Cancer survivorship programs at the Dana-Farber Cancer Institute.

PURPOSE: We sought to present the current status of survivorship programs at Dana-Farber Cancer Institute which include the David B. Perini, Jr. Quality of Life Clinic for survivors of childhood cancer, Stop and Shop Neuro-Oncology Outcomes Clinic for pediatric brain tumor survivors, and Adult Survivorship Program for adult cancer survivors including those diagnosed as adults (age 18 years and older) and adult survivors of childhood cancer, in an effort to share best practices as well as challenges. METHODS: Description of programs and discussion. RESULTS: Our institutional programs are detailed regarding their history and the multidisciplinary approach and both consultative and long-term care delivery models for pediatric and adult cancer survivors, with the goal of meeting the spectrum of survivorship care needs, from diagnosis and management of long-term effects of cancer-directed therapy and surveillance for subsequent cancer, to healthy lifestyle promotion and psychosocial support. Program investigators conduct research to understand the risks and unmet needs of cancer survivors, and to develop and test interventions to improve care delivery and medical and psychosocial outcomes. There are also educational initiatives detailed. CONCLUSIONS: Survivorship programs at Dana-Farber are designed to optimize care and outcomes for cancer survivors including conducting quality improvement initiatives and research to further understand and meet the clinical needs of the large, heterogenous, and growing population cancer survivors into the future. IMPLICATIONS FOR CANCER SURVIVORS: Programs like ours as well as those ongoing and planned aim to improve the comprehensive care of diverse cancer survivors.

Cancer prevention, risk reduction, and control: opportunities for the next decade of health care delivery research.

In this commentary, we discuss opportunities to optimize cancer care delivery in the next decade building from evidence and advancements in the conceptualization and implementation of multi-level translational behavioral interventions. We summarize critical issues and discoveries describing new directions for translational behavioral research in the coming decade based on the promise of the accelerated application of this evidence within learning health systems. To illustrate these advances, we discuss cancer prevention, risk reduction (particularly precision prevention and early detection), and cancer treatment and survivorship (particularly risk- and need-stratified comprehensive care) and propose opportunities to equitably improve outcomes while addressing clinician shortages and cross-system coordination. We also discuss the impacts of COVID-19 and potential advances of scientific knowledge in the context of existing evidence, the need for adaptation, and potential areas of innovation to meet the needs of converging crises (e.g., fragmented care, workforce shortages, ongoing pandemic) in cancer health care delivery. Finally, we discuss new areas for exploration by applying key lessons gleaned from implementation efforts guided by advances in behavioral health.

Implementing Quality Colon Cancer Survivorship Care: A Practical Proposal for a Path Forward.

There are currently close to 17 million survivors of cancer in the United States. This number is expected to grow as both an aging population and improved treatment increase the number of survivors. Consequently, the importance of quality survivorship care has been recognized, but implementing, measuring, and paying for this care in a highly fragmented health care system, across a broad spectrum of diseases, is difficult. Quality measurement tied to payment is one approach that has commonly been used to improve the quality of care in the US health care system, but the complexity of applying quality measurement metrics across the spectrum of cancer survivorship care had led to stalemate. In this article, we draw on prior work to develop a quality cancer survivorship framework and propose a practical path forward with a focus on the provision of colon cancer survivorship care within integrated health care delivery networks. With this narrowly defined approach, we hope that we can promote a practical solution that can be extended to other diseases and payment systems over time.

Survivorship objectives in comprehensive cancer control plans: a systematic review.

PURPOSE: Over a decade ago, the National Academy of Medicine (NAM) recommended that states develop, implement, and evaluate plans that include consideration of survivorship care. The purpose of this study was to review comprehensive cancer control plans in the USA, specifically to identify the inclusion of cancer survivorship-focused goals and objectives and examine alignment of survivorship-focused objectives with the NAM recommendations. METHODS: Plans from 50 states, 7 territories, 5 tribal organizations, and the District of Columbia were reviewed to assess inclusion of survivorship goals and objectives. One territory plan was excluded because it did not include a survivorship-focused goal or objective (final n = 62). Objectives were assigned to domains based on NAM survivorship recommendations. RESULTS: Plans included between 1 and 19 survivorship-related objectives. Of the 345 survivorship objectives extracted and analyzed, the most prevalent domains addressed were raising awareness, survivorship care plans, healthcare professional capacity, and models of coordinated care. Employment-related concerns, developing and implementing quality measures, and investments in research were not frequently included in objectives. CONCLUSIONS: Comprehensive cancer control plans represent an important strategy that may reduce the impact of cancer and its treatment. State, territorial, and tribal coalitions can use these results to systematically focus future survivorship efforts on areas relevant to their region and population. IMPLICATIONS FOR CANCER SURVIVORS: The growing number of survivors requires broad-ranging policy strategies. Future efforts are needed to assess the implementation and impact of plan strategies to improve the overall wellness of cancer survivors.

Developing a Quality of Cancer Survivorship Care Framework: Implications for Clinical Care, Research, and Policy.

There are now close to 17 million cancer survivors in the United States, and this number is expected to continue to grow. One decade ago the Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition, outlined 10 recommendations aiming to provide coordinated, comprehensive care for cancer survivors. Although there has been noteworthy progress made since the release of the report, gaps remain in research, clinical practice, and policy. Specifically, the recommendation calling for the development of quality measures in cancer survivorship care has yet to be fulfilled. In this commentary, we describe the development of a comprehensive, evidence-based cancer survivorship care quality framework and propose the next steps to systematically apply it in clinical settings, research, and policy.

Financial difficulty, worry about affording care, and benefit finding in long-term survivors of cancer.

OBJECTIVE: To examine the associations of worry about affording care and reporting financial difficulties with benefit finding in long-term cancer survivors. METHODS: Long-term survivors of cancer (n = 547) in 3 integrated health care delivery systems completed the Medical Expenditure Panel Survey Cancer Survivorship Supplement. The relationship between benefit finding (becoming a stronger person, coping better, and making positive changes) and the potentially interacting factors of worry about affording care and financial difficulties was examined using multivariate logistic regression models. RESULTS: Of the total sample, 20% reported worry and 15% reported financial difficulty. Among those who reported no worry, financial difficulty was positively associated with becoming a stronger person (odds ratio [OR] = 2.89, 95% CI: 1.07, 7.80). Coping better was not associated with worry, financial difficulties, or the interaction of the two. Among those with no financial difficulty, worry was positively associated with making positive changes (OR = 2.64, 95% CI: 1.41, 4.96), and among those reporting no worry, financial difficulty had a non-significant positive association with making positive changes (OR = 1.98, 95% CI: 0.91, 4.31). Among those reporting worry, having financial difficulties was associated with lower odds of making positive changes (OR = 0.32, 95% CI: 0.13, 0.78). CONCLUSIONS: Our results suggest a complex relationship between financial difficulty, worry, and benefit finding. The combination of worry about affording care and financial difficulty needs to be addressed and further studied among cancer survivors, as the presence of both, but not alone, was negatively associated with making positive changes, an aspect of benefit finding.

Clinical risk score to predict likelihood of recurrence after ductal carcinoma in situ treated with breast-conserving surgery.

PURPOSE: A majority of women with ductal carcinoma in situ (DCIS) receive breast-conserving surgery (BCS) but then face a risk of ipsilateral breast tumor recurrence (IBTR) which can be either recurrence of DCIS or invasive breast cancer. We developed a score to provide individualized information about IBTR risk to guide treatment decisions. METHODS: Data from 2762 patients treated with BCS for DCIS at centers within the National Comprehensive Cancer Network (NCCN) were used to identify statistically significant non-treatment-related predictors for 5-year IBTR. Factors most associated with IBTR were estrogen-receptor status of the DCIS, presence of comedo necrosis, and patient age at diagnosis. These three parameters were used to create a point-based risk score. Discrimination of this score was assessed in a separate DCIS population of 301 women (100 with IBTR and 200 without) from Kaiser Permanente Northern California (KPNC). RESULTS: Using NCCN data, the 5-year likelihood of IBTR without adjuvant therapy was 9% (95% CI 5-12%), 23% (95% CI 13-32%), and 51% (95% CI 26-75%) in the low, intermediate, and high-risk groups, respectively. Addition of the risk score to a model including only treatment improved the C-statistic from 0.69 to 0.74 (improvement of 0.05). Cross-validation of the score resulted in a C-statistic of 0.76. The score had a c-statistic of 0.67 using the KPNC data, revealing that it discriminated well. CONCLUSIONS: This simple, no-cost risk score may be used by patients and physicians to facilitate preference-based decision-making about DCIS management informed by a more accurate understanding of risks.

Integrating primary care providers in the care of cancer survivors: gaps in evidence and future opportunities.

Since the release of the Institute of Medicine report: From cancer patient to cancer survivor: lost in transition, in 2005, there has been a national call in the USA to provide coordinated, comprehensive care for cancer survivors, with an emphasis on the role of primary care. Several models of care have been described, which focus on primary care providers (PCPs) as receiving cancer survivors who are transferred after successful treatment, and who are given specific types of information from oncology-based care (eg, survivorship care plans), and not as active members of the cancer survivorship team. In this Series paper, we assessed survivorship models that have been described in the literature, with a specific focus on strategies that aim to integrate PCPs into the care of cancer survivors across different settings. We offer insights differentiating PCPs' level of expertise in cancer survivorship and how such expertise could be used. We provide recommendations for education, clinical practice, research, and policy initiatives that might advance the integration of PCPs in the care of cancer survivors in diverse clinical settings.

The Cancer Research Network: a platform for epidemiologic and health services research on cancer prevention, care, and outcomes in large, stable populations.

PURPOSE: The ability to collect data on patients for long periods prior to, during, and after a cancer diagnosis is critical for studies of cancer etiology, prevention, treatment, outcomes, and costs. We describe such data capacities within the Cancer Research Network (CRN), a cooperative agreement between the National Cancer Institute (NCI) and organized health care systems across the United States. METHODS: Data were extracted from each CRN site's virtual data warehouse using a centrally written and locally executed program. We computed the percent of patients continuously enrolled ≥1, ≥5, and ≥10 years before cancer diagnosis in 2012-2015 (year varied by CRN site). To describe retention after diagnosis, we computed the cumulative percentages enrolled, deceased, and disenrolled each year after the diagnosis for patients diagnosed in 2000. RESULTS: Approximately 8 million people were enrolled in ten CRN health plans on December 31, 2014 or 2015 (year varied by CRN site). Among more than 30,000 recent cancer diagnoses, 70 % were enrolled for ≥5 years and 56 % for ≥10 years before diagnosis. Among 25,274 cancers diagnosed in 2000, 28 % were still enrolled in 2010, 45 % had died, and 27 % had disenrolled from CRN health systems. CONCLUSIONS: Health plan enrollment before cancer diagnosis was generally long in the CRN, and the proportion of patients lost to follow-up after diagnosis was low. With long enrollment histories among cancer patients pre-diagnosis and low post-diagnosis disenrollment, the CRN provides an excellent platform for epidemiologic and health services research on cancer incidence, outcomes, and costs.

Outcomes and satisfaction after delivery of a breast cancer survivorship care plan: results of a multicenter trial.

PURPOSE: Survivorship care plans (SCPs) have been suggested to reduce fragmentation of care experienced by cancer survivors. Acceptance of SCPs is high, but trials in the United States are few. This pilot study used a quasiexperimental design to examine the outcomes achieved by breast cancer survivors receiving a standardized SCP visit at one of seven comprehensive cancer centers. MATERIALS AND METHODS: Outcomes were assessed before and again 3 months after delivery of an SCP and included survivors' use of and satisfaction with SCPs, perceived knowledge about survivorship, and assessment of the quality and coordination of survivorship care. RESULTS: One hundred thirty-nine survivors of breast cancer completed baseline and follow-up measures and received a standardized SCP visit. Participants most commonly used SCP materials to make decisions about exercise (64%), which tests to receive and when (62%), and dietary changes (62%). Only 21% shared the SCP with their primary care provider during that time. Satisfaction with the SCP was high, with 90% of participants reporting being at least satisfied with the SCP. Perceived knowledge about survivorship improved after SCP delivery, as did perceived care coordination and the provider's knowledge of the effects of cancer on survivors (all P < .001). Individuals closer to the time of diagnosis reported greater satisfaction with and use of SCPs. CONCLUSION: This study demonstrates improvements in perceived knowledge and quality of survivorship care after receipt of a comprehensive SCP. Survivors were satisfied with their SCP, and those closer to diagnosis reported greater satisfaction with and use of the materials.

Characterization and treatment of local recurrence following breast conservation for ductal carcinoma in situ.

PURPOSE: The optimal treatment strategy for ductal carcinoma in situ (DCIS) continues to evolve and should consider the consequences of initial treatment on the likelihood, type, and treatment of recurrences. METHODS: We conducted a retrospective cohort study using two data sources of patients who experienced a recurrence (DCIS or invasive cancer) following breast-conserving surgery (BCS) for index DCIS: patients with an index DCIS diagnosed from 1997 to 2008 at the academic institutions of the National Comprehensive Cancer Network (NCCN; N = 88) and patients with an index DCIS diagnosed from 1990 to 2001 at community-based integrated healthcare delivery sites of the Health Maintenance Organization Cancer Research Network (CRN) (N = 182). RESULTS: Just under half of local recurrences in both cohorts were invasive cancer. While 40 % of patients in both cohorts underwent mastectomy alone at recurrence, treatment of the remaining patients varied. In the earlier CRN cohort, most other patients underwent repeat BCS (39 %) with only 18 % receiving mastectomy with reconstruction, whereas only 16 % had repeat BCS and 44 % had mastectomy with reconstruction in the NCCN cohort. Compared with patients not treated with radiation, those who received radiation for index DCIS were less likely to undergo repeat BCS (NCCN: 6.6 vs. 37 %, p = 0.001; CRN: 20 vs. 48 %, p = 0.0004) and more likely to experience surgical complications after treatment of recurrence (NCCN: 15 vs. 4 %, p = 0.17; CRN: 40 vs. 25 %, p = 0.09). CONCLUSION: We found that treatment of recurrences after BCS and subsequent complications may be affected by the use of radiotherapy for the index DCIS. Initial treatment of DCIS may have long-term implications that should be considered.

Cancer research network: using integrated healthcare delivery systems as platforms for cancer survivorship research.

INTRODUCTION: Much progress has been made in cancer survivorship research, but there are still many unanswered questions that can and need to be addressed by collaborative research consortia. METHODS: Since 1999, the National Cancer Institute-funded HMO Cancer Research Network (CRN) has engaged in a wide variety of research focusing on cancer survivorship. With a focus on thematic topics in cancer survivorship, we describe how the CRN has contributed to research in cancer survivorship and the resources it offers for future collaborations. RESULTS: We identified the following areas of cancer survivorship research: surveillance for and predictors of recurrences, health care delivery and care coordination, health care utilization and costs, psychosocial outcomes, cancer communication and decision making, late effects of cancer and its treatment, use of and adherence to adjuvant therapies, and lifestyle and behavioral interventions following cancer treatment. CONCLUSIONS: With over a decade of experience using cancer data in community-based settings, the CRN investigators and their collaborators are poised to generate evidence in cancer survivorship research. IMPLICATIONS FOR CANCER SURVIVORS: Collaborative research within these settings can improve the quality of care for cancer survivors within and beyond integrated health care delivery systems.

Utilization of HER2 genetic testing in a multi-institutional observational study.

INTRODUCTION: Human epidermal growth factor receptor 2 (HER2) expression is amplified in about 20% of breast cancer tumors, and evaluation of HER2 status should influence therapy selection. A critical gap in our knowledge is the real-world implementation of HER2 testing and its impact on treatment decisions for women diagnosed with breast cancer. OBJECTIVES: To assess use of HER2 testing, to describe characteristics of patients who do or do not receive HER2 testing, to describe which HER2 tests were used (fluorescence in situ hybridization or immunohistochemistry), and to evaluate trastuzumab use as a function of HER2 results. STUDY DESIGN: The population included 6460 women diagnosed with invasive breast cancer between 1999 and 2007 at 8 geographically distributed Cancer Research Network healthcare delivery systems in the United States. METHODS: Electronic records were used to identify patient and tumor characteristics and treatment with trastuzumab. Chart abstraction was performed for 400 women (50 per site) to identify receipt of HER2 testing and results. RESULTS: More than 90% of study participants received HER2 testing. Everyone who received trastuzumab had a HER2 test, and nearly all (>95%) who received trastuzumab had a positive HER2 test result recorded in their medical chart. Most (77%) eligible patients with a positive HER2 test result diagnosed after 2005 received trastuzumab. This study expands upon previous work in individual health plans. CONCLUSIONS: HER2 status has been successfully incorporated into medical practice to guide treatment decisions for breast cancer patients in diverse integrated healthcare delivery settings.

Providing care for cancer survivors in integrated health care delivery systems: practices, challenges, and research opportunities.

PURPOSE: Optimal approaches to cancer survivorship care are needed. This study sought to identify practices, barriers, and research opportunities in meeting the care needs of cancer survivors in integrated health care delivery systems. METHODS: This study was conducted at 10 sites within the Cancer Research Network, a National Cancer Institute-funded consortium of integrated health care delivery systems providing care for nearly 11 million enrollees. We identified 48 clinical leaders, administrators, and providers in oncology, primary care, nursing administration, and specialty care. Forty (83%) completed semi-structured, audio-recorded, transcribed telephone interviews, which we analyzed using an immersion-crystallization approach. RESULTS: Respondents were aware of the needs of cancer survivors and the difficulties they face in transitioning from treatment to follow-up care. Respondents from all sites reported that oncology and primary care are jointly responsible for the care of cancer survivors, often through the use of electronic medical records. Many respondents were not familiar with standardized survivorship care plans. Only two sites had formal cancer survivorship programs in place, and two were developing such programs. Respondents at sites with and without programs acknowledged existing gaps in evidence on the effectiveness of formal survivorship care and expressed a desire for additional research. CONCLUSION: Our exploratory study suggests an awareness of cancer survivorship care in integrated health care delivery systems, although approaches to providing such care vary across systems. These settings may offer a unique opportunity to develop, test, and implement innovative models of care, which can be systematically evaluated to inform and enhance cancer survivorship care in diverse health care settings.

Ten-year risk of diagnostic mammograms and invasive breast procedures after breast-conserving surgery for DCIS.

BACKGROUND: Breast-conserving surgery (BCS) is the most common treatment for ductal carcinoma in situ (DCIS); however, how often women experience subsequent diagnostic evaluations over time is not known. METHODS: We identified 2948 women with DCIS who were treated with BCS from 1990 to 2001 and followed for up to 10 years at three integrated health-care delivery systems. We calculated the percentages of diagnostic mammograms and ipsilateral invasive procedures following the initial breast excision to treat DCIS, estimated the 10-year cumulative incidence of these procedures, and determined hazard ratios for both types of procedures with Cox regression modeling. All statistical tests were two-sided. RESULTS: Over 10 years, 907 women (30.8%) had 1422 diagnostic mammograms and 1813 (61.5%) had 2305 ipsilateral invasive procedures. Diagnostic mammograms occurred in 7.3% of women in the first 6 months and continued at a median annual rate of 4.3%. Ipsilateral invasive procedures occurred in 51.5% of women in the first 6 months and continued at a median annual rate of 3.1%. The estimated 10-year cumulative risk of having at least one diagnostic mammogram after initial DCIS excision was 41.0% (95% confidence interval [CI] = 38.5% to 43.5%); at least one invasive procedure, 65.7% (95% CI = 63.7% to 67.8%); and either event, 76.1% (95% CI = 74.1% to 78.1%). Excluding events in the first 6 months following initial DCIS excision, corresponding risks were 36.4% (95% CI = 33.8% to 39.0%) for diagnostic mammograms, 30.4% (95% CI = 26.9% to 33.8%) for invasive procedures, and 49.5% (95% CI = 45.6% to 53.5%) for either event. CONCLUSIONS: Women with DCIS treated with BCS continue to have diagnostic and invasive breast procedures in the conserved breast over an extended period. The frequency of ongoing diagnostic breast evaluations should be included in discussions about treatment.

Validity of eight integrated healthcare delivery organizations' administrative clinical data to capture breast cancer chemotherapy exposure.

BACKGROUND: Cancer Research Network (CRN) sites use administrative data to populate their Virtual Data Warehouse (VDW). However, information on VDW chemotherapy data validity is limited. The purpose of this study was to assess the validity of VDW chemotherapy data. METHODS: This was a retrospective cohort study of women ≥18 years with incident, invasive breast cancer diagnosed between January 1999 and December 2007. Pharmacy and procedure chemotherapy data were extracted from each site's VDW. Random samples of 50 patients stratified on trastuzumab, anthracyclines, and no chemotherapy exposure was selected from each site for detailed chart abstraction. Weighted sensitivities and specificities of VDW compared with abstracted data were calculated. Cumulative doses calculated from VDW data were compared with doses obtained from the medical chart review. RESULTS: The cohort included 13,497 patients with 6,456 (48%) chart review eligible. Patients in the sample (N = 400) had a mean age of 65 years. Trastuzumab, anthracycline, and other chemotherapy weighted sensitivities were 95%, 97%, and 100%, respectively; specificities were 99%, 99%, and 93%, respectively; positive predictive values were 96%, 99%, and 55%, respectively; and negative predictive values were 99%, 96%, and 100%. Trastuzumab and anthracyclines VDW mean doses were 873 and 386 mg, respectively, whereas abstracted mean doses were 1,734 and 369 mgs, respectively (R(2) = 0.14, P < 0.01 and R(2) = 0.05, P = 0.03, respectively). CONCLUSIONS: Sensitivities and specificities for CRN chemotherapy VDW data were high and dosages were correlated with chart information. IMPACT: The findings support the use of CRN data in evaluating chemotherapy exposures and related outcomes.

Barriers in identification and referral to genetic counseling for familial cancer risk: the perspective of genetic service providers.

The purpose of this study was to obtain genetic counselors' perspectives about the identification of appropriate patients and barriers to referral of high-risk patients for cancer genetic counseling services. Genetic service providers from eight integrated health systems were surveyed. Data analysis included descriptive statistics. Twenty-eight of 40 potential participants responded (70%). Referrals for familial cancer risk assessment overwhelmingly came from providers (89%); only 10% were self-referrals. Use of guidelines to assist providers with referral was reported by 46% of the respondents. Genetic service providers perceived patient barriers to seeking genetic counseling after referral included: risk evaluation viewed as a non-priority (72%), concerns about impact on insurability (52%), distance to appointments (48%), lack of insurance (44%), lack of patient/provider knowledge about the value of genetic counseling (36%), discouragement by family members (28%), and fear (20%). The best approaches suggested by respondents to increase appropriate referrals were attending meetings and giving presentations to oncologists, surgeons, primary care and gynecologists. The genetic service providers reported several barriers to the referral and use of genetic counseling. This finding is consistent with current literature from the providers' perspective. Our survey adds the genetic service providers' perspective and identifies areas of opportunity for further research and intervention as few of the perceived barriers are being addressed through current educational efforts.

Hormone therapy discontinuation: physician practices after the Women's Health Initiative.

OBJECTIVE: No guidelines or randomized trials address best practices for hormone therapy (HT) discontinuation. METHODS: We conducted a survey study to explore HT discontinuation practices at Group Health and Harvard Vanguard, large integrated health systems in the Northwest and Northeast United States, focusing on differences between specialties and study site. RESULTS: The response rate to the written questionnaire (mailed between December 2005 and May 2006) was 78.5% (736/928); this article reports the results for 483 eligible physicians. To discontinue oral HT, most physicians (91%) advised tapering, not immediate cessation (8%), and most (60%) suggested decreasing both dose and days per week. Almost 60% of physicians reported no experience with tapering patches. Harvard Vanguard physicians were more likely than Group Health physicians to encourage discontinuing HT and less likely to recommend resuming HT when a woman's symptoms returned after discontinuing HT. Physicians were most strongly influenced by their own experience (48%), advice from colleagues (25%), and the woman's preference (19%) when choosing a discontinuation strategy; only 2% relied on research evidence. Physicians endorsed various approaches to manage symptoms after HT discontinuation, most often behavioral changes (44%) and increased exercise (37%), and these approaches were more often endorsed by Harvard Vanguard physicians and obstetrician/gynecologists than Group Health physicians or family practitioners or internists. CONCLUSIONS: Two health plans in the Northwestern and Northeastern United States have no standard protocol for HT discontinuation. Physicians customized approaches, influenced by their location, colleagues, and specialty. Research is needed to guide approaches to HT discontinuation.

Treatment of ductal carcinoma in situ among patients cared for in large integrated health plans.

OBJECTIVE: To examine whether use of adjuvant therapy varies by race/ethnicity among patients with ductal carcinoma in situ (DCIS) at 3 integrated health plan delivery sites based in California and Massachusetts. STUDY DESIGN: Cross-sectional study nested within a cohort of women diagnosed as having DCIS between 1990 and 2001. METHODS: We reviewed medical records of 3000 non-Hispanic white (69%), black (10%), Hispanic (9%), and Asian or Pacific Islander (12%) women diagnosed as having DCIS between 1990 and 2001 and treated with breast-conserving therapy. chi(2) Test and multinomial logistic regression analysis were used to examine the association between race/ethnicity and use of adjuvant treatments after controlling for patient and clinical variables, including certain pathologic factors. RESULTS: We found no significant differences in DCIS adjuvant treatment among racial/ethnic groups in bivariate or multinomial analyses after adjusting for demographic characteristics, comorbidity, and clinical factors. Minority women were as likely to undergo adjuvant radiation therapy as non-Hispanic white women. However, women 70 years or older (odds ratio, 0.40; 95% confidence interval, 0.31-0.51) and women who lived in areas with low geocoded median family income (odds ratio, 0.65; 95% confidence interval, 0.48-0.89) were less likely to receive adjuvant radiation therapy. Tumor size and comedo histologic growth pattern were associated with increased likelihood of receiving radiation therapy. CONCLUSION: Use of adjuvant therapy by minority women in these managed care plans is similar to that by non-Hispanic white women, although use was less among older women and among women who lived in poorer neighborhoods.