The Implications of Insurance Status on Presentation, Surgical Management and Mortality among Non-Metastatic Breast Cancer Patients in Indiana

Background The National Breast and Cervical Cancer Early Detection Program seeks to reduce health care disparities by providing uninsured and underinsured women access to screening mammograms. The objective of this study is to identify the differences in presentation, surgical management, and mortality among nonmetastatic uninsured patients diagnosed through Indiana's Breast and Cervical Cancer Program compared with patients with private and government (Medicare or Medicaid) insurance. Methods Study data were obtained using the Indiana state cancer registry and Indiana's Breast and Cervical Cancer Program. Women aged 50 to 64 with an index diagnosis of stage 0 to III breast cancer from January 1, 2006 to December 31, 2013, were included in the study. Bivariate intergroup analysis was conducted. Kaplan-Meier estimates between insurance types were compared using the log rank test. All-cause mortality was evaluated using a mixed effects model. Results The groups differed significantly for sociodemographic and clinical variables. Uninsured Indiana Breast and Cervical Cancer Program patients presented with later disease stage (P < .001) and had the highest overall mortality (hazard ratio 2.2, P = .003). Surgical management only differed among stage III patients (P = .012). Conclusion To improve insurance-based disparities in Indiana, implementation of the Breast and Cervical Cancer Program in conjunction with expansion of insurance coverage to vulnerable low-income populations need to be optimized

Financial Toxicity Is Associated With Worse Physical and Emotional Long-term Outcomes After Traumatic Injury

Background Increasing healthcare costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health related quality of life outcomes (HRQOL). The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQOL. Methods Adult patients with an injury severity score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1, 2, 4 and 12 months. Screens for depression and post-traumatic stress syndrome (PTSD) were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. Results 500 patients were enrolled and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80–85%). Factors independently associated with financial toxicity were lower age (OR 0.96 [0.94–0.98]), and lack of health insurance (OR 0.28 [0.14–0.56]) and larger household size (OR 1.37 [1.06–1.77]). After risk adjustment, patients with financial toxicity had worse HRQOL, and more depression and PTSD in a step-wise fashion based on severity of financial toxicity. Conclusions Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified and interventions to counteract the negative effects should be developed to improve long-term outcomes. Level of Evidence Prognostic/epidemiologic study, level II

Oncology clinical trials and insurance coverage: An update in a tenuous insurance landscape

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151873/1/cncr32360_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151873/2/cncr32360.pd

A fiber optoacoustic guide with augmented reality for precision breast-conserving surgery

Lumpectomy, also called breast-conserving surgery, has become the standard surgical treatment for early-stage breast cancer. However, accurately locating the tumor during a lumpectomy, especially when the lesion is small and nonpalpable, is a challenge. Such difficulty can lead to either incomplete tumor removal or prolonged surgical time, which result in high re-operation rates (~25%) and increased surgical costs. Here, we report a fiber optoacoustic guide (FOG) with augmented reality (AR) for sub-millimeter tumor localization and intuitive surgical guidance with minimal interference. The FOG is preoperatively implanted in the tumor. Under external pulsed light excitation, the FOG omnidirectionally broadcasts acoustic waves through the optoacoustic effect by a specially designed nano-composite layer at its tip. By capturing the acoustic wave, three ultrasound sensors on the breast skin triangulate the FOG tip's position with 0.25-mm accuracy. An AR system with a tablet measures the coordinates of the ultrasound sensors and transforms the FOG tip's position into visual feedback with <1-mm accuracy, thus aiding surgeons in directly visualizing the tumor location and performing fast and accurate tumor removal. We further show the use of a head-mounted display to visualize the same information in the surgeons' first-person view and achieve hands-free guidance. Towards clinical application, a surgeon successfully deployed the FOG to excise a "pseudo tumor" in a female human cadaver. With the high-accuracy tumor localization by FOG and the intuitive surgical guidance by AR, the surgeon performed accurate and fast tumor removal, which will significantly reduce re-operation rates and shorten the surgery time

High‐speed Intraoperative Assessment of Breast Tumor Margins by Multimodal Ultrasound and Photoacoustic Tomography

Conventional methods for breast tumor margins assessment need a long turnaround time, which may lead to re‐operation for patients undergoing lumpectomy surgeries. Photoacoustic tomography (PAT) has been shown to visualize adipose tissue in small animals and human breast. Here, we demonstrate a customized multimodal ultrasound and PAT system for intraoperative breast tumor margins assessment using fresh lumpectomy specimens from 66 patients. The system provides the margin status of the entire excised tissue within 10 minutes. By subjective reading of three researchers, the results show 85.7% [95% confidence interval (CI), 42.0% ‐ 99.2%] sensitivity and 84.6% (95% CI, 53.7% ‐ 97.3%) specificity, 71.4% (95% CI, 30.3% ‐ 94.9%) sensitivity and 92.3% (95% CI, 62.1% ‐ 99.6%) specificity, and 100% (95% CI, 56.1% ‐ 100%) sensitivity and 53.9% (95% CI, 26.1% ‐ 79.6%) specificity respectively when cross‐correlated with post‐operational histology. Furthermore, a machine learning‐based algorithm is deployed for margin assessment in the challenging ductal carcinoma in situ tissues, and achieved 85.5% (95% CI, 75.2% ‐ 92.2%) sensitivity and 90% (95% CI, 79.9% ‐ 95.5%) specificity. Such results present the potential of using mutlimodal ultrasound and PAT as a high‐speed and accurate method for intraoperative breast tumor margins evaluation

Communicating Critical Information to Cancer Survivors: an Assessment of Survivorship Care Plans in Use in Diverse Healthcare Settings

Survivorship care plans (SCPs) serve to communicate critical information needed for cancer survivors' long-term follow-up care. The extent to which SCPs are tailored to meet the specific needs of underserved patient populations is understudied. To fill this gap, this study aimed to assess the content and communication appropriateness of SCPs collected from diverse healthcare settings. We analyzed collected SCPs (n = 16) for concordance with Institute of Medicine (IOM) recommendations for SCP content and for communication appropriateness using the Suitability Assessment of Materials (SAM) instrument. All plans failed to incorporate all IOM criteria, with the majority of plans (n = 11) incorporating less than 60% of recommended content. The average reading grade level of all the plans was 14, and only one plan received a superior rating for cultural appropriateness. There is significant variation in the format and content of SCPs used in diverse hospital settings and most plans are not written at an appropriate reading grade level nor tailored for underserved and/or minority patient populations. Co-designing SCPs with diverse patient populations is crucial to ensure that these documents are meeting the needs and preferences of all cancer survivors

Association of Hospital Quality and Neighborhood Deprivation With Mortality After Inpatient Surgery Among Medicare Beneficiaries

Importance: Although the hospital at which a patient is treated is a known source of variation in mortality after inpatient surgery, far less is known about how the neighborhoods from which patients come may also contribute. Objective: To compare postoperative mortality among Medicare beneficiaries based on the level of neighborhood deprivation where they live and hospital quality where they received care.Design, Setting, and Participants: This cross-sectional study examined outcomes among Medicare beneficiaries undergoing 1 of 5 common surgical procedures (colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair) between 2014 and 2018. Hospital quality was assigned using the Centers for Medicare & Medicaid Services Star Rating. Each beneficiary's neighborhood was identified at the census tract level and sorted in quintiles based on its Area Deprivation Index score, a composite measure of neighborhood quality, including education, employment, and housing quality. A risk matrix across hospital quality and neighborhood deprivation was created to determine the relative contribution of each to mortality after surgery. Data were analyzed from June 1 to December 31, 2021. Exposures: Hospital quality and neighborhood deprivation.Main Outcomes and Measures: The main outcome was risk-adjusted 30-day mortality after surgery using a multivariable logistic regression model taking into account patient factors and procedure type.Results: A total of 1 898 829 Medicare beneficiaries (mean [SD] age, 74.8 [7.0] years; 961 216 [50.6%] male beneficiaries; 28 432 [1.5%] Asian, 145 160 [77%] Black, and 1 622 304 [86.5%] White beneficiaries) were included in analyses. Patients from all neighborhood deprivation group quintiles sought care at hospitals across hospital quality levels. For example, 9.1% of patients from the highest deprivation neighborhoods went to a hospital in the highest star rating of quality and 4.2% of patients from the lowest deprivation neighborhoods went to a hospital in the lowest star rating of quality. Thirty-day risk-adjusted mortality varied across high- and low-quality hospitals (4.3% vs 7.2%; adjusted odds ratio [aOR], 1.78; 95% CI, 1.66-1.92) and across the least and most deprived neighborhoods (4.5% vs 6.8%; aOR, 1.58; 95% CI, 1.53-1.64). When combined, comparing patients from the least deprived neighborhoods going to high-quality hospitals vs patients from the most deprived neighborhoods going to low-quality hospitals, the variation increased further (3.8% vs 8.1%; aOR, 2.20; 95% CI, 1.96-2.46).Conclusions and Relevance: These findings suggest that characteristics of a patient's neighborhood and the hospital where they received treatment were both associated with risk of death after commonly performed inpatient surgical procedures. The associations of these factors on mortality may be additive. Efforts and investments to address variation in postoperative mortality should include both hospital quality improvement as well as addressing drivers of neighborhood deprivation.</p

A fiber optoacoustic guide with augmented reality for precision breast-conserving surgery

Lumpectomy, also called breast-conserving surgery, has become the standard surgical treatment for early-stage breast cancer. However, accurately locating the tumor during a lumpectomy, especially when the lesion is small and nonpalpable, is a challenge. Such difficulty can lead to either incomplete tumor removal or prolonged surgical time, which result in high re-operation rates (~25%) and increased surgical costs. Here, we report a fiber optoacoustic guide (FOG) with augmented reality (AR) for sub-millimeter tumor localization and intuitive surgical guidance with minimal interference. The FOG is preoperatively implanted in the tumor. Under external pulsed light excitation, the FOG omnidirectionally broadcasts acoustic waves through the optoacoustic effect by a specially designed nano-composite layer at its tip. By capturing the acoustic wave, three ultrasound sensors on the breast skin triangulate the FOG tip's position with 0.25-mm accuracy. An AR system with a tablet measures the coordinates of the ultrasound sensors and transforms the FOG tip's position into visual feedback with <1-mm accuracy, thus aiding surgeons in directly visualizing the tumor location and performing fast and accurate tumor removal. We further show the use of a head-mounted display to visualize the same information in the surgeons' first-person view and achieve hands-free guidance. Towards clinical application, a surgeon successfully deployed the FOG to excise a "pseudo tumor" in a female human cadaver. With the high-accuracy tumor localization by FOG and the intuitive surgical guidance by AR, the surgeon performed accurate and fast tumor removal, which will significantly reduce re-operation rates and shorten the surgery time