Delivery Of Breast Cancer Care Research Articles

Comparison of care process for newly diagnosed breast cancer in insured versus uninsured populations: Opportunities for improving health equity.

e18518 Background: Initiatives enhancing equitable oncologic care are an increasingly emphasized priority. Our study aims to identify aspects of breast cancer (BC) care in which differences exist based on insurance coverage status. Methods: We performed a retrospective, case control study consisting of 39 Hispanic ethnicity uninsured patients (UP) with newly diagnosed BC at federally qualified health centers and 119 insured patients (IP) diagnosed at Mayo Clinic Arizona (MCA). Patients were matched 3:1 for age, stage, year of diagnosis, ER and HER2 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 ultimately received their cancer treatment at MCA. Results: Similar treatment patterns with chemotherapy, surgery, and radiation treatment 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 ˂ 0.001, percent of high school or lower (53.0 % v 23.2 %, p ˂ 0.001), and lower income for UP (33733.5 v 64728.0 p values ˂ 0.001). UP BMI was significantly higher (30.6 V 24.7, p=0.005), with presence of more co-morbidities; diabetes (28.2% v 5.0%, p ˂ 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 ˂ 0.001). IP had higher alcohol use (52.9% v 5.3%, p ˂ 0.001). Genetics consultation was performed for 62.2% IP versus 35.9% UP (p=0.004), lower acceptance of oncology nutrition consultation for UP (29.4% vs 7.4%, p= 0.024) Median time from abnormal 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 (primarily Hispanic, Spanish-speaking) and IP (primarily non-Hispanic White, English-speaking) 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 services, access to oncology nutrition consultation, and timeliness of diagnostic biopsy and initiation of treatment as disparate features in the care pathway. These observations can allow development of tailored interventions to achieve greater equity in delivery of BC care.

P050. Breast cancer management during a pandemic: A DGH experience

Introduction: COVID-19 has put a strain on regular healthcare worldwide. The delivery of breast cancer care has changed significantly to reduce the risk of transmission of COVID-19 and immunosuppression secondary to cancer treatment. This study shares a DGH experience of the effect of covid-19 on decision making in breast cancer treatment during the pandemic and a description of novel ways of service delivery to reduce the delay in treatment.

Determinants of Guideline-Discordant Breast Cancer Care

Evidence-based breast cancer treatment guidelines recommend the most appropriate course of therapy based on tumor characteristics and extent of disease. Evaluating the multilevel factors associated with guideline discordance is critical to identifying strategies to eliminate breast cancer survival disparities. We identified females diagnosed with a first primary, stage I-III breast cancer between the ages of 20-69 years of age from the population-based Seattle-Puget Sound Surveillance, Epidemiology, and End Results registry. Participants completed a survey about social support, utilization of patient support services, hypothesized barriers to care, and initiation of breast cancer treatment. We used logistic regression to estimate odds ratios and 95% confidence intervals (CI). Among 1,390 participants, 10% reported guideline-discordant care. In analyses adjusted for patient-level sociodemographic factors, individuals who did not have someone to go with them to appointments or drive them home (OR 1.96; 95% CI, 1.09-3.59) and those who had problems talking to their doctors or their staff (OR 2.03; 95% CI, 1.13-3.64) were more likely to be guideline discordant than those with social support or without such problems, respectively. Use of patient support services was associated with a 43% lower odds of guideline discordance (OR 0.57; 95% CI, 0.36-0.88). Although guideline discordance in this cohort of early-stage breast cancer survivors diagnosed <70 years of age was low, instrumental social support, patient support services, and communication with doctors and their staff emerged as potential multilevel intervention targets for improving breast cancer care delivery. This study supports extending the reach of interventions designed to improve guideline concordance.

Improving Results in Oncoplastic Surgery.

After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of oncoplastic procedures for partial breast reconstruction, and how they compare to breast conservation-therapy alone. 2. Have a working knowledge of oncoplastic techniques and how they are addressed from the multidisciplinary perspective. 3. Understand the limitations of oncoplastic techniques and how to avoid unfavorable results. Oncoplastic surgical techniques have expanded indications for breast conservation and have improved both oncologic and reconstructive outcomes. This article will focus on some of the barriers to adoption and discuss ways to improve safety through streamlining the process, understanding the oncologic concerns, and evaluating unfavorable outcomes that might interfere with the appropriate delivery of breast cancer care.

The COVID-19 pandemic impact on breast cancer care delivery at an academic center in New York City.

88 Background: The coronavirus disease 2019 (COVID-19) pandemic has altered healthcare delivery. To save resources and reduce patient exposure, non-urgent care has been postponed. Previous work has focused on cancer patients with COVID-19, but little has been reported on the impact on patients without COVID-19. We aimed to characterize breast cancer (BC) patients without COVID-19 whose care was impacted by the COVID-19 pandemic at an academic center in New York City. Methods: We performed a retrospective cohort study of BC patients treated at a medical oncology practice between 2/1/2020-4/30/2020. Patients were included if they were scheduled to receive intravenous or injectable therapy or were scheduled as a new patient. Patients were excluded if they tested positive for COVID-19 or transferred care during the study period. Demographic and treatment information were obtained by chart review. Delays/changes in systemic therapy, imaging, interventional radiology procedures, radiation, and surgery were tracked. Delays were defined as postponements of scheduled care. Changes were defined as care alterations without postponements. Care impact was defined as any change/delay in any of the above oncologic care a patient was scheduled for. We conducted a univariate analysis to compare demographics and care impact using χ2 analyses. Results: Of 351 eligible patients, the majority had stage 0-III BC (71.9%) and hormone receptor-positive HER2-negative BC (69.5%). Less than half were Caucasian (43.9%). Care was impacted due to the pandemic in 149 (42.5%) of patients. Surgery changes/delays were most frequent (37 of 84 patients, 44.0%), followed by changes/delays in systemic therapy (90 of 351 patients, 25.6%) and imaging (58 of 282 patients, 20.6%). Patients of Asian, Black, and other non-reported races were more likely to experience a care impact vs. Caucasian patients (47.1% vs. 44.4% vs. 55.6% vs. 31.2%, p = 0.001). Hispanic patients were more frequently impacted vs. non-Hispanic patients (47.6% vs. 35.9%, p = 0.06). Medicaid and Medicare patients were also more frequently impacted vs. commercially insured patients (54.7% vs. 41.4% vs. 36.2%, p = 0.02). BC stage and hormone receptor status were not significantly associated with care impacts. Conclusions: We found that nearly half of our BC patients experienced a change/delay in workup or treatment during the COVID-19 pandemic. We also found significant racial and socioeconomic disparities in the likelihood of care impact. Ongoing studies will determine the impact of alterations in care on cancer outcomes.

Effects of COVID-19 on an academic breast oncology center in New York City.

51 Background: The influx of patients to the healthcare system due to COVID-19 impacted healthcare practices including the care of breast cancer patients. Our aim is to describe the impact this pandemic had on breast cancer care delivery at an academic center in NYC to inform policy and procedure for future crises that limit patient access to on-site facilities. Methods: A survey was sent to physicians involved in the care of patients with breast cancer at Columbia University Irving Medical Center in May 2020. Participants were asked about practice structure and changes to breast cancer care. The primary outcome was the degree that providers believed breast oncology patients’ clinical outcomes were significantly impacted by COVID-19. Secondary outcomes included changes in diagnostic and management approaches and advice for future providers faced with a similar pandemic. Results: The response rate was 65.4% (17/26). This included physicians from medical oncology (n = 7), radiology (n = 4), breast surgery (n = 3), radiation oncology (n = 2), and plastic surgery (n = 1). Seventy-six percent of physicians somewhat agreed, agreed, or strongly agreed that oncologic outcomes may be significantly impacted by the COVID-19 pandemic. Nearly half (47%) of respondents reported delays in the workup of patients due to COVID-19 with 50.0% for mammograms, 47.5% for bone scans, 46.0% for ultrasounds, 43.8% for PET scans, and 43.3% for biopsies. Eighty-two percent reported delays in overall oncologic management. Delays to systemic therapy were: intravenous/targeted therapy (37.9%), intramuscular/subcutaneous endocrine therapy (28.3%), oral chemotherapy/targeted therapy (22.9%), and oral endocrine therapy (12.8%). Delays to local therapy were: surgery (64.4%) and radiation therapy (44.6%). Almost two-thirds (64.7%) reported it necessary to use alternative oncologic management strategies. The most common piece of advice our providers offered was to increase testing capacity to all patients, especially when coming to a healthcare facility. Conclusions: The COVID-19 pandemic has caused major disruption to breast cancer practices. Breast oncology physicians reported delays in management in over 80% of patients, and the need to use alternative management strategies in over 60% of patients. Effects of these disruptions on oncologic outcomes are unknown, but over 75% of our physicians believe this will significantly impact breast oncology patients’ outcomes. There's a need for policies and procedures to structure patient care should there be a future crisis that limits patient access to oncologic care.

Breast Cancer Surgery During the COVID-19 Pandemic Peak in the UK: Operative Outcomes.

Introduction The COVID-19 pandemic caused widespread changes in delivery of breast cancer care, aiming to protect vulnerable patients whilst minimising compromise to oncological outcomes. This multicentre observational study aimed to establish early surgical outcomes from breast cancer surgery performed during the peak of the COVID-19 pandemic. Materials and methods Data were collected on consecutive patients that underwent breast surgery in four units between 16 March and 24 April 2020. Outcome data at 30 days post-operation were collected, including documented COVID-19 cases in patients and reported cases in healthcare workers directly involved in their care. Recommended modifications to practice to reduce COVID-19 transmission risk, both to patients and healthcare workers in each centre, are described. Results A total of 202 patients underwent surgery in four hospitals delivering breast services in the West Yorkshire region over the six-week period at the peak of the pandemic. The age ranged from 28 to 91 years (median 57, interquartile range, 48-65) with 22% having co-morbidities linked to COVID-19, e.g. diabetes or respiratory disease. No patients presented post-operatively with COVID-19 symptoms and at 30 days there had not been any identified COVID-19 cases. There were no unexpected critical care admissions or deaths. One healthcare worker involved in the delivery of breast surgery was diagnosed with COVID-19 during this time and made an uneventful recovery. Conclusion Breast cancer surgery, in selected groups and with meticulous adherence to measures designed to reduce COVID-19 transmission, does not appear to be associated with elevated risk to patients or healthcare workers.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

BackgroundRacial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2–3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings. MethodsTranslating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost. ConclusionTRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

Breast cancer survivorship care beyond local and systemic therapy

Despite persistent inequities in access to care and treatments, advances in combined modality care have led to a steady improvement in outcomes for breast cancer patients across the globe. When estimating the magnitude of clinical benefit of therapies, providers and patients must contend with a multitude of factors that impact treatment decisions and can have long-term effects on quality of life and survival. These include commonly described early toxicities, like aromatase inhibitor-associated musculoskeletal syndrome and neuropathy. But longer-term comorbidities often observed among cancer survivors including weight gain, obesity, infertility, psychological distress, sexual dysfunction, second cancers, bone loss, and body image issues can have lasting effects on quality of life. Equally important, system-level factors such as access to care and resource allocation can have a systemic impact on survival and on the quality of survivorship. Financial toxicity including underemployment can have a lasting impact on patients and caregivers. The resulting disparities in access to treatment can help explain much of the observed variability in outcomes, even within high-income countries like the US. This article revisits some of secondary effects from therapies discussed in a prior 2015 review article, along with other impediments to the optimal delivery of breast cancer care that can affect patients anywhere.

The impact of patient navigation on the delivery of diagnostic breast cancer care in the National Patient Navigation Research Program: a prospective meta-analysis.

Patient navigation is emerging as a standard in breast cancer care delivery, yet multi-site data on the impact of navigation at reducing delays along the continuum of care are lacking. The purpose of this study was to determine the effect of navigation on reaching diagnostic resolution at specific time points after an abnormal breast cancer screening test among a national sample. A prospective meta-analysis estimated the adjusted odds of achieving timely diagnostic resolution at 60, 180, and 365days. Exploratory analyses were conducted on the pooled sample to identify which groups had the most benefit from navigation. Clinics from six medical centers serving vulnerable populations participated in the Patient Navigation Research Program. Women with an abnormal breast cancer screening test between 2007 and 2009 were included and received the patient navigation intervention or usual care. Patient navigators worked with patients and their care providers to address patient-specific barriers to care to prevent delays in diagnosis. A total of 4675 participants included predominantly racial/ethnic minorities (74%) with public insurance (40%) or no insurance (31%). At 60days and 180days, there was no statistically significant effect of navigation on achieving timely diagnostic care, but a benefit of navigation was seen at 365days (aOR 2.12, CI 1.36-3.29). We found an equal benefit of navigation across all groups, regardless of race/ethnicity, language, insurance status, and type of screening abnormality. Patient navigation resulted in more timely diagnostic resolution at 365days among a diverse group of minority, low-income women with breast cancer screening abnormalities. Trial registrations clinicaltrials.gov Identifiers: NCT00613275, NCT00496678, NCT00375024, NCT01569672.

How Structural Design Relates To Decision-Maker Attention in Three Health Systems

Background: Some scholars have suggested that the design of organizations can play an important role in determining how attention and effort are distributed within firms. However, our understanding of how existing organizational structures focus attention in health care is limited. Purpose/Methodology: We view breast cancer care delivery efforts through the lens of organization design and the attention-based view of the firm. More specifically, we use exploratory evidence from comparative case studies of three health systems to help us understand how the placement of organizational boundaries relates to where organizations focus their attention. Non-probability discriminative snowball sampling was used to identify the final sample of key informants and we employed a grounded approach to analyzing and interpreting the interview data. Findings: We found variation across the three health systems in terms of where organizational attention was primarily focused. More specifically, each organization was categorized as having one of three dominant foci of attention types (tactical-focused attention, patient-focused attention, and provider relationship-focused attention) that manifested themselves via the specific issues most frequently discussed by key informants from each health system. Conclusions: Study findings suggest that the placement of organizational boundaries (i.e., physician contracting paradigm used, the extent of inter- organizational coordination, clinical structure, and location of breast cancer services) can create situations where an organization’s structural design distributes the focus of attention across different types of issues. Moreover, having a “one-stop shop,” where all services are provided in a single location doesn’t appear to be a necessary, or even sufficient, means to having a patient-centered orientation.

How breast cancer care is coordinated in hospitals serving predominantly minority women.

e17592 Background: Underuse of adjuvant breast cancer treatment results from system failures and occurs more commonly in minority women. We assessed organizational processes associated with care coordination prior to implementing an intervention. Methods: We interviewed 29 clinical and 20 administrative key informants from 6 hospitals with high volumes of minority breast cancer patients. We analyzed qualitative interview data using the constant comparative method. Results: Hospitals varied in approaches to coordinate adjuvant therapy delivery. All hospitals made a “basic” effort to follow up with patients who missed appointments (e.g., certified letters), but some sites included “extra” efforts such as clinician calls. Processes to coordinate handoffs among providers involved use of clerical staff to reach out across specialties in most sites; several sites also explicitly involved clinicians. Effective tracking and handoffs were hindered where electronic health record (EHR) systems were not fully integrated. A critical distinction was whether breast cancer care delivery was integrated within the hospital. Better integration appeared to facilitate communication among clinicians, as well as promote service coordination. Accountability was an important factor contributing to integration, particularly in sites that were less integrated. Conclusions: Appropriate delivery of adjuvant therapies to breast cancer patients appears to be facilitated by better integration of care and services within the hospitals we studied. A fully integrated EHR and enhanced processes for tracking no shows and supporting handoffs seemed to increase integration in these hospitals. Integration was further facilitated when there was accountability for results. Strong clinical leadership can promote integration, but its impact may be lessened if hospitals’ processes are integrated. [Table: see text]

Abstract A51: Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors.

Abstract Background: Of the 13.7 million cancer survivors in the United States, 22% are breast cancer survivors. By 2050, this number is expected to double. The 2005 Institute of Medicine's Report “From Cancer Patient to Cancer Survivor: Lost in Transition,” identified 4 essential components of survivorship care. Central to this includes the coordination between specialists and primary care providers. Primary Care Providers (PCPs) often play a critical role in the follow-up care for patients with chronic diseases. Cancer survivorship can now be viewed as a chronic disease however PCPs have little access to training and education in survivorship care. By offering culturally appropriate and trusted care in a setting that is familiar and accessible to their patients, PCPs in the community setting are in a unique position to impact cancer follow-up care for their patients. Thus greater involvement by community PCPs is likely to impact cancer survivorship disparities. We sought to survey PCP attitudes regarding cancer survivorship care delivery. Methods: The Illinois Breast and Cervical Cancer Program (IBCCP) is part of the Center for Disease Control's National Breast and Cervical Cancer Early Detection Program. This program provides access to breast and cervical cancer screening services to underserved women. Illinois has 36 lead agencies. A 10-question survey based on the National Cancer Institute's Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) was given to IBCCP providers. Providers were surveyed about their attitudes and self-efficacy as well as preferences for breast cancer care delivery. The SPARCCS surveyed over 1000 PCPs on their knowledge and attitudes on breast cancer survivorship care. 83% of SPARCCS PCPs work in either private practice or as part of a large healthcare system. Results: 110 PCPs completed the IBCCP survey. 54% (n=59) were physicians, 28% (n= 31) nurse practitioners, and 17% (n= 19) identified as other. 94.5% (n= 104) of the respondents reported having patients with a breast cancer history. Compared to PCPs in the original SPARCCS survey, 37% IBCCP providers' preferred oncologists take primary responsibility (SPARCCS 25%, p=0.0057) and 13% IBCCP providers' preferred survivorship care be delivered in specialized survivorship clinics led by a clinician other than a physician (SPARCCS 4%, p=0.0002). The other survivorship care model preference differences were not statistically significant. Overall, community-PCPs surveyed preferred follow-up care be delivered through specialized clinics and/or by cancer specialists. Conclusions: Limited information exists regarding the role of community PCPs in breast cancer survivorship follow-up care for the underserved. Most providers in our survey stated they preferred follow-up care be delivered by the cancer specialist or through specialized survivorship clinics. The role to which improving provider knowledge, attitudes, and self-efficacy can impact preferences for care delivery needs to be explored. Citation Format: Zakiya Moton, Danielle Weston, Rebecca McFarland, Tamara Hamlish, Daniel Johnson, Maureen Mencarni, Shannon Lightner, Jean Becker, Funmi Olopade, Susan Hong. Understanding community-based primary care providers' attitudes toward caring for breast cancer survivors. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A51.

Disparities in breast cancer care delivery: solving a complex puzzle

Breast cancer care delivery is known to be uneven in the United States [1]. Clinicians and researchers have long observed differences in the process and outcomes of care for women diagnosed with breast cancer that can be attributed to observable individual and societal characteristics [2–6]. Researchers have reported noteworthy differences in screening, diagnosis, treatment, and mortality by age, race, ethnicity, geographic location, education, and income. It is important to recognize there are contradictory findings in the literature, specifically regarding the relationship between race/ethnicity and quality of chemotherapy care. The seminal Institute of Medicine report Unequal Treatment recognized these differences and the broader impact of disparities in health care delivery on the nation’s health [7]. The report’s authors noted the complexity in both understanding and remedying the current state. A persistent challenge to correcting disparities in breast cancer care delivery is the limited understanding of the reasons for the observed disparities [8]. Currently, we have a problem of uncertain size, scope, and etiology. Research studies that include triangulated data across sources, such as cancer registries, clinical registries, and surveys of patients and providers, will help disentangle current confusion and stimulate evidence-based quality improvement and policy efforts. In this context, the paper by Lipscomb et al. in this issue of Breast Cancer Research and Treatment is a necessary piece to solve this complex puzzle. A key contribution from this paper is that the findings stem from a unique combination of cancer registry data and clinical records. The authors used the Georgia Comprehensive Cancer registry to identify incident cases of breast cancer and abstracted records on 868 women treated in 27 oncology settings located in relatively rural Southwest Georgia. These linked data enable us to understand, at least in part, how several personal characteristics may influence variation in high-quality breast cancer care. The authors should be commended for their exhaustive attention to potentially confounding variables through sensitivity analyses and examination of interaction effects. Their careful attention to these issues increases the confidence in the principal study findings. In multivariable models, they found no differences in chemotherapy initiation by race. However, women who resided in impoverished areas were significantly less likely to initiate chemotherapy. This is an important finding that merits further attention and discussion. Of all the women in the study who initiated chemotherapy, 10% did not complete their originally intended plan, primarily due to toxicity. In a multivariable model that included interaction terms between race and marital status and race and comorbidity, unmarried black women had higher likelihood of chemotherapy completion compared with unmarried white women. Unmarried women with comorbid conditions were less likely to complete chemotherapy than unmarried women without comorbid conditions. Differences in chemotherapy initiation and completion were negligible for married women in the sample. One way to interpret these interesting findings is through the lens of social support. Marital status may serve as a proxy for the larger concept of social support, which may influence treatment decisions and outcomes. While social support was not This is an invited commentary to article doi: 10.1007/s10549-011-1916-1

Oncology Medical Home to address challenges in breast cancer care delivery.

e16641 Background: Care fragmentation and poor coordination in oncology negatively impact patient outcomes (IOM 2001, 2005). The Patient Centered Medical Home (PCMH) promises improved coordination of primary and chronic care (IOM, 2008). We previously identified unique challenges in breast cancer care coordination (Schink JC, ARM-1162-2010). Here we explored the distinct characteristics of Oncology Medical Home (OMH) which may address these challenges. Methods: 59 semi-structured interviews with: breast cancer care providers (n=26), patients (n=9), executives (n=24) from 5 major payers. Three multi-disciplinary focus groups included a subset of interviewed individuals (n=17, n=25, n=15). Interviews and focus groups were recorded, transcribed and analyzed according to the framework approach. Results: Theme analysis identified 4 unique characteristics of OMH: 1. OMH should have a lead physician—oncologist or breast surgeon (early stage patients)—for the entire episode of cancer care, then transfer survivors to PCMH. 2. Lead physician facilitates the cross-domain care team from diagnosis through survivorship, including surgery medical oncology, radiology, supportive and primary care. 2. Care and team should be managed as a project, with key events sequenced and timed in a plan, by a care project manager (e.g. APN). 4. OMH requires a unique reimbursement model to incentivize team participation and coordination. Patients strongly encouraged the lead physician feature. Providers suggested all OMH features. Half the payers were not certain of specific OMH features, but most recognized the need for a new reimbursement model. Conclusions: Oncology has unique care coordination and reimbursement challenges. An Oncology Medical Home may address these challenges, but should incorporate features distinct to cancer care and be facilitated by redesigned provider reimbursement. Implementation of OMH may be challenging, but could revolutionize care for cancer patients. OMH pilots will inform implementation and dissemination. OMH characteristics Providers Payers Patients Oncologist or surgeon lead physician 73% 46% 89% Cross-domain care team 81% 63% 78% Care project plan 73% 38% 67% Unique reimbursement model 85% 88% 33%

Care pathways for patients with breast cancer

AbstractAlthough the incidence of breast cancer is increasing in the UK, mortality is decreasing thanks to significant achievements in the organisation and delivery of breast cancer care, with multidisciplinary working at its centre. Copyright © 2010 Wiley Interface Ltd

The identification and treatment of isolated tumor cells reflect disparities in the delivery of breast cancer care

Background Disparities in the quality of health care delivered among different socioeconomic strata (SES), race/ethnic groups, and health care systems are well documented; however, relevant quality measures in breast cancer have been debated. The identification of isolated tumor cells (ITCs) in axillary lymph nodes of patients with breast cancer requires diagnosis of early stage disease, appropriate implementation of sentinel lymph node (SLN) dissection, and pathologic analysis of the SLN with serial sectioning and immunohistochemical staining. We hypothesized that ITCs could be interpreted as a quality indicator and sought to determine factors that are associated with the identification and treatment of ITCs. Methods We performed a retrospective cohort review of women with N0(i+) breast cancer diagnosed between 2004 and 2006 in the California Cancer Registry. The proportions of patients in SES quintiles (1 = lowest, 5 = highest), race/ethnicity groups, and hospital surgical volume tertiles (low, 1–241 cases/y; medium, 242–491 cases/y; high, ≥492 cases/y) were compared for use of SLN dissection, identification of ITCs, and treatment of ITCs with additional axillary surgery or chemotherapy. Results SLN dissections were performed less frequently in women of lower SES, of nonwhite race/ethnicity, and in hospitals with lower surgical volumes ( P <.0001). A total of 369 patients had ITCs (.6%). With increasing SES, the proportion of patients with ITCs increased: 7.1% of patients with ITCs were from SES 1; 15.7% were from SES 2; 20.3% were from SES 3; 23.9% were from SES 4; and 33.1% were from SES 5. A total of 69.4% of patients with ITCs were non-Hispanic white, 12.8% were Asian, 11.9% were Hispanic, and 5.2% were non-Hispanic black. A total of 46.9% of ITCs were identified in high-volume hospitals, although high-volume hospitals represented only one third of all surgical cases. There were no differences in the use of additional axillary surgery among different groups with ITCs, but chemotherapy was given more frequently to Hispanic women ( P = .002) and those in higher-volume hospitals ( P = .01). Conclusions Although the identification and chemotherapy treatment of ITCs vary among SES categories, race/ethnic groups, and hospitals, the infrequent occurrence of ITCs precludes its use as a valid quality indicator. Because significant disparities exist in the use of SLN dissection, further research will be required to validate the use of SLN dissection as a quality measure.

Strategic health communication across the continuum of breast cancer care in limited-resource countries

Strategic health communication is a critical component of healthcare that should be implemented across the continuum of care. Recognizing the importance of communication strategies and incorporating such strategies into healthcare policies, programs, and interventions is essential to the effective delivery of breast cancer care. The authors reviewed relevant literature and suggested practical evidence-based strategies for effective communication interventions across the continuum of care for breast cancer patients, including early detection, diagnosis, treatment, survivorship, palliative care, and end-of-life care. Examples were provided from limited-resource nations to support health communication recommendations.

Breast Cancer in Resource-Limited Countries

As one of the major causes of morbidity, mortality and disease burden, breast cancer continues to receive significant attention. However, this attention is most conspicuous in resource-rich countries. In resource-limited countries, breast cancer has not yet been identified as a priority healthcare issue because infectious disease is still the major threat in these countries. There is also a remarkable diversity in the rate of economic growth, political and social conditions and the current status of the delivery of breast cancer care across the resource-limited countries. In addition, the emerging increase in the incidence rate of breast cancer by up to 5%/year is alarming and requires international attention. Breast cancer is becoming an urgent public health problem in resource-limited countries and requires comprehensive resource-appropriate strategies for breast cancer control and management, regardless of age, ethnicity, religion and nationality. There has been significant improvement in breast healthcare over the past few decades, primarily due to advances in health research by diverse teams of basic scientists, physicians, pharmacists, industry, nurses and social workers. This research has involved inquiries regarding fundamental biological alterations in breast cancer, differences in diagnostic modalities and treatment options in various outcome studies. An increase in public awareness of breast cancer, an interest in women’s health issues, advances in radiological imaging, the development of new chemotherapeutic agents and the availability of molecular genetic tests have brought remarkable opportunities to a new insight in breast cancer. These efforts have resulted in earlier breast cancer detection and better outcomes. However, at a global level, there are some countries in the