Association between socioeconomic factors and outcomes in breast cancer.

BACKGROUND: Persistent socioeconomic disparities are evident in the delivery of health care. Despite previous research into health disparities, the extent of the effect of economic inequalities in the management of breast cancer is not well understood. The purpose of our study is to perform a national assessment of the impact of economic factors on key aspects of breast cancer management. METHODS: This is a retrospective study using data from the National Cancer Database. The population consisted of female patients with primary breast cancer diagnosed between 2011 and 2015. Patients were categorized based on household income and insurance status. Outcomes investigated were stage at diagnosis, rate of breast conservation therapy, use of immediate reconstruction following mastectomy, and administration of systemic therapy for stage 3 and 4 disease. Multivariable logistic regression analyses were performed to determine significant associations between economic factors and clinical outcomes. Survival analysis was performed to evaluate the influence of income and insurance on survival. RESULTS: In total, 666 487 women were evaluated. Multivariable regression analyses revealed that patients with lower income (OR, 1.23) and no insurance (OR, 1.64) were more often diagnosed with later stage disease. Patients with lower income (OR, 1.08) and no insurance (OR, 1.05) had a higher likelihood of undergoing mastectomy instead of breast conserving therapy. Patients with lower income (OR, 0.51) and no insurance (OR, 0.27) were less likely to receive immediate breast reconstruction. Administration of systemic therapy was less frequent in patients with lower income (OR, 0.90) and no insurance (OR, 0.52). A survival benefit was demonstrated in patients with high income and insurance. CONCLUSION: Our findings demonstrate prevailing disparities in the delivery of care among patients with limited economic resources, which pertains to some of the most important aspects of breast cancer care. The full etiology of the observed disparities is complex and multifactorial, and a better understanding of these issues offers the potential to close the existing gap in quality of care.

Oncotype DX® Recurrence Score as a Predictor of Response to Neoadjuvant Chemotherapy.

BACKGROUND: The Oncotype DX® assay has been validated in predicting response to adjuvant chemotherapy in breast cancer. Its role in neoadjuvant chemotherapy (NCT) has not been established. METHODS: The National Cancer Database was used to identify all patients with T1-T3, ER-positive, HER2-negative primary invasive breast cancer diagnosed from 2010 to 2015 who had Oncotype DX recurrence scores (RS) and received NCT. RS were classified as low, intermediate, or high. Unadjusted and adjusted regression analyses were performed to determine the association between pathologic complete response (pCR) and RS. RESULTS: A total of 989 patients (mean age, 54.6 years) with available RS who underwent NCT were identified. RS were low in 227 (23.0%) patients, intermediate in 450 (45.5%) patients, and high in 312 (31.5%) patients. Most patients had a T1 (431 [43.6%]) or T2 tumor (451 [45.6%]). Most had N0 disease (757 [76.5%]). Tumor grades were 1 (123 [12.4%]), 2 (517 [52.3%]), or 3 (349 [35.3%]). pCR was achieved by 42 (4.3%) patients. Adjusted multivariable analysis showed a significant association between pCR and high RS (odds ratio 4.87; 95% confidence interval 2.01-11.82). CONCLUSIONS: High Oncotype DX RS was associated with pCR after NCT in this national cohort of ER-positive, HER2-negative patients. Oncotype DX testing could help to identify patients most suited for NCT and should be considered for incorporation into the multidisciplinary decision-making process.

Surgical Risk Factors for the Delayed Initiation of Adjuvant Chemotherapy in Breast Cancer.

BACKGROUND: Timely administration of adjuvant chemotherapy for breast cancer is associated with a survival benefit. Specific elements of surgical management may lead to delays initiating chemotherapy, resulting in unfavorable outcomes. The purpose of this study was to determine the correlation between surgical factors and delayed chemotherapy in breast cancer patients. METHODS: A retrospective analysis of the National Cancer Database was performed. The study cohort consisted of female patients with stage 1-3 breast cancer diagnosed between 2010 and 2014. Initiation of chemotherapy beyond 90 days after surgery was defined as delayed. Multivariable logistic regression modeling was performed to establish associations between delayed chemotherapy and clinical and demographic factors of interest. Survival analysis was performed using the Kaplan-Meier estimation and Cox proportional hazards regression to evaluate potential 5-year overall survival disadvantage of delayed initiation of chemotherapy. RESULTS: Of 166,681 women assessed, 4.3% had a delay in the initiation of chemotherapy. Surgery-specific risk factors included unplanned readmission in the postoperative period, lower surgical volume, mastectomy with immediate autologous reconstruction, and positive surgical margins. Adjusted survival analysis showed a survival disadvantage of delayed initiation of chemotherapy (hazard ratio [HR] 1.46; p < 0.01). CONCLUSIONS: Risk factors for delayed initiation of chemotherapy specific to the surgical process were identified. Delayed initiation of adjuvant chemotherapy was associated with a survival detriment. Efforts should be made to address these surgical management issues and optimize the perioperative process to ensure timely patient treatment.