Initiation Of Breast Cancer Treatment Research Articles

Delays in receipt of neoadjuvant chemotherapy compared to upfront surgery in patients with operable breast cancer.

e13561 Background: Delays in time from breast cancer (BC) diagnosis to BC treatment initiation (BCTI) including upfront breast surgery (UBS) or neoadjuvant chemotherapy (NACT), can negatively impact BC survival. We evaluated odds of delay in BCTI among patients (pts) who received NACT compared to pts who received UBS. Methods: We conducted a retrospective cohort study using the National Cancer Database. Eligibility included age ≥18 years, diagnosis of non-metastatic BC between 1/1/2010 – 12/31/2020, who were treated with NACT followed by surgery or UBS followed by adjuvant chemotherapy (AC). Pts who did not receive NACT or UBS within 180 days of diagnosis were excluded. The cohort was stratified by first BC treatment (NACT or UBS), and time to NACT (TTNACT) or time to surgery (TTS) was recorded for each patient in days. Pts were categorized into sub-cohorts by receptor status and clinical stage: 1) Hormone Receptor positive/HER-2 negative (HR+/HER2-) lymph node (LN)+; 2) HER-2 positive (HER2+) cT2+ or LN+; and 3) triple negative BC (TNBC) cT2+ or LN+. Logistic regression adjusted for demographic, socioeconomic, and tumor characteristics was used to identify delays in BCTI > 60 days. Multiple imputation was used for missing data. Inverse probability treatment weighting (IPTW) was done as a sensitivity analysis. Results: We identified 218,049 eligible pts, 75% were White, 18% were Black, and 8.6% were Hispanic. Median age was 53 years (range 18-90). There were 145,697 (67%) pts who received NACT with median TTNACT of 32 days (range 0-180), and 9.8% had a delay > 60 days (Table). There were 72,353 (33.0%) pts who received UBS followed by AC, with a median TTS of 33 days (range 0-180), and 13% with a delay > 60 days. In multivariable analysis, pts who received UBS had higher odds of BCTI delays compared to NACT, with OR 1.50 (95%CI 1.42-1.57) [HR+/HER2-], OR 1.49 (95%CI 1.41-1.58) [HER2+], and OR 1.26 (95%CI 1.18-1.34) [TNBC]. Results from IPTW analysis were similar, groups were well balanced, and pts who received UBS had higher odds of BCTI OR 1.50 (95%CI 1.44-1.57) [HR+/HER2-], OR 1.75 (95%CI 1.67-1.83) [HER2+], and OR 1.46 (95%CI 1.38-1.53) [TNBC]. Conclusions: Among high clinical risk BC patients who received surgery and chemotherapy, those who underwent NACT were less likely to experience delays in BCTI compared to pts who received UBS first. Among eligible pts, use of NACT may reduce delays in BCTI. [Table: see text]

320 (PB-136) Poster - Variations in time to breast cancer treatment initiation and survival across ethnoracial groups: a DAGs based approach to systematic review

320 (PB-136) Poster - Variations in time to breast cancer treatment initiation and survival across ethnoracial groups: a DAGs based approach to systematic review

Time to Cancer Treatment and Chemotherapy Relative Dose Intensity for Patients With Breast Cancer Living With HIV

Patients with breast cancer and comorbid HIV experience higher mortality than other patients with breast cancer. To compare time to cancer treatment initiation and relative dose intensity (RDI) of neoadjuvant and adjuvant chemotherapy among patients with breast cancer with vs without HIV. A retrospective, matched cohort study enrolled women who received a diagnosis of breast cancer from January 1, 2000, through December 31, 2018. The electronic medical records of 3 urban, academic cancer centers were searched for women with confirmed HIV infection prior to or simultaneous with diagnosis of stage I to III breast cancer. Tumor registry data were used to identify 2 control patients with breast cancer without HIV for each participant with HIV, matching for study site, stage, and year of cancer diagnosis. Statistical analysis was performed from December 2022 to October 2023. HIV infection detected before or within 90 days of participants' breast cancer diagnosis. The primary outcome was time to breast cancer treatment initiation, defined as the number of days between cancer diagnosis and first treatment. The secondary outcome was overall RDI for patients who received chemotherapy. These outcomes were compared by HIV status using Cox proportional hazards regression and linear regression modeling, respectively, adjusting for confounding demographic and clinical factors. Exploratory outcomes included instances of anemia, neutropenia, thrombocytopenia, and liver function test result abnormalities during chemotherapy, which were compared using Fisher exact tests. The study enrolled 66 women with comorbid breast cancer and HIV (median age, 51.1 years [IQR, 45.7-58.2 years]) and 132 with breast cancer alone (median age, 53.9 years [IQR, 47.0-62.5 years]). The median time to first cancer treatment was not significantly higher among patients with HIV than those without (48.5 days [IQR, 32.0-67.0 days] vs 42.5 days [IQR, 25.0-59.0 days]; adjusted hazard ratio, 0.78, 95% CI, 0.55-1.12). Among the 36 women with HIV and 62 women without HIV who received chemotherapy, the median overall RDI was lower for those with HIV vs without HIV (0.87 [IQR, 0.74-0.97] vs 0.96 [IQR, 0.88-1.00]; adjusted P = .01). Grade 3 or higher neutropenia during chemotherapy occurred among more women with HIV than those without HIV (13 of 36 [36.1%] vs 5 of 58 [8.6%]). This matched cohort study suggests that patients with breast cancer and HIV may have experienced reduced adjuvant chemotherapy RDI, reflecting greater dose reductions, delays, or discontinuation. Strategies for supporting this vulnerable population during chemotherapy treatment are necessary.

Abstract A039: Translating research into practice: Results of a community-engaged, city-wide breast cancer patient navigation implementation study to reduce disparities

Abstract Introduction: Delays in accessing breast cancer care contribute to poor outcomes among women of color and those underinsured. Patient navigation is one of few proven interventions that overcome inequity in cancer care delivery, yet there is a need to address barriers to widespread implementation. Methods: Led by a city-wide coalition of multi-sector stakeholders, we conducted a Type 1 hybrid clinical effectiveness-implementation trial across five hospitals in Boston to test the impact of navigation on timely initiation of breast cancer treatment, while also exploring implementation outcomes including acceptability of and fidelity to an evidence-informed 11-step navigation protocol. A randomized cluster stepped wedge study design allowed for rolling out a multi-level navigation protocol iteratively in real life practices from 2019 through 2022. Hospital cancer registries sourced eligible cancer cases, while electronic medical record abstraction documented timely treatment, defined as within 60 or 90 days depending on the diagnosis. Odds ratios adjusted for time by calendar quarter and accounted for clustering by study site. Fidelity to protocol was measured using navigator documentation of interactions with patients and conducting social needs screenings. Key informant interviews and field observations were conducted to assess acceptability. Results: A total of 1,732 women with newly diagnosed breast cancer were included in the intent to treat analysis (553 historical control period, 1,179 intervention period). By study design, the majority of women were nonwhite (80%) and more than half were non-English speaking and on public health insurance. During the intervention period, 50% (n=587) had no documented evidence of receiving any contact from a navigator, 15% (n=181) had only one documented interaction with the navigator while 35% (n=407) were navigated and received social needs screens in accordance with study protocol. Compared with historical controls, navigated patients who received a social needs screen had twice the odds of receiving timely treatment (aOR 2.06, 95% CI 1.39, 3.06), those who had only one documented interaction with the navigator had 1.4 greater odds of timely treatment (aOR 1.44, 95% CI 1.08, 1.93) and those with no documented evidence of navigation were no more likely to receive timely treatment (aOR 1.42, 95% CI 0.81, 2.48. We found variability in how navigators identified patients, with significant disruption during the COVID pandemic. Navigators found navigation protocols and social needs screening acceptable, and patients reported feeling supported when asked about social needs. The study protocol formalized the navigation process within and across hospitals, yet tension for change in existing workflows and complexity in documentation served as barriers to adoption. Conclusions: Receipt of navigation is associated with more timely care among a diverse group of women at risk for poor outcomes. Despite stakeholder engagement, implementation of evidence-based breast cancer patient navigation remains suboptimal. Citation Format: Tracy A. Battaglia, Karen M. Freund, Jennifer S. Haas, Stephenie C. Lemon, Translating Research Into Practice (TRIP) Consortium. Translating research into practice: Results of a community-engaged, city-wide breast cancer patient navigation implementation study to reduce disparities [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A039.

The Military Health System: Minimizing Disparities inBreast Cancer Treatment.

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population. A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs. Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004). There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.

Using a disparities dashboard to identify racial/ethnic differences in breast cancer treatment: Implications for improving cancer care delivery.

161 Background: Delays in the initiation of breast cancer treatment (e.g., surgery, chemotherapy, adjuvant endocrine therapy) contributes to breast cancer survival disparities. Yet, the use of a cancer dashboard to assess and inform real time assessments of the timing of surgery and systemic treatment by race/ethnicity is unclear. The purpose of this study is to investigate whether a cancer disparities dashboard can be used to assess racial/ethnic differences in the initiation of first line of treatment and timeliness of breast cancer surgery. Methods: A disparities dashboard was built using data from the tumor registry and the electronic medical record’s Data Warehouse. Key fields assessing patient race/ethnicity, cancer stage, receptor status, surgery type, treatments received and dates of surgery. This retrospective analysis included women diagnosed with a new primary breast cancer who underwent definitive surgery at Mount Sinai Hospital (2010-2020). We defined delays as &gt;8 weeks to treatment initiation, and delay to breast surgery as &gt; 6 weeks from diagnosis. Chi-square and t tests were used to assess independent variables (e.g., stage, age) by race/ethnicity. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and delays to initiation of first treatment and surgical delays. Results: Of 8,403 women identified (46.5% non-Hispanic White, 17.7% Black, 16.9% Hispanic), 64.5% had stage I cancer, 80.8% had estrogen receptor cancer. 18.5% of the sample had delays to initial treatment and 42.6% experienced delays to surgery. After adjusting for stage, age and receptor status Black patients compared to non-Hispanic White patients had the greatest likelihood of delayed initial treatment (OR: 3.03; 95% CI:2.6-3.5) or surgery delays (OR:2.45; 95% CI:2.1-2.8). With regards to clinical/sociodemographic factors younger patients (22-39 vs. 40-64; p&lt;0.001), mastectomy surgery type (; p=0.031), higher stage (stage 3 vs.1; p&lt;0.0001), HER2 and TNBC receptor status (vs. ER; p&lt;0.0001),) were more likely to experience surgery delays. Conclusions: Breast cancer treatment delays were more common among minoritized patients compared to White counterparts. A Disparities Dashboard can be used to assess differences in care. These data can be used to inform quality initiatives to improve cancer care delivery for at-risk patient populations who experience worse cancer outcomes.

Abstract P1-05-02: Reducing Delays of Breast Cancer Care Using An Innovative Digital Health Platform

Abstract Background: For breast cancer patients, prolonged time from core needle biopsy to initiation of treatment is associated with an incremental decrease in overall survival. This overall survival reduction disproportionately affects patients with stage I and II breast cancer (hazard ratio: 1.09-1.16, p&amp;lt; 0.001), the subgroup of breast cancer patients for which a survival reduction would be least expected due to its early stage and least accepted due to its large population size and potential increased cost of healthcare. Materials and Methods: We conducted an IRB-approved quality improvement initiative among patients with Medicare Advantage at a large integrated healthcare organization in Nevada to assess the ability of an innovative digital health platform to reduce the time interval between positive core needle biopsy to initiation of breast cancer treatment compared to a historical cohort of Medicare Advantage patients diagnosed and treated at the same facility over the preceding 6-month period. The study was restricted to women evaluated at a single contracted breast imaging center for inconclusive (Bi-RADS 0) and suspicious (BI-RADS 4 &amp; 5) mammograms, ultrasound, and/or breast MRI. Time to treatment (TTT) calculations were limited to the subset of patients diagnosed with in situ and invasive breast cancer by core needle biopsy. The primary goal was to reduce the historical TTT by greater than 50%. A secondary goal was to reduce TTT to &amp;lt; 30 days, well below the interval where overall survival would be adversely affected. Results: Between September 2021 and April 2022, 552 patients with BI-RADS 0, 4, and 5 breast imaging were enrolled in the quality improvement initiative and managed on the XpediteMD digital health platform. 208 patients were designated as BI-RADS 4 or 5 (i.e., suspicious imaging findings), all of whom ultimately underwent a diagnostic core needle biopsy. Of these, 75 patients were found to have invasive or in situ breast cancer and were subsequently referred to surgery or medical oncology where treatment was initiated. Among these patients, average TTT was 32 days with use of the digital health platform compared to 74 days in the historical cohort, a statistically significant 57% reduction in TTT, exceeding the 50% TTT goal. Although the study did not meet the target goal of average TTT &amp;lt; 30 days from needle biopsy to initiation of treatment, failure to achieve this goal was largely attributable to 3 patients who elected to delay cancer therapy for personal or health reasons. Excluding these 3 patients would have yielded an average TTT of 28.75 days, which is within our &amp;lt; 30-day goal. Conclusions: This quality improvement initiative demonstrated the successful deployment of a novel digital health platform which achieved a 57% reduction in the time interval from a positive core needle biopsy to performance of breast cancer surgery or initiation of systemic therapy. By reducing TTT to 32 days, the initiative eliminated any delay in initiation of cancer therapy that could have compromised patients’ overall survival. Citation Format: Dennis R. Holmes, Riya Pulicharam. Reducing Delays of Breast Cancer Care Using An Innovative Digital Health Platform [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-05-02.

Abstract PD1-05: Racial/Ethnic Segregation and Inequities in Metastatic Breast Cancer Treatment Initiation and Overall Survival

Abstract Background While racial/ethnic segregation, a form of structural racism, has been linked to health inequities, there is limited information regarding segregation and its potential impact on breast cancer care and outcomes. Here we assessed whether and to what extent racial/ethnic segregation is associated with timeliness of care and real-world overall survival (rwOS) in patients diagnosed with metastatic breast cancer (mBC). Methods This retrospective study used the nationwide Flatiron Health electronic health record-derived de-identified database. The cohort included community oncology patients (≥ 18 years) diagnosed with mBC between January 2011 and April 2022. Census tract data from the American Community Survey (2015-2019) was used to characterize neighborhoods based on the most recent recorded patient address. Segregation was defined as predominant race/ethnicity (e.g., tracts whose population was ≥ 50% non-Latinx Black were labeled as predominantly Black neighborhoods). Timeliness of care was defined as biomarker (estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2) testing within 30 days and systemic treatment initiation within 60 days of metastatic diagnosis (evaluated using Χ2 tests). We estimated Cox proportional hazard models adjusted for age and sex to examine rwOS (patients were followed from diagnosis to death or last recorded activity). Results Among 18,884 patients diagnosed with mBC (median age: 65 years), 71.0% lived in predominantly White neighborhoods, 7.5% in Black neighborhoods, and 8.7% in Latinx neighborhoods. Compared with patients residing in predominantly White neighborhoods, patients in Black and Latinx neighborhoods were more likely to be diagnosed with de novo mBC (30.7% vs. 34.8% and 33.5%, respectively) and have Medicaid (7.6% vs. 15.8% and 15.3%). Fewer patients in predominantly Black (74.4%) and Latinx (69.9%) neighborhoods received timely biomarker testing compared to patients in White (77.7%) neighborhoods (p &amp;lt;.01). Similarly, fewer patients in predominantly Black (73.5%) and Latinx (72.6%) neighborhoods had timely treatment initiation compared to patients in White (79.6%) neighborhoods (p &amp;lt;.01). Patients in Black neighborhoods (HR 1.24, 95% CI 1.16-1.33) had worse rwOS than patients in White (ref.) and Latinx neighborhoods (HR 0.90, 95% CI 0.83-0.97). Conclusions Our results suggest that racial/ethnic segregation is associated with inequities in breast cancer care and outcomes, where patients in predominantly Black and Latinx neighborhoods are less likely to receive timely care than those in White neighborhoods. Living in predominantly Black neighborhoods was also associated with reduced survival. Therefore, efforts to reduce cancer inequities should target higher-order structural factors associated with worse cancer care and outcomes, including segregation and other forms of structural racism. Citation Format: Jenny S. Guadamuz, Gregory S. Calip, Alemseged A. Asfaw, Xiaoliang Wang, Harlan Pittell, Maneet Kaur, Amy E. Pierre, Cleo A. Ryals. Racial/Ethnic Segregation and Inequities in Metastatic Breast Cancer Treatment Initiation and Overall Survival [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-05.

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

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

Factors affecting timely breast cancer treatment among black women in a high-risk urban community: a qualitative study

BackgroundBlack women diagnosed with breast cancer in the U.S. tend to experience significantly longer waits to begin treatment than do their white counterparts, and such treatment delay has been associated with poorer survival. We sought to identify the factors driving or mitigating treatment delay among Black women in an urban community where treatment delay is common.MethodsApplying the SaTScan method to data from Ohio’s state cancer registry, we identified the community within Cuyahoga County, Ohio (home to Cleveland) with the highest degree of breast cancer treatment delay from 2010 through 2015. We then recruited breast cancer survivors living in the target community, their family caregivers, and professionals serving breast cancer patients in this community. Participants completed semi-structured interviews focused on identifying barriers to and facilitators of timely breast cancer treatment initiation after diagnosis.ResultsFactors reported to impact timely treatment fell into three primary themes: informational, intrapersonal, and logistical. Informational barriers included erroneous beliefs and lack of information about processes of care; intrapersonal barriers centered on mistrust, fear, and denial; while logistical barriers involved transportation and financial access, as well as patients’ own caregiving obligations. An informational facilitator was the provision of objective and understandable disease information, and a common intrapersonal facilitator was faith. Logistical facilitators included financial counseling and mechanisms to assist with Medicaid enrollment. Crosscutting these themes, and mentioned frequently, was the centrality of both patient navigators and support networks (formal and, especially, informal) as critical lifelines for overcoming barriers and leveraging facilitating factors.ConclusionsThe present study describes the numerous hurdles to timely breast cancer treatment faced by Black women in a high-risk urban community. These hurdles, as well as corresponding facilitators, can be classified as informational, intrapersonal, and logistical. Observing similar results on a larger scale could inform the design of interventions and policies to reduce race-based disparities in processes of cancer care.

The patient's needs before and six months after the initiation of breast cancer treatment: A prospective study in 600 breast cancer patients.

e24062 Background: Our aim was to determine the frequency of health-related problems faced by breast cancer patients before and six months after the initiation of breast cancer treatment. Methods: This prospective study involved 600 female breast cancer patients (26-65 years, mean 52), who participated in the pilot study in the novel individualized integrated rehabilitation programme in 2019-2022 and were followed for at least six months. The patients completed three questionnaires (EORTC QLQ - C30, B23 and NCCN) before the initiation of cancer treatment and six months after. The patients received neoadjuvant chemotherapy in 22% of the cases, tumorectomy in 53%, mastectomy in 39%, breast reconstruction in 27%, sentinel node biopsy in 67%, lymphadenectomy in 23%, external beam radiotherapy in 73%, chemotherapy in 45%, anti-HER-2 therapy in 11% and hormonal therapy in 74% of the cases. Data on the patients’ demographics, disease extent, cancer treatment and problems reported in the questionnaires were collected and analysed using descriptive analysis. Results: The problems reported by patients before the initiation of cancer treatment and after six months are presented in Table. In 14 out of 22 parameters, the frequency of problems increased in the six months after the initiation of treatment: fatigue, insomnia, lymphedema, shoulder movement impairment, disturbing scars, heart problems, hot flashes/sweating, gynaecological problems, sexual problems, body image worries, inappropriate nutrition, pain in the shoulder or arm, alopecia and concerns about returning to work. On the other hand, the frequency of problems decreased six months after the initiation of cancer treatment in 6 out of 22 parameters. Our patients less often had depression or anxiety, were too little physically active, smoked, consumed alcohol or used food supplements than before. Conclusions: Six months after the initiation of breast cancer treatment patients have more problems than at the time before treatment.[Table: see text]

Abstract P5-14-13: Impact of race on time to treatment initiation and survival in breast cancer patients

Abstract Background: Delays in cancer care can have a detrimental impact on breast cancer outcomes. Despite advances in breast cancer treatment and improvements in survival, disparities between racial groups persist. At our own institution, we observed worse breast cancer outcomes in Black versus White patients in spite of similar treatments received. Higher stage at diagnosis and differences in histology appeared to account for only part of the difference. In this study, we evaluate the impact of race on time to initiation of first oncology treatment and overall survival in a large cohort of breast cancer patients treated at our center. Methods: Women diagnosed with stage I-IV breast cancer between 2015 and 2020 at the Cleveland Clinic were identified from our local tumor registry. All women over the age of 18 who followed up at the Cleveland Clinic Main Campus and identified as either Black or White in the electronic medical record (EMR) were included in the initial query. Men and individuals who identified as a race other than Black or White were excluded due to small numbers. There were forty-nine patients in whom the date of first treatment was unknown. Clinical data were reviewed by author D.B. and data not available in the tumor registry were obtained from the EMR. Baseline characteristics, and time to first treatment initiation were reported. Time to treatment initiation was defined as the days from biopsy demonstrating cancer to the date of initiation of any breast cancer treatment modality (surgery, chemotherapy, endocrine therapy, or radiation therapy). Results: A total of 6095 patients were included in the analysis with a median follow-up of 2.7 years. Median age was 62 and Black patients were slightly older than White patients (63 years [range 21-98] versus 62 [range 21-99]; p=0.048). Fewer Black patients had private insurance (38% versus 51%) and more had Medicaid or Medicare compared to White patients (59% versus 45%) (p&amp;lt;0.001). Only 1% of patients had no insurance and this was similar for both Black and White patients. The time from diagnosis to treatment differed by race. Black patients had a median of 36 days from diagnosis to treatment and White patients had a median of 32 days from diagnosis to treatment (p&amp;lt;0.001). Three-year overall survival was 86% (95% CI: 83-89%) for Black patients and 92% (95%CI: 91%-93%) for White patients (p&amp;lt;0.0001). No difference was observed in breast cancer recurrence rates by race (p=0.56). Additional analyses will investigate the contribution of comorbidities, cancer stage, histology, and other patient related factors to racial disparities in overall survival and time to treatment. Conclusion:. Our study highlights real world data on racial disparities in breast cancer treatment initiation and overall survival. Further investigation will seek to identify the impact of patient related factors on these important outcomes. It is critically important for breast cancer treatment teams to be aware of these racial disparities to implement interventions that can attempt to limit them. Citation Format: Diana Basali, Emily C. Zabor, Narcissa Houston, Halle CF Moore. Impact of race on time to treatment initiation and survival in breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-13.

Abstract PO-220: Associations of timing of Medicaid enrollment with stage at diagnosis, treatment delays, and mortality in women with breast cancer

Abstract Patients insured by Medicaid present with more late-stage breast cancer and poorer survival than privately insured patients. Delayed coverage may contribute to these disparities, since, in many states, diagnoses of cancer and other illnesses influence Medicaid eligibility. Prior studies have linked post-diagnosis Medicaid coverage with lower rates of screening mammography and greater risk of late-stage cancer, but less is known about its impacts on risks of breast cancer treatment delays and mortality. In this study, we examined the relations of timing of Medicaid enrollment in Missouri to breast cancer stage at diagnosis, treatment delays, and mortality. Using Medicaid administrative claims linked to the Missouri Cancer Registry, we identified 4,583 women ages 18 to 65 who were enrolled in Medicaid and diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate the odds ratio (OR) of late-stage diagnosis for pre-diagnosis (≥30 days before diagnosis) versus post-diagnosis (within 30 days before diagnosis or later) enrollment, adjusting for age, race/ethnicity, marital status, and ten census tract-level socioeconomic variables. We performed similar regression to analyze odds of treatment delay, further adjusting for tumor characteristics. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- versus post-diagnosis enrollment, sequentially adjusting for sociodemographic factors, tumor characteristics, and treatment. Timing of Medicaid enrollment was also defined using two other cutoffs, 90 days and 1 year. Patients enrolled in Medicaid ≥30 days before diagnosis were significantly less likely to be diagnosed at a late stage compared to those who enrolled in Medicaid after diagnosis (OR=0.69, 95% CI=0.60-0.79). This result persisted using 90-day (OR=0.64, 95% CI=0.56-0.74) and 1-year thresholds (OR=0.55, 95% CI=0.47-0.65). We did not observe any significant difference in the likelihood of treatment delays between the two groups using the 30-day (OR=0.93, 95% CI=0.80-1.10), 90-day (OR=1.00, 95% CI=0.85-1.18) or 1-year thresholds (OR=0.93, 95% CI=0.77-1.12). After adjustment for sociodemographic factors, there was no significant difference in the risk of breast cancer mortality for patients enrolled in Medicaid ≥30 days pre-diagnosis relative to patients enrolled post-diagnosis (HR=0.98, 95% CI=0.83-1.14). The same model, however, showed a lower risk of mortality for patients enrolled in Medicaid before diagnosis when using 90 days (HR=0.85, 95% CI=0.72-0.999) or 1 year (HR=0.79, 95% CI=0.66-0.96) as the threshold. These findings suggest that women who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits. Timing of Medicaid enrollment does not appear to play a role in timely initiation of breast cancer treatment. Citation Format: Evaline Xie, Graham A. Colditz, Min Lian, Tracy Greever-Rice, Chester Schmaltz, Jill Lucht, Ying Liu. Associations of timing of Medicaid enrollment with stage at diagnosis, treatment delays, and mortality in women with breast cancer [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-220.

Development of Machine Learning Algorithms for the Prediction of Financial Toxicity in Localized Breast Cancer Following Surgical Treatment.

PURPOSEFinancial burden caused by cancer treatment is associated with material loss, distress, and poorer outcomes. Financial resources exist to support patients but identification of need is difficult. We sought to develop and test a tool to accurately predict an individual's risk of financial toxicity based on clinical, demographic, and patient-reported data prior to initiation of breast cancer treatment.PATIENTS AND METHODSWe surveyed 611 patients undergoing breast cancer therapy at MD Anderson Cancer Center. We collected data using the validated COmprehensive Score for financial Toxicity (COST) patient-reported outcome measure alongside other financial indicators (credit score, income, and insurance status). We also collected clinical and perioperative data. We trained and tested an ensemble of machine learning (ML) algorithms (neural network, regularized linear model, support vector machines, and a classification tree) to predict financial toxicity. Data were randomly partitioned into training and test samples (2:1 ratio). Predictive performance was assessed using area-under-the-receiver-operating-characteristics-curve (AUROC), accuracy, sensitivity, and specificity.RESULTSIn our test sample (N = 203), 48 of 203 women (23.6%) reported significant financial burden. The algorithm ensemble performed well to predict financial burden with an AUROC of 0.85, accuracy of 0.82, sensitivity of 0.85, and specificity of 0.81. Key clinical predictors of financial burden from the linear model were neoadjuvant therapy (βregularized, .11) and autologous, rather than implant-based, reconstruction (βregularized, .06). Notably, radiation and clinical tumor stage had no effect on financial burden.CONCLUSIONML models accurately predicted financial toxicity related to breast cancer treatment. These predictions may inform decision making and care planning to avoid financial distress during cancer treatment or enable targeted financial support. Further research is warranted to validate this tool and assess applicability for other types of cancer.

Time from breast cancer diagnosis to treatment among Idaho's National Breast and Cervical Cancer Early Detection Program population, 2011-2017.

Idaho's Women's Health Check (WHC) Program provides breast and cervical cancer screening to under- and uninsured women via funding from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Because WHC serves populations with less access to health care, this study evaluated time from breast cancer diagnosis to treatment for women enrolled in the WHC program and linked to Cancer Data Registry of Idaho (CDRI) case data (WHC-linked) and the remainder of female Idaho resident breast cases. Among Idaho residents aged 50-64years diagnosed during 2011-2017 with ductal carcinoma in situ or invasive breast cancer, we assessed differences in the median time from definitive diagnosis to treatment initiation overall and by demographic and tumor characteristics, and differences in the distribution of demographic and tumor-related variables between 231 WHC-linked and 3,040 non-linked breast cancer cases. WHC-linked cases were significantly less likely to be non-Hispanic white, and more likely to live in poorer census tracts, be diagnosed at a later stage, and be treated with mastectomy. Most WHC-linked (92%) and non-linked women (94%) began treatment within 60days of diagnosis; no differences in time to treatment were observed. Disparities in the interval from definitive diagnosis to breast cancer treatment initiation were not observed for women enrolled in the WHC program relative to other Idaho women.

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.

Machine learning algorithms to predict financial toxicity associated with breast cancer treatment.

2047 Background: Financial burden caused by cancer treatment is associated with material loss, distress, and poorer outcomes. Financial resources exist to support patients but objective identification of individuals in need is difficult. Accurate predictions of an individual’s risk of financial toxicity prior to initiation of breast cancer treatment may facilitate informed clinical decision making, reduce financial burden, and improve patient outcomes. Methods: We retrospectively surveyed 611 patients who had undergone breast cancer therapy at MD Anderson Cancer Center to assess the financial impact of their care. All patients were over 18 and received either a lumpectomy or a mastectomy. We collected data using the FACT-COST patient-reported outcome measures alongside other financial indicators including income and insurance status. We extracted clinical and perioperative data from the electronic health record. Missing data were imputed using multiple imputation. We used this data to train and validate a neural network, LASSO-regularized linear model, and support vector machines. Data were randomly partitioned into training and validation samples (3:1 ratio). Analyses were informed by international PROBAST recommendations for developing multivariate predictors. We combined algorithms into a voting ensemble and assessed predictive performance using area under the receiver operating characteristics curve (AUROC), accuracy, sensitivity, and specificity. Results: In our validation sample, 48 of 203 (23.6%) women reported FACT-COST scores commensurate with significant financial burden. The algorithm predicted significant financial burden relating to cancer treatment with high accuracy (Accuracy = .83, AUROC = .82, sensitivity = .81, specificity = .82). Key clinical predictors of financial burden from linear models were neo-adjuvant therapy (βregularized 0.12) and autologous, rather than implant-based, reconstruction (βregularized 0.10). Conclusions: Machine learning models were able to accurately predict the occurrence of financial toxicity related to breast cancer treatment. These predictions may be used to inform decision making and care planning to avoid financial distress during cancer treatment or to enable targeted financial support for individuals. Further research is warranted to further improve this tool and assess applicability for other types of cancer.

Serum Trace Elements and Their Associations with Breast Cancer Subgroups in Korean Breast Cancer Patients

The relationships between serum levels of trace elements and breast cancer remain relatively unknown. In this study, we investigate serum levels of seven trace elements in Korean breast cancer patients compared to controls without breast cancer. Serum trace element levels were determined using inductively coupled plasma mass spectrometry in Korean breast cancer patients before initiation of breast cancer treatment. Korean females without breast cancer served as a control group. Trace element levels were measured in the discovery cohort (n = 287) and were validated in an independent cohort (n = 142). We further investigated possible associations between trace element levels and the presence of lymph node metastasis, distant metastasis, or triple-negative breast cancer among breast cancer patients in subgroup analyses. Serum manganese and molybdenum levels were significantly higher (p < 0.05) in breast cancer patients than in controls. Serum copper levels were significantly higher in breast cancer patients with distant metastasis, while selenium levels were significantly lower. Other trace elements were neither significantly different between breast cancer patients and controls nor between subgroups of breast cancer patients. Our study provides insights about the potential roles and impacts of trace elements through an assessment of the associations between trace elements and breast cancer.

Understanding the causes of breast cancer treatment delays at a teaching hospital in Ghana.

Poor outcomes for breast cancer in Ghana have been attributed to late presentation of symptoms at biomedical facilities. This study explored factors accounting for delays in initiation of breast cancer treatment at the Korle-Bu Teaching Hospital in Accra. Focus group discussions were conducted with 20 women with breast cancer. A theory-driven thematic analysis identified three multilevel factors influencing treatment seeking delays: (1) patient (e.g. misinterpretation of symptoms, fear), (2) healthcare provider (e.g. negative attitudes) and (3) health systems (e.g. shortage of medicines). Addressing treatment delays will require multilevel interventions, including culturally congruent education, psychosocial counselling/support and strengthening health systems.

Abstract PR11: Temporal patterns of breast cancer treatment initiation and completion among black and white women in the Carolina Breast Cancer Study

Abstract Black women suffer from a persistent disparity in breast cancer mortality after controlling for prognostic and sociodemographic factors, suggesting that differential receipt or efficacy of treatment may contribute to their poorer outcomes. Black women are more likely to experience delays in diagnostic workup and initiation of treatment, but it is not known whether i) timeliness of subsequent care is also impacted, and ii) racial disparities in time to treatment initiation and completion persist among black and white women with comparable clinical and sociodemographic characteristics. The Carolina Breast Cancer Study Phase III is a large population-based cohort of North Carolina women newly diagnosed with breast cancer. This study was restricted to black and white women undergoing surgery for the treatment of nonmetastatic disease. We investigated mean differences in the distribution of time from diagnosis to earliest surgery, chemotherapy, or radiation treatment (treatment initiation) and once started, time to treatment completion (treatment duration) by race. Only treatment-oriented surgeries excluding biopsies were included in this analysis, and last or definitive surgery was defined as the final treatment-oriented surgery occurring prior to recurrence and within 18 months of diagnosis. Cumulative incidence curves were used to graphically examine the distributions of time to treatment initiation and treatment duration, and general linear models were used to estimate crude and adjusted mean differences in time to treatment initiation and duration between black and white women. We also conducted stratified analyses to examine racial disparities by age and stage at diagnosis, hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) positivity, treatment pathway (surgery only, surgery plus chemotherapy, surgery plus radiation, or all three modalities), marital status, education level, income, and insurance type. A total of 1,328 black and 1,331 white women met study inclusion criteria. Overall, black women had an average of 3.68 additional days to treatment initiation and 34.26 days longer treatment duration than white women, for 37.94 days longer total treatment time (95% confidence interval (CI): 34.21-41.67). Adjustment for clinical and sociodemographic factors resulted in a greater estimated mean difference in time to initiate treatment (4.04 days, 95% CI: 3.08-5.00), while it attenuated the mean difference in treatment duration towards the null (9.07 days, 95% CI: 6.82-11.32). Black women experienced significantly longer time to initiate treatment and treatment duration in nearly every stratum of clinical or sociodemographic factor examined. Black women with stage II or III tumors had significantly longer time to initiate treatment than white women (4.50 and 7.84 days, respectively), and after starting treatment, treatment duration was approximately 25 days longer for black women with stage I and II disease. Black women undergoing radiation and/or chemotherapy had longer time to initiate treatment and significantly longer treatment durations. Having a college education or higher or being insured through Medicaid were associated with the greatest mean differences in time to treatment initiation comparing black and white women. Younger age at diagnosis, HR+ or HER2- disease, being unmarried, having less than a high school education, and being uninsured were associated with the greatest mean differences in treatment duration by race. Overall, black women experienced longer intervals between diagnosis and treatment initiation and greater treatment durations after controlling for clinical and sociodemographic factors. Racial disparities were more pronounced in examination of treatment duration, suggesting that interventions to improve care coordination and timeliness should be targeted at high-risk groups. Citation Format: Sophie E. Mayer, Melissa Troester, Stephanie B. Wheeler, Andrew Olshan, Lisa A. Carey, Jessica Tse, Katherine E. Reeder-Hayes. Temporal patterns of breast cancer treatment initiation and completion among black and white women in the Carolina Breast Cancer Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR11.