Improving Quality in Breast Cancer Treatment

Objectives: The goal of this study is to evaluate and compare care received following implementation of the multidisciplinary care tumor board at a community hospital in Detroit, MI. Methods: This is a retrospective chart review of patients who were newly diagnosed with invasive breast cancer one year prior to and one year following the implemenation of the MDC tumor board. Demographic information including race, age, insurance type (private vs public) and hospital site (urban vs suburban) where treatment was received was obtained. Additionally, stage at diagnosis, hormone receptor (HR) status, eligibility for and receipt of breast conserving treatment, neoadjuvant chemotherapy, hormonal therapy, radiation therapy, adjuvant chemotherapy, fertility sparing counseling, oncotype testing and genetic counseling was also obtained. SPSS was used for multivariate analysis. Significance was determined to be p\u3c0.05. Results: A total of 539 patients were eligible for the study. Average age of women in the MDC group was 62 years vs. average age of women in the non-MDC group of 59 years. The racial make up included 57% white, 43% black. There was no significant difference between eligibility and receipt of neoadjuvant chemotherapy, breast conserving therapy, endocrine therapy, radiation therapy or adjuvant chemotherapy in patients who were treated prior to the implementation of the MDC tumor board as compared to those receiving treatment after the implementation of the MDC tumor board. However, there was a significant difference in the frequency of oncotype testing and fertility counseling offered to patients who were diagnosed after the MDC was implemented. In a subset analysis, there was a significant difference in the receipt of breast conserving therapy in black women irrespective of participation in the multidisciplinary group (p=0.016). In fact, all women who received care at the urban facility were less likely to receive breast-conserving therapy (p=0.009) and were less likely to receive and be offered chemotherapy or Herceptin. Conclusions: While the Multidisciplinary care tumor board implementation has not yet established a significant difference in receipt of cancer care among all women, the ability to offer eligible patients fertility counseling and oncotype testing has improved significantly.https://scholarlycommons.henryford.com/merf2019qi/1014/thumbnail.jp

Utilization of genetic testing in breast cancer treatment after implementation of comprehensive multi-disciplinary care.

To evaluate the utilization of genetic testing after implementing a comprehensive multi-disciplinary care (cMDC) program for breast cancer and to assess for racial disparities. This retrospective study included patients newly diagnosed with invasive breast cancer 1 year before and 1 year after implementing a cMDC program to assess the rate of genetic referrals. Appropriate genetic referrals were defined by age, family history, triple-negative status, and personal history based on National Comprehensive Cancer Network guidelines. Secondary outcomes included rates of recommended testing, actual testing, compliance, and equity in genetic referrals across demographics (race, insurance type, and hospital site). Statistical analyses used the Fisher exact test or chi-square test. The 431 patients identified included 116 non-cMDC and 315 cMDC patients. Following implementation of cMDC, a significant increase occurred not only in appropriate genetic referrals (35.3%-55.5%) but also in inappropriate referrals (1.7%-15.5%) (P = .001). Overall attendance increased among both cohorts, Caucasians were more compliant with attending their genetic appointment compared to their African American counterparts (non-cMDC P = .025, cMDC P = .004). In the cMDC group, African Americans demonstrated a 6% increase in attendance compared to a 2% decrease among Caucasians. More appropriate genetic referrals were made to those with private insurance following implementation of cMDC. Utilizing a cMDC approach to breast cancer care may help increase appropriate utilization of genetics

Definitive radiation therapy for cervical cancer: Non-white race and public insurance are risk factors for delayed completion, a pilot study.

This is a pilot study to assess whether racial disparities exist in time to initiation and completion of external beam pelvic radiation therapy and brachytherapy in cervical cancers treated with definitive chemoradiation. A retrospective analysis was conducted on all cervical cancer patients treated with definitive radiotherapy between 2006 and 2016 at a single institution. Patient demographics including age, race, insurance status and stage at diagnosis were obtained. Analyses were performed according to the following definitions of wait times: interval from pathologic diagnosis of cervical cancer to (Siegel et al., 2016) initiation of radiation therapy, (Yoo et al., 2017) completion of external beam radiation therapy and (DeSantis et al., 2016) completion of external beam radiation therapy plus brachytherapy if indicated. Of 50 women, 21 self-identified as white, 25 as black and 4 as Hispanic. Due to small numbers, Hispanic women were included with black women as a non-white group. The average age was 52 years for women in this cohort. Mean days to initiation of radiation therapy were 41.8 days: 33.7 days among white patients versus 47.8 days for non-white patients (p-value 0.101). Mean days from diagnosis to completion of external beam pelvic radiation therapy were 81.3 days: 70.9 days among white patients versus 88.9 days among non-white patients (p-value 0.006). Non-white patients were more likely to have public insurance, which was also associated with a longer time to completion of radiation treatment. We conclude that non-white patients experienced delays to completing external beam radiation therapy, which was no longer present after adjusting for insurance status

Does a Multidisciplinary Approach to Invasive Breast Cancer Care Improve Time to Treatment and Patient Compliance?

PURPOSE: This study aimed to evaluate whether comprehensive multidisciplinary care (cMDC) for breast cancer patients affected time from diagnosis to treatment, compliance with appointments and to assess for racial disparities. METHODS: This institutional review board approved retrospective study included adult patients diagnosed with invasive breast cancer between February 2015 and February 2017 and treated at an academic health system where the cMDC program was implemented in February 2016. The cMDC and non-cMDC groups as well as black and white patients were compared to assess time from diagnosis (date of pathology result indicating invasive breast cancer) to treatment (date of surgery or chemotherapy). Compliance was measured by appointments characterized as no shows or canceled due to personal reasons in the electronic medical record. RESULTS: Of 541 patients (419 cMDC and 122 non-cMDC), mean time from diagnosis to treatment was significantly longer for blacks than whites in the non-cMDC group (46.9 ± 64.6 days vs 28.2 ± 14.8 days, p = 0.024) and the cMDC group (39.9 ± 34.1 days vs 31.4 ± 16.3 days, p = 0.001). Of 38 (7.2%) patients who started treatment \u3e 60 days after diagnosis, 25 (65.8%) were black. Implementation of cMDC significantly improved patient compliance (missed appointments 4.9 ± 7.6 non-cMDC vs 3.2 ± 4.6 cMDC, p = 0.029). CONCLUSION: Use of cMDC for invasive breast cancer at our institution highlighted an area for improvement for care administered to blacks and improved patient compliance with appointments

Does a comprehensive multidisciplinary care program impact utilization of genetics in breast cancer management?

Methods: Researchers emailed a web-based survey to program directors or coordinators for 204 pediatric and 498 family medicine programs, with a request to forward the survey to residents in each program. Responses were recorded, and relationships between participants\u27 demographics, knowledge, and experience regarding contraceptive implants were assessed using chi-squared analyses. Results: Among 665 participants, 81.2% recommended the contraceptive implant to adolescents, yet 73.2% had never inserted an implant in this population. 68.5% had received lectures and 52.0% had received hands-on training regarding contraceptive implants. Compared to pediatric residents, more family medicine residents had received lectures (80.1% vs 49.0%, P\u3c.00001) and hands-on training (77.8% vs 19.2%, P\u3c.00001). More family medicine residents had placed one or more implants than pediatric residents (40.5% vs 9.2%, P\u3c.00001). Most participants correctly answered three knowledge-based questions about the contraceptive implant (66.0%, 72.5%, 85.6% correct). Reported setbacks to provision of contraceptive implants included lack of training or experience, lack of patient interest, and lack of implant availability at clinical sites. Conclusion: The provision of contraceptive implants for adolescents by primary care residents is low, particularly among pediatric residents. Primary care residency programs should focus more on contraceptive implant training

Rate of Urologic Injury with Robotic Hysterectomy.

STUDY OBJECTIVE: To evaluate rates of urologic injury in patients who underwent robotic hysterectomy compared with laparoscopic, vaginal, and open hysterectomy. DESIGN: A retrospective analysis (Canadian Task Force classification II-2). SETTING: Henry Ford Health System, 2013 to 2016. PATIENTS: Women who underwent robotic, vaginal, laparoscopic, and open abdominal hysterectomy. INTERVENTIONS: Robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, vaginal hysterectomy, and abdominal hysterectomy. MEASUREMENTS AND MAIN RESULTS: To identify patients with urologic injury, a departmental database for quality improvement was searched for reported urologic injuries. In addition, patients who had urology consultation within 90 days of hysterectomy were screened for injury. A total of 3114 hysterectomies were identified by retrospective chart review. One thousand eighty-eight robotic, 782 laparoscopic, 304 vaginal, and 940 abdominal hysterectomies were analyzed for urologic complications. A total of 27 injuries were confirmed (7 during laparoscopic hysterectomy, 10 during robotic hysterectomy, 1 during vaginal hysterectomy, and 9 during abdominal hysterectomy). The overall rate of urologic injury was 0.87% with a 0.55% risk of bladder injury and a 0.32% risk of injury to the ureter. When the route of hysterectomy was taken into account, the risk of urologic injury was 0.92% for robotic hysterectomy, 0.90% for laparoscopic hysterectomy, 0.33% for vaginal hysterectomy, and 0.96% for open hysterectomy. The mean body mass index (BMI) for all patients was 32.7 kg/m CONCLUSION: Rates of urologic injury with robotic hysterectomy are similar to those of laparoscopic hysterectomy in our population. BMI was not significantly different in patients who had urologic injuries. Surgeon volume was not associated with risk for urologic injury

Rate of Urologic Injury with Robotic Hysterectomy

STUDY OBJECTIVE: To evaluate rates of urologic injury in patients who underwent robotic hysterectomy compared with laparoscopic, vaginal, and open hysterectomy. DESIGN: A retrospective analysis (Canadian Task Force classification II-2). SETTING: Henry Ford Health System, 2013 to 2016. PATIENTS: Women who underwent robotic, vaginal, laparoscopic, and open abdominal hysterectomy. INTERVENTIONS: Robotic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, vaginal hysterectomy, and abdominal hysterectomy. MEASUREMENTS AND MAIN RESULTS: To identify patients with urologic injury, a departmental database for quality improvement was searched for reported urologic injuries. In addition, patients who had urology consultation within 90 days of hysterectomy were screened for injury. A total of 3114 hysterectomies were identified by retrospective chart review. One thousand eighty-eight robotic, 782 laparoscopic, 304 vaginal, and 940 abdominal hysterectomies were analyzed for urologic complications. A total of 27 injuries were confirmed (7 during laparoscopic hysterectomy, 10 during robotic hysterectomy, 1 during vaginal hysterectomy, and 9 during abdominal hysterectomy). The overall rate of urologic injury was 0.87% with a 0.55% risk of bladder injury and a 0.32% risk of injury to the ureter. When the route of hysterectomy was taken into account, the risk of urologic injury was 0.92% for robotic hysterectomy, 0.90% for laparoscopic hysterectomy, 0.33% for vaginal hysterectomy, and 0.96% for open hysterectomy. The mean body mass index (BMI) for all patients was 32.7 kg/m2; injured patients had a mean BMI of 34.6 kg/m2, and noninjured patients had a mean BMI of 32.0 kg/m2 (p = .10). CONCLUSION: Rates of urologic injury with robotic hysterectomy are similar to those of laparoscopic hysterectomy in our population. BMI was not significantly different in patients who had urologic injuries. Surgeon volume was not associated with risk for urologic injury

Multi-disciplinary clinic discussion associated with decreased performance of breast MRI and increased eligibility for breast conservation

Background/Objective: The management of breast cancer benefits from a multi-disciplinary approach as this leads to better adherence to management guidelines. There is much variability in the utilization of MRI in the management of breast cancer. This study examines the effect of implementation of a multi-disciplinary clinic (MDC) on the utilization of MRI and breast-conserving therapy (BCT). Methods: We conducted a retrospective review of patients who were diagnosed with invasive breast cancer 1 year prior to and after the implementation of an MDC at our institution. We examined various clinical factors including age, sex, tumor characteristics, radiologic studies, surgical and medical treatment, and rates of BCT. We performed univariate analysis to compare differences among rates of pre-treatment MRI and BCT between patients who were and were not presented at the MDC. Results: A total of 539 patients were eligible for the study. There were 122 patients who were diagnosed prior to MDC, and 419 patients discussed at MDC. There was no difference in the average age (59.9 vs 62.2, p=0.1). There were no differences between the non-MDC and MDC patients among rates of BCT offered if eligible (96.8% vs 96.7%, p=0.95) and BCT performed if eligible (98.8% vs 93.9%, p=0.07). There was, however, a significant difference between the 2 groups in rates of pre-treatment MRI performed (32.2% vs 14.4%, p\u3c0.001). When comparing the groups that did not have a pre-treatment MRI and those that did, there was a decrease in the rate of BCT eligibility (82% vs 72.9%, p=0.02), BCT offered (98.6% vs 87.0%, p\u3c0.001), but not in the rates of BCT performed if eligible (95% vs 94.2%, p=0.82). Conclusions: Having a pre-treatment MRI resulted in patients more likely to be considered ineligible for BCT, and also less likely to be offered BCT. Having lower rates of BCT offered is a negative repercussion that may be mitigated through an MDC approach because patients are less likely to have a pretreatment MRI when presented at MDC. Further research is warranted, and more detailed conclusions may be obtained through prospective trials such as the ALLIANCE-MRI trial