Annual Meeting Proceedings Part 1 - American Society of Clinical ...

6061 General Poster Session (Board #4B), Mon, 1:15 PM-5:15 PM
Disparities in preoperative imaging for breast cancer: Not so black and
white. Presenting Author: Richard J. Bleicher, Fox Chase Cancer Center,
Philadelphia, PA
Background: Controversy exists about racial/ethnic differences in the care of
breast cancer patients. Imaging plays a critical role in evaluation, but little
national data exists on breast imaging by race. This study was performed to
determine if imaging disparities exist in Medicare patients, when adjusting
for socioeconomic (SE) factors. Methods: Surveillance Epidemiology and
End Results (SEER) data linked to Medicare claims were reviewed for
patients diagnosed with invasive nonmetastatic breast cancer between
2000 and 2005, undergoing surgery as their 1st treatment modality.
Diagnostic imaging was reviewed during the interval between the 1st physician visit and surgery (“preoperative interval”[POI]) and imaging use
was defined as �1 imaging-specific claim. SE factors included rural/urban
setting, and education, poverty, and median income per census tract.
Results: Among 39,790 patients, there were 34,774 White (87%), 2,341
Black (5.9%), 1,459 Hispanic (3.7%), and 1,216 Asian/Pacific Islander
(3.1%) patients. Univariate racial differences were noted for all imaging
types (p’s �0.0001 to 0.007). During the POI, when adjusting for
demographics, tumor characteristics, and SE factors in multivariable
analysis, use of mammogram, ultrasound (US), breast MRI, CT, and bone
scan were not different between Blacks and Whites. Education level was a
predictor for US (p�0.007), breast MRI (p�0.0001), CT (p�0.006) and
bone scan use (p�0.002), but not mammography (p�0.90). There were
varying correlations between Hispanics or Asians vs Whites for all imaging
types. Stage, histology, U.S. region, and comorbidity index were most
consistently predictive of imaging use of all types. When evaluating 6 mos
prior to the 1st physician visit along with the POI, 96.4% of all patients had
�1 mammogram, with 94.1% of Blacks having mammograms vs 96.5% of
Whites (OR 0.7, 95% CI 0.6-0.9; p�0.001). Conclusions: There is little
racial difference in imaging performed during the POI for Medicare patients
having breast cancer, and efforts to determine causes of survival disparities
in such patients should be focused elsewhere. Whether these findings
apply to the privately insured or the uninsured requires additional exploration.
6063 General Poster Session (Board #4D), Mon, 1:15 PM-5:15 PM
Rural versus urban differences among patients (pts) with hormone-receptor
positive (HR�) breast cancer (BC) and a 21-gene assay recurrence score (RS).
Presenting Author: Molly Andreason, University of Wisconsin, Madison, WI
Background: Differences in BC outcomes have been noted between rural and urban
women. The influence of tumor biology vs treatment factors as the driver of these
differences remains unclear. The Oncotype Dx 21-gene assay RS predicts distant
recurrence risk for HR�BC;aRS�18 indicates possible chemotherapy benefit. We
assessed rural vs urban differences in RS and therapies received (endocrine therapy;
chemotherapy for RS�18). Methods: Retrospective chart review was conducted on
BC pts diagnosed 2005–2010 with a 21-gene assay RS. Stage, grade, medications
and receptor status were abstracted; RS information was obtained from Genomic
Health. Rural-Urban Commuting Area (RUCA) codes defined rural vs urban status.
Comparisons between rural vs urban pts were made using two-sample tests,
chi-square or Fisher’s exact test for discrete data such as RS (� 18 vs � 18), stage
and ER status. T- or Wilcoxon rank sum test were used for continuous data (RS
0-100 and age.) All tests were at a two-sided significance level of 0.05. Results: Of
495pts with RS, 488 had RUCA codes (91% white, 61% postmenopausal). For
rural vs urban pts, mean RS was 18 vs 19, p�0.15. The table shows univariate
analysis for other predictors. For treatment, 321/354 (97%) rural vs 118/134
(94%) urban pts started endocrine therapy (p�0.2). For RS�18, 17/55 (31%) rural
vs 83/165 (50%) urban pts received chemotherapy (p�0.02, Chi-square test).
Conclusions: Rural pts did not have significantly different RS compared with urban
pts, but received significantly less chemotherapy for RS�18. This suggests that for
HR� BC, rural vs urban discrepancies may be explained in part by treatment factors.
We suggest prospective comparison or confirmation in another cohort.
BC in rural vs urban women.
Rural
N�134 (%)
Urban
N�354 (%) p value
RS #
Age
18 (8.8) 19 (9.0) 0.15*
#
BMI
58 (10.3) 56 (10.1) 0.08*
#
30.0 (7.3) 28.8 (7.5) 0.12*
Hormone use at diagnosis
Yes 17 (13) 60 (17) 0.28 ^
No 113 (84) 279 (79)
Unknown 4 (3) 15 (4)
Stage
I 92 (69) 247 (70) 1 ^
II 36 (27) 95 (27)
Unknown 6 (5) 12 (4)
Grade
1 36 (27) 116 (33) 0.13 ^
2 71 (53) 191 (54)
3 24 (18) 41 (12)
Unknown 3 (2) 6 (2)
# Mean (SD); *t-test; ^ Chi-square test (excludes unknown).
Health Services Research
397s
6062 General Poster Session (Board #4C), Mon, 1:15 PM-5:15 PM
Patient-related predictors of poor-quality pain care in advanced lung
cancer patients. Presenting Author: Inga Tolin Lennes, Massachusetts
General Hospital Cancer Center, Boston, MA
Background: Unrelieved pain remains a major problem for all patients,
including those with cancer, despite national standards for pain management.
Screening and addressing pain is an integral part of oncology visits
and an ASCO QOPI indicator of quality oncology care. The goal of this study
was to assess associations between patient-related factors, particularly
patient distress, and meeting ASCO quality metrics for appropriate management
of pain in patients with advanced lung cancers. Identification of
patient related factors could lead to targeted quality improvement efforts.
Methods: From 8/07 to 9/10, we recruited consecutive new patients in a
multidisciplinary thoracic oncology clinic to participate in a research
database for which patients completed self-report instruments for distress,
depression (PHQ-9) and anxiety (GAD-7), at their first oncology visit. We
then performed a QOPI chart audit for patients with advanced lung cancer
who received care at our institution. A composite measure of appropriate
pain management was calculated. Components of the composite measure
included 1) documentation of pain assessment, and 2) for patients with
moderate-severe pain (�4 on 10 point scale) plan of care documentation.
Results: 253 patients completed baseline assessments and had follow up.
Pain was assessed in 252 (99%) patients. Over a third (88/253) of newly
diagnosed advanced lung cancer patients had at least moderate pain on
their first visit to the medical oncologist. Almost half of patients with
moderate-severe pain were depressed (40/88). Of the patients with
moderate-severe pain, 54/88 (63%) had a plan of care related to pain
documented in the oncologist’s note. In total, 219 (87%) patients received
appropriate pain assessment and care. In a multivariate model including
age, sex, histology, ECOG PS, provider, depression, and anxiety, only
depression independently predicted inadequate pain care. Depressed
patients were 3 times more likely to receive poor quality pain care (OR
2.75, 95% CI 1.04-7.25, p�0.04). Conclusions: At initial oncology visit,
pain is present in over a third of patients with advanced lung cancer.
Depression is highly co-morbid with pain and appears to be a risk factor for
inadequate pain care.
6064 General Poster Session (Board #4E), Mon, 1:15 PM-5:15 PM
Impact of county-level surgical specialist density on breast (BrCa) and lung
cancer (LuCa) mortality. Presenting Author: Andrei Karpov, British Columbia
Cancer Agency, Vancouver, BC, Canada
Background: Variations in distribution of the surgical workforce may result
in differential access to cancer screening and treatment. Our aim was to
explore the relationship between county-level surgical specialist density
and BrCa and LuCa mortality. Methods: Using data from Area Resource File,
US Census and National Cancer Institute, regression models that controlled
for cancer incidence, county demographics and socioeconomic
factors were constructed to examine the association among a) general
surgeon (GS) and radiation oncologist (RO) density with BrCa mortality and
b) thoracic surgeon (ThS) and RO density with LuCa mortality. Plastic (PS)
and transplant surgeons (TrS) were used as surgical controls as they were
not expected to correlate significantly with BrCa or LuCa mortality. Results:
A total of 1,557 and 2,044 US counties were analyzed for BrCa and LuCa,
respectively: mean incidences were 119 and 75 and death rates were 25
and 59 per 100,000 people, respectively, for BrCa and LuCa. Mean
specialist densities were 7.72 (GS), 0.80 (RO), and 0.97 (PS) [for BrCa
counties] and 0.55 (ThS), 0.55 (RO), and 0.01 (TrS) [for LuCa counties]
per 100,000. When compared to counties with no surgical specialist, those
with at least one GS and RO for BrCa and at least one ThS and RO for LuCa
were associated with decreased mortality (Table). Increasing the density of
GS and RO beyond 9 and 1 per 100,000 did not result in significant
reductions in BrCa mortality. Likewise, increasing the density of ThS and
RO to above 1 each per 100,000 failed to yield further improvements in
LuCa mortality. Counties with more elderly residents also correlated with
worse BrCa and LuCa outcomes. Conclusions: The presence of specific
surgical specialists is associated with lower BrCa and LuCa mortality. There
appears to be a threshold at which point further increase in their density do
not contribute to continued improvements in outcomes. Distributing the
surgical workforce across all counties will offer population-based improvements
in BrCa and LuCa mortality.
BrCa LuCa
Specialist Effect on mortality* p Effect on mortality* p
GS -0.21 0.001 n/a n/a
RO -0.10 0.003 -0.03 0.032
ThS n/a n/a -0.04 0.009
PS -0.04 0.29 n/a n/a
TrS n/a n/a -0.01 0.84
*Beta estimates
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