Isolation and survival: The impact of local and MSA isolation on survival among non-Hispanic Black women diagnosed with breast cancer in the United States using a SEER-Medicare cohort.

BACKGROUND: Residential segregation is an important factor that negatively impacts cancer disparities, yet studies yield mixed results and complicate clear recommendations for policy change and public health intervention. In this study, we examined the relationship between local and Metropolitan Statistical Area (MSA) measures of Black isolation (segregation) and survival among older non-Hispanic (NH) Black women with breast cancer (BC) in the United States. We hypothesized that the influence of local isolation on mortality varies based on MSA isolation-specifically, that high local isolation may be protective in the context of highly segregated MSAs, as ethnic density may offer opportunities for social support and buffer racialized groups from the harmful influences of racism. METHODS: Local and MSA measures of isolation were linked by Census Tract (CT) with a SEER-Medicare cohort of 5,231 NH Black women aged 66-90 years with an initial diagnosis of stage I-IV BC in 2007-2013 with follow-up through 2018. Proportional and cause-specific hazards models and estimated marginal means were used to examine the relationship between local and MSA isolation and all-cause and BC-specific mortality, accounting for covariates (age, comorbidities, tumor stage, and hormone receptor status). FINDINGS: Of 2,599 NH Black women who died, 40.0% died from BC. Women experienced increased risk for all-cause mortality when living in either high local (HR = 1.20; CI = 1.08-1.33; p < 0.001) or high MSA isolation (HR = 1.40; CI = 1.17-1.67; p < 0.001). A similar trend existed for BC-specific mortality. Pairwise comparisons for all-cause mortality models showed that high local isolation was hazardous in less isolated MSAs but was not significant in more isolated MSAs. INTERPRETATION: Both local and MSA isolation are independently associated with poorer overall and BC-specific survival for older NH Black women. However, the impact of local isolation on survival appears to depend on the metropolitan area's level of segregation. Specifically, in highly segregated MSAs, living in an area with high local isolation is not significantly associated with poorer survival. While the reasons for this are not ascertained in this study, it is possible that the protective qualities of ethnic density (e.g., social support and buffering from experiences of racism) may have a greater role in more segregated MSAs, serving as a counterpart to the hazardous qualities of local isolation. More research is needed to fully understand these complex relationships. FUNDING: National Cancer Institute.

Centralization of Initial Care and Improved Survival of Poor Patients With Breast Cancer.

PURPOSE: Poor women with breast cancer have worse survival than others, and are more likely to undergo surgery in low-volume facilities. We leveraged a natural experiment to study the effectiveness of a policy intervention undertaken by New York (NY) state in 2009 that precluded payment for breast cancer surgery for NY Medicaid beneficiaries treated in facilities performing fewer than 30 breast cancer surgeries annually. METHODS: We identified 37,822 women with stage I-III breast cancer during 2004-2008 or 2010-2013 and linked them to NY hospital discharge data. A multivariable difference-in-differences approach compared mortality of Medicaid insured patients with that of commercially or otherwise insured patients unaffected by the policy. RESULTS: Women treated during the postpolicy years had slightly lower 5-year overall mortality than those treated prepolicy; the survival gain was significantly larger for Medicaid patients (P = .018). Women enrolled in Medicaid had a greater reduction than others in breast cancer-specific mortality (P = .005), but no greater reduction in other causes of death (P = .50). Adjusted breast cancer mortality among women covered by Medicaid declined from 6.6% to 4.5% postpolicy, while breast cancer mortality among other women fell from 3.9% to 3.8%. A similar effect was not observed among New Jersey Medicaid patients with breast cancer treated during the same years. CONCLUSION: A statewide centralization policy discouraging initial care for breast cancer in low-volume facilities was associated with better survival for the Medicaid population targeted. Given these impressive results and those from prior research, other policymakers should consider adopting comparable policies to improve breast cancer outcomes.[Media: see text].

Medication delivery factors and adjuvant endocrine therapy adherence in breast cancer.

PURPOSE: Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence. METHODS: We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables. RESULTS: Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence. CONCLUSION: Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients.

Analysis of Clinician and Patient Factors and Completion of Telemedicine Appointments Using Video.

Importance: Telemedicine provides patients access to episodic and longitudinal care. Policy discussions surrounding future support for telemedicine require an understanding of factors associated with successful video visits. Objective: To assess patient and clinician factors associated with successful and with failed video visits. Design, Setting, and Participants: This was a quality improvement study of 137 846 scheduled video visits at a single academic health system in southeastern Wisconsin between March 1 and December 31, 2020, supplemented with patient experience survey data. Patient information was gathered using demographic information abstracted from the electronic health record and linked with block-level socioeconomic data from the US Census Bureau. Data on perceived clinician experience with technology was obtained using the survey. Main Outcomes and Measures: The primary outcome of interest was the successful completion of a scheduled video visit or the conversion of the video visit to a telephone-based service. Visit types and administrative data were used to categorize visits. Mixed-effects modeling with pseudo R2 values was performed to compare the relative associations of patient and clinician factors with video visit failures. Results: In total, 75 947 patients and 1155 clinicians participated in 137 846 scheduled video encounters, 17 190 patients (23%) were 65 years or older, and 61 223 (81%) patients were of White race and ethnicity. Of the scheduled video encounters, 123 473 (90%) were successful, and 14 373 (10%) were converted to telephone services. A total of 16 776 patients (22%) completed a patient experience survey. Lower clinician comfort with technology (odds ratio [OR], 0.15; 95% CI, 0.08-0.28), advanced patient age (66-80 years: OR, 0.28; 95% CI, 0.26-0.30), lower patient socioeconomic status (including low high-speed internet availability) (OR, 0.85; 95% CI, 0.77-0.92), and patient racial and ethnic minority group status (Black or African American: OR, 0.75; 95% CI, 0.69-0.81) were associated with conversion to telephone visits. Patient characteristics accounted for systematic components for success; marginal pseudo R2 values decreased from 23% (95% CI, 21.1%-26.1%) to 7.8% (95% CI, 6.3%-9.4%) with exclusion of patient factors. Conclusions and Relevance: As policy makers consider expanding telehealth coverage and hospital systems focus on investments, consideration of patient support, equity, and friction should guide decisions. In particular, this quality improvement study suggests that underserved patients may become disproportionately vulnerable by cuts in coverage for telephone-based services.

Pharmacy deserts and patients with breast cancer receipt of influenza vaccines.

BACKGROUND: Yearly influenza vaccination is strongly recommended at age 65 and reimbursed by Medicare without copays or deductibles at pharmacies and clinical settings. Uptake is low among patients with a high risk for influenza complications and good access to specialist care, such as recent cancer survivors. We hypothesized that more accessible pharmacies could be associated with higher immunization uptake in such patients. OBJECTIVES: To determine whether pharmacy access is associated with influenza vaccination in subjects recently diagnosed with breast cancer, and whether this association differs by additional risk factors for influenza complications. METHODS: We examined a cohort of patients with stage 0-III breast cancer diagnosed 2011-2015 from the Surveillance, Epidemiology, and End Results-Medicare cancer registry. All retail pharmacies in the United States were identified, and pharmacy access was measured by assessing supply and demand in each census tract using a 2-stage floating catchment area approach that accounted for pharmacy driving distances recommended by the Centers for Medicare and Medicaid Services. We examined the association of pharmacy access with influenza vaccination after breast cancer diagnosis in regression models. RESULTS: More than 11% of 45,722 patients with breast cancer lived in census tracts where no pharmacies were within recommended driving distances from the population-weighted tract center. Vaccination in the year after diagnosis was less likely for patients in these very low-access tracts (adjusted odds ratio 0.92 [95% CI 0.86-0.96]), black (0.55 [0.51-0.60]) and Hispanic (0.76 [0.70-0.83]) women, and Medicaid recipients (0.74 [0.69-0.79]). Vaccination was inversely associated with per capita income in the subject's census tract, but there was no difference in the pharmacy effect by race, ethnicity, or census tract income. CONCLUSION: Very low pharmacy access is associated with modest reductions in vaccination that could be useful for policy and planning regarding vaccinator resources and outreach.

Mortgage Lending Bias and Breast Cancer Survival Among Older Women in the United States.

PURPOSE: The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States. METHODS: A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates. RESULTS: Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality. CONCLUSION: Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.

Impact of Pre-visit Contextual Data Collection on Patient-Physician Communication and Patient Activation: a Randomized Trial.

BACKGROUND: Patient contextual data (PCD) are often missing from electronic health records, limiting the opportunity to incorporate preferences and life circumstances into care. Engaging patients through tools that collect and summarize such data may improve communication and patient activation. However, differential tool adoption by race might widen health care disparities. OBJECTIVE: Determine if a digital tool designed to collect and present PCD improves communication and patient activation; secondarily, evaluate if use impacts outcomes by race. DESIGN, SETTING, AND PARTICIPANTS: A pragmatic, two-armed, non-blinded, randomized controlled trial conducted during 2019 in a primary care setting. INTERVENTION: The PCD tool (PatientWisdom) invited patients to identify preferences, values, goals, and barriers to care. Patients were randomized to a standard pre-visit email or facilitated enrollment with dedicated outreach to encourage use of the tool. MAIN OUTCOMES AND MEASURES: Outcomes of interest were post-visit patient communication and patient activation measured by the Communication Assessment Tool (CAT) and Patient Activation Measure (PAM), respectively. Outcomes were evaluated using treatment-on-the-treated (TOT) and intention-to-treat (ITT) principles. KEY RESULTS: A total of 301 patients were enrolled. Facilitated enrollment resulted in a five-fold increase in uptake of the PCD tool. TOT analysis indicated that the PCD tool was associated with notable increases in specific CAT items rated as excellent: "treated me with respect" (+ 13 percentage points; p = 0.04), "showed interest in my ideas" (+ 14 percentage points; p = 0.03), "showed care and concern" (+ 16 percentage points; p = 0.02), and "spent about the right amount of time with me" (+ 11 percentage points; p = 0.05). There were no significant pre/post-visit differences in PAM scores between arms (- 4.41 percentage points; p = 0.58). ITT results were similar. We saw no evidence of the treatment effect varying by race in ITT or TOT analyses. CONCLUSIONS AND RELEVANCE: The inclusion of PCD enhanced essential aspects of patient-provider communication but did not affect patient activation. Outcomes did not differ by race. TRIAL REGISTRATION: Clincaltrials.gov identifier: NCT03766841.

The Impact of Previsit Contextual Data Collection on Patient-Provider Communication and Patient Activation: Study Protocol for a Randomized Controlled Trial.

BACKGROUND: Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values. To provide patient-centered care, clinicians need to know and incorporate patients' context into their communication and care with patients. Patient contextual data (PCD) encompass social determinants of health and patients' needs, values, goals, and preferences relevant to their care. PCD can be challenging to collect as a routine component of the time-limited primary care visit. OBJECTIVE: This study aims to determine if patient-provider communication and patient activation are different for patient users and patient nonusers of an electronic health record (EHR)-integrated PCD tool and assess if the impact of using PCD on patient-provider communication and patient activation differs for Black and White patients. METHODS: We describe a randomized controlled trial of a prospective cohort of non-Hispanic White and Black patients who receive primary care services at a midwestern academic health care system in the United States. We will evaluate whether providing PCD through a consumer informatics tool enhances patient-provider communication, as measured by the Communication Assessment Tool, and we will evaluate patient activation, as measured by the Patient Activation Measure for PCD tool users and nonusers. Furthermore, owing to racial disparities in care and communication, we seek to determine if the adoption and use of the tool might narrow the differences between patient groups. RESULTS: The trial was funded in November 2017 and received local ethics review approval in February 2019. The study began recruitment in April 2019 and enrollment concluded in October 2019 with 301 participants. The analysis was completed in May 2020, and trial results are expected to be published in winter 2020. CONCLUSIONS: Recently, there has been increased attention to the role of health information technology tools to enable patients to collaborate with providers through the sharing of PCD. The adoption of such tools may overcome the barriers of current EHRs by directly engaging patients to submit their contextual data. Effectively, these tools would support the EHR in providing a more holistic understanding of the patient. Research further supports that individuals who have robust digital engagement using consumer informatics tools have higher participation in treatment follow-up and self-care across populations. Therefore, it is critical to investigate interventions that elicit and share patients' social risks and care preferences with the health care team as a mechanism to improve individualized care and reduce the gap in health outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03766841; https://clinicaltrials.gov/ct2/show/NCT03766841. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/20309.

The impact of generic aromatase inhibitors on initiation, adherence, and persistence among women with breast cancer: Applying multi-state models to understand the dynamics of adherence.

PURPOSE: Clinical trials have clearly documented the survival benefit of aromatase inhibitors (AIs); however, many women fail to initiate (primary nonadherence) or remain adherent to AIs (secondary nonadherence). Prior studies have found that costs impact secondary nonadherence to medications but have failed to examine primary nonadherence. The purpose of this study is to examine primary and secondary adherence following the reduction in copays due to the introduction of generic AIs. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 50 054 women diagnosed with incident breast cancer between 2008 and 2013. We compare women whose copays would change and those whose would not, due to the receipt of cost-sharing subsidies before and after generics were introduced using a difference-in-difference (DinD) analysis. To examine primary and secondary nonadherence, we rely on a multistate model with four states (Not yet initiated, User, Not Using, and Death). We adjusted for baseline factors using inverse probability treatment weights and then simulated adherence for 36 months following diagnosis. RESULTS: The generic introduction of AIs resulted in patients initiating AIs faster (DinD = -4.7%, 95%CI = -7.0, -2.3; patients not yet initiating treatment at 6-months), being more adherent (DinD ranging in absolute increase of 8.1%-10.4%) and being less likely to not be using the therapy (DinD range in absolute decrease of 1.2% at 6 months to 8.8% at 24 months) for women that do not receive a subsidy after generics were available. CONCLUSIONS: Introduction of generic alternatives to AIs significantly reduced primary and secondary nonadherence.

Prevalence and scope of advanced practice provider oncology care among Medicare beneficiaries with breast cancer.

PURPOSE: Advanced practice providers (APPs) have increasingly become members of the oncology care team. Little is known about the scope of care that APPs are performing nationally. We determined the prevalence and extent of APP practice and examined associations between APP care and scope of practice regulations, phase of cancer care, and patient characteristics. METHODS: We performed an observational study among women identified from Medicare claims as having had incident breast cancer in 2008 with claims through 2012. Outpatient APP care included at least one APP independently billing for cancer visits/services. APP scope of practice was classified as independent, reduced, or restricted. A logistic regression model with patient-level random effects was estimated to determine the probability of receiving APP care at any point during active treatment or surveillance. RESULTS: Among 42,550 women, 6583 (15%) received APP care, of whom 83% had APP care during the surveillance phase and 41% during the treatment phase. Among women who received APP care during a given year of surveillance, the overall proportion of APP-billed clinic visits increased with each additional year of surveillance (36% in Year 1 to 61% in Year 4). Logistic regression model results indicate that women were more likely to receive APP care if they were younger, black, healthier, had higher income status, or lived in a rural county or state with independent APP scope of practice. CONCLUSIONS: This study provides important clinical and policy-relevant findings regarding national practice patterns of APP oncology care. Among Medicare beneficiaries with incident breast cancer, 15% received outpatient oncology care that included APPs who were billing; most of this care was during the surveillance phase. Future studies are needed to define the degree of APP oncology practice and training that maximizes patient access and satisfaction while optimizing the efficiency and quality of cancer care.

Racial disparities of liver cancer mortality in Wisconsin.

PURPOSE: To calculate tract-level estimates of liver cancer mortality in Wisconsin and identify relationships with racial and socioeconomic variables. METHODS: County-level standardized mortality ratios (SMRs) of liver cancer in Wisconsin were calculated using traditional indirect adjustment methods for cases from 2003 to 2012. Tract-level SMRs were calculated using adaptive spatial filtering (ASF). The tract-level SMRs were checked for correlations to a socioeconomic advantage index (SEA) and percent racial composition. Non-spatial and spatial regression analyses with tract-level SMR as the outcome were conducted. RESULTS: County-level SMR estimates were shown to mask much of the variance within counties across their tracts. Liver cancer mortality was strongly correlated with the percent of Black residents in a census tract and moderately associated with SEA. In the multivariate spatially-adjusted regression analysis, only Percent Black composition remained significantly associated with an increased liver cancer SMR. CONCLUSIONS: Using ASF, we developed a high-resolution map of liver cancer mortality in Wisconsin. This map provided details on the distribution of liver cancer that were inaccessible in the county-level map. These tract-level estimates were associated with several racial and socioeconomic variables.

Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas.

BACKGROUND: Cancer contributes substantially to the life expectancy gap between US blacks and whites, and racial cancer disparities remain stubborn to eradicate. Disparities vary geographically, suggesting that they are not inevitable. METHODS: The authors examined the relationship between housing discrimination and the size of cancer disparities across large US metropolitan statistical areas (MSAs). MSA-level cancer disparities were measured using data from the US Centers for Disease Control and Prevention. Mortgage discrimination for each MSA was estimated using the Home Mortgage Disclosure Act database, and MSA racial segregation was determined using US Census data. Patterns of housing discrimination and cancer disparities were mapped, and the associations between these place-based factors and cancer disparities across MSAs were measured. RESULTS: Black-to-white cancer mortality disparities (rate ratios) varied geographically, ranging from 1.50 to 0.86; 88% of mortality ratios were >1, indicating higher mortality for blacks. In areas with greater mortgage discrimination, the gap between black and white cancer mortality rates was larger (correlation coefficient [r] = 0.32; P = .001). This relationship persisted in sex-specific analyses (males, r = 0.37; P < .001; females, r = 0.23; P = .02) and in models controlling for confounders. In contrast, segregation was inconsistently associated with disparities. Adjusting for incidence disparities attenuated, but did not eliminate, the correlation between mortgage discrimination and mortality disparities (r = 0.22-0.24), suggesting that cancer incidence and survival each account for part of the mortality disparity. CONCLUSIONS: Mortgage discrimination is associated with larger black-to-white cancer mortality disparities. Some areas are exceptions to this trend. Examination of these exceptions and of policies related to housing discrimination may offer novel strategies for explaining and eliminating cancer disparities.

Are aromatase inhibitors associated with higher myocardial infarction risk in breast cancer patients? A Medicare population-based study.

BACKGROUND: Theoretically, the estrogen deprivation induced by aromatase inhibitors (AIs) might cause ischemic heart disease, but empiric studies have shown mixed results. We aimed to compare AIs and tamoxifen with regard to cardiovascular events among older breast cancer patients outside of clinical trials. We hypothesized that AIs increase the risk of myocardial infarction. METHODS: We identified women age ≥67 years diagnosed with breast cancer from June 30, 2006 to June 1, 2008 in the surveillance, epidemiology, and end results (SEER)-Medicare database, treated with either tamoxifen or an AI, and followed through December 31, 2012. To compare myocardial infarction (MI) risk for the treatment groups of AIs vs tamoxifen, we developed and assigned stabilized probability of treatment weights and used the Fine and Gray model for time to MI with death not related to MI as a competing risk. RESULTS: Of the cohort of 5648 women, 4690 were treated with AIs and 958 with tamoxifen; a total of 251 patients developed MI, and 22 patients died of MI during the study period while 476 died of other causes. The hazard for MI was not significantly different between AI vs tamoxifen groups (HR = 1.01, 95% CI 0.72-1.42), after adjusting for the following known MI risk factors at the start of adjuvant therapy: diabetes, ischemic heart disease, congestive heart failure, MI, and peripheral vascular disease. CONCLUSIONS: In this SEER-Medicare-based population study, there were no significant differences in the risk of MI between AI and tamoxifen users after adjustment for known risk factors.

Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer.

BACKGROUND: Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity. OBJECTIVE: Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND. RESEARCH DESIGN/SUBJECTS: Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009. MEASURES: Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated. RESULTS: Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases. CONCLUSIONS: In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.

Fractures in a nationwide population-based cohort of users of breast cancer hormonal therapy.

PURPOSE: Although users of aromatase inhibitors have higher total fracture risk in some randomized trials, little is known about their risk outside of clinical trials or in older higher-risk cohorts. METHODS: In a population-based retrospective cohort study, we identified all older US Medicare D prescription drug insurance plan-enrolled women who had initial breast cancer surgery in 2006-2008 and began hormonal therapy (an aromatase inhibitor (AI) or tamoxifen) within the subsequent year. Total nonvertebral and hip fractures through 2012 were identified using a validated algorithm. The association of fracture outcomes with hormonal therapy type was assessed using competing risk regression models that accounted for differences in measured baseline covariates. Treatment assignment bias was reduced using inverse probability of treatment weighting computed from propensity scores. RESULTS: Among 23,378 women taking hormonal therapy (23.2% aged 80 or over), there were 3000 total and 436 hip fractures. Although AI users were younger and had lower comorbidity, after propensity score weighting, these and other covariates were balanced. Total nonvertebral risk was higher for users of AIs compared with tamoxifen, HR 1.11 (1.02-1.21), but the small increase in risk for hip fracture was not statistically significant, HR 1.04 (0.84-1.30). CONCLUSIONS: Although total nonvertebral fracture risk was higher among AI users, differences in hip fractures were not significant in a large population-based cohort of older women. IMPLICATIONS FOR CANCER SURVIVORS: Use of aromatase inhibitors by older women is associated with high risk for nonvertebral fracture that is increased compared with use of tamoxifen. Fracture risk should be assessed among patients taking these medications.

Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D.

BACKGROUND: Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents. OBJECTIVES: Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program. DESIGN: Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D. SUBJECTS: Female Medicare beneficiaries with early-stage breast cancer: 54,772 diagnosed in 2001 and 46,371 in 2007. MEASURES: SES was based on Medicaid enrollment and zip code per capita income, all-cause mortality from Medicare, and cause of death from National Death Index. RESULTS: Among women diagnosed pre-Part D, 40.5% of poor beneficiaries had died within 5 years compared with 20.3% of high-income women (P<0.0001). Post-Part D, 33.6% of poor women and 18.4% of high-income women died by 5 years. After adjustment for potential confounders, improvement in all-cause mortality post-Part D was greater for poorer women compared with more affluent women (P=0.002). However, absolute improvement in breast cancer-specific mortality was 1.8%, 1.2%, and 0.8% (P=0.88 for difference in improvement by SES), respectively for poor, near-poor, and high-income women, whereas analogous improvement in mortality from other causes was 5.1%, 3.8%, and 0.9% (P=0.067 for difference in improvement by SES). CONCLUSIONS: Large survival disparities by SES exist among breast cancer patients. The Part D program successfully ameliorated SES disparities in all-cause mortality. However, improvement was concentrated in causes of death other than breast cancer, suggesting remaining gaps in care.

Medicare D Subsidies and Racial Disparities in Persistence and Adherence With Hormonal Therapy.

Purpose To investigate the role of out-of-pocket cost supports through the Medicare Part D Low-Income Subsidy on disparities in breast cancer hormonal therapy persistence and adherence by race or ethnicity. Methods A nationwide cohort of women age ≥ 65 years with a breast cancer operation between 2006 and 2007 and at least one prescription filled for oral breast cancer hormonal therapy was identified from all Medicare D enrollees. The association of race or ethnicity with nonpersistence (90 consecutive days with no claims for a hormonal therapy prescription) and nonadherence (medication possession rate < 80%) was examined. Survival analyses were used to account for potential differences in age, comorbidity, or intensity of other treatments. Results Among the 25,111 women in the study sample, 77% of the Hispanic and 70% of the black women received a subsidy compared with 21% of the white women. By 2 years, 69% of black and 70% of Hispanic patients were persistent compared with 61% of white patients. In adjusted analyses, patients in all three unsubsidized race or ethnicity groups had greater discontinuation than subsidized groups (white patients: hazard ratio [HR], 1.83; 95% CI, 1.70 to 1.95; black patients: HR, 2.09; 95% CI, 1.73 to 2.51; Hispanic patients: HR, 3.00; 95% CI, 2.37 to 3.89). Racial or ethnic persistence disparities that were present for unsubsidized patients were not present or reversed among subsidized patients. All three subsidized race or ethnicity groups also had higher adherence than all three unsubsidized groups, although with the smallest difference occurring in black women. Conclusion Receipt of a prescription subsidy was associated with substantially improved persistence to breast cancer hormonal therapy among white, black, and Hispanic women and lack of racial or ethnic disparities in persistence. Given high subsidy enrollment among black and Hispanic women, policies targeted at low-income patients have the potential to also substantially reduce racial and ethnic disparities.

New spatially continuous indices of redlining and racial bias in mortgage lending: links to survival after breast cancer diagnosis and implications for health disparities research.

Racial health disparities continue to be a serious problem in the United States and have been linked to contextual factors, including racial segregation. In some cases, including breast cancer survival, racial disparities appear to be worsening. Using the Home Mortgage Disclosure Act (HMDA) database, we extend current spatial analysis methodology to derive new, spatially continuous indices of (1) racial bias in mortgage lending and (2) redlining. We then examine spatial patterns of these indices and the association between these new measures and breast cancer survival among Black/African American women in the Milwaukee, Wisconsin metropolitan area. These new measures can be used to examine relationships between mortgage discrimination and patterns of disease throughout the United States.

The introduction of generic aromatase inhibitors and treatment adherence among Medicare D enrollees.

BACKGROUND: Aromatase inhibitors (AIs) substantially reduce breast cancer mortality in clinical trials, but high rates of nonadherence to these long-term oral therapies have reduced their impact outside of trials. We examined the association of generic AI availability with AI adherence among a large national breast cancer cohort. METHODS: Using a quasi-experimental prepost design, we examined the effect of generic AI introductions (7/2010 and 4/2011) on adherence among a national cohort of women with incident breast cancer in 2006 and 2007 who were enrolled in the Medicare D pharmaceutical coverage program. Medicare D claims were used to calculate AI adherence, defined as a medication possession ratio of 80% or more of eligible days, over 36 months. Multivariable logistic regression models estimated with generalized estimating equations were applied to longitudinal adherence data to control for possible confounders, including receipt of a Medicare D low-income subsidy, and to account for repeated measures. All statistical tests were two-sided. RESULTS: Sixteen thousand four hundred sixty-two Medicare D enrollees were eligible. Adherence declined throughout the study. However, among women without a subsidy, the median quarterly out-of-pocket cost of anastrozole fell from $183 in the fourth quarter of 2009 to $15 in 2011, and declines in adherence were attenuated with generic AI introductions. Regression-adjusted adherence probabilities were estimated to be 5.4% higher after generic anastrozole was introduced in 2010 and 11% higher after generic letrozole/exemestane was introduced in 2011. Subsidy recipients had higher adherence rates throughout the study. CONCLUSIONS: The introduction of generic medications attenuated the decline in adherence to AIs over three years of treatment among breast cancer survivors not receiving low-income subsidies for Medicare D coverage.