Subjective social status, race, and metabolic syndrome in women with breast cancer.

PURPOSE: To evaluate the association of subjective social status (SSS) with metabolic syndrome (MetS) severity and its potential contribution to racial health disparities in women with breast cancer. METHODS: Multicenter cross-sectional study (10 US hospitals) in women (n = 1206) with primary diagnosis of invasive breast cancer received during Mar/2013-Feb/2020. Participants, self-identified as non-Hispanic White or Black, underwent physical and laboratory examinations and survey questions assessing socioeconomic parameters, medical history, and behavioral risks. SSS was measured with the 10-rung MacArthur scale. MetS severity was measured with a validated Z-Score. Generalized linear mixed modeling was used to analyze the associations. Missing data were handled using multiple imputation. RESULTS: Average age was 58 years. On average, the SSS of Black women, given equivalent level of income and education, was lower than the SSS of White women: 6.6 (6.1-7.0) vs 7.7 (7.54-7.79) among college graduates and 6.8 (6.4-7.2) vs 7.6 (7.5-7.8) among women in the high-income category (> $75,000). In multivariable analysis, after controlling for age, income, education, diet, and physical activity, increasing SSS was associated with a decrease in MetS-Z score, - 0.10 (- 0.16 to - 0.04) per every 2 rung increase in the MacArthur scale. CONCLUSION: Black women with breast cancer rank their SSS lower than White women with breast cancer do at each level of income and education. As SSS is strongly associated with MetS severity these results identify potentially modifiable factors that contribute to racial disparities.

Association of Insulin Resistance and Higher Oncotype DX™ Recurrence Score.

BACKGROUND: Black women with breast cancer have a worse overall survival compared with White women; however, no difference in Oncotype DX™ (ODX) recurrence scores has been observed to explain this health disparity. Black women are also disproportionately affected by insulin resistance. We evaluated whether insulin resistance is associated with a higher ODX recurrence score and whether there is a difference between White and Black women to explain disparate clinical outcomes. METHODS: A subgroup analysis of patients in a multi-institutional cross-sectional study evaluating differences in insulin resistance between White and Black women was performed. Women diagnosed with a new hormone receptor-positive, HER2/neu-negative breast cancer with an ODX recurrence score were identified. Fasting blood glucose and insulin measurements were used to calculate the homeostatic model assessment of insulin resistance (HOMA-IR) score, a method for assessing insulin resistance, and compared against ODX scores. RESULTS: Overall, 412 women (358 White women, 54 Black women) were identified. Compared with White women, Black women had a higher body mass index (30 vs. 26 kg/m2, p < 0.0001), higher HOMA-IR score (2.4 vs. 1.4, p = 0.004), and more high-grade tumors (30% vs. 16%, p = 0.01). There was a direct positive association with an increasing ODX score and HOMA-IR (p = 0.014). On subset analysis, this relationship was seen in White women (p = 0.005), but not in Black women (p = 0.55). CONCLUSION: In women with newly diagnosed breast cancer, increasing insulin resistance is associated with a higher recurrence score; however, this association was not present in Black women. This lack of association may be due to the small number of Black women in the cohort, or possibly a reflection of a different biological disease process of the patient's tumor.

Can Regionalization of Care Reduce Socioeconomic Disparities in Breast Cancer Survival?

BACKGROUND: Breast cancer patients of low socioeconomic status (SES) have worse survival than more affluent women and are also more likely to undergo surgery in low-volume facilities. Since breast cancer patients treated in high-volume facilities have better survival, regionalizing the care of low SES patients toward high-volume facilities might reduce SES disparities in survival. OBJECTIVE: We leverage a natural experiment in New York state to examine whether a policy precluding payment for breast cancer surgery for New York Medicaid beneficiaries undergoing surgery in low-volume facilities led to reduced SES disparities in mortality. RESEARCH DESIGN: A multivariable difference-in-differences regression analysis compared mortality of low SES (dual enrollees, Medicare-Medicaid) breast cancer patients to that of wealthier patients exempt from the policy (Medicare only) for time periods before and after the policy implementation. SUBJECTS: A total of 14,183 Medicare beneficiaries with breast cancer in 2006-2008 or 2014-2015. MEASURES: All-cause mortality at 3 years after diagnosis and Medicaid status, determined by Medicare administrative data. RESULTS: Both low SES and Medicare-only patients had better 3-year survival after the policy implementation. However, the decline in mortality was larger in magnitude among the low SES women than others, resulting in a 53% smaller SES survival disparity after the policy after adjustment for age, race, and comorbid illness. CONCLUSION: Regionalization of early breast cancer care away from low-volume centers may improve outcomes and reduce SES disparities in survival.

Insulin resistance contributes to racial disparities in breast cancer prognosis in US women.

BACKGROUND: Racial disparities in breast cancer survival between Black and White women persist across all stages of breast cancer. The metabolic syndrome (MetS) of insulin resistance disproportionately affects more Black than White women. It has not been discerned if insulin resistance mediates the link between race and poor prognosis in breast cancer. We aimed to determine whether insulin resistance mediates in part the association between race and breast cancer prognosis, and if insulin receptor (IR) and insulin-like growth factor receptor (IGF-1R) expression differs between tumors from Black and White women. METHODS: We conducted a cross-sectional, multi-center study across ten hospitals. Self-identified Black women and White women with newly diagnosed invasive breast cancer were recruited. The primary outcome was to determine if insulin resistance, which was calculated using the homeostatic model assessment of insulin resistance (HOMA-IR), mediated the effect of race on prognosis using the multivariate linear mediation model. Demographic data, anthropometric measurements, and fasting blood were collected. Poor prognosis was defined as a Nottingham Prognostic Index (NPI) > 4.4. Breast cancer pathology specimens were evaluated for IR and IGF-1R expression by immunohistochemistry (IHC). RESULTS: Five hundred fifteen women were recruited (83% White, 17% Black). The MetS was more prevalent in Black women than in White women (40% vs 20%, p < 0.0001). HOMA-IR was higher in Black women than in White women (1.9 ± 1.2 vs 1.3 ± 1.4, p = 0.0005). Poor breast cancer prognosis was more prevalent in Black women than in White women (28% vs 15%. p = 0.004). HOMA-IR was positively associated with NPI score (r = 0.1, p = 0.02). The mediation model, adjusted for age, revealed that HOMA-IR significantly mediated the association between Black race and poor prognosis (ß = 0.04, 95% CI 0.005-0.009, p = 0.002). IR expression was higher in tumors from Black women than in those from White women (79% vs 52%, p = 0.004), and greater IR/IGF-1R ratio was also associated with higher NPI score (IR/IGF-1R >  1: 4.2 ± 0.8 vs IR/IGF-1R = 1: 3.9 ± 0.8 vs IR/IGF-1R < 1: 3.5 ± 1.0, p < 0.0001). CONCLUSIONS: In this multi-center, cross-sectional study of US women with newly diagnosed invasive breast cancer, insulin resistance is one factor mediating part of the association between race and poor prognosis in breast cancer.

The Challenges, Joys, and Career Satisfaction of Women Graduates of the Robert Wood Johnson Clinical Scholars Program 1973-2011.

BACKGROUND: To ensure a next generation of female leaders in academia, we need to understand challenges they face and factors that enable fellowship-prepared women to thrive. We surveyed woman graduates of the Robert Wood Johnson Clinical Scholars Program (CSP) from 1976 to 2011 regarding their experiences, insights, and advice to women entering the field. METHODS: We surveyed every CSP woman graduate through 2012 (n = 360) by email and post. The survey, 12 prompts requiring open text responses, explored current work situation, personal definitions of success, job negotiations, career regrets, feelings about work, and advice for others. Four independent reviewers read overlapping subsets of the de-identified data, iteratively created coding categories, and defined and refined emergent themes. RESULTS: Of the 360 cohort, 108 (30%) responded. The mean age of respondents was 45 (range 32 to 65), 85% are partnered, and 87% have children (average number of children 2.15, range 1 to 5). We identified 11 major code categories and conducted a thematic analysis. Factors common to very satisfied respondents include personally meaningful work, schedule flexibility, spousal support, and collaborative team research. Managing professional-personal balance depended on career stage, clinical specialty, and children's age. Unique to women who completed the CSP prior to 1995 were descriptions of "atypical" paths with career transitions motivated by discord between work and personal ambitions and the emphasis on the importance of maintaining relevance and remaining open to opportunities in later life. CONCLUSIONS: Women CSP graduates who stayed in academic medicine are proud to have pursued meaningful work despite challenges and uncertain futures. They thrived by remaining flexible and managing change while remaining true to their values. We likely captured the voices of long-term survivors in academic medicine. Although transferability of these findings is uncertain, these voices add to the national discussion about retaining clinical researchers and keeping women academics productive and engaged.

Patients' and oncologists' views on family involvement in goals of care conversations.

OBJECTIVE: Family members can significantly impact advanced cancer patients' treatment and are important participants in goals of care (GoC) conversations. Yet, research on patient and physician perspectives about family involvement and influence on GoC conversations is limited. Our purpose was to describe patients' and oncologists' perspectives about family involvement and influence on GoC conversations among patients with advanced cancer. METHODS: We conducted semi-structured interviews at academic, community, and municipal hospitals (n = 4) with patients with advanced cancer (n = 39) and their oncologists (n = 21). Interviews were audiotaped and transcribed. We analyzed data using interpretive description. Three coders independently coded transcripts, compared codes, and resolved discrepancies. RESULTS: We identified 4 themes common to patients and oncologists regarding family involvement in GoC conversations: (1) Presence and Duration of Family Involvement; (2) Family Expectations; (3) Protecting patients'/Family Members' Feelings; and (4) Patient-Family Disagreement. For patients, we identified 2 additional themes: (1) Family and Oncologist Relationship and (2) Effects of Cancer on Family. Both patients and oncologists emphasized the importance of family support for the patient's understanding of their illness and on patients' emotions. We also identified ways in which family involvement may benefit or prove challenging to GoC conversations. CONCLUSIONS: Patients and oncologists have similar views about family involvement in GoC conversations. Learning how to communicate with family members should be a critical component of physician education in palliative care.

Facilitators and Barriers to Oncologists' Conduct of Goals of Care Conversations.

INTRODUCTION: Goals of care (GoC) conversations optimally begin early in the course of cancer care, yet most happen near the end of life. We sought to describe oncologist-reported facilitators of and barriers to GoC conversations with patients who have advanced cancer. METHODS AND MATERIALS: We conducted individual, semistructured qualitative interviews with oncologists from 4 academic, community, municipal, and rural hospitals in New York and Connecticut. Interview topics included approach to GoC conversations, facilitators, barriers, and organizational influences. We analyzed data using interpretive description. We collected demographic and practice information and surveyed oncologists on their communication skills training. We calculated descriptive statistics for quantitative data. RESULTS: Oncologists (n = 21) had a mean age of 46 years (range: 34-68), 67% were male, 71% were White, 24% were Asian, 10% were Hispanic, and 5% were Black. They reported an average of 20 years in practice (range: 8-42), and 62% had received training on having GoC conversations. Facilitators included patient's poor functional status, patient's high health literacy, family understanding and acceptance, oncologist's practice experience, and a supportive practice environment. Barriers included certain patient demographic and clinical characteristics, patient religion and culture, patient's denial, and lack of time. CONCLUSION: GoC conversations may be facilitated by enabling oncologists to conduct these conversations despite difficult circumstances and emotional reactions by activating patients and family via increased health literacy and by advancing palliative-informed practice environments.

Patient-provider communication and hormonal therapy side effects in breast cancer survivors.

Side effects from hormonal therapy (HT) for breast cancer treatment occur frequently and are associated with worse quality of life and HT non-adherence. Whether improved patient-physician communication is associated with patients' reporting of side effects is unknown. We undertook this study to assess factors associated with women's reports of HT side effects. Between December 2012 and April 2013, we conducted a cross-sectional survey of breast cancer patients undergoing HT in an urban medical center. Descriptive statistics, univariate analyses, and multivariate analyses were used to evaluate associations. Of the 100 participants, 67% reported having HT side effects. However, when prompted, an additional 9% reported experiencing specific HT-related symptoms. Despite very high communication scores, one-third of participants reported they had not discussed side effects with providers. Multivariate analysis showed that after controlling for age, education, race, and medication beliefs, women who had difficulty asking providers for more information were more likely to report side effects (odds ratio 8.27, 95% confidence interval 1.01-69.88). Although HT side effects often occur and are bothersome, patient-provider discussions about side effects remain suboptimal. Providers should actively ask patients about medication side effects so that they can be addressed to improve quality of life and potentially, medication adherence.

Factors Affecting the Completion of Adjuvant Chemotherapy in Early-Stage Breast Cancer.

BACKGROUND: Despite the survival benefit associated with adjuvant chemotherapy in early-stage breast cancer, many do not complete treatment. This study identified factors associated with noncompletion of adjuvant chemotherapy among a select population of women with early-stage breast cancer. METHODS: The study sample was obtained from a multicenter study designed to evaluate patient-assistance program usage among early-stage breast cancer patients requiring adjuvant therapy. In this study, 333 patients with stages I and II breast cancer undergoing surgery from October 2006 to September 2009 completed 6-month follow-up surveys assessing their experiences with care, health status, social support, self-efficacy, and treatment beliefs. In- and outpatient medical records were abstracted to assess treatment completion. Of the 333 patients, 198 initiated adjuvant chemotherapy and formed our study cohort. The study compared patients who did and did not complete adjuvant chemotherapy. RESULTS: The median patient age was 53 years (range 28-86 years). According to self-identification, 41 % of the patients were non-Hispanic white and 21 % were black. A total of 13 patients (7 %) did not complete adjuvant chemotherapy. In the bivariate analysis, the patients not completing chemotherapy were more likely to be black and unmarried women with low emotional social support and a poor body image after treatment. In the multivariate analysis, black race [odds ratio (OR) 5.62; 95 % confidence interval (CI) 1.63-20.36] and poor body image (OR 9.75; 95 % CI 2.12-95.95) were independently associated with noncompletion of chemotherapy. CONCLUSIONS: Overall chemotherapy noncompletion rates were low among women exposed to patient-assistance programs. However, poor body image and black race were independent predictors of uncompleted chemotherapy. The true impact of race in this group may result from social factors that occur more often among black women, including poor social support.

Using Qualitative Comparative Analysis of Key Informant Interviews in Health Services Research: Enhancing a Study of Adjuvant Therapy Use in Breast Cancer Care.

BACKGROUND: Qualitative comparative analysis (QCA) is a methodology created to address causal complexity in social sciences research by preserving the objectivity of quantitative data analysis without losing detail inherent in qualitative research. However, its use in health services research (HSR) is limited, and questions remain about its application in this context. OBJECTIVE: To explore the strengths and weaknesses of using QCA for HSR. RESEARCH DESIGN: Using data from semistructured interviews conducted as part of a multiple case study about adjuvant treatment underuse among underserved breast cancer patients, findings were compared using qualitative approaches with and without QCA to identify strengths, challenges, and opportunities presented by QCA. SUBJECTS: Ninety administrative and clinical key informants interviewed across 10 NYC area safety net hospitals. MEASURES: Transcribed interviews were coded by 3 investigators using an iterative and interactive approach. Codes were calibrated for QCA, as well as examined using qualitative analysis without QCA. RESULTS: Relative to traditional qualitative analysis, QCA strengths include: (1) addressing causal complexity, (2) results presentation as pathways as opposed to a list, (3) identification of necessary conditions, (4) the option of fuzzy-set calibrations, and (5) QCA-specific parameters of fit that allow researchers to compare outcome pathways. Weaknesses include: (1) few guidelines and examples exist for calibrating interview data, (2) not designed to create predictive models, and (3) unidirectionality. CONCLUSIONS: Through its presentation of results as pathways, QCA can highlight factors most important for production of an outcome. This strength can yield unique benefits for HSR not available through other methods.

The Challenge of Improving Breast Cancer Care Coordination in Safety-net Hospitals: Barriers, Facilitators, and Opportunities.

BACKGROUND: Minority breast cancer patients tend to have higher rates of adjuvant treatment underuse. We implemented a web-based intervention that closes referral loops between surgeons and oncologists at inner-city safety-net hospitals serving high volumes of minority breast cancer patients to assist these hospitals and improve care coordination. RESEARCH DESIGN: Following intervention implementation, we conducted interviews with key personnel to improve our understanding of the implementation process and to identify barriers, facilitators, and opportunities for improvement. We used the constant comparative method of analysis to code interview transcripts and identify common themes regarding intervention implementation. SUBJECTS: We interviewed 64 administrative and clinical key informants from 10 inner-city safety-net hospitals with high volumes of minority breast cancer patients. RESULTS: We found substantial barriers to implementing an intervention designed to support care coordination efforts, despite initial feedback that the intervention itself was both easy to use and in line with organizational goals. We also characterized facilitators and challenges of breast cancer care coordination in the safety-net environment, as well as opportunities to improve intervention design to support increased quality of breast cancer care. CONCLUSIONS: Coordination of care for women with breast cancer is extremely important, but safety-net hospitals face considerable resource constraints from lack of time, support, and information systems. As safety-net hospital networks grow across numerous care sites, the challenge of care coordination will likely increase, highlighting the importance of interventions that can be successfully implemented and used to promote better care.

Metabolic syndrome and pre-diabetes contribute to racial disparities in breast cancer outcomes: hypothesis and proposed pathways.

BACKGROUND: Women with obesity and type 2 diabetes (T2D) are at greater risk of dying from breast cancer than women without these conditions. Obesity and T2D are associated with insulin resistance and endogenous hyperinsulinemia and are more common in Black women. There is increasing disparity in breast cancer mortality between Black and White women in the USA. We hypothesize that insulin resistance and endogenous hyperinsulinemia in Black women with breast cancer contribute to their greater breast cancer mortality and are associated with increased insulin receptor signalling in tumours. METHODS: We will recruit 350 Black women and 936 White women with newly diagnosed breast cancer. We will determine the presence or absence of the metabolic syndrome/pre-diabetes and insulin resistance by measuring body mass index, waist circumference, lipids, blood pressure, glucose, insulin-like growth factor binding protein 1 and insulin. Breast cancer prognosis will be determined by a Nottingham Prognostic Index (NPI), with poor prognosis being defined as NPI >4.4. Tumour insulin receptor signalling will be determined by immunohistochemistry. Insulin receptor subtype expression will be measured using Nanostring. Analysis of these factors will determine whether endogenous hyperinsulinemia is associated with a worse prognosis in Black women than White women and increased tumour insulin receptor signalling. CONCLUSIONS: The results of this study will determine if the metabolic syndrome and pre-diabetes contribute to racial disparities in breast cancer mortality. It may provide the basis for targeting systemic insulin resistance and/or tumour insulin receptor signalling to reduce racial disparities in breast cancer mortality. Copyright © 2016 John Wiley & Sons, Ltd.

Comparing Prostate Cancer Treatment Decision Making in a Resource-rich and a Resource-poor Environment: A Tale of two Hospitals.

OBJECTIVE: Black men with prostate cancer are diagnosed later, have poorer treatment outcomes, and higher mortality from the disease than all other racial groups. While existing literature has explored differences in the treatment decision making process between black and white men with localized prostate cancer, little is known about how environmental factors may affect the treatment decision process for men with clinically significant disease for whom treatment improves survival. The aim of this study was to compare and contrast the treatment decision process, from both patients' and treating physicians' perspectives, in a resource-rich and a resource-poor hospital. METHODS: Qualitative interviews and focus groups were conducted with patients and their treating physicians from two urban hospitals. Patients were identified through retrospective review of pathology and tumor registries; their charts abstracted to ascertain treatments. Treating physicians were identified and contacted to discuss the treatment decision process. Physicians were also asked to discuss patients who did not receive definitive treatment. Transcripts were analyzed deductively using themes from the Health Belief Model, and inductively to explore emergent themes. RESULTS: Overall, patients and physicians discussed similar factors that influenced the decision making process at both hospitals. However, a few important differences were found: providers at the resource-poor hospital discussed cost as a barrier, highlighted having limited treatment options for their patients, and noted issues with follow-up as external factors affecting treatment decisions. Patients at the resource-poor hospital expressed greater fear and anxiety, and less self-efficacy and motivation in comparison to patients treated at the hospital with greater resources. Importantly, patients at both hospitals described significant trust in their physician, yet only at the resource-poor hospital did patients suggest that they lacked knowledge regarding treatment side-effects, despite physicians at both hospitals describing their attempt to disclose all side-effects. CONCLUSION: These findings identify both medical-system factors, and practice-level factors that can help guide the development of interventions to reduce prostate cancer treatment disparities.

Emotional and Financial Stressors in New York City During the COVID-19 Pandemic: A Consecutive Cross-Sectional Analysis.

Mental and financial hardship during the COVID-19 pandemic in New York City was severe, but how vulnerable groups have been disproportionately impacted is incompletely understood. In partnership with community stakeholders, we administered a web-based survey to a convenience sample of New York City residents (18 + years) from May 2020 to April 2021 to evaluate their financial and emotional stressors. We analyzed outcomes by race, ethnicity, and education level. A total of 1854 adults completed the survey across three consecutive non-overlapping samples. Fifty-five percent identified other than non-Latinx White. Sixty-four percent reported emotional stress; 38%, 32%, and 32% reported symptoms of anxiety, depression, and post-traumatic stress disorder respectively; and 21% reported a large adverse financial impact. The leading unmet needs were mental health and food services (both 19%), and health services (18%). Need for both resources grew over time. Adverse financial impact directly correlated with presence of all four adverse mental health outcomes above. In multivariate analysis, non-White race and lack of college degree were associated with adverse financial impact, whereas LGBT identity and lack of college degree were associated with mental health impact. Throughout the COVID-19 pandemic, participants in this research demonstrated a large and growing mental and financial strain, disproportionately associated with lower education level, non-White race, and LGBT status. Our findings suggest an urgent need to differentially target COVID-19 mental health and resource support in New York City to persons in these vulnerable communities.

Disentangling the effects of race/ethnicity and socioeconomic status of neighborhood in cancer stage distribution in New York City.

PURPOSE: Stage at diagnosis is an important prognostic factor for the majority of cancers; it may be an indicator for quality of access to health care and is usually correlated with socioeconomic status (SES) and ethnicity/race. We aimed to investigate the association between stage of cancer at diagnosis with neighborhood of residence (as proxy for SES) and ethnicity/race, while controlling for each other, in selected areas of New York City (NYC). METHODS: The cancer summary data (1999-2008) were provided by the New York State Cancer Registry. Multinomial logistic regression models were applied to calculate risk estimates for being diagnosed with late- or unknown-stage (versus early-stage) cancers in two low-SES and two high-SES neighborhoods of NYC and among several ethnic/racial groups for all cancers combined and cancers of the female breast, lung, colorectum, and prostate, with additional adjustments for sex (for all cancers combined), age, and year of diagnosis. RESULTS: A total of 34,981 cancer cases were included in this study. There were significant and independent ethnic/racial and neighborhood disparities in stage of cancer at diagnosis of most of the cancers studied. The effect of ethnicity/race on the disparity appeared stronger than the effect of neighborhood. There was an overall decreasing trend in the proportion of late-stage cancers, particularly for colorectal cancer, and to a greater extent in the proportion of cancers without staging information. CONCLUSIONS: In this population, ethnicity/race seems to be a stronger predictor for late stage at diagnosis than SES, stressing the need for ethnicity/race-oriented programs for cancer screening and improved access to care.

Understanding the challenges of adjuvant treatment measurement and reporting in breast cancer: cancer treatment measuring and reporting.

BACKGROUND: Healthcare accrediting organizations and insurers increasingly require reporting of clinical data, and cancer treatment is one area of enhanced scrutiny. OBJECTIVES: To compare rates of received versus reported adjuvant breast cancer treatments, and to assess barriers to measuring and reporting treatments to the tumor registry (TR) of a high-volume medical center with both hospital-based and community-based oncologists. RESEARCH DESIGN: We calculated rates of received treatments using data collected using chart abstraction (N=115) and compared these with rates of reported treatments from the TR (N=535). We conducted 31 indepth interviews with clinical and administrative informants. Asking about perceptions of the TR, current reporting methods, and reporting barriers. Interviews were recorded, transcribed, and analyzed using deductive and inductive methods. RESULTS: : Rates of reported versus received treatments were radiation therapy after breast-conserving surgery 22% versus 84% (P < 0.0001); chemotherapy for stage 2 or 3: 17% versus 79% (P < 0.0001); hormonal therapy for stage 2 or 3: 1% versus 91% (P < 0.0001). Comparing community-based versus hospital-based oncologists' rates reported to the TR, we found the following differences: radiation therapy post-breast conserving surgery 12% versus 32% (< 0.0001); chemotherapy 8% versus 29% (< 0.0001); and hormonal therapy 0% versus 3% (0.09). We found 4 key barriers to measuring and reporting poor understanding about the TR, limited information technology capabilities, poor communication, and mistrust. CONCLUSIONS: : Efforts to improve cancer care quality by improved treatment reporting must overcome key barriers, especially those involving information exchange and mistrust. Communications between the TR and oncology practices must improve to facilitate better treatment measurement and reporting.

Breast cancer treatment decision-making: are we asking too much of patients?

OBJECTIVE: Physicians are mandated to offer treatment choices to patients, yet not all patients may want the responsibility that entails. We evaluated predisposing factors for, and long-term consequences of, too much and not enough perceived decision-making responsibility among breast cancer patients. DESIGN: Longitudinal assessment, with measurements collected just after surgical treatment (baseline) and 6-month follow-up. PARTICIPANTS: Women with early-stage breast cancer treated surgically at eight NYC hospitals, recruited for a randomized controlled trial of patient assistance to improve receipt of adjuvant treatment. MEASUREMENTS: Using logistic regression, we explored multivariable-adjusted associations between perceived treatment decision-making responsibility and a) baseline knowledge of treatment benefit and b) 6-month decision regret. RESULTS: Of 368 women aged 28-89 years, 72 % reported a "reasonable amount", 21 % "too much", and 7 % "not enough" responsibility for treatment decision-making at baseline. Health literacy problems were most common among those with "not enough" (68 %) and "too much" responsibility (62 %). Only 29 % of women had knowledge of treatment benefits; 40 % experienced 6-month decision regret. In multivariable analysis, women reporting "too much" vs. "reasonable amount" of responsibility had less treatment knowledge ([OR] = 0.44, [95 % CI] = 0.20-0.99; model c = 0.7343;p < 0.01) and more decision regret ([OR] = 2.,91 [95 % CI] = 1.40-6.06; model c = 0.7937;p < 0.001). Findings were similar for women reporting "not enough" responsibility, though not statistically significant. CONCLUSION: Too much perceived responsibility for breast cancer treatment decisions was associated with poor baseline treatment knowledge and 6-month decision regret. Health literacy problems were common, suggesting that health care professionals find alternative ways to communicate with low health literacy patients, enabling them to assume the desired amount of decision-making responsibility, thereby reducing decision regret.

How to improve breast cancer care measurement and reporting: suggestions from a complex urban hospital.

Increasing scrutiny of clinical data reporting by healthcare accrediting organizations is challenging hospitals to improve measurement and reporting, especially in the area of cancer care. We sought to explore barriers to breast cancer adjuvant treatment measurement and reporting to a hospital tumor registry (TR) and to identify opportunities to improve these processes. We conducted 31 key informant interviews with administrators and clinicians associated with a large urban hospital that treats a high volume of breast cancer patients. In this setting, up to 40 percent of early-stage breast cancer cases are treated by community-based oncologists, but reporting to the hospital's TR has been problematic. We asked about barriers to treatment measurement and reporting and sought suggestions to improve these processes. We used deductive and inductive methods to analyze interview transcripts. We found seven management barriers to adjuvant treatment measurement and reporting: process complexity, limited understanding of TR reporting, competing priorities, resource needs, communications issues, lack of supporting information technologies (IT), and mistrust of management. The four facilitators of measurement and reporting we noted were increasing awareness, improving communications and relationships, enhancing IT, and promoting the value of measurement and reporting. Four factors deemed critical to successful improvements were organizational commitment, leadership support, resources, and communication. Organizations striving to improve cancer care quality must overcome key barriers, especially those involving gaps in understanding and communication. In practice, hospitals should make explicit efforts to educate physicians and administrators about the importance of treatment reporting and to improve communications between the hospital's TR and physicians to ensure that needed adjuvant therapies are appropriately delivered.

Facilitators of Multiple Myeloma Treatment: A Qualitative Study.

OBJECTIVES: To examine factors that lead to the facilitation of multiple myeloma (MM) treatment. SAMPLE & SETTING: 29 patients who had been diagnosed with MM at Mount Sinai Hospital in New York City. METHODS & VARIABLES: Semistructured qualitative interviews were administered by trained research staff. Interview topics included illness beliefs, illness experiences, treatment experiences, and treatment decision-making. Interviews were audio recorded and transcribed verbatim. Four coders independently coded the transcripts, and the authors analyzed data using interpretive description. RESULTS: The following facilitators of treatment were identified: (a) healthcare team trust and support, (b) personal resilience and initiative-taking, and (c) external support (emotional/social support and instrumental/organizational support). Healthcare team trust and support were established through rapport-building and compassion, accessibility and time spent with the patient, shared decision-making, and provider reputation. Personal resilience was manifested by patients through positive attitudes, taking control of their illness, and self-advocacy. IMPLICATIONS FOR NURSING: Understanding factors that facilitate MM treatment may lead to better patient outcomes and can potentially inform oncology nursing practice by providing a framework for tailored health education and care management practices for patients with MM.