Differential response to neoadjuvant endocrine therapy for Black/African American and White women in NCDB.

PURPOSE: Compared to White women, there are higher mortality rates in Black/African American (BAA) women with hormone receptor-positive breast cancer (HR + BC) which may be partially due to differences in treatment resistance. We assessed factors associated with response to neoadjuvant endocrine therapy (NET). METHODS: The National Cancer Database (NCDB) was queried for women with clinical stage I-III HR + BC diagnosed 2006-2017 and treated with NET. Univariate and multivariate analyses described associations between the sample, duration of NET, and subsequent treatment response, defined by changes between clinical and pathological staging. RESULTS: The analytic sample included 9864 White and 1090 BAA women. Compared to White women, BAA women were younger, had more co-morbidities, were higher stage at presentation, and more likely to have > 24 weeks of NET. After excluding those with unknown pT/N/M, 3521 White and 365 BAA women were evaluated for NET response. On multivariate analyses, controlling for age, stage, histology, HR positivity, and duration of NET, BAA women were more likely to downstage to pT0/Tis (OR 3.0, CI 1.2-7.1) and upstage to Stage IV (OR 2.4, CI 1.002-5.6). None of the women downstaged to pT0/Tis presented with clinical stage III disease; only 2 of the women upstaged to Stage IV disease presented with clinical Stage I disease. CONCLUSION: Independent of NET duration and clinical stage at presentation, BAA women were more likely to experience both complete tumor response and progression to metastatic disease. These results suggest significant heterogeneity in tumor biology and warrant a more nuanced therapeutic approach to HR + BC.

Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study.

PURPOSE: To examine racial-ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors. METHODS: Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties. RESULTS: Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79-0.88), ORAIAN 0.66 (0.54-0.81); known stage: ORBlack 0.87 (0.80-0.94), ORAIAN 0.63 (0.47-0.85); seeing an oncologist: ORBlack 0.75 (0.71-0.79), ORAIAN 0.60 (0.47-0.72); locoregional treatment: ORBlack 0.80 (0.76-0.84), ORAIAN 0.84 (0.68-1.02); systemic therapies: ORBlack 0.90 (0.83-0.98), ORAIAN 0.66 (0.48-0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits. CONCLUSIONS: This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial-ethnic disparities in breast cancer care.

Anti-racism bystander training: A critical need in medical schools.

Despite increasing acknowledgment of racism in both the curricular and clinical spaces, it continues to pervade the medical field, with clear detrimental impacts to the health of our patients. The introduction of anti-racism bystander training (ARBT) may provide a unique opportunity to reduce inequitable care and health disparities that occur secondary to racism in healthcare. ARBT, in its various forms, has been shown to be an effective method to increase participants' confidence and efficacy in intervening on observed racist encounters. This training can take numerous forms, and the authors provide one successful template used with medical students at their own institution. If medical centers, educators, and leaders in the field of medicine truly hope to mitigate the individual racist behaviors that remain in healthcare, ARBT must be employed to a much wider degree in medical education.

Stigma manifestations in cardiomyopathy care impact outcomes for black patients: a qualitative study.

INTRODUCTION: Inequities in clinical care may contribute to racial disparities observed in studies of heart disease morbidity and cardiogenetic testing outcomes. There is a lack of research aimed at understanding the complexity of those inequities, but stigma likely contributes. This qualitative exploratory study helps close that gap in the literature by describing intersectional stigma manifestations perceived by the Black cardiomyopathy patient population at one academic medical center. METHODS: Qualitative interviews were conducted with 14 Black cardiomyopathy patients. Interviews aimed to elicit patients' experiences with discrimination related to diagnosis, symptoms, genetic testing, knowledge of genetic results, genetic counseling, providers' actions, and providers' communication. The interview guide was informed by The Health Stigma and Discrimination Framework. Data were also collected about participant demographics, type of cardiomyopathy, age of diagnosis, documentation of relevant family history, and completion of genetic counseling and/or genetic testing. RESULTS: More than half of participants reported intersectional stigma manifestations related to their race, age, and/or weight while receiving care from cardiologists, nurse practitioners, genetic counselors, or clinical support staff. Stigma manifestations included physical roughness during patient care, withholding diagnostically-relevant information from the patient, impersonal care, coercion, and use of offensive stereotyped language by providers. These stigma manifestations impacted access to care, uptake of genetic testing, timeline to diagnosis, patient emotion, patient-provider trust, and adherence to medical recommendations. CONCLUSIONS: This study provides nuanced qualitative descriptions of stigma manifestations that affect patient and clinical outcomes in cardiology care and genetic services in one medical center in the Southeastern United States. The results of this study suggest that provider bias and stigma manifestations have an adverse effect on cardiogenetic and clinical outcomes among Black cardiomyopathy patients. Clinical interventions are suggested to assist health professionals in providing culturally-competent and respectful care. These results help inform patient-provider communication, clinical policies, and evidence-based practice in cardiology care and genetics. Continued study of this topic across more institutions and with a larger sample size is needed to confirm the generalizability of the conclusions.

Re-imagining metastatic breast cancer care delivery: a patient-partnered qualitative study.

PURPOSE: While significant progress in metastatic breast cancer (MBC) treatment has prolonged survival and improved prognosis, there remain substantial gaps in providing patient-centered supportive care. The specific care delivery needs for metastatic cancer differ from that of early-stage cancer due to the incurable nature and lifelong duration of the condition. The objective of this study was to assess how patients living with MBC would re-imagine cancer care delivery. METHODS: This qualitative study was conducted in partnership with patient-led organizations Guiding Researchers and Advocates to Scientific Partnerships (GRASP) and Project Life, a nonprofit, online wellness community founded by patients with MBC for patients living with MBC. Virtual semi-structured interviews (n = 36) were conducted with Project Life members purposively sampled from the groups' overall membership. The interview guide contained items surrounding patients' lived experiences of MBC, greatest unmet needs related to care, and perspectives on virtual wellness community involvement. Interviews were coded using two-stage deductive and inductive analysis. RESULTS: Three major themes for re-imagining cancer care delivery were identified, including holistic care, information needs, and conceptual shifts. Within these several subthemes emerged with patients re-imagining referrals to non-oncological services, caregiver support, acceptance of integrative medicine, streamlined clinical trial enrollment, curated quality patient resources, MBC-specific terminology and approaches, long-term life and goal-of-care planning, and patient-centered voice throughout. CONCLUSION: People living with metastatic cancers have specific supportive care needs. These findings highlight patient-driven areas for re-imagination that are most salient for individuals with MBC.

Trends in surgical treatment of early-stage breast cancer reveal decreasing mastectomy use between 2003 and 2016 by age, race, and rurality.

PURPOSE: To examine trends in the surgical treatment of breast cancer by age, rurality, and among Black women in a populous, racially diverse, state in the Southeastern United States of America. METHODS: We identified women diagnosed with localized or regional breast cancer between 2003 and 2016 in the North Carolina Central Cancer Registry (n = 86,776). Using Joinpoint regression we evaluated the average annual percentage change in proportion of women treated with mastectomy versus breast-conserving surgery overall, by age group, among Black women, and for women residing in rural areas. RESULTS: Overall, the rate of mastectomy usage in the population declined 2.5% per year between 2003 and 2016 (95% CI - 3.2, - 1.7). Over this same time interval, breast-conserving surgery increased by 1.6% per year (95% CI 0.9, 2.2). These temporal trends in surgery were also observed among Black women and rural residing women. Trends in surgery type varied by age group: mastectomy declined over time among women > 50 years, but not among women aged 18-49 at diagnosis. DISCUSSION: In contrast to national studies that reported increasing use of mastectomy, we found declining mastectomy rates in the early 2000s in a Southern US state with a racially and geographically diverse population. These decreasing trends were consistent among key subgroups affected by cancer inequities, including Black and White rural women.

Validity of breast cancer surgery treatment information in a state-based cancer registry.

PURPOSE: Surgery is an important part of early stage breast cancer treatment that affects overall survival. Many studies of surgical treatment of breast cancer rely on data sources that condition on continuous insurance coverage or treatment at specified facilities and thus under-sample populations especially affected by cancer care inequities including the uninsured and rural populations. Statewide cancer registries contain data on first course of cancer treatment for all patients diagnosed with cancer but the accuracy of these data are uncertain. METHODS: Patients diagnosed with stage I-III breast cancer between 2003 and 2016 were identified using the North Carolina Central Cancer Registry and linked to Medicaid, Medicare, and private insurance claims. We calculated the sensitivity, specificity, positive predictive value, negative predictive value, and Kappa statistics for receipt of surgery and type of surgery (breast conserving surgery or mastectomy) using the insurance claims as the presumed gold standard. Analyses were stratified by race, insurance type, and rurality. RESULTS: Of 26,819 patients who met eligibility criteria, 23,125 were identified as having surgery in both the claims and registry for a sensitivity of 97.9% (95% CI 97.8%, 98.1%). There was also strong agreement for surgery type between the cancer registry and the insurance claims (Kappa: 0.91). Registry treatment data validity was lower for Medicaid insured patients than for Medicare and commercially insured patients. CONCLUSIONS: Cancer registry treatment data reliably identified receipt and type of breast cancer surgery. Cancer registries are an important source of data for understanding cancer care in underrepresented populations.

Performance of ABCD-10 and SCORTEN mortality prediction models in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis.

BACKGROUND: Age, bicarbonate, cancer, dialysis, 10% body surface area risk model (ABCD-10) has recently been proposed as an alternative to the SCORe of toxic epidermal necrolysis (SCORTEN) model for predicting in-hospital mortality in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). In contrast to SCORTEN, ABCD-10 incorporates prior dialysis and upweights the impact of cancer. OBJECTIVE: To determine the performance of ABCD-10 compared with that of SCORTEN in mortality prediction at a large, tertiary burn center. METHODS: A retrospective analysis of 192 patients with SJS/TEN admitted to the North Carolina Jaycee Burn Center from January 1, 2009, to December 31, 2019, was conducted. Data on these patients were collected using the burn registry and a manual chart review. The performance of both the mortality prediction models was assessed using univariate logistic regression and the Hosmer-Lemeshow test. RESULTS: The overall mortality was 22% (n = 43). Nine (5%) patients had cancer, and 7 (4%) had undergone prior dialysis; neither factor was associated with mortality (P = .11 and P = .62, respectively). SCORTEN was well calibrated to predict inpatient mortality (P = .82), whereas ABCD-10 appeared to have a poorer fit (P < .001) in these patients. Both the models showed good discrimination. LIMITATIONS: Small sample size. CONCLUSION: SCORTEN was a better predictor of inpatient mortality than ABCD-10 in a North American cohort of patients treated at the tertiary burn center.

Obesity Increases the Risk of Hospital Readmission Following Intestinal Surgery for Children With Crohn Disease.

OBJECTIVES: Obese habitus can lead to adverse outcomes for colorectal surgeries due to technical challenges and pro-inflammatory immune mediators associated with excess adipose tissue. Surgical planning, pre-operative risk stratification, and patient counseling of pediatric Crohn disease (CD) patients are limited by the scarcity of data on this topic. We sought to determine the association between obesity and hospital readmission in children with CD undergoing intestinal resection. METHODS: We used the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to identify pediatric CD patients undergoing intestinal resection between 2012 and 2018. We calculated age- and sex-adjusted body mass index (BMI) z scores using CDC population statistics. We used logistic regression to evaluate the association between obesity and readmission compared to average-BMI patients adjusting for age, race, sex, steroid exposure, disease activity, and surgery type. RESULTS: We evaluated 1258 pediatric CD intestinal resections occurring between 2012 and 2018. Patients were predominantly adolescent (91%), white (84%), and male (56%). Those with average BMI comprised 50% of the cohort, 31% were underweight, 11% overweight, and 8% obese. The overall 30-day hospital readmission rate was 8.8%. Compared to those with average BMI, obese children had a 2-fold (adjusted odds ratio 1.9, 95% confidence interval 1.0-3.8) increase in risk of hospital readmission. CONCLUSIONS: Obese patients undergoing intestinal resection face a higher risk of 30-day hospital readmission compared to average-BMI patients. These results can inform pre-surgical risk counseling and underscore the need for long-term weight management strategies to aid in risk reduction for obese children with CD at risk of future surgery.

Premenopausal gynecologic surgery and survival among black and white women with breast cancer.

PURPOSE: In the United States, hysterectomies and oophorectomies are frequently performed before menopause for benign conditions. The procedures are associated with reduced breast cancer-specific mortality among White women. The relationship between premenopausal gynecologic surgery and mortality in Black women with breast cancer is unknown. METHODS: This investigation used incident invasive cases of breast cancer from Phases 1 and 2 of the Carolina Breast Cancer Study a population-based study that recruited Black and White women in North Carolina between 1993 and 2001. Premenopausal gynecologic surgery was operationalized in three categories: no surgery; hysterectomy with bilateral oophorectomy; hysterectomy with conservation of ≥ 1 ovary. Mortality was ascertained using the National Death Index, last updated in 2016. Multivariable-adjusted Cox Proportional Hazard Models were used to estimate the effect of premenopausal surgery on breast cancer-specific and all-cause mortality RESULTS: Hysterectomy with bilateral oophorectomy was associated with reduced breast cancer-specific mortality (HR 0.68; 95% CI 0.49, 0.96). White and Black women had a similar reduction in breast cancer-specific mortality. (HR among white: 0.66; 95% CI 0.43, 1.02), (HR among Black: 0.67; 95% CI 0.37, 1.21). CONCLUSIONS: There was a similar reduction in breast cancer-specific mortality following premenopausal, pre-diagnosis hysterectomy with bilateral oophorectomy across both Black and White women.

Effectiveness of Fresh to You, a Discount Fresh Fruit and Vegetable Market in Low-Income Neighborhoods, on Children's Fruit and Vegetable Consumption, Rhode Island, 2010-2011.

INTRODUCTION: Eating fruits and vegetables is associated with lowered risk for many chronic diseases. However, most Americans, especially members of low-income and minority populations, do not eat adequate amounts. Fresh to You is a public-private partnership program that brings discount fresh produce markets into low-income neighborhoods. We conducted a mixed-methods evaluation of Fresh to You to assess the effect of the program on children's consumption of fruits and vegetables. METHODS: A local produce distributor brought the Fresh to You markets to 6 community organizations serving low-income families in Rhode Island. The markets, held weekly for 5 months at each site, sold fresh produce at below-retail prices. Parents (N = 480) of children aged 3 to 13 years were recruited at the markets to participate in a 5-month cohort study. The primary outcome was change in children's fruit and vegetable intake, measured by a validated screener. We also conducted postintervention focus groups at each site with parents and qualitative interviews with site contacts to collect feedback about Fresh to You. RESULTS: From baseline to 5 months, there was a significant increase in children's daily fruit and vegetable consumption of 0.48 cups (t = 4.16, P < .001). Data from follow-up parent surveys, focus groups, and site contact interviews provided positive feedback about Fresh to You and recommendations for improvement. CONCLUSION: Fresh to You was effective at increasing consumption of fruits and vegetables among racially and ethnically diverse low-income children aged 3 to 13 years whose parents shopped at the markets. The intervention could serve as a model program for replication in other cities. Refinements and a more rigorous evaluation are needed.

Oncologists Must Consider Participant Data When Using Large-Scale Cancer Data Sets.

Primer that helps clarify large-scale clinical data sets and participant demographics for oncologists.

Racial discrimination and healthcare system trust among American adults with and without cancer.

BACKGROUND: Racial and ethnic minoritized groups report disproportionately lower trust in the healthcare system. Lower healthcare system trust is potentially related to increased exposure to racial discrimination in medical settings, but this association is not fully understood. We examined the association between racial discrimination in medical care and trust in the healthcare system among people with and without a personal cancer history. METHODS: We examined racial discrimination and trust in a nationally representative American adult sample from the Health Information National Trends Survey 6. Racial discrimination was defined as any unfair treatment in healthcare based on race or ethnicity. Trust in the healthcare system (eg, hospitals and pharmacies) was grouped into low, moderate, and high trust. Multinomial logistic regression models were used to compare low and moderate trust relative to high trust in the healthcare system and estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: A total of 5,813 respondents (15% with a personal cancer history) were included 92% (n = 5,355) reported no prior racial discrimination experience during medical treatment. Prior experiences of racial discrimination were positively associated with low (OR = 6.12, 95% CI: 4.22-8.86) and moderate (OR = 2.70, 95% CI: 1.96-3.72) trust in the healthcare system, relative to high trust. Similar associations were observed when stratifying by personal cancer history. CONCLUSION: Respondents who reported racial discrimination during medical encounters had lower trust in the healthcare system, especially respondents with a personal cancer history. Our findings highlight the need to address racial discrimination experiences during medical care to build patient trust and promote healthcare access.

Structural Racism and Treatment Delay Among Black and White Patients With Breast Cancer.

PURPOSE: Structural racism (SR) is a potential driver of health disparities, but research quantifying its impacts on cancer outcomes has been limited. We aimed to develop a multidimensional county-level SR measure and to examine the association of SR with breast cancer (BC) treatment delays among Black and White patients. METHODS: The cohort included 32,095 individuals from the North Carolina Central Cancer Registry with stage I to III BC diagnosed between 2004 and 2017 and linked to multipayer insurance claims from the Cancer Information and Population Health Resource. County-level data were drawn from multiple public sources aggregated in the Robert Wood Johnson County Health Rankings database. Racial gaps in eight social determinants across five domains were quantified at the county level and ranked on a 0-100 minimum-maximum scale. Domain scores were averaged to create a SR Composite Index (SRCI) score. We used multilevel logistic regression with random intercepts and multiple cross-level interaction terms to evaluate the association between county-level SRCI and patient-level treatment delays, adjusting for patient-level characteristics and stratified by race. RESULTS: The SRCI score ranged from 21 to 75 with a median (IQR) of 39.0 (31.8, 45.7). For Black patients, a 10-unit increase in SRCI score was associated with increased odds of delay (Adjusted odds ratios [aOR], 1.25; 95% confidence limits [CL], 1.08 to 1.45). No such association was found for White patients (OR, 1.05; 95% CL, 0.97 to 1.15). CONCLUSION: Area-level SR measured by a composite index is associated with higher odds of BC treatment delays among Black, but not White patients. Increasing county-level SR is associated with increasing Black-White disparities in treatment delay. Further research is needed to refine the measurement of SR and to examine its association with other cancer care disparities.

Material, Psychological, and Behavioral Financial Hardship Among Lesbian, Gay, and Bisexual Cancer Survivors in the United States.

PURPOSE: Driven by anti-LGBTQ+ stigma, emerging literature suggests that lesbian, gay, and bisexual (LGB) cancer survivors experience financial hardship (FH) more frequently than heterosexual survivors. However, few studies have used nationally representative samples to estimate this inequity. METHODS: National Health Interview Survey data from 2019 to 2022 were pooled and weighted. Outcomes included material, psychological, and behavioral FH. The behavioral domain was further broken down into subdomains including medical care, prescription medications, and mental health care. Multivariable logit models controlling for a variety of factors were used to generate LGB and heterosexual predicted probabilities and differential effects for each FH outcome. Stratified estimates were generated by sex and age groups. RESULTS: A total of N = 374 LGB and N = 12,757 heterosexual cancer survivors were included in this analysis. In adjusted analyses, LGB cancer survivors had significantly higher material (19%, 95% CI, 15 to 24 v 12%, 95% CI, 11 to 13; P = .004), psychological (44%, 95% CI, 38 to 51 v 37%, 95% CI, 36 to 38; P = .035), and behavioral (23%, 95% CI, 18 to 28 v 13%, 95% CI, 13 to 14; P < .0001) FH than heterosexual survivors. LGB cancer survivors also had higher medical behavioral (11%, 95% CI, 7 to 15 v 7%, 95% CI, 6 to 7; P = .030), prescription medication behavioral (14%, 95% CI, 10 to 19 v 10%, 95% CI, 9 to 10; P = .032), and mental health behavioral (9%, 95% CI, 6 to 13 v 3%, 95% CI, 3 to 4; P < .0001) FH than heterosexual survivors. Stratified estimates revealed young LGB cancer survivors had the highest probability of each outcome (material: 31%, 95% CI, 23 to 40; psychological: 58%, 95% CI, 50 to 66; behavioral: 45%, 95% CI, 36 to 53). CONCLUSION: In this nationally representative analysis, LGB cancer survivors experience substantial inequities in all FH outcomes. It is crucial that future FH interventional work should prioritize populations at the highest risk of FH, such as LGB cancer survivors.

Simulating the population impact of interventions to reduce racial gaps in breast cancer treatment.

BACKGROUND: Inequities in guideline-concordant treatment receipt contribute to worse survival in Black patients with breast cancer. Inequity-reduction interventions (eg, navigation, bias training, tracking dashboards) can close such treatment gaps. We simulated the population-level impact of statewide implementation of inequity-reduction interventions on racial breast cancer inequities in North Carolina. METHODS: Using registry-linked multipayer claims data, we calculated inequities between Black and White patients receiving endocrine therapy (n = 12 033) and chemotherapy (n = 1819). We then built cohort-stratified (endocrine therapy and chemotherapy) and race-stratified Markov models to simulate the potential increase in the proportion of patients receiving endocrine therapy or chemotherapy and subsequent improvements in breast cancer outcomes if inequity-reducing intervention were implemented statewide. We report uncertainty bounds representing 95% of simulation results. RESULTS: In total, 75.6% and 72.1% of Black patients received endocrine therapy and chemotherapy, respectively, over the 2006-2015 and 2004-2015 periods (vs 79.3% and 78.9% of White patients, respectively). Inequity-reduction interventions could increase endocrine therapy and chemotherapy receipt among Black patients to 89.9% (85.3%, 94.6%) and 85.7% (80.7%, 90.9%). Such interventions could also decrease 5-year and 10-year breast cancer mortality gaps from 3.4 to 3.2 (3.0, 3.3) and from 6.7 to 6.1 (5.9, 6.4) percentage points in the endocrine therapy cohorts and from 8.6 to 8.1 (7.7, 8.4) and from 8.2 to 7.8 (7.3, 8.1) percentage points in the chemotherapy cohorts. CONCLUSIONS: Inequity-focused interventions could improve cancer outcomes for Black patients, but they would not fully close the racial breast cancer mortality gap. Addressing other inequities along the cancer continuum (eg, screening, pre- and postdiagnosis risk factors) is required to achieve full equity in breast cancer outcomes.

Disparities in OncotypeDx Testing and Subsequent Chemotherapy Receipt by Geography and Socioeconomic Status.

BACKGROUND: OncotypeDx is a prognostic and predictive genomic assay used in early-stage hormone receptor-positive, HER2- (HR+/HER2-) breast cancer. It is used to inform adjuvant chemotherapy decisions, but not all eligible women receive testing. We aimed to assess variation in testing by demographics and geography, and to determine whether testing was associated with chemotherapy. METHODS: For 1,615 women in the Carolina Breast Cancer Study with HR+/HER2-, Stage I-II tumors, we estimated prevalence differences (PD) and 95% confidence intervals (CI) for receipt of OncotypeDx genomic testing in association with and sociodemographic characteristics. We assessed associations between testing and chemotherapy receipt overall and by race. Finally, we calculated the proportion of eligible women receiving OncotypeDx by county-level rurality, census tract-level socioeconomic status, and Area Health Education Center regions. RESULTS: 38% (N = 609) of potentially eligible women were tested, with lower testing prevalences in Black (31%; PD, -11%; 95% CI, -16%-6%) and low-income women (24%; PD, -20%; 95% CI, -29% to -11%) relative to non-Black and higher income women. Urban participants were less likely to be tested than rural participants, though this association varied by region. Among women with low genomic risk tumors, tested participants were 29% less likely to receive chemotherapy than untested participants (95% CI, -40% to -17%). Racial differences in chemotherapy were restricted to untested women. CONCLUSIONS: Both individual and area-level socioeconomics predict likelihood of OncotypeDx testing. IMPACT: Variable adoption of OncotypeDx by socioeconomics and across geographic settings may contribute to excess chemotherapy among patients with HR+/HER2- cancers. See related In the Spotlight, p. 635.

Risk of Mortality After a Diagnosis of Melanoma In Situ.

Importance: The incidence of melanoma in situ (MIS) is increasing more rapidly than any invasive or in situ cancer in the US. Although more than half of melanomas diagnosed are MIS, information about long-term prognosis following a diagnosis of MIS remains unknown. Objective: To evaluate mortality and factors associated with mortality after a diagnosis of MIS. Design, Setting, and Participants: This population-based cohort study of adults with a diagnosis of first primary MIS from 2000 to 2018 included data from the US Surveillance, Epidemiology, and End Results Program, which were analyzed from July to September 2022. Main Outcomes and Measures: Mortality after a diagnosis of MIS was evaluated using 15-year melanoma-specific survival, 15-year relative survival (ie, compared with similar individuals without MIS), and standardized mortality ratios (SMRs). Cox regression was used to estimate hazard ratios (HRs) for death by demographic and clinical characteristics. Results: Among 137 872 patients with a first-and-only MIS, the mean (SD) age at diagnosis was 61.9 (16.5) years (64 027 women [46.4%]; 239 [0.2%] American Indian or Alaska Native, 606 [0.4%] Asian, 344 [0.2%] Black, 3348 [2.4%] Hispanic, and 133 335 [96.7%] White individuals). Mean (range) follow-up was 6.6 (0-18.9) years. The 15-year melanoma-specific survival was 98.4% (95% CI, 98.3%-98.5%), whereas the 15-year relative survival was 112.4% (95% CI, 112.0%-112.8%). The melanoma-specific SMR was 1.89 (95% CI, 1.77-2.02); however, the all-cause SMR was 0.68 (95% CI, 0.67-0.7). Risk of melanoma-specific mortality was higher for older patients (7.4% for those 80 years or older vs 1.4% for those aged 60-69 years; adjusted HR, 8.2; 95% CI, 6.7-10.0) and patients with acral lentiginous histology results (3.3% for acral lentiginous vs 0.9% for superficial spreading; HR, 5.3; 95% CI, 2.3-12.3). Of patients with primary MIS, 6751 (4.3%) experienced a second primary invasive melanoma and 11 628 (7.4%) experienced a second primary MIS. Compared with patients without a subsequent melanoma, the risk of melanoma-specific mortality was increased for those with a second primary invasive melanoma (adjusted HR, 4.1; 95% CI, 3.6-4.6) and was decreased for those with a second primary MIS (adjusted HR, 0.7; 95% CI, 0.6-0.9). Conclusions and relevance: The results of this cohort study suggest that patients with a diagnosis of MIS have an increased but low risk of melanoma-specific mortality and live longer than people in the general population, suggesting that there is significant detection of low-risk disease among health-seeking individuals. Factors associated with death following MIS include older age (≥80 years) and subsequent primary invasive melanoma.

A Qualitative Study of the Impact of the COVID-19 Pandemic on Metastatic Breast Cancer Care.

The COVID-19 pandemic substantially impacted the delivery of oncology care, particularly for individuals with metastatic cancers. The objective of this study was to qualitatively evaluate the impacts of COVID-19 on metastatic breast cancer (MBC) care among patients. This study consisted of 36 semi-structured qualitative interviews conducted virtually with people living with MBC, who were members of a patient support organization called Project Life. Project Life is an MBC patient-led, web-based wellness community. Responses were analyzed using Phronetic Iterative Analysis. Interviews were conducted from March 14, 2022, to May 31, 2022. Analysis from 36 individual in-depth qualitative interviews revealed the following themes during COVID-19: (1) variable preferences for telehealth (2) disruptions to care, (3) virtualization of social care. Wide variations existed in preferences surrounding telehealth, centered around ideas of convenience. Disruptions to care included delays to diagnostic care, isolation from caregivers, and interruptions associated with COVID-19 infection. These results call for adaptability in oncology care given wide-ranging preferences on telehealth and the shifting of available support services.