Breast Care and Health Equity. Kristi Funk, MD, FACS

Transcription

1 Breast Care and Health Equity Kristi Funk, MD, FACS

2 Mortality Rates Prevalence Death Heart Dz 43,000, ,188 Lung Ca 105,590 71,660 Breast Ca 231, ,290 Colon Ca 63,610 23,600 2

3 Health Disparity Health disparities are differences in the incidence, prevalence, and mortality of a disease and the related adverse health conditions that exist among specific population groups. 3

4 Health Disparity Sex Age Race or ethnicity Education Income Disability Geographic location Sexual orientation Insurance Social class 4

5 Health Disparity Sex Age Race or ethnicity Education Income Disability Geographic location Sexual orientation Insurance Social class 5

6 Incidence and Mortality by Race Sources: Copeland et al.25 Mortality: US mortality data, National Center for Health Statistics, Centers for Disease Control and Prevention.

7 Trends in Breast Cancer Mortality AGE SPECIFIC INCIDENCE & MORTALITY RATES Mortality trends by race, SEER

8 Trends in Breast Cancer Mortality AGE SPECIFIC INCIDENCE & MORTALITY RATES WHITES: 23% 34% BLACKS: 35% 2% Mortality trends by race, SEER

9 Trends in Breast Cancer Mortality by Race AGE SPECIFIC INCIDENCE & MORTALITY RATES American Cancer Society, Inc., Surveillance Research, 2015

10 Trends in Breast Cancer Mortality by Race AGE SPECIFIC INCIDENCE & MORTALITY RATES American Cancer Society, Inc., Surveillance Research, 2015

11 Breast Cancer 5YS by Race American Cancer Society, Inc., Surveillance Research, 2015

12 Age-specific Incidence, Mortality and Race AGE SPECIFIC INCIDENCE & MORTALITY RATES American Cancer Society, Inc., Surveillance Research, 2015

13 Age-specific Incidence, Mortality and Race AGE SPECIFIC INCIDENCE & MORTALITY RATES B 33% W 22% American Cancer Society, Inc., Surveillance Research, 2015

14 Age-specific Incidence, Mortality and Race AGE SPECIFIC INCIDENCE & MORTALITY RATES B 33% W 22% 2x American Cancer Society, Inc., Surveillance Research, 2015

15 AGE SPECIFIC Breast INCIDENCE Cancer & Staging MORTALITY RATES

16 Breast Cancer Stage by Race American Cancer Society, Inc., Surveillance Research, 2015

17 Breast Cancer 5YS by Stage and Race American Cancer Society, Inc., Surveillance Research, 2015

18 AGE SPECIFIC Size INCIDENCE Matters: & MORTALITY 5YRS RATES T Size 5YRS < 2.0 cm 95% cm 84% > 5.0 cm 70%

19 AGE SPECIFIC INCIDENCE Size Matters & MORTALITY RATES T Size 5YRS < 2.0 cm 95% cm 84% > 5.0 cm 70% Dx at > 2 cm: Blacks: 61.7% Whites: 48.6% California Cancer Registry, Kurian et al

20 Iqbal et.al. Differences in breast cancer stage at diagnosis and cancerspecific survival by race and ethnicity in the US.JAMA2015;313: More AGE SPECIFIC than Younger INCIDENCE Age & and MORTALITY Later Stage RATES 373,563 women with IBC, Tumors < 2 cm

21 Iqbal et.al. Differences in breast cancer stage at diagnosis and cancerspecific survival by race and ethnicity in the US.JAMA2015;313: More AGE SPECIFIC than Younger INCIDENCE Age & and MORTALITY Later Stage RATES 373,563 women with IBC, Tumors < 2 cm MEASURE BLACKS WHITES Lymph Node Metastases Distant Metastases Triple-Negative Tumor Cause-specific Death

22 Iqbal et.al. Differences in breast cancer stage at diagnosis and cancerspecific survival by race and ethnicity in the US.JAMA2015;313: More AGE SPECIFIC than Younger INCIDENCE Age & and MORTALITY Later Stage RATES 373,563 women with IBC, Tumors < 2 cm MEASURE BLACKS WHITES Lymph Node Metastases 24.1% 18.4% Distant Metastases Triple-Negative Tumor Cause-specific Death

23 Iqbal et.al. Differences in breast cancer stage at diagnosis and cancerspecific survival by race and ethnicity in the US.JAMA2015;313: More AGE SPECIFIC than Younger INCIDENCE Age & and MORTALITY Later Stage RATES 373,563 women with IBC, Tumors < 2 cm MEASURE BLACKS WHITES Lymph Node Metastases 24.1% 18.4% Distant Metastases 1.5% 1.0% Triple-Negative Tumor Cause-specific Death

24 Iqbal et.al. Differences in breast cancer stage at diagnosis and cancerspecific survival by race and ethnicity in the US.JAMA2015;313: More AGE SPECIFIC than Younger INCIDENCE Age & and MORTALITY Later Stage RATES 373,563 women with IBC, Tumors < 2 cm MEASURE BLACKS WHITES Lymph Node Metastases 24.1% 18.4% Distant Metastases 1.5% 1.0% Triple-Negative Tumor 17.2% 8.0% Cause-specific Death

25 Iqbal et.al. Differences in breast cancer stage at diagnosis and cancerspecific survival by race and ethnicity in the US.JAMA2015;313: More AGE SPECIFIC than Younger INCIDENCE Age & and MORTALITY Later Stage RATES 373,563 women with IBC, Tumors < 2 cm MEASURE BLACKS WHITES Lymph Node Metastases 24.1% 18.4% Distant Metastases 1.5% 1.0% Triple-Negative Tumor 17.2% 8.0% Cause-specific Death 9.0% 4.6%

26 Age and Stage by themselves are not significant, but rather, they gain importance by how they highlight differences in: Tumor biology Genomics Patterns of care

27 Tumor Biology: Receptors

28 Tumor Biology Howlander N, et al. US incidence of breast cancer subtypes defined by joint hormone receptor and HER2 status. JNCI. 2014;106

29 Tumor Biology Howlander N, et al. US incidence of breast cancer subtypes defined by joint hormone receptor and HER2 status. JNCI. 2014;106

30 Tumor Biology Howlander N, et al. US incidence of breast cancer subtypes defined by joint hormone receptor and HER2 status. JNCI. 2014;106

31 When TNBC patients were excluded from the analysis, breast cancer-specific survival remained significantly worse among premenopausal African American women. Iqbal et.al. Differences in breast cancer stage at diagnosis and cancer-specific survival by race and ethnicity in the US.JAMA2015;313:

32 AN Tumor Biology: Grade Higher Grade = Lower 10YS Schwartz AM, etal. Histologic grade remains a prognostic factor for breast cancer regardless of the number of positive lymph nodes and tumor size: a study of 161,708 cases of breast cancer from the SEER program. Arch Pathol Lab Med. 2014;138:

33 AN Tumor Biology: Grade AA have more Grade 3 tumors at Every Age, Every Stage, and Every Tumor Size (except < 1 cm) Henson DE,etal. Histologic grade, stage, and survival in breast carcinoma: comparison of African American and Caucasian women. Cancer. 2003; 98:

34 The research has demonstrated that tumor biology is different in many African American and white patients. It must be assessed as a potentially significant contributing factor to the survival disparity.

35 AGE SPECIFIC Genomics: INCIDENCE Germline & MORTALITY MutationsRATES

36 BRCA1 AGE SPECIFIC and BRCA2 INCIDENCE Germline & MORTALITY Mutations RATES BRCA 1 CHECKLIST: Premenopausal diagnosis Higher grade tumor Triple negative receptor status

37 BRCA1 AGE SPECIFIC and BRCA2 INCIDENCE Germline & MORTALITY Mutations RATES Positive Mutations: African ancestry = 28% Nanda R, et al. Genetic testing in an ethnically diverse cohort of high-risk women: a comparative analysis of BRCA1 and BRCA2 mutations in American families of European and African ancestry. JAMA. 2005;294:

38 BRCA1 AGE SPECIFIC and BRCA2 INCIDENCE Germline & MORTALITY Mutations RATES Positive Mutations: African ancestry = 28% Non-Jewish Whites = 46% Nanda R, et al. Genetic testing in an ethnically diverse cohort of high-risk women: a comparative analysis of BRCA1 and BRCA2 mutations in American families of European and African ancestry. JAMA. 2005;294:

39 AGE SPECIFIC BRCA1 INCIDENCE and & BRCA2 MORTALITY RATES Polymorphisms and VUS Variants: Nanda R, et al. Genetic testing in an ethnically diverse cohort of high-risk women: a comparative analysis of BRCA1 and BRCA2 mutations in American families of European and African ancestry. JAMA. 2005;294:

40 AGE SPECIFIC BRCA1 INCIDENCE and & BRCA2 MORTALITY RATES Polymorphisms and VUS Variants: African ancestry = 44% Non-Jewish Whites = 12% Nanda R, et al. Genetic testing in an ethnically diverse cohort of high-risk women: a comparative analysis of BRCA1 and BRCA2 mutations in American families of European and African ancestry. JAMA. 2005;294:

41 AGE Genomics: SPECIFIC INCIDENCE Somatic & Mutations: MORTALITY p53 RATES *Ademuyiwa FO, et al. Racial differences in genetic factors associated with breast cancer. Cancer Metastasis Rev. 2003;22: *Dookeran KA, et al. p53 as a marker of prognosis in African American women with breast cancer. Ann Surg Oncol. 2010;17: *Shiao YH, et al. Racial disparity in the association of p53 gene alterations with breast cancer survival. Cancer Res. 1995;55: *Blaszyk H, et al. Novel pattern of p53 gene mutations in an American black cohort with high mortality from breast cancer. Lancet. 1994;343:

42 Genomics: Germline and Somatic AGE SPECIFIC INCIDENCE Mutations & MORTALITY RATES The Cancer Genome Atlas The International Cancer Genome Atlas Germline and Somatic Mutations National Human Genome Research Insti- tute. The Cancer Genome Atlas. cancergenome.nih.gov. International Cancer Genome Consortium. ICGC Cancer Genome Projects. icgc.org.

43 AGE SPECIFIC INCIDENCE Epigenetics & MORTALITY RATES

44 AGE SPECIFIC Epigenetics: INCIDENCE RASSF1A & MORTALITY RATES Higher risk of relapse Worse survival Higher in AA, <50, HR (-) Mehrotra J, et al. Estrogen receptor/progesterone receptor- negative breast cancers of young African- American women have a higher frequency of methylation of multiple genes than those of Caucasian women. Clin Cancer Res. 2004;10:

45 AGE SPECIFIC Epigenetics: INCIDENCE & BRCA1 MORTALITY RATES CtBP links BRCA1 transcription and expression with metabolic status of cells Glycolysis or Hypoxia Obesity and Diabetes Di LJ, Fernandez AG, De Siervi A, Longo DL, Gardner K. Transcriptional regulation of BRCA1 expression by a metabolic switch. Nat Struct Mol Biol. 2010;17:

46 Chapter AGE SPECIFIC One:Tumor INCIDENCE Biology & MORTALITY and Genomics RATES although mammography uptake may be simi- lar, there remain differences in the quality and follow-up of abnormal imaging results.

47 African American Breast Cancer Mortality for the United States AGE SPECIFIC INCIDENCE & MORTALITY RATES Hunt et al. Increasing black:white disparities in breast cancer mortality in the 50 largest cities in the US. Cancer Epidemiol. 2014; 38:

48 Patterns of Care: Referral to AGE SPECIFIC Cancer INCIDENCE Risk & Clinics MORTALITY RATES Odds Ratio = 0.22; 95% CI, Armstrong K, Micco E, Carney A, Stopfer J, Putt M. Racial differences in the use of BRCA1/2 testing among women with a family history of breast or ovarian cancer. JAMA. 2005;293:

49 Patterns of Care: Referral to AGE SPECIFIC Cancer INCIDENCE Risk & Clinics MORTALITY RATES PATIENT INQUIRY! Odds Ratio = 5.52; 95% CI, Wideroff L et al. Physician use of genetic testing for cancer susceptibility: results of a national survey. Cancer Epidemiol Biomarkers Prev. 2003; 12:

50 Patterns of Care: Screening AGE SPECIFIC INCIDENCE Mammography & MORTALITY RATES 50.6% Blacks 51.5% Whites DeSantis C, etal. Cancer statistics for African Americans. CA Cancer J Clin. 2013;63:

51 Patterns of Care: Inequality of AGE SPECIFIC INCIDENCE Mammography & MORTALITY RATES Measure Primarily Minority Women Primarily Non-Hispanic White Women Academic 27% 71% Private 29% 43% Digital Mammo 18% 71% Dedicated Imager 23% 87% Ansell D, Grabler P, Whitman S, et al. A community effort to reduce the black/ white breast cancer mortality disparity in Chicago. Cancer Causes Control. 2009;20:

52 Patterns of Care: Inequality of AGE SPECIFIC Mammography INCIDENCE & Follow-up MORTALITY RATES 6722 Women with an Abnormal Mammogram 14 days Whites 20 days African Americans 21 days Hispanics Press R, et.al. Racial/ethnic disparities in time to follow-up after an abnormal mam- mogram. J Womens Health. 2008;17:

53 Patterns of Care: Inequality of AGE SPECIFIC Mammography INCIDENCE & Follow-up MORTALITY RATES Women with BIRADS 4,5 without Same Day Imaging 14 days Whites 23 days Hispanics P < days African Americans Press R, et.al. Racial/ethnic disparities in time to follow-up after an abnormal mam- mogram. J Womens Health. 2008;17:

54 AGE Patterns SPECIFIC of INCIDENCE Care: Delays & MORTALITY in Treatment RATES Mean Time from Dx to Tx: African American = 29.2 days Whites = 22.5 days P <.001 Silber JH, et al. Characteristics associated with differences in survival among black and white women with breast cancer. JAMA. 2013; 310:

55 AGE Patterns SPECIFIC of INCIDENCE Care: Delays & MORTALITY in Treatment RATES > 3 Months between Consultation and Tx: 22.4% African Americans 14.3% Whites Gwyn K, et al. Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer. 2004;100:

56 AGE Patterns SPECIFIC of INCIDENCE Care: Misuse & MORTALITY of Treatment RATES African American women with stage I or II disease were 60% less likely to receive appropriate treatment (P<.05), which was defined as meeting 2000 NCCN practice guidelines. Li CI, Malone KE, Daling JR. Differences in breast cancer stage, treatment, and survival by race and ethnicity. Arch Intern Med. 2003;163:49-56.

57 AGE Patterns SPECIFIC of INCIDENCE Care: Misuse & MORTALITY of Treatment RATES Use of a non-standard chemo regimen: 19% African American 11% Whites P =.0457 Griggs JJ, et al. Social and racial differences in selection of breast cancer adjuvant chemotherapy regimens. J Clin Oncol. 2007;25:

58 Patterns of Care: Underuse of Treatment Rates of definitive local therapy for Stages I and II breast cancer: AGE SPECIFIC INCIDENCE & MORTALITY RATES 82.8% African American 86.0% Whites P <.0001 Freedman RA, et al. Trends in racial and age disparities in definitive local therapy of early stage breast cancer. J Clin Oncol. 2009;27:

59 Patterns of Care: Underuse of Treatment Rates of chemotherapy for Stages I to III breast cancer at 10 different tx sites. AGE SPECIFIC INCIDENCE & MORTALITY RATES Griggs JJ, Racial disparity in the dose and dose intensity of breast cancer adjuvant chemotherapy. Breast Cancer Res Treat. 2003;81:21-31.

60 Patterns of Care: Underuse of Treatment Rates of chemotherapy for Stages I to III breast cancer at AGE SPECIFIC INCIDENCE & MORTALITY RATES 10 different tx sites. Lower dose proportion 0.80 African American 0.85 Whites P <.03 Griggs JJ, Racial disparity in the dose and dose intensity of breast cancer adjuvant chemotherapy. Breast Cancer Res Treat. 2003;81:21-31.

61 Patterns of Care: Underuse of Treatment Rates of chemotherapy for Stages I to III breast cancer at AGE SPECIFIC INCIDENCE & MORTALITY RATES 10 different tx sites. More African Americans had chemotherapy dose reductions for the first cycle of treatment (P<.05) Griggs JJ, Racial disparity in the dose and dose intensity of breast cancer adjuvant chemotherapy. Breast Cancer Res Treat. 2003;81:21-31.

62 AGE Patterns SPECIFIC of Care: INCIDENCE Underuse & MORTALITY of Treatment RATES 677 women s/p surgery for Stages I and II Underuse defined as Omissions of: 1.XRT after lumpectomy 2.Adjuvant chemotherapy after lumpectomy for HR (-) tumors >1 cm 3.Hormonal therapy for HR (+) tumors >1 cm. Bickell NA, et al. Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol. 2006;24:

63 AGE Patterns SPECIFIC of Care: INCIDENCE Underuse & MORTALITY of Treatment RATES Underuse of appropriate adjuvant treatment was found in: 34% African American 16% Whites P <.001 Bickell NA, et al. Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol. 2006;24:

64 AGE Patterns SPECIFIC of Care: INCIDENCE Underuse & MORTALITY of Treatment RATES 2378 low income breast cancer patients Number of days covered by Tamoxifen filled Rx Partridge AH, et al. Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. J Clin Oncol. 2003;21:

65 AGE Patterns SPECIFIC of Care: INCIDENCE Underuse & MORTALITY of Treatment RATES 2378 low income breast cancer patients Number of days covered by Tamoxifen filled Rx Nonwhite patients had significantly lower adherence rates than white patients (OR, 1.62; 95% CI ) High cost sharing and low income (P <.05) Partridge AH, et al. Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. J Clin Oncol. 2003;21:

66 Treatment adherence has been recently identified by the Association of American Medical Colleges as a critically underrepresented area in disparitiesfocused health services research

67 The same treatment strategies that have been shown to be delayed, misused, or underused in African American patients in the aforementioned studies have been demonstrated to improve disease-free and overall survival in large randomized trials.

68 These quality-of-care failures in breast cancer treatment for minority patients are thought to partially explain the racial survival disparity because it has been proposed that African American and white patients derive a similar benefit from systemic therapy when it is administered in accordance with their clinical and pathologic presentation. Dignam JJ. Efficacy of systemic adjuvant therapy for breast cancer in African- American and Caucasian women. J Natl Cancer Inst Monogr. 2001;2001:36-43.

69 AGE Patterns SPECIFIC of INCIDENCE Care: The & MORTALITY Trial Setting RATES The association between race and: Discontinuation/delay White blood cell counts Survival Hershman DL, et al. Treatment quality and outcomes of African American versus white breast cancer patients: retrospective analysis of Southwest Oncology Studies S8814/S8897. J Clin Oncol. 2009;27:

70 AGE Patterns SPECIFIC of INCIDENCE Care: The & MORTALITY Trial Setting RATES Discontinuation/delay: 87% vs 81% (P<.04). Not from toxicities Missed appointments: 19% vs 9% (P<.0002) Hershman DL, et al. Treatment quality and outcomes of African American versus white breast cancer patients: retrospective analysis of Southwest Oncology Studies S8814/S8897. J Clin Oncol. 2009;27:

71 AGE Patterns SPECIFIC of INCIDENCE Care: Economic & MORTALITY Barriers RATES

72 AGE Patterns SPECIFIC of INCIDENCE Care: The & MORTALITY Trial Setting RATES Discontinuation/delay: 87% vs 81% (P<.04). Not from toxicities Missed appointments: 19% vs 9% (P<.0002) Mean relative dose intensity: 87% vs 86% Hershman DL, et al. Treatment quality and outcomes of African American versus white breast cancer patients: retrospective analysis of Southwest Oncology Studies S8814/S8897. J Clin Oncol. 2009;27:

73 AGE Patterns SPECIFIC of INCIDENCE Care: The & MORTALITY Trial Setting RATES Survival Analysis: Disease-free survival (HR, 1.56; 95% CI, ) Overall survival (HR, 1.95; 95% CI, ) Hershman DL, et al. Treatment quality and outcomes of African American versus white breast cancer patients: retrospective analysis of Southwest Oncology Studies S8814/S8897. J Clin Oncol. 2009;27:

74 First, even in the controlled setting of a clinical trial, African American patients face barriers to optimal treatment. Second, despite attempts to control for treatment quality and delivery, African American women still had worse outcomes.

75 AGE SPECIFIC Patterns INCIDENCE of Care: & Comorbidity MORTALITY RATES 1 adverse comorbidity 86% vs 65.7 (OR, 3.20; 95% CI, ) Tammemagi CM, et al. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294:

76 AGE SPECIFIC Patterns INCIDENCE of Care: & Comorbidity MORTALITY RATES 1 adverse comorbidity 86% vs 65.7 (OR, 3.20; 95% CI, ) Tammemagi CM, et al. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294:

77 Patterns of Care: Comorbidity and AGE SPECIFIC INCIDENCE Obesity & MORTALITY RATES 1 adverse comorbidity 86% vs 65.7 (OR, 3.20; 95% CI, ) Tammemagi CM, et al. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294:

78 Patterns of Care: Comorbidity and AGE SPECIFIC INCIDENCE Obesity & MORTALITY RATES 1 adverse comorbidity 86% vs 65.7 (OR, 3.20; 95% CI, ) 72% African Americans 49.7% of whites (P <.001). *Griggs JJ,et al. Under- treatment of obese women receiving breast cancer chemotherapy. Arch Intern Med. 2005;165: *Cohen SS, et al. Obesity and screening for breast, cervical, and colorectal cancer in women: a review. Cancer. 2008;112: *Elmore JG, et al. The association between obesity and screening mammography accuracy. Arch Intern Med. 2004;164: Tammemagi CM, et al. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294:

79 Patterns of Care: Comorbidity and AGE SPECIFIC INCIDENCE Obesity & MORTALITY RATES Griggs still receive nonstandard tx Clinical Trials worse survival, controlled comorbidities Hershmann worse survival, controlled BSA Curtis - comorbidity contributed 2% in their model Curtis E, et al. Racial and ethnic differences in breast cancer survival: how much is explained by screening, tumor severity, biology, treatment, comorbidities, and demographics? Cancer.2008;112:

80 The unfolding story of the search for the source of the breast cancer racial survival disparity has identified protagonists: Chapter One: tumor biology and genomics, and Chapter Two: differences in screening, followup, and treatment. However, the consensus from the research is that no feature alone is sufficient to explain the breast cancer survival gap.

81 The conclusion to be drawn this: To close the gap, policymakers must consider both the biological differences and the patterns of care differences concurrently to form effective interventions.

82 Interventions: Insurance

83 Interventions: Insurance Advanced-stage disease No breast-conserving surgery for nonmetastatic T1/T2 tumors Receive nonstandard treatment. *Ayanian JZ,et al. The relationship between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med. 1993;329: *Coburn N,et al. Treatment variation by insurance status for breast cancer patients. Breast J. 2008;14: *Voti L,et al. The effect of race/ethnicity and insurance in the administration of standard therapy for local breast cancer in Florida. Breast Can- cer Res Treat. 2006;95:89-95.

84 AGE SPECIFIC Interventions: INCIDENCE & Insurance MORTALITY RATES The effect of race and health insurance on the diagnostic time. Hypothesis: Every insured patient would receive the same timely diagnosis as any other patient with equivalent insurance, regardless of race or ethnicity. Hoffman HJ,et al. Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the Dist of Columbia. Cancer2011;117:

85 AGE SPECIFIC Interventions: INCIDENCE & Insurance MORTALITY RATES The effect of race and health insurance on the diagnostic time. With government insurance: Whites = 12 days African Americans = 39 days With private insurance: Whites = 16 days African Americans = 27 days P<.0003 Hoffman HJ,et al. Having health insurance does not eliminate race/ethnicity-associated delays in breast cancer diagnosis in the Dist of Columbia. Cancer2011;117:

86 Interventions must go beyond just providing health insurance to minorities in order to have a significant impact on the mortality gap.

87 Interventions: Patient Education and Physician Communication Low-income Ethnically diverse women Older than 40 years Allen JD, et al. Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. Patient Educ Couns. 2008;72:

88 Interventions: Patient Education and Physician Communication Themes in those who delayed timely follow-up: Dissatisfaction with the communication of results Disrespect on the part of providers and clinic staff Logistical barriers to accessing services Anxiety and fear about a possible cancer diagnosis Lack of information about breast cancer screening and symptoms. Allen JD, et al. Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study. Patient Educ Couns. 2008;72:

89 Interventions: Patient Education and Physician Communication Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res. 2008;43:

90 Interventions: Patient Education and Physician Communication Minority women were more likely than whites to be uncertain about : Survival knowledge Recurrence risk (P <.001) Neither surgeon characteristics nor treatment setting attenuated observed racial disparities in knowledge. Hawley ST, Fagerlin A, Janz NK, Katz SJ. Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go? Health Serv Res. 2008;43:

91 Without effective, culturally competent communication, there are treatment delays and omissions that result in poor quality care. These communication deficits are found across provider and treatment center types.

92 Interventions: Culturally Competent Communication African immigrants: Have limited knowledge about cancer care Associate breast cancer with certain death Sometimes attribute breast cancer to a punishment from God Have ideas, emotions, and cultural values perceived to be at odds with screening and medicine *Hurtado-de-Mendoza A,et al.addressing cancer control needs of African-born immigrants in the US: a systematic litera- ture review. Prev Med. 2014;67: *Percac-Lima S, et al.decreasing disparities in breast cancer screening in refugee women using culturally tailored patient navigation. J Gen Intern Med. 2013;28:

93 Interventions: Culturally Competent Communication African immigrants were educated with a linguistically and culturally tailored breast cancer screening program: Mammography rates for refugee women in the program climbed from 64.1% to 81.2% *Hurtado-de-Mendoza A,et al.addressing cancer control needs of African-born immigrants in the US: a systematic litera- ture review. Prev Med. 2014;67: *Percac-Lima S, et al.decreasing disparities in breast cancer screening in refugee women using culturally tailored patient navigation. J Gen Intern Med. 2013;28:

94 Interventions: Patient Navigation Vargas RB,et al. Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treat- ment of breast cancer. Cancer. 2008;113:

95 Interventions: Patient Navigation 4-fold reduction in the time to diagnostic resolution for navigated women versus nonnavigated women who resolved with cancer. Hoffman HJ,, et al. Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia. Cancer Epidemiol Biomarkers Prev. 2012;21:

96 Interventions: Patient Navigation Hypothesis: Breast cancer patients assigned a navigator would be more likely to receive recommended standard treatment than patients without a navigator. Quality measures were having patients start: Antiestrogens Radiation Chemo Ko NY, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from a national patient navigation research program. J Clin Oncol. 2014;32:

97 Interventions: Patient Navigation Hypothesis: Breast cancer patients assigned a navigator would be more likely to receive recommended standard treatment than patients without a navigator. Quality measures were having patients start: Antiestrogens P<.004 Radiation P<.22 Chemo could not assess Ko NY, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from a national patient navigation research program. J Clin Oncol. 2014;32:

98 Interventions: Patient Navigation Barriers faced by minority patients with breast cancer Intrapersonal Interpersonal Institutional Knowledge Belief Attitudes Transportation Financial barriers Social support system Child care Employment issues Policies Characteristics Tejeda S,et al. Patient barriers to follow-up care for breast and cervical cancer abnormalities. J Womens Health. 2013;22:

99 Patient navigation in a vacuum does not work. It is only in examining the entire health care system that changes can be implemented to eliminate barriers to quality care and to close the racial mortality chasm.

100 Interventions: System Change A systematic review of the disparities intervention literature: Change the patient: education, training Health care system improvements Community involvement Ko NY, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from a national patient navigation research program. J Clin Oncol. 2014;32:

101 Interventions: System Change A systematic review of the disparities intervention literature: Providers Health care institutions Community organizers Policy makers Ko NY, et al. Can patient navigation improve receipt of recommended breast cancer care? Evidence from a national patient navigation research program. J Clin Oncol. 2014;32:

102 Interventions: System Change! A tracking and feedback registry to close the referral loop between surgeons and oncologists to decrease the underuse of valuable adjuvant treatments. Leadership Tracking software Bickell NA, Shastri K, Fei K, et al. A track- ing and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst. 2008;100:

103 Interventions: System Change! Among African American and Hispanic women, there were statistically significant decreases in the underuse of: Radiotherapy: 23% before vs 10% after (P<.02) Chemotherapy 26% before vs 6% after (P<.01) Hormonal tx 27% before vs 11% after (P<.01) Bickell NA, Shastri K, Fei K, et al. A track- ing and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst. 2008;100:

104 Interventions: Delivery System Reform Fox J. Lessons from an oncology medical home collaborative. Am J Manag Care. 2013;19:SP5-SP9.

105 Interventions: Delivery System Reform Accountable Care Organizations (ACOs)

106 Interventions: Delivery System Reform

107 Interventions: Precision Medicine Initiative Zhang SQ, Polite BN. Achieving a deeper understanding of the implemented provisions of the Affordable Care Act. Am Soc Clin Oncol Educ Book. 2014

108 Interventions: Precision Medicine Initiative

109 The Book of Life and Death

110 The Book of Life and Death Tumor biology and Genomics Patterns of care

111 The Book of Life and Death

112 pinklotusfoundation.org facebook.com/pinklotusfoundation

113 vegasin24.com facebook.com/vegasin24