modes and Effects Analysis (FMEA) approach with Time-Driven Activity-Based Costing (TDABC). We assess the workflow for safety, quality, and economic implications, providing a holistic understanding of the MRgRT implementation. The aim is to offer valuable insights to healthcare practitioners and administrators, facilitating informed decision-making regarding the 0.35T MRIdian MR-Linac system's clinical workflow. For FMEA, a multidisciplinary team followed the TG-100 methodology to assess the MRgRT workflow's potential failure modes. Following the mitigation of primary failure modes and workflow optimization, a treatment process was established for TDABC analysis. The TDABC was applied to both MRgRT and computed tomography guided RT (CTgRT) for typical five-fraction stereotactic body RT (SBRT) treatments, assessing total workflow and costs associated between the two treatment workflows. A total of 279 failure modes were identified, with 31 categorized as high-risk, 55 as medium-risk, and the rest as low-risk. The top 20% risk priority numbers (RPN) were determined for each radiation oncology care team member. Total MRgRT and CTgRT costs were assessed. Implementing technological advancements, such as real-time multi leaf collimator (MLC) tracking with volumetric modulated arc therapy (VMAT), auto-segmentation, and increasing the Linac dose rate, led to significant cost savings for MRgRT. In this study, we integrated FMEA with TDABC to comprehensively evaluate the workflow and the associated costs of MRgRT compared to conventional CTgRT for five-fraction SBRT treatments. FMEA analysis identified critical failure modes, offering insights to enhance patient safety. TDABC analysis revealed that while MRgRT provides unique advantages, it may involve higher costs. Our findings underscore the importance of exploring cost-effective strategies and key technological advancements to ensure the widespread adoption and financial sustainability of MRgRT in clinical practice.

1673: Advancing in Radiation Oncology Care: A Year of Telemedicine in a Brazilian Public Hospital.

1673: Advancing in Radiation Oncology Care: A Year of Telemedicine in a Brazilian Public Hospital.

Integration of Telemedicine Consultation Into a Tertiary Radiation Oncology Department: Predictors of Use, Treatment Yield, and Effects on Patient Population.

The COVID-19 pandemic led to rapid expansion of telemedicine. The implications of telemedicine have not been rigorously studied in radiation oncology, a procedural specialty. This study aimed to evaluate the characteristics of in-person patients (IPPs) and virtual patients (VPs) who presented to a large cancer center before and during the pandemic and to understand variables affecting likelihood of receiving radiotherapy (yield) at our institution. A total of 17,915 patients presenting for new consultation between 2019 and 2021 were included, stratified by prepandemic and pandemic periods starting March 24, 2020. Telemedicine visits included video and telephone calls. Area deprivation indices (ADIs) were also compared. The overall population was 56% male and 93% White with mean age of 63 years. During the pandemic, VPs accounted for 21% of visits, were on average younger than their in-person (IP) counterparts (63.3 years IP v 62.4 VP), and lived further away from clinic (215 miles IP v 402 VP). Among treated VPs, living closer to clinic was associated with higher yield (odds ratio [OR], 0.95; P < .001). This was also seen among IPPs who received treatment (OR, 0.96; P < .001); however, the average distance from clinic was significantly lower for IPPs than VPs (205 miles IP v 349 VP). Specialized radiotherapy (proton and brachytherapy) was used more in VPs. IPPs had higher ADI than VPs. Among VPs, those treated had higher ADI (P < .001). Patient characteristics and yield were significantly different between IPPs and VPs. Telemedicine increased reach to patients further away from clinic, including from rural or health care-deprived areas, allowing access to specialized radiation oncology care. Telemedicine has the potential to increase the reach of other technical and procedural specialties.

ACR-ARS Practice Parameter for Communication: Radiation Oncology.

This practice parameter was revised collaboratively by the American College of Radiology (ACR), and the American Radium Society (ARS). Timely, accurate, and effective communications are critical to quality and safety in contemporary medical practices. Radiation oncology incorporates the science and technology of complex, integrated treatment delivery and the art of providing care to individual patients. Through written physical and/or electronic reports and direct communication, radiation oncologists convey their knowledge and evaluation regarding patient care, clinical workup, and treatment provided to others in the management of the patient. Applicable practice parameters need to be revised periodically regarding medical record documentation for professional and technical components of services delivered. This practice parameter was developed and revised according to the process described under the heading "The Process for Developing ACR Practice Parameters and Technical Standards" on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ARS. Both societies have reviewed and approved the document. This practice parameter addresses radiation oncology communications in general, including (a) medical record, (b) electronic, and (c) doctor-patient communications, as well as specific documentation for radiation oncology reports such as (a) consultation, (b) clinical treatment management notes (including inpatient communication), (c) treatment (completion) summary, and (d) follow-up visits. The radiation oncologist's participation in the multidisciplinary management of patients is reflected in timely, medically appropriate, and informative communication with patients, caregivers, referring physician, and other members of the health care team. The ACR-ARS Practice Parameter for Communication: Radiation Oncology is an educational tool designed to assist practitioners in providing appropriate communication regarding radiation oncology care for patients.

Cancer patients’ awareness of extent of disease: anxiety, depression, quality of life

ObjectiveIn Asian cultures, the belief that full disclosure would harm the patient’s health would lead to non-disclosure. The study aimed to determine whether making patients aware of the extent of...

Association of patient experience with overall satisfaction with care in a radiation oncology center.

363 Background: To better understand what aspects of positive patient experience are associated with patients’ overall satisfaction with Radiation Oncology care, we analyzed patient responses to the Press Ganey Outpatient Oncology Radiation Therapy Survey. Methods: Survey responses completed by 3,533 patients treated at the MD Anderson Radiation Oncology Department from December 2018 to June 2021 were compiled. Responses to individual questions about patient experience were categorized as good/very good vs. very poor/poor/fair. Spearman’s rank correlations among key patient characteristics and all survey questions were calculated. Multivariate logistic regression was performed with selected uncorrelated patient characteristics and questions with strong association with either overall satisfaction or likelihood of recommending services to others. All analyses were performed in SAS 9.4 [SAS Institute Inc., Cary, NC]. Results: Median age was 66 years and 50% were female. On multivariate analysis (MVA) predicting good/very good overall rating of care, the following were positively associated with satisfaction: degree to which care was well coordinated among doctors/other caregivers (adjusted odds ratio [aOR] 4.65 [95%CI 2.66-8.13], p&lt;0.001); staff courtesy during radiation therapy (aOR 4.49 [2.29-8.77], p&lt;0.001); and staff concern for privacy (aOR 3.31 [1.48-7.84], p=0.004). Region of residency had mixed association (USA, Non-Texas (TX) vs. TX (aOR 2.97 [0.58, 15.23]) and Non-USA vs. TX (aOR 0.10 [0.01, 0.91], p=0.04). Ease of reaching the office staff on the telephone, cleanliness of the facility, ease of finding way around facility, privacy of changing rooms, ease of registration, waiting time in the radiation therapy area and patient age were not associated with overall rating of care on MVA (all p&gt;0.05). On MVA predicting good/very good likelihood of recommending services to others, degree to which care was well coordinated among doctors/other caregivers (aOR 4.98 [3.20-7.74], p&lt;0.001), staff courtesy during radiation therapy (aOR 3.07 [1.72-5.48], p&lt;0.001), and ease of reaching on phone (aOR 1.88 [1.12-3.17], p=0.004) were positively associated. Cleanliness of the facility, ease of finding way around facility, privacy of changing rooms, ease of registration, waiting time in the radiation therapy area and patient age and region of residency were not associated with likelihood of recommending services to others on MVA (p &gt;0.05). Conclusions: Degree to which care was well coordinated and staff courtesy during radiation therapy were most highly associated with overall satisfaction with care and likelihood to recommend services to others in a Radiation Oncology Center. This suggests efforts to improve staff courtesy and care coordination will enhance patient’s overall satisfaction with radiation oncology care.

Access to radiotherapy in Hispanic and Latinx populations in the United States: An update.

142 Background: Radiation therapy (RT) is a mainstay of oncology care and has been shown to optimize outcomes for patients in many settings. Disparities in access to RT therefore represent substandard care. The Hispanic/Latinx population has consistently faced disparities in oncology access and outcomes, with cancer being the leading cause of death in the Hispanic American population. In this study, we aim to evaluate recent research in RT disparities among the Hispanic/Latinx population in the United States since the seminal analysis from 2017 (PMID: 29904731). Methods: A PubMed literature search was conducted for articles published from January 2017 through March 2023. Four term combinations were utilized, including: (1) “Hispanic” and “Radiotherapy” and “Disparities”, (2) “Latino” and “Radiotherapy” and “Hispanic”, (3) “Hispanic” and “Radiation” and “Disparities”, and (4) “Latino” and “Radiation” and “Disparities.” All articles returned from each search were documented and duplicates were removed. Following the initial search, research studies qualifying for inclusion included studies taking place in the United States, examination of radiation oncology care, and examination of health disparities in the Hispanic/Latinx population. Articles meeting criteria were then organized by disparity type that they address. Results: Our initial PubMed search returned 245 articles. Of these articles, 60 met inclusion criteria and spanned 5 disparity-types: (1) Time to Treatment Initiation &amp; Completion, (2) Receipt of Treatment and Guideline-Concordant Care, (3) Geography, (4) RT Clinical Trial Access and (5) Insurance and Treatment Center Type. The most common disparity evaluated (n=23 studies) was receipt of treatment and guideline-concordant care, showing that the Hispanic/Latinx population was found to be less likely to receive any treatment. Another commonly identified disparity (n=10 studies) was the time to treatment initiation and completion, which highlighted that compared to the Non-Hispanic White population, the Hispanic/Latinx population had greater times to initiating RT and decreased likelihood of timely completion. Additionally, the Hispanic/Latinx population faced disparities in RT access due to geography (n=4 studies), RT clinical trial access (n=3 studies), insurance and treatment center access (n=5 studies). Conclusions: Disparities in radiotherapy access and quality care remain prominent for the Hispanic/Latinx population, despite increasing interest in health care disparities research. This population faces disparities in access via a multitude of barriers. Continued health care disparities research with tangible intervention is needed in radiation oncology in order to properly understand and address this problem.

Disparities in Access to Radiotherapy Among Hispanic/Latinx Populations in the United States: How Far Have We Left to Go?

The Hispanic/Latinx population has consistently faced disparities in oncology access and outcomes with cancer being the leading cause of death in this population. We evaluate recent research in radiation therapy disparities among the Hispanic/Latinx population in the United States since our seminal analysis from 2017. A PubMed literature search was conducted for articles published from January 2017 through March 2023. Four term combinations were utilized, including: (1) "Hispanic" and "Radiotherapy" and "Disparities", (2) "Latino" and "Radiotherapy" and "Hispanic", (3) "Hispanic" and "Radiation" and "Disparities", and (4) "Latino" and "Radiation" and "Disparities." Included studies were those taking place in the United States, examined radiation oncology care, and examined health disparities. Fifty-eight of 245 articles returned met inclusion criteria and spanned 6 disparity-types: (1) Stage at Presentation, (2) Time to Treatment Initiation & Completion, (3) Receipt of Treatment and Guideline-Concordant Care, (4) Geography, (5) Clinical Trial Access and (6) Insurance Barriers and Treatment Center Type. The most common disparity was receipt of treatment and guideline-concordant care (n=39 studies), demonstrating that the Hispanic/Latinx population was less likely to receive guideline-concordant treatment or treatment at all. In additon, studies identified disparities in time to treatment and completion (n=12), geography (n=5), clinical trial access (n=3), and insurance and treatment center access (n=5). Disparities in radiotherapy access remain prominent for the Hispanic/Latinx population through a multitude of barriers, despite increasing interest in disparities research. Continued health care disparities research with tangible interventions are needed in radiation oncology to properly understand and address this problem.

Incident Learning in an Academic Radiation Oncology Practice during the COVID Era.

Incident learning is key to developing and maintaining quality and safety in healthcare. We aimed to characterize acute and sustained changes in incident submissions, point of incident origin/detection, severity and associated contributing factors during the COVID-19 pandemic. The frequency and pattern of incident origin/detection were changed by altered workflows in response to COVID-19. Events from our experienced incident learning system were analyzed between three 12-month intervals: pre-COVID (March 1, 2019 - February 29, 2020), early-COVID (March 1, 2020 - February 28, 2021), and late-COVID (March 1, 2021 - February 28, 2022). In addition to review by the department quality and safety committee, at least two physicians reviewed all incidents. Using descriptive statistics and chi-square test as applicable, we compared the reporting rates, incident severity, contributing factors, points of origin/ detection according to time the pre-specified time intervals prior to and during COVID. See Table. During COVID the number of reported incidents, particularly incidents reaching the patient, markedly declined. The number of incidents per patient increased with early-COVID altered workflows. This suggests that existing quality and safety checks were effective during early-COVID. The point of incident origin was similar across time periods. During early-COVID, the point of incident detection shifted to earlier points in the care pathway (e.g., pre-RT chart checks vs chart checks during RT), p<0.001. During late-COVID, as clinical workflows adapted, the point of detection shifted to later in the care pathway consistent with pre-COVID patterns. During COVID, workload was implicated in fewer incidents (in the setting of reduced treatment volumes), while communication and hand-offs were more frequently cited as contributing factors (in the setting of remote work). Our data supports the utility of consistent standards, minimizing inter-provider variations and maintaining robust quality and safety checks to optimize communication and safe patient care in radiation oncology.

Radiation Oncology Health Disparities in Pakistan.

This article discusses problems and potential solutions for improving radiation oncology care in Pakistan.

Benchmarking of the Cervical Cancer Care Cascade and Survival Outcomes After Radiation Treatment in a Low- and Middle-Income Country Setting.

Timely radiation treatment (RT) is critical in cervical cancer treatment, but patients in low- and middle-income countries (LMICs) in sub-Saharan Africa often face barriers that delay care. Time to care was benchmarked in a multidisciplinary team (MDT) setting in Botswana. Time intervals between steps in care were recorded for 230 patients reviewed at MDT between January 2016 and July 2018. Associations between RT delay and overall survival (OS) were evaluated using Kaplan-Meier curves and multivariable Cox proportional hazards models. For patients who received RT (n = 187; 81.3%), the median biopsy to pathology reporting interval was 25 (IQR, 19-36) days and was 57 (IQR, 28-68) days for patients who did not (P = .003). Intervals in care did not differ between patients who did and did not receive RT. Among treated patients, the uppermost quartile interval from pathology reporting to RT initiation was ≥111 days and that from RT simulation to initiation was ≥12 days. Among patients receiving a RT dose of ≥65 Gy (n = 100), the delay from RT simulation to initiation of >12 days was associated with worse median OS (2.0 v 4.6 years; P = .048); this association trended toward, although did not meet, statistical significance on multivariable analysis (hazard ratio, 2.35; 95% CI, 0.95 to 5.85; P = .07). The MDT-coordinated care model allows for systematic benchmarking of the patient treatment cascade. Barriers to timely treatment exist for this cohort in Botswana, and RT delay may be associated with OS of patients receiving curative treatment. Interventions to accelerate the timing of the radiation oncology care cascade may improve clinical outcomes in this LMIC setting.

Geographic variation in out-of-pocket costs for radiation oncology services.

To examine out-of-pocket costs incurred by patients for radiation oncology services and their variation by geographic location. Analysis of patient-level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study. People who received Medicare-subsidised radiation oncology services in New South Wales, 2006-2017. Mean out-of-pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode-based), overall and after excluding episodes with no out-of-pocket costs (fully bulk-billed). During 2006-2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode-defined geographic areas. The proportion of episodes for which the out-of-pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out-of-pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non-zero out-of-pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006-2017. The proportion of radiation oncology episodes bulk-billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out-of-pocket costs for individual care episodes varied widely; in ten areas with lower bulk-billing rates, the interquartile range for costs ranged from $240 to $1857. Out-of-pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.

Radiology and radiation oncology considerations for transgender and intersex patients: A qualitative study.

In this qualitative study, we explored experiences of radiologists and radiation oncologists in providing clinical care to transgender, gender diverse (TGD), and intersex patients by asking about comfort level, relevant past training and training gaps, and clinical recommendations for TGD and intersex patient care. A purposive sample of radiology and radiation oncology professionals (n= 16) from diverse practice settings were interviewed on a videoconferencing platform. Transcripts were auto-populated and checked manually for accuracy. Two coders used a mix of deductive and inductive coding to identify key themes. Member checking was conducted with interviewees. Participants reported major gaps in training, knowledge, and confidence related to all aspects of TGD and intersex patient care. Recommendations for improvements included training that encompassed key terminology, how to conduct a physical exam on TGD and intersex patients, radiology and radiation oncology adaptations for TGD and intersex patients, and care coordination among multi-disciplinary oncology team members and gender affirming care providers. Exposure to diverse TGD and intersex persons in personal and professional life contributed to higher levels of comfort among providers in caring for TGD and intersex patients. Gaps in knowledge and limited confidence characterized the sample. Training at all levels is needed to improve radiology and radiation oncology care for TGD and intersex patients.

Integration of art and technology in personalized radiation oncology care: Experiences, evidence, and perspectives.

Cancer diagnoses expose patients to traumatic stress, sudden changes in daily life, changes in the body and autonomy, with even long-term consequences, and in some cases, to come to terms with the end-of-life. Furthermore, rising survival rates underline that the need for interventions for emotional wellbeing is in growing demand by patients and survivors. Cancer patients frequently have compliance problems, difficulties during treatment, stress, or challenges in implementing healthy behaviors. This scenario was highlighted during the COVID-19 emergency. These issues often do not reach the clinical attention of dedicated professionals and could also become a source of stress or burnout for professionals. So, these consequences are evident on individual, interpersonal, and health system levels. Oncology services have increasingly sought to provide value-based health care, considering resources invested, with implications for service delivery and related financing mechanisms. Value-based health care can improve patient outcomes, often revealed by patient outcome measures while seeking balance with economical budgets. The paper aims to show the Gemelli Advanced Radiation Therapy (ART) experience of personalizing the patients' care pathway through interventions based on technologies and art, the personalized approach to cancer patients and their role as "co-stars" in treatment care. The paper describes the vision, experiences, and evidence that have guided clinical choices involving patients and professionals in a co-constructed therapeutic pathway. We will explore this approach by describing: the various initiatives already implemented and prospects, with particular attention to the economic sustainability of the paths proposed to patients; the several pathways of personalized care, both from the patient's and healthcare professional perspective, that put the person's experience at the Gemelli ART Center. The patient's satisfaction with the treatment and economic outcomes have been considered. The experiences and future perspectives described in the manuscript will focus on the value of people's experiences and patient satisfaction indicators, patients, staff, and the healthcare organization.

Modifiable Barriers and Facilitators for Breast Cancer Care: A Thematic Analysis of Patient and Provider Perspectives

IntroductionWe sought to examine patient and provider perspectives regarding modifiable contributors to breast cancer treatment and to assess perceptual alignment between these two groups. MaterialsParticipants were women≥18 y with stage 0-IV breast cancer who received all oncologic care in a single health system and physicians and advanced practice providers who provided medical, radiation, or surgical oncology care for breast cancer. All completed ∼45-min semistructured interviews that were recorded and transcribed verbatim. A 5-stage approach to thematic analysis was conducted, with emergent themes and exemplar quotes placed into clinical, psychological, social/logistical, financial, and lifestyle categories using a multilevel conceptual framework. ResultsEighteen patients (9 Black, 9 White, and median age 60 y) and 10 providers (6 physicians and 4 advanced practice providers) were interviewed from May to November 2018. Both patients and providers perceived suboptimal communication, parking and transportation, and competing family-caregiving responsibilities as modifiable barriers to care. Treatment costs were cited by patients as barriers that were inadequately addressed even with referrals to financial counselors, but providers did not raise the issue of cost unless prompted by patients and did not feel prepared to discuss the topic when it arose. Providers cited obesity as a barrier to treatment, a view not shared by patients. ConclusionsSeveral modifiable factors were recognized by both patients and providers as either promoting or detracting from treatment receipt, but there was also significant incongruence and asymmetry. Alignment of provider and patient perceptions regarding contributors to guideline-concordant care receipt could mitigate disparities in breast cancer treatment and outcomes.