Annals of surgical oncology 2025 Jun 29

Authors: HoSang KM

PMID: 40581882 [PubMed - as supplied by publisher]

Annals of surgical oncology 2025 Jun 02

Authors: HoSang KM, Bleicher RJ

Abstract
The National Accreditation Program of Breast Centers (NAPBC) developed comprehensive, multidisciplinary standards to improve quality outcomes. We have previously shown that institutions treating larger proportions of breast cancer patients of low socioeconomic status (SES) achieve these benchmarks at lower rates. This study assesses whether a patient's SES interacts with an institution's SES mix in achieving the 2018 NAPBC standards.
Using the National Cancer Database, low SES patients were defined by insurance status, income and educational attainment, and low SES institutions were defined as the decile containing the largest proportion of low SES patients. Cohorts were created for each measurable NAPBC standard: breast-conserving surgery, sentinel lymphadenectomy, adjuvant radiation, adjuvant chemotherapy, and adjuvant endocrine therapy. Adjusted odds of standard-compliant treatment (SCT) were analyzed.
We included 3,156,604 patients (23% being low SES) treated at 1180 non-low SES institutions and 283,155 patients (59% being low SES) treated at 131 low SES institutions. All subgroups reached the 50% threshold for breast-conserving surgery, with rates of SCT > 70% for all other standards. Both low SES institution and low SES patient status were independently associated with a lower probability of SCT for all standards (p < 0.001), except there was no association between institution type and receiving adjuvant radiation (p = 0.21).
Patient and institution SES impact the achievement of NAPBC standards; low SES patients received lower SCT regardless of institution SES. Further work to create strategies that address SES-related disparities are imperative to provide equitable care.

PMID: 40456972 [PubMed - as supplied by publisher]

Breast cancer research and treatment 2025 May

Authors: Fefferman ML

Abstract
We examined the impact of the COVID-19 consortium recommendations on the surgical management of breast cancer during the first year of the pandemic.
Patients with newly diagnosed ER + DCIS, ER- DCIS, AJCC Stage cT1-2N0-1 ER + , HER2-, HER2 + , and triple negative breast cancer were identified from the National Cancer Database from 2018 to 2021. An interrupted time series design evaluated differences in surgical delay and use of neoadjuvant chemotherapy/immunotherapy (NAC) and endocrine therapy (NET) before and after the pandemic.
A total of 895116 female patients were included in the study with a mean age of 61.7 years. Time to surgery decreased by an average 5.5 days from January 2020 to May 2020 for all breast cancer types, corresponding with a 62.2% decrease in breast cancer diagnoses per month from January 2020 to April 2020. The use of NET increased from 5.6 to 23.6% from January to March 2020 for patients with ER + DCIS and 8.0 to 31.1% for ER + cT1-2N0 cancer (both p < 0.01). The use of NAC for HER2 + tumors and triple negative breast cancers has been increasing since 2018 and a larger than expected increase was seen from 57.2 to 63.6% for HER2 + tumors and 55.6 to 68.7% for triple negative breast cancers (both p < 0.01). Treatment practices returned to pre-pandemic levels in June 2020.
Prior to the publication of the Consortium recommendations, time to surgery decreased while the use of NET and NAC increased, with the resumption of pre-pandemic practices by June 2020.

PMID: 39865151 [PubMed - as supplied by publisher]

Annals of surgical oncology 2025 Mar

Authors: Fefferman ML

Abstract
Since 2022, the Commission on Cancer (CoC) has developed three new breast cancer quality measures (QMs): time to surgery (BCSdx) and radiation (BCSRT) and the use of neoadjuvant therapy for triple negative and HER2/neu positive breast cancer (BneoCT). This study assesses CoC center historical performance for these measures and facility factors associated with low performance.
We examined the median number of days for time to surgery and radiation, and the proportion of facilities that achieved an estimated performance rate (EPR) of 70%, 80%, and 90% from 2004 to 2020 for all three measures. Multivariable logistic regression analysis was used to determine the association between facility factors and not achieving 80% EPR for all three measures.
The median number of days to surgery and radiation in 2004 were 16 and 43, respectively, compared with 34 and 48 in 2020 (p < 0.01). For BneoCT, BCSdx, and BCSRT measures, the proportion of facilities that attained ≥ 80% EPR was 68.5%, 72.2%, and 35.2%, respectively. The proportion of facilities that attained ≥ 80% EPR in 2004 was 92.3% for BCSdx and 49.8% for BCSRT compared with 69.6% and 39.4%, respectively, in 2020. BneoCT performance improved over time. Academic facilities and facilities serving a larger proportion of socioeconomically disadvantaged patients were approximately twice as likely to be unable to achieve compliance with all three QMs.
Performance levels for BCSRT are the lowest of all three measures. Academic centers and centers with a higher proportion of Medicaid patients are more likely to have lower adherence with all three QMs.

PMID: 39658720 [PubMed - as supplied by publisher]

JCO oncology practice 2025 Jun

Authors: Thompson DM

Abstract
The National Accreditation Program for Breast Centers (NAPBC) launched the Patient-Reported Observations for Medical Procedure Timeliness quality collaborative to assess time intervals between screening and treatment for patients with breast cancer.
Sites submitted monthly timeliness data in calendar days from 2019 to 2021 along with their perceptions of timeliness at their centers and facility characteristics. All patients were included in the interval from screening to diagnosis, whereas only patients with cancer were included in the biopsy to treatment intervals. Institutions were compared and assessed for differences and associations with center characteristics via the Kruskal-Wallis test.
Three hundred seventy-three (64.5%) NAPBC-accredited breast centers enrolled, and 311 (83.3%) provided complete timeliness metrics. Two hundred nine (56%) sites did not have trainees, 154 (41.3%) sites were within 10 miles of a major city, and the median number of annual breast cancer cases was 280 (IQR, 189-366). From 2019 to 2021, the time between diagnosis and treatment was as follows: 11-12 days between screening mammogram (MGM) and diagnostic MGM, 8-9 days between diagnostic MGM and biopsy, 32-34 days between biopsy and neoadjuvant therapy, and 39-42 days between biopsy and surgery. The enrolled centers believe that these intervals should be 7, 7, 21, and 28 days, respectively. Higher annual case volume and a larger number of surgeons exclusively devoted to breast disease were significantly associated with longer time intervals.
Time from biopsy to first treatment is longer than that centers expected compared with time from screening to diagnosis. There is significant variability across NAPBC in time from screening mammogram to treatment, and some institutions will face more challenges with timely quality measures than others. Further investigation into whether these differences confer outcome differences should be pursued.

PMID: 39621953 [PubMed - as supplied by publisher]

Breast cancer research and treatment 2024 Nov

Authors: Fefferman ML

Abstract
Timeliness of care is an important healthcare outcome measure. The objective of this study was to explore patient perspectives on the timeliness of breast cancer diagnosis and treatment at accredited breast cancer centers.
In this qualitative study, 1 hour virtual interviews were conducted with participants 18-75 years old who were diagnosed and treated for stage 0-III breast cancer at a National Accreditation Program for Breast Centers facility from 2018 to 2022. Thematic analysis was used to identify key themes of participant experiences.
Twenty-eight participants were interviewed. Two thematic domains were identified: etiologies of expedited or delayed care and the impact of delayed or expedited care on patients. Within these domains, multiple themes emerged. For etiologies of expedited or delayed care, participants discussed (1) the effect of scheduling appointments, (2) the COVID-19 pandemic, (3) dissatisfaction with the timeline for various parts of the diagnostic workup, and (4) delays related to patient factors, including socioeconomic status. For the impact of expedited or delayed care, patients discussed (1) the emotional and mental impact of waiting, (2) the importance of communication and clear expectations, and (3) the impact of electronic health portals. Patients desired each care interval (e.g., the time from mammogram to breast biopsy) to be approximately 7 days, with longer intervals sometimes preferred prior to surgery.
These patient interviews identify areas of delay and provide patient-centered, actionable items to improve the timeliness of breast cancer care.

PMID: 38965153 [PubMed - as supplied by publisher]

NPJ breast cancer 2024 Jun 15

Authors: Dhungana A, Vannier A, Zhao F, Freeman JQ

Abstract
Given high costs of Oncotype DX (ODX) testing, widely used in recurrence risk assessment for early-stage breast cancer, studies have predicted ODX using quantitative clinicopathologic variables. However, such models have incorporated only small cohorts. Using a cohort of patients from the National Cancer Database (NCDB, n = 53,346), we trained machine learning models to predict low-risk (0-25) or high-risk (26-100) ODX using quantitative estrogen receptor (ER)/progesterone receptor (PR)/Ki-67 status, quantitative ER/PR status alone, and no quantitative features. Models were externally validated on a diverse cohort of 970 patients (median follow-up 55 months) for accuracy in ODX prediction and recurrence. Comparing the area under the receiver operating characteristic curve (AUROC) in a held-out set from NCDB, models incorporating quantitative ER/PR (AUROC 0.78, 95% CI 0.77-0.80) and ER/PR/Ki-67 (AUROC 0.81, 95% CI 0.80-0.83) outperformed the non-quantitative model (AUROC 0.70, 95% CI 0.68-0.72). These results were preserved in the validation cohort, where the ER/PR/Ki-67 model (AUROC 0.87, 95% CI 0.81-0.93, p = 0.009) and the ER/PR model (AUROC 0.86, 95% CI 0.80-0.92, p = 0.031) significantly outperformed the non-quantitative model (AUROC 0.80, 95% CI 0.73-0.87). Using a high-sensitivity rule-out threshold, the non-quantitative, quantitative ER/PR and ER/PR/Ki-67 models identified 35%, 30% and 43% of patients as low-risk in the validation cohort. Of these low-risk patients, fewer than 3% had a recurrence at 5 years. These models may help identify patients who can forgo genomic testing and initiate endocrine therapy alone. An online calculator is provided for further study.

PMID: 38879577 [PubMed - as supplied by publisher]

JAMA network open 2024 May 01

Authors: Freeman JQ

Abstract
Declining treatment negatively affects health outcomes among patients with cancer. Limited research has investigated national trends of and factors associated with treatment declination or its association with overall survival (OS) among patients with breast cancer.
To examine trends and racial and ethnic disparities in treatment declination and racial and ethnic OS differences stratified by treatment decision in US patients with breast cancer.
This retrospective cross-sectional study used data for patients with breast cancer from the 2004 to 2020 National Cancer Database. Four treatment modalities were assessed: chemotherapy, hormone therapy (HT), radiotherapy, and surgery. The chemotherapy cohort included patients with stage I to IV disease. The HT cohort included patients with stage I to IV hormone receptor-positive disease. The radiotherapy and surgery cohorts included patients with stage I to III disease. Data were analyzed from March to November 2023.
Race and ethnicity and other sociodemographic and clinicopathologic characteristics.
Treatment decision, categorized as received or declined, was modeled using logistic regression. OS was modeled using Cox regression. Models were controlled for year of initial diagnosis, age, sex, health insurance, median household income, facility type, Charlson-Deyo comorbidity score, histology, American Joint Committee on Cancer stage, molecular subtype, and tumor grade.
The study included 2 837 446 patients (mean [SD] age, 61.6 [13.4] years; 99.1% female), with 1.7% American Indian, Alaska Native, or other patients; 3.5% Asian or Pacific Islander patients; 11.2% Black patients; 5.6% Hispanic patients; and 78.0% White patients. Of 1 296 488 patients who were offered chemotherapy, 124 721 (9.6%) declined; 99 276 of 1 635 916 patients (6.1%) declined radiotherapy; 94 363 of 1 893 339 patients (5.0%) declined HT; and 15 846 of 2 590 963 patients (0.6%) declined surgery. Compared with White patients, American Indian, Alaska Native, or other patients (adjusted odds ratio [AOR], 1.47; 95% CI, 1.26-1.72), Asian or Pacific Islander patients (AOR, 1.29; 95% CI, 1.15-1.44), and Black patients (AOR, 2.01; 95% CI, 1.89-2.14) were more likely to decline surgery; American Indian, Alaska Native, or other patients (AOR, 1.13; 95% CI, 1.05-1.21) and Asian or Pacific Islander patients (AOR, 1.21; 95% CI, 1.16-1.27) were more likely to decline chemotherapy; and Black patients were more likely to decline radiotherapy (AOR, 1.05; 95% CI, 1.02-1.08). Asian or Pacific Islander patients (AOR, 0.81; 95% CI, 0.77-0.85), Black patients (AOR, 0.86; 95% CI, 0.83-0.89), and Hispanic patients (AOR, 0.66; 95% CI, 0.63-0.69) were less likely to decline HT. Furthermore, Black patients who declined chemotherapy had a higher mortality risk than White patients (adjusted hazard ratio [AHR], 1.07; 95% CI, 1.02-1.13), while there were no OS differences between Black and White patients who declined HT (AHR, 1.05; 95% CI, 0.97-1.13) or radiotherapy (AHR, 0.98; 95% CI, 0.92-1.04).
This cross-sectional study highlights racial and ethnic disparities in treatment declination and OS, suggesting the need for equity-focused interventions, such as patient education on treatment benefits and improved patient-clinician communication and shared decision-making, to reduce disparities and improve patient survival.

PMID: 38722630 [PubMed - as supplied by publisher]

Cancer medicine 2024 Jan

Authors: Fefferman M

Abstract
The objective of this study was to examine the impact of the early part of the COVID-19 pandemic on the number of newly diagnosed breast cancer cases at Commission on Cancer (CoC)-accredited facilities relative to the United States (U.S.) population.
We examined the incidence of breast cancer cases at CoC sites using the U.S. Census population as the denominator. Breast cancer incidence was stratified by patient age, race and ethnicity, and geographic location.
A total of 1,499,806 patients with breast cancer were included. For females, breast cancer cases per 100,000 individuals went from 188 in 2015 to 203 in 2019 and then dropped to 176 in 2020 with a 15.7% decrease from 2019 to 2020. Breast cancer cases per 100,000 males went from 1.7 in 2015 to 1.8 in 2019 and then declined to 1.5 in 2020 with a 21.8% decrease from 2019 to 2020. For both females and males, cases per 100,000 individuals decreased from 2019 to 2020 for almost all age groups. For females, rates dropped from 2019 to 2020 for all races and ethnicities and geographic locations. The largest percent change was seen among Hispanic patients (-18.4%) and patients in the Middle Atlantic division (-18.6%). The stage distribution (0-IV) for female and male patients remained stable from 2018 to 2020.
The first year of the COVID-19 pandemic was associated with a decreased number of newly diagnosed breast cancer cases at Commission on Cancer sites.

PMID: 38140789 [PubMed - as supplied by publisher]

American journal of surgery 2024 Jan

Authors: Fefferman M, Kuchta K, Nicholson K, Attai D, Victorson D, Pesce C, Kopkash K, Poli E, Smith TW, Yao K

Abstract
The objective of this study was to describe patient values and personality traits associated with breast surgery choice for patients with breast cancer.
A survey based on qualitative patient interviews and the Big-Five personality trait profile was distributed to Love Research Army volunteers aged 18-70 years old who underwent breast cancer surgery from 2009 to 2020. Multivariable logistic regression analysis was used to determine independent patient values and personality traits for the choice of breast-conserving surgery (BCS), unilateral mastectomy (UM) and bilateral mastectomy (BM).
1497 participants completed the survey. Open-mindedness was associated with UM and sociability was associated with BM. A majority of patients prioritized cancer outcomes. Compared to BM patients, BCS and UM patients were significantly more likely to choose values associated with maintaining their self-image, optimizing surgical recovery, and following their doctor's recommendation.
Other values besides cancer outcomes differentiate patient surgical choice for BCS or mastectomy.

PMID: 37858372 [PubMed - as supplied by publisher]