Expanding the use of patient navigation: health coaching-based navigation as a novel approach to addressing deficits in breast cancer survivorship support.

Patient navigation (PN) was created to address barriers to screening and workup for cancers. Since its inception it has resulted in improved mammography utilization, diagnostic resolution, and time to breast cancer treatment initiation in medically underserved populations. Because an abundance of evidence has established PN's positive impact, its use has expanded within the breast cancer care continuum, from screening, treatment, and ultimately survivorship. Increasing applications for navigation now also include support in the treatment and survivorship phase. After treatment, populations who struggle with the complex medical systems where oncology care is often delivered, also lack the support resources needed to successfully transition to survivorship. Support in the psychosocial realm is important for these patients as they continue surveillance and adherence to maintenance medications, such as hormonal therapy.

Axillary Management: How Much Is Too Much?

PURPOSE OF REVIEW: To review the current management of the axilla in breast cancer. RECENT FINDINGS: Axillary dissection is no longer indicated in patients with clinically node-negative axilla with 1-2 positive sentinel lymph nodes following upfront surgery or in patients with clinically node-negative axilla following neoadjuvant chemotherapy. Breast cancer has evolved away from routine axillary clearance to the less invasive sentinel lymph node biopsy to now complete omission of axillary sampling in select patients. We will review the most salient evidence that has shaped these practice changes over the last three decades. Current practice controversies are especially relevant for elderly populations and those receiving neoadjuvant therapy. Ongoing clinical trials will provide data to further guide breast cancer surgical management.

Implementation of a Breast Intraoperative Oncoplastic Form to Aid Management of Oncoplastic Surgery.

INTRODUCTION: Oncoplastic breast conservation surgery (BCS) uses concurrent reduction and/or mastopexy with lumpectomy to improve aesthetic outcomes. However, tissue rearrangement can shift the original tumor location site in relation to external breast landmarks, resulting in difficulties during re-excision for a positive margin and accurate radiation targeting. We developed the Breast Intraoperative Oncoplastic (BIO) form to help depict the location of the tumor and breast reduction specimen. This study seeks to assess physician perspectives of the implementation outcomes. METHODS: From February 2021 to April 2021, the BIO form was used in 11 oncoplastic BCS cases at a single institution. With institutional review board approval, surgical oncologists (SOs), plastic surgeons (PSs), and radiation oncologists (ROs) were administered a 12-question validated survey on Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM), using a 5-point Likert scale during initial implementation and at 6-month reassessment. RESULTS: Twelve physicians completed the survey initially (4 SOs, 4 PSs, and 4 ROs). The mean scores for Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure were high (4.44, 4.56, and 4.56, respectively). Twelve completed the second survey (5 SOs, 3 PSs, and 4 ROs). The mean scores were marginally lower (4.06, 4.21, and 4.25). There were no significant differences when stratified by number of years in practice or specialty. Free text comments showed that 75% of physicians found the form helpful in oncoplastic BCS. CONCLUSIONS: The data indicate high feasibility, acceptability, and appropriateness of the BIO form. Results of this study suggest multidisciplinary benefits of implementing the BIO form in oncoplastic BCS.

Are there differences in outcomes by race among women with metastatic triple-negative breast cancer?

PURPOSE: Black women have higher breast cancer mortality rates than other groups, with Triple-negative breast cancer (TNBC) being more common among AAs with a worse prognosis. Our study seeks to explore differences among Non-Hispanic Black (NHB) vs. White (NHW) women, with Stage IV TNBC, focusing on survival and treatment patterns. METHODS: SEER database was queried for TNBC patients diagnosed with metastatic disease from 2012 to 2016. Neighborhood socioeconomic status (nSES) was defined using the Yost index based on income, education, housing, and employment. Univariate and multivariate analyses were performed to evaluate receipt of surgery, radiation, and chemotherapy. Overall survival was evaluated using Kaplan-Meier curve and Cox proportional hazards model analysis. RESULTS: 25,761 TNBC cases were identified with 1420 being metastatic (5.5%). Bone was the most common site for metastasis, with patients' age being 63.7 years for NHW vs. 59.5 years for NHB. NHB women had the highest percentage of low nSES (62.3% vs 29.3%; p value = 0.001). On univariate analysis, fewer NHBs received radiation compared to NHWs (27.1 vs. 32.6%; p value = 0.040). On multivariate analysis, all women were less likely to undergo treatment if unmarried (p value < 0.01). NHB women had lower median survival compared to NHW women (13 vs. 15 months; p value < 0.01). Receipt of surgery and chemotherapy reduced the risk of mortality (p value < 0.01). CONCLUSION: NHB women had lower median survival with metastatic TNBC. Race was associated with different treatment utilization. With a mortality differential between NHW and NHB women with metastatic TNBC, more investigation is needed to inform strategies to reduce this disparity.

Surgery Refusal Among Black and Hispanic Women with Non-Metastatic Breast Cancer.

BACKGROUND: Studies have shown a lower receipt of treatment among minority women with non-metastatic breast cancer. Those who refuse surgery have increased disease-specific mortality, contributing to disproportionately higher breast cancer mortality in non-Hispanic black (NHB) and Hispanic women. This study aimed to assess surgery refusal in these groups, identify factors associated with surgery refusal, and characterize the association between surgery refusal and survival. METHODS: Surveillance, Epidemiology, and End Results (SEER) Program data from 2005 to 2015 for NHB and Hispanic women with a diagnosis of non-metastatic breast cancer (n = 113,987) was divided into data of those who underwent surgery and data of those who refused surgery. Sociodemographic and tumor clinical/pathologic differences were analyzed by multivariate logistic regression of predictors of surgery refusal and Cox-proportional hazard model of disease-specific mortality. RESULTS: Of 799 patients who refused surgery, 562 were NHB and 237 were Hispanic. The percentage of patients refusing surgery increased from 0.6% in 2005 to 0.9% in 2015. The women who refused surgery were more likely to be older than 81 years, less likely to be married, and more likely to be uninsured or have Medicaid. The refusers presented with more advanced disease and more frequent estrogen receptor-positivity (ER+) and progesterone receptor-positivity (PR+) subtype on histology. Breast cancer-specific mortality increased significantly with surgery omission. Surgery refusal was independently associated with NHB race. CONCLUSION: Surgery refusal among NHB and Hispanic women with potentially curable non-metastatic breast cancer is rising, especially among NHB women, women older than 60 years, single women, and women with a later stage of disease at diagnosis. Additional studies are needed to analyze qualitative data in these populations and their underlying health beliefs, communication needs, and possible use of alternative medicine.

Call to action: breast cancer screening recommendations for Black women.

African-American/Black women have more aggressive breast cancer subtypes, are diagnosed at younger ages, and have an increasing incidence rate. These disparities have resulted in Black women continuing to experience the highest mortality rate from breast cancer of any US racial or ethnic group. However, national screening mammography guidelines do not reflect the high-risk status of Black women. Here we review breast cancer screening guidelines and address the lack of inclusion of the specific needs of Black women. In order to equitably care for the health needs of Black women, high-risk designation would improve access to earlier screening and supplemental imaging including breast MRI.

Hormone receptor-positive breast cancer and black race: does sex matter?

PURPOSE: Black breast cancer patients have worse clinical outcomes than their White counterparts. There are few studies comparing clinical outcomes between Black male breast cancer (MBC) and female breast cancer (FBC) patients. The objective of this study is to examine differences in presentation, treatment, and mortality between Black MBC and FBC. METHODS: The National Cancer Database was queried for all Black MBC and FBC patients, ages 18-90, with hormone receptor-positive breast cancer diagnosed between 2010 and 2016. Hormone receptor positivity was defined as estrogen receptor-positive, progesterone-positive and HER 2-negative cancer. Sociodemographic and clinical variables were compared between MBC and FBC patients on bivariable analysis. After propensity score matching, overall survival was evaluated using the log-rank test and Cox proportional hazards. RESULTS: Compared to FBC patients, MBC patients had higher rates of metastatic disease (stage 4, MBC 4.4% vs. FBC 2.6%, p < 0.001), larger tumors (tumor size < 2 cm, MBC 32.1 vs. FBC 49.1%, p < 0.001) and a higher percentage of poorly differentiated tumors (grade 3, MBC 28.5% vs. FBC 21.4%, p < 0.001). MBC patients had lower rates of hormone therapy (MBC 66.4% vs. FBC 80.7%, p < 0.001) and neoadjuvant chemotherapy (MBC 5.8% vs. FBC 7.5%, p = 0.05) than FBC. On propensity score matched analysis, Black MBC patients had a higher overall mortality (p25 of 60 months vs. 74 months) compared to FBC patients (p = 0.0260). CONCLUSION: Among hormone receptor-positive Black MBC and FBC patients, there are sex-based disparities in stage, hormone therapy use and overall survival.

Racial Differences in Response to Neoadjuvant Chemotherapy: Impact on Breast and Axillary Surgical Management.

BACKGROUND: Neoadjuvant chemotherapy (NAC), an increasingly used method for breast cancer patients, has the potential to downstage patient tumors and thereby have an impact on surgical options for treatment of the breast and axilla. Previous studies have identified racial disparities in tumor heterogeneity, nodal recurrence, and NAC completion. This report compares the effects of NAC response among non-Hispanic white women and black women in relation to surgical treatment of the breast and axilla. METHODS: A retrospective review of 85,303 women with stages 1 to 3 breast cancer in the National Cancer Database who received NAC between 1 January 2010 and 31 December 2016 was conducted. Differences in sociodemographic and clinical variables between black patients and white patients with breast cancer were tested. RESULTS: The study identified 68,880 non-Hispanic white and 16,423 non-Hispanic black women who received NAC. The average age at diagnosis was 54.8 years for the white women versus 52.5 years for the black women. A higher proportion of black women had stage 3 disease, more poorly differentiated tumors, and triple-negative subtype. The black women had lower rates of complete pathologic response, more breast-conservation surgery, and higher rates of axillary lymph node dissection, but fewer sentinel lymph node biopsies. Axillary management for the women who were downstaged showed more use of axillary lymph node dissection for black women compared with sentinel lymph node biopsy. CONCLUSIONS: The black patients were younger at diagnosis, had more advanced disease, and were more likely to have breast-conservation surgery. De-escalating axillary surgery is being adopted increasingly but used disproportionately for white women.

Racial disparities in low-value surgical care and time to surgery in high-volume hospitals.

BACKGROUND: The objective of this study is to examine racial differences in receipt of low-value surgical care and time to surgery (TTS) among women receiving treatment at high-volume hospitals. METHODS: Stage I-III non-Hispanic Black (NHB) and Non-Hispanic White (NHW) breast cancer patients were identified in the National Cancer Database. Low-value care included (1) sentinel lymph node biopsy (SLNB) among T1N0 patients age ≥70 with hormone receptor-positive cancers, (2) axillary lymph node dissection (ALND) in patients meeting ACOSOG Z0011 criteria, and (3) contralateral prophylactic mastectomy (CPM) with unilateral cancer. TTS was days from biopsy to surgery. Bivariate and logistic regression analyses were used to compare the groups. RESULTS: Compared to NHWs, NHBs had lower rates of SLNB among women age ≥70 with small hormone-positive cancers (NHB 58.5% vs. NHW 62.2% p < .001) and CPM (NHB 26.3% vs. NHW 36%; p < .001). ALND rates for patients meeting ACOSOG Z0011 criteria were similar between both groups (p = .13). The odds of surgery >60 days were higher among NHBs (odds ratio, 1.77; 95% confidence interval, 1.64-1.91; NHW ref). CONCLUSIONS: NHBs treated at high-volume hospitals have higher rates of surgical delay but are less likely to undergo low-value surgical procedures compared to NHW women.

Breast density in multiethnic women presenting for screening mammography.

Data on ethnic variations in breast density are limited and often not inclusive of underrepresented minorities. As breast density is associated with elevated breast cancer risk, investigating racial and ethnic difference may elucidate the observed differences in breast cancer risk among different populations. We reviewed breast density from initial screening of women from the Capital Breast Care Center and Georgetown University Hospital from 2010 to 2014. Patient demographics including race, age at screening, education, menopausal status, and body mass index were abstracted. We recorded the BI-RADS density categories: (1) "fatty," (2) "scattered fibroglandular densities," (3) "heterogeneously dense," and (4) "extremely dense." Multivariable unconditional logistic regression was used to identify predictors of breast density. Density categorization was recorded for 2146 women over the 5-year period, comprising Blacks (n = 940), Hispanics (n = 893), and Whites (n = 314). Analysis of subject characteristics by breast density showed that high category is observed in younger, Hispanic, nulliparous, premenopausal, and nonobese women (t-test or chi-square test, P-values <.0001). Obese women are 70% less likely to have high density. Being Hispanic, premenopausal, and nonobese were predictive of high density on logistic regression. In this analysis of density distribution in a diverse sample, Hispanic women have the highest breast density, followed by Blacks and Whites. Unique in our findings is women who identify as Hispanic have the highest breast density and lower rates of obesity. Further investigation of the impact of obesity on breast density, especially in the understudied Hispanic group is needed.

Fertility Preservation for the Young Breast Cancer Patient.

BACKGROUND: The American Society of Clinical Oncology (ASCO) guidelines include incorporation of fertility preservation guidelines in the care of breast oncology patients. This study aimed to examine the baseline knowledge and preferences concerning fertility preservation among women of childbearing age with newly diagnosed breast cancer at the time of their initial visit to Memorial Sloan Kettering Cancer Center (MSKCC). METHODS: A questionnaire on reproductive history, fertility knowledge, and preservation options was administered to women 18-45 years of age with newly diagnosed breast cancer at MSKCC between May and September 2011. RESULTS: The inclusion criteria were met by 60 women eligible for analysis who had a median age of 40 years (range 20-45 years). The findings showed that 50 % of the women either desired children in the future or were unsure whether they wanted children, with 9 % reporting that they received information about fertility preservation options before their MSKCC visit. Women who had never been pregnant were more likely than those with prior pregnancies to consider having children in the future (p = 0.001) and to contemplate fertility preservation options both before (p = 0.001) and after (p = 0.0002) cancer treatment. CONCLUSION: Early referral allows patients to take advantage of fertility preservation options while preventing delay in the initiation of systemic therapy. Referral by the breast surgical oncologist at the time of the initial visit has the potential to increase fertility knowledge because it appears that many women have not yet received fertility information at this early treatment stage.

Disparities in breast cancer surgery delay: the lingering effect of race.

BACKGROUND: Delays to surgical breast cancer treatment of 90 days or more may be associated with greater stage migration. We investigated racial disparities in time to receiving first surgical treatment in breast cancer patients. METHODS: Insured black (56 %) and white (44 %) women with primary breast cancer completed telephone interviews regarding psychosocial (e.g., self-efficacy) and health care factors (e.g., communication). Clinical data were extracted from medical charts. Time to surgery was measured as the days between diagnosis and definitive surgical treatment. We also examined delays of more than 90 days. Unadjusted hazard ratios (HRs) examined univariate relationships between delay outcomes and covariates. Cox proportional hazard models were used for multivariate analyses. RESULTS: Mean time to surgery was higher in blacks (mean 47 days) than whites (mean 33 days; p = .001). Black women were less likely to receive therapy before 90 days compared to white women after adjustment for covariates (HR .58; 95 % confidence interval .44, .78). Health care process factors were nonsignificant in multivariate models. Women with shorter delay reported Internet use (vs. not) and underwent breast-conserving surgery (vs. mastectomy) (p < .01). CONCLUSIONS: Prolonged delays to definitive breast cancer surgery persist among black women. Because the 90-day interval has been associated with poorer outcomes, interventions to address delay are needed.

County characteristics associated with refusing breast cancer surgery: Evidence from the Surveillance, Epidemiology, and End Results program.

BACKGROUND: Individuals' communities impact cancer disparities and are intimately related to social determinants of health. Studies show that personal factors affect treatment refusals for a potentially curable cancer, but few studies have investigated whether community-based characteristics affect the receipt of surgery. METHODS: We used Surveillance Epidemiology and End Results Program registries from 2010 to 2015 to examine differences in rates of surgery refusal among non-Hispanic White, non-Hispanic Black, and Hispanic women diagnosed with nonmetastatic breast cancer. The community factor measures were based on county-level factors. Sociodemographic and community differences were analyzed using Pearson's χ2 tests and analysis of variance. Multivariate logistic regression of predictors of surgery refusal and the Cox proportional hazard model of disease-specific mortality were performed. RESULTS: Surgery refusers among non-Hispanic Black and Hispanic all races lived in counties with lower rates of educational attainment, median family and household income, and higher rates of poverty, unemployment, foreign-born, language isolation, urban population, and women more than 40 years old having mammography in last 2 years. Multivariate analysis shows surgery refusal rates increased in counties having a high percentage of urban population and declined in counties with an increased percentage of less than high school level education, unemployment, and median household income. Breast cancer-specific mortality increased significantly with surgery refusal. CONCLUSION: Residence in counties with the lowest socioeconomic status and disproportionately populated by racial and ethnic minorities is associated with surgery refusal. Given the high mortality associated with refusing surgery, culturally sensitive education on the benefits of care may be appropriate.

Utilization of cancer survivorship services during the COVID-19 pandemic in a tertiary referral center.

BACKGROUND: All Commission on Cancer-accredited comprehensive cancer centers offer survivorship programs (SPs) to women upon completion of treatment. These SPs can include clinical and non-clinical programming such as physical rehabilitation, emotional and psychosocial support, nutrition, and exercise programming. Concern about the availability and access to these programs during the COVID-19 pandemic has been described in recent literature. We sought to identify the impact of the COVID-19 pandemic on participation in these supportive services for breast cancer patients within a single institution. METHODS: The Ohio State University tertiary care center offers clinical and non-clinical breast cancer support services. Descriptive statistics were utilized to summarize referral and patient participation data from January 2019 through July 2021. Data from calendar year 2019 was used as a normative comparison for pre-COVID-19. In-person and telehealth use was tracked longitudinally. RESULTS: During the lockdown due to the COVID-19 pandemic (March through May 2020), provider referrals to SPs declined by 10%, while the overall total for the calendar year modestly increased from 1195 in 2019 to 1210 in 2020, representing a 1.3% increase. Psycho-oncology referrals increased from 280 to 318 (13.5%). The most significant change of participation rates in non-clinical SPs during the pandemic was utilization of exercise content, which increased by 220% from 2019 to 2020. The total proportion of breast cancer participants choosing an exercise program increased from 16.8% in 2019 to 42.2% in 2021, making it the most selected program area overall. Previously, nutrition was the most selected program area as it comprised 42.5% of overall utilization in 2019. CONCLUSION: The pandemic's potential to place barriers to participation in SPs is a legitimate concern. We found a modest decline in provider referrals to clinical services during the lockdown period, while patient-directed participation increased with more survivors engaging in exercise-based programs. Transitioning to virtual platforms served to maintain access for patients. IMPLICATIONS FOR CANCER SURVIVORS: As we grapple with the COVID-19 pandemic, patients with cancer deserve increased attention due to the expected stressors associated with the diagnosis. Those in the survivorship stage utilize services for psychosocial support, and the observed increase in utilization of SPs suggests an elevated need for connectivity. To meet this need, telehealth platforms have been expanded to allow for continued participation. It remains to be seen whether this will be sustained post-COVID-19 or whether reduced human contact will create new needs for programming.

Trends in utilization of contralateral prophylactic mastectomy among different age, racial and ethnic groups.

Background: The use of contralateral prophylactic mastectomy (CPM) has increased over the last two decades with variations in the frequency of reconstruction. The objective of this cohort study is to elucidate the use of CPM and reconstruction among underrepresented racial and ethnic groups and women over 65 years. Methods: Women over 18 years, diagnosed with stages I to III breast cancer who underwent mastectomy from 2004-2017 were identified in the National Cancer Database (NCDB) and grouped into CPM vs. non-CPM. Multivariable analyses were used to examine the associations between CPM and reconstruction with sociodemographic and clinical factors. Results: A total of 571,649 patients were identified. Patients who underwent CPM were under 50 years (45.9%), White (88.4%) and with private insurance (73.5%). On multivariable analysis, women over 65 years [odds ratio (OR): 0.18, P<0.001], non-White (Black, OR: 0.56, P<0.001) and without private insurance (uninsured, OR: 0.50, P<0.001) had decreased odds of CPM. Women over 65 years (OR: 0.11, P<0.001), non-White (Asian/Pacific Islander, OR: 0.58, P<0.001) and without private insurance (Medicaid, OR: 0.41, P<0.001) had decreased odds of reconstruction. Conclusions: Non-White women and women over the age of 65 years were less likely to have CPM or reconstruction than their White counterparts from 2004 to 2017. Research is needed to understand factors impacting decision-making.

Breast cancer screening: clinical, radiologic, and biochemical.

Breast cancer screening is a highly complex and more recently a controversial topic. Conventional screening includes breast self-examination, clinical breast examination, and screening mammography. Several newer imaging modalities have been introduced into the screening armamentarium including breast magnetic resonance imaging and whole-breast automated ultrasound. Novel imaging techniques like positron emission mammography are currently under clinical investigation in the hopes of improving the sensitivity of breast cancer screening. In addition, the development of biochemical assays, which employ minimally invasive sampling are also promising.

Receipt of breast conservation over mastectomy in Black women- does breast cancer subtype matter?

BACKGROUND: Breast conservation surgery (BCS) and mastectomy have equivalent survivability. However, perception of surgical benefit may be affected by breast cancer subtypes, impacting procedure choice. We evaluate surgical management among non-Hispanic Black (NHB) and White (NHW) breast cancer patients based on subtypes. METHODS: Queried the National Cancer Database (NCDB) including BCS eligible women with T1 (<2cm) breast cancer between 2011 and 2016. We selected NHB and NHW women and evaluated differences in sociodemographic variables and treatment including surgery. To determine factors associated with receipt of BCS, a multivariable logistic regression analysis was performed adjusting for age, race, surgery type and breast cancer subtypes. RESULTS: Analyzed 390,278 women with 89.7% NHW and 10.3% NHB, of mean age 63 years. 55.4% vs. 53.5% of NHW compared to NHB women had BCS (p<.001) as initial cancer therapy. Statistically significant differences between NHB and NHW in surgery were found on univariate analysis in all breast cancer subtypes except Luminal B. NHB women with TNBC and Luminal A subtypes were more likely to undergo BCS on multivariate analysis. CONCLUSIONS: Significant differences are found in the surgical management of breast cancer with Black women more likely to receive BCS, less likely to undergo mastectomy compared to White counterparts even with TNBC or her-2+ subtypes. Understanding surgical decision making and how knowledge of subtype is applied deserves further study in women of diverse racial and ethnic groups.

In search of lost time: Delays in adjuvant therapy for pancreatic adenocarcinoma among under-resourced patient populations.

BACKGROUND: The initiation of adjuvant chemotherapy for pancreatic adenocarcinoma within 12 weeks after surgery is recommended by the National Comprehensive Cancer Network. This study seeks to identify factors associated with delayed adjuvant chemotherapy and whether delays impact survival in under-resourced populations. METHODS: Patients with nonmetastatic pancreatic adenocarcinoma who received a definitive resection followed by adjuvant chemotherapy between 2006 and 2017 were queried from the National Cancer Database. Multivariate logistic regression models were constructed to determine the relationship between socioeconomic/clinical variables and delayed adjuvant chemotherapy. Kaplan Meier curves compared survival between under-resourced patients receiving delayed versus timely adjuvant chemotherapy. RESULTS: Among 25,008 patients, timely adjuvant chemotherapy varied by stage (stage 1: 67.9% vs stage 2: 75.8% vs stage 3: 89.2%; P < .001). Older age (odds ratio 1.02, 95% confidence interval 1.02-1.03; P < .001), Non-Hispanic Black race (odds ratio 1.25, 95% confidence interval 1.11-1.41; P < .001), increasing comorbidity score (odds ratio 1.18, 95% confidence interval 1.12-1.23; P < .001), 30-day readmission (odds ratio 1.45, 95% confidence interval 1.28-1.63; P < .001), and undergoing a Whipple (odds ratio 1.30, 95% confidence interval 1.16-1.44; P < .001) were associated with delayed adjuvant chemotherapy. Conversely, the highest neighborhood median income quartile (odds ratio 0.84, 95% confidence interval 0.73-0.97; P = .021), private insurance (odds ratio 0.59, 95% confidence interval 0.46-0.76; P < .001), Medicare (odds ratio 0.68, 95% confidence interval 0.52-0.88; P = .003), and receipt of neoadjuvant therapy (odds ratio 0.05, 95% confidence interval 0.04-0.06; P < .001) were associated with timely adjuvant chemotherapy. Non-Hispanic Black patients and patients with the lowest neighborhood education had worse overall survival when receiving delayed versus timely adjuvant chemotherapy. CONCLUSION: Timely adjuvant chemotherapy for pancreatic adenocarcinoma was only achieved in 73.3% of patients. Age, race, comorbidities, median income, and insurance were identified as barriers. Delayed adjuvant chemotherapy was associated with worse survival among under-resourced populations.