Are Diagnostic Delays Associated with Distress in Breast Cancer Patients?

Introduction: Receiving a new breast cancer diagnosis can cause anxiety and distress, which can lead to psychologic morbidity, decreased treatment adherence, and worse clinical outcomes. Understanding sources of distress is crucial in providing comprehensive care. This study aims to evaluate the relationship between delays in breast cancer diagnosis and patient-reported distress. Secondary outcomes include assessing patient characteristics associated with delay. Methods: Newly diagnosed breast cancer patients who completed a distress screening tool at their initial evaluation at an academic institution between 2014 and 2019 were retrospectively evaluated. The tool captured distress levels in the emotional, social, health, and practical domains with scores of "high distress" defined by current clinical practice guidelines. Delay from mammogram to biopsy, whether diagnostic or screening mammogram, was defined as >30 days. Result: 745 newly diagnosed breast cancer patients met inclusion criteria. Median time from abnormal mammogram to core biopsy was 12 days, and 11% of patients experienced a delay in diagnosis. The non-delayed group had higher emotional (p = 0.04) and health (p = 0.03) distress than the delayed group. No statistically significant differences in social distress were found between groups. Additionally, patients with higher practical distress had longer time interval between mammogram and surgical intervention compared to those with lower practical distress. Older age, diagnoses of invasive lobular carcinoma or ductal carcinoma in situ, and clinical anatomic stages 0-I were associated with diagnostic delay. Conclusion: Patients with higher emotional or health-related distress were more likely to have timely diagnoses of breast cancer, suggesting that patients with higher distress may seek healthcare interventions more promptly. Improved understanding of sources of distress will permit early intervention regarding the devastating impact of breast cancer diagnosis.

High-risk Disease and Poor Follow-up: The Importance of Renal Mass Biopsy in a Cohort of Veterans.

OBJECTIVE: To assess the clinical utility of renal mass biopsy (RMB) in our multistate system. RMB is useful in the management of masses ≤4 cm (T1a), but evaluation of RMB in the uniquely vulnerable Veteran population is lacking. METHODS: About 136 RMB in 130 patients performed between 06/2015 and 11/2020 were identified in this Quality Improvement analysis. Demographics, size, pathology, treatment, and biopsy complications were analyzed. Of 101 T1a masses, 89 were either diagnostic or not decompressed cysts and 77 met inclusion criteria for follow-up imaging compliance analysis. RESULTS: The median age was 66 years. The diagnostic rate was 94.1% (128/136) for all masses and 94.1% (95/101) for T1a renal masses, with a complication rate of 2.2%. Among solid T1a masses, unexpectedly aggressive lesions (Fuhrman Grade 4, Type 2 papillary or sarcomatoid features) were identified in 8/89 (9.0%). Fifty-seven (64%) patients were treated with cryoablation or surgery and 32 (36%) patients elected active surveillance (AS). A neoplastic finding (oncocytoma or renal cell carcinoma (RCC)) was present in 16 patients choosing AS (50%) compared to 52 patients choosing treatment (91%). Compliance with National Comprehensive Cancer Network-recommended imaging was 50% and 47% for AS and treatment groups, respectively. CONCLUSION: In this VA cohort, we found a significant incidence of high-risk lesions and poor compliance with follow-up imaging. Aggressive biopsy protocols with high consideration of treatment may be appropriate to limit risk in those lost to follow-up. Given that 9% of our small renal masses were highly aggressive, biopsy may be critical in the selection of AS candidates.

Disparity between pre-existing management of penile cancer and NCCN guidelines.

OBJECTIVE: To determine the locoregional management of penile cancer before the introduction of NCCN guidelines and how much shift in practice patterns is required to meet the guidelines. METHODS: The National Cancer Data Base was queried to identify 6,396 patients with squamous cell carcinoma of the penis diagnosed between 2004 and 2013. The cohort was divided into management groups based on the NCCN guidelines: cTa and cTis (cTa/is), pT1 low grade (T1LG), pT1 high grade (T1HG), and pT2 or greater (T234). These groups were analyzed to determine if management of locoregional disease complies with the 2016 NCCN guidelines and logistic regression analyses were performed to determine factors associated with adherence. RESULTS: Nationwide management of the primary tumor closely follows the NCCN guidelines, with 96.9% adherence for cTa/is, 91.4% for T1LG, and 94.2% for T234. Management of regional lymph nodes (LNs) was inadequate with only 62.9% of patients with clinical N1 or N2 disease undergoing regional LN dissection (LND). The percentage of patients with known LN metastases who received regional LND increased over time (46.2% in 2004 to 69.4% in 2013, P = 0.034). Patients treated at community cancer programs (odds ratio [OR] = 0.26, 95% CI: 0.19-0.35), comprehensive community cancer programs (OR = 0.34, 95% CI: 0.29-0.41), and integrated network cancer programs (OR = 0.36, 95% CI: 0.25-0.52) were significantly less likely to receive LND compared with patients treated at academic comprehensive cancer programs. CONCLUSIONS: Before the introduction of NCCN guidelines, national practice patterns for the management of the primary tumor were consistent with the recommendations. However, the management of regional LNs deviated from the guidelines, reflecting an area for improvement.

Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort.

OBJECTIVE: To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States. MATERIALS AND METHODS: We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type. RESULTS: During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P <.001) and academic (OR: 0.62; P <.001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P <.001), comprehensive cancer community (OR: 1.24; P <.001), and academic (OR: 1.55; P <.001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P <.001) and academic hospitals (OR: 1.23; P <.001). CONCLUSION: Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities.

Trends in disparate treatment of African American men with localized prostate cancer across National Comprehensive Cancer Network risk groups.

OBJECTIVE: To determine whether African Americans (AAs) with intermediate- to high-risk prostate cancer (PCa) receive similar treatment as white patients and whether any observed disparities are narrowing with time. METHODS: We used Surveillance, Epidemiology, and End Results to identify 128,189 men with localized intermediate- to high-risk PCa (prostate-specific antigen ≥10 ng/mL, Gleason score ≥7, or T stage ≥T2b) diagnosed from 2004 to 2010. We used multivariate logistic regression analyses to determine the impact of race on the receipt of definitive treatment. RESULTS: AA men were significantly less likely to receive curative-intent treatment than white men (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.79-0.86; P <.001). There was no evidence of this disparity narrowing over time (Pinteraction 2010 vs 2004 = .490). Disparities in the receipt of treatment between AA and white men were significantly larger in high-risk (AOR, 0.60; 95% CI, 0.56-0.64; P <.001) than in intermediate-risk disease (AOR, 0.92; 95% CI, 0.88-0.97; P = .04; Pinteraction <.001). After adjusting for treatment, demographics, and prognostic factors, AA men had a higher risk of prostate cancer-specific mortality (adjusted hazard ratio, 1.12; 95% CI, 1.01-1.25; P = .03). CONCLUSION: AA men with intermediate- to high-risk PCa are less likely to be treated with curative intent than white men. This disparity is worse in high-risk disease and is not improving over time. Factors underlying this treatment disparity should be urgently studied as it is a potentially correctable contributor to excess PCa mortality among AA patients.