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Background: Interventions aimed at upstream factors contributing to late-stage diagnoses could reduce disparities and improve breast cancer outcomes. This study examines the association between measures of housing stability and contemporary mortgage lending bias on breast cancer stage at diagnosis among older women in the United States., Methods: We studied 67,588 women aged 66-90 from the SEER-Medicare linked database (2010-2015). The primary outcome was breast cancer stage at diagnosis. Multinomial regression models adjusted for individual and neighborhood socio-economic factors were performed using a three-category outcome (stage 0, early stage, and late stage). Key census tract-level independent variables were residence in the same house as the previous year, owner-occupied homes, and an index of contemporary mortgage lending bias., Results: In models adjusted for individual factors, higher levels of mortgage lending bias were associated with later stage diagnosis (RR = 1.10, 95% CI 1.02-1.20; RR = 1.31, 95% CI 1.16-1.49; RR = 1.41, 95% CI 1.24-1.60 for least to high, respectively). In models adjusted for individual and neighborhood socio-economic factors, moderate and high levels of mortgage lending bias were associated with later stage diagnosis (RR = 1.16, 95% CI 1.02-1.33 for moderate and RR = 1.18, 95% CI 1.02-1.37 for high). Owner occupancy and tenure were not associated with later stage diagnosis in adjusted models., Conclusions: Contemporary mortgage lending bias demonstrated a significant gradient relationship with later stage at diagnosis of breast cancer. Policy interventions aimed at reducing place-based mortgage disinvestment and its impacts on local resources and opportunities should be considered as part of an overall strategy to decrease late-stage breast cancer diagnosis and improve prognosis., (© 2024 The Author(s). Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Residential segregation is an important factor that negatively impacts cancer disparities, yet studies yield mixed results and complicate clear recommendations for policy change and public health intervention. In this study, we examined the relationship between local and Metropolitan Statistical Area (MSA) measures of Black isolation (segregation) and survival among older non-Hispanic (NH) Black women with breast cancer (BC) in the United States. We hypothesized that the influence of local isolation on mortality varies based on MSA isolation-specifically, that high local isolation may be protective in the context of highly segregated MSAs, as ethnic density may offer opportunities for social support and buffer racialized groups from the harmful influences of racism., Methods: Local and MSA measures of isolation were linked by Census Tract (CT) with a SEER-Medicare cohort of 5,231 NH Black women aged 66-90 years with an initial diagnosis of stage I-IV BC in 2007-2013 with follow-up through 2018. Proportional and cause-specific hazards models and estimated marginal means were used to examine the relationship between local and MSA isolation and all-cause and BC-specific mortality, accounting for covariates (age, comorbidities, tumor stage, and hormone receptor status)., Findings: Of 2,599 NH Black women who died, 40.0% died from BC. Women experienced increased risk for all-cause mortality when living in either high local (HR = 1.20; CI = 1.08-1.33; p < 0.001) or high MSA isolation (HR = 1.40; CI = 1.17-1.67; p < 0.001). A similar trend existed for BC-specific mortality. Pairwise comparisons for all-cause mortality models showed that high local isolation was hazardous in less isolated MSAs but was not significant in more isolated MSAs., Interpretation: Both local and MSA isolation are independently associated with poorer overall and BC-specific survival for older NH Black women. However, the impact of local isolation on survival appears to depend on the metropolitan area's level of segregation. Specifically, in highly segregated MSAs, living in an area with high local isolation is not significantly associated with poorer survival. While the reasons for this are not ascertained in this study, it is possible that the protective qualities of ethnic density (e.g., social support and buffering from experiences of racism) may have a greater role in more segregated MSAs, serving as a counterpart to the hazardous qualities of local isolation. More research is needed to fully understand these complex relationships., Funding: National Cancer Institute., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: Poor women with breast cancer have worse survival than others, and are more likely to undergo surgery in low-volume facilities. We leveraged a natural experiment to study the effectiveness of a policy intervention undertaken by New York (NY) state in 2009 that precluded payment for breast cancer surgery for NY Medicaid beneficiaries treated in facilities performing fewer than 30 breast cancer surgeries annually., Methods: We identified 37,822 women with stage I-III breast cancer during 2004-2008 or 2010-2013 and linked them to NY hospital discharge data. A multivariable difference-in-differences approach compared mortality of Medicaid insured patients with that of commercially or otherwise insured patients unaffected by the policy., Results: Women treated during the postpolicy years had slightly lower 5-year overall mortality than those treated prepolicy; the survival gain was significantly larger for Medicaid patients ( P = .018). Women enrolled in Medicaid had a greater reduction than others in breast cancer-specific mortality ( P = .005), but no greater reduction in other causes of death ( P = .50). Adjusted breast cancer mortality among women covered by Medicaid declined from 6.6% to 4.5% postpolicy, while breast cancer mortality among other women fell from 3.9% to 3.8%. A similar effect was not observed among New Jersey Medicaid patients with breast cancer treated during the same years., Conclusion: A statewide centralization policy discouraging initial care for breast cancer in low-volume facilities was associated with better survival for the Medicaid population targeted. Given these impressive results and those from prior research, other policymakers should consider adopting comparable policies to improve breast cancer outcomes.[Media: see text].

Purpose: Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence., Methods: We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables., Results: Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence., Conclusion: Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Adjuvant endocrine therapy (AET) for breast cancer reduces mortality, but one-third to one-half of patients discontinue it early or are nonadherent., Objective: We developed a pilot single-site study of patients with evidence of early nonadherence to AET to assess the feasibility of a novel, clinical pharmacist-led intervention targeting symptom and medication management., Methods: Patients with prescription fill records showing nonadherence were enrolled in a single-arm feasibility study. Automated reminders were sent by e-mail or text with a link to symptom monitoring assessments weekly for 1 month and monthly until 6 months. Clinical oncology pharmacists used guideline-based symptom management and other medication management tools to support adherence and ameliorate symptoms reported on the assessments. Patient-reported outcome assessments included physical, mental, and social health domains and self-efficacy to manage symptoms and medications. Feasibility outcomes included completion of symptom reports and pharmacist recommendations., Results: Of 19 participants who were nonadherent who enrolled and completed initial assessments, 18 completed all final study procedures, with 14 completing all assessments and no patient missing more than 3 assessments. All 18 participants reported at least one of 3 symptom types, and the majority reported attempting pharmacist recommendations. Patient-reported measures of physical, mental, and social health and self-efficacy improved, and 44% of the patients became adherent., Conclusion: An intervention using pharmacists in an oncology practice to systematically monitor and manage symptoms shows promise to reduce symptoms, enhance support and self-efficacy, and improve adherence to AET., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background: Yearly influenza vaccination is strongly recommended at age 65 and reimbursed by Medicare without copays or deductibles at pharmacies and clinical settings. Uptake is low among patients with a high risk for influenza complications and good access to specialist care, such as recent cancer survivors. We hypothesized that more accessible pharmacies could be associated with higher immunization uptake in such patients., Objectives: To determine whether pharmacy access is associated with influenza vaccination in subjects recently diagnosed with breast cancer, and whether this association differs by additional risk factors for influenza complications., Methods: We examined a cohort of patients with stage 0-III breast cancer diagnosed 2011-2015 from the Surveillance, Epidemiology, and End Results-Medicare cancer registry. All retail pharmacies in the United States were identified, and pharmacy access was measured by assessing supply and demand in each census tract using a 2-stage floating catchment area approach that accounted for pharmacy driving distances recommended by the Centers for Medicare and Medicaid Services. We examined the association of pharmacy access with influenza vaccination after breast cancer diagnosis in regression models., Results: More than 11% of 45,722 patients with breast cancer lived in census tracts where no pharmacies were within recommended driving distances from the population-weighted tract center. Vaccination in the year after diagnosis was less likely for patients in these very low-access tracts (adjusted odds ratio 0.92 [95% CI 0.86-0.96]), black (0.55 [0.51-0.60]) and Hispanic (0.76 [0.70-0.83]) women, and Medicaid recipients (0.74 [0.69-0.79]). Vaccination was inversely associated with per capita income in the subject's census tract, but there was no difference in the pharmacy effect by race, ethnicity, or census tract income., Conclusion: Very low pharmacy access is associated with modest reductions in vaccination that could be useful for policy and planning regarding vaccinator resources and outreach., (Copyright © 2021 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Purpose: The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States., Methods: A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates., Results: Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality., Conclusion: Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer., Competing Interests: Jamila KwartengEmployment: Boston ScientificNo other potential conflicts of interest were reported.

Background: The aim of this large nationwide study was to validate two novel composite treatment scores that address guideline-concordant locoregional and systemic breast cancer care. We examined the relationship between these two scores and their association with survival., Methods: Women with Stage I-III unilateral breast cancer were identified within the National Cancer Database. For each woman, a locoregional and a systemic treatment score (0, 1, 2) was assigned based on receipt of guideline-concordant care. Multivariable Cox regression models evaluated the association between the scores and survival., Results: 623,756 women were treated at 1,221 different American College of Surgeons Commission on Cancer (CoC) facilities. Overall, 86% had a locoregional treatment score of 2 (most guideline-concordant), 75% had a systemic treatment score of 2, and 72% had both scores of 2. Median follow-up was 4.5 years. Compared to women with a locoregional treatment score of 2, those with a score of 1 or 0 had a 1.7-fold and 2.0-fold adjusted greater risk of death. Compared to women with a systemic treatment score of 2, those with a score of 1 or 0 had a 1.5-fold and 2.1-fold adjusted greater risk of death. Risk-adjusted 5-year overall survival was 91.6% when both scores were 2 compared to 73.4% when both scores were 0., Conclusions: In this large national study of CoC facilities, two composite scores capturing guideline-concordant breast cancer care had independent and combined robust effects on survival. These clinically constructed novel scores are promising tools for health services research and quality-of-care studies.

Purpose: Clinical trials have clearly documented the survival benefit of aromatase inhibitors (AIs); however, many women fail to initiate (primary nonadherence) or remain adherent to AIs (secondary nonadherence). Prior studies have found that costs impact secondary nonadherence to medications but have failed to examine primary nonadherence. The purpose of this study is to examine primary and secondary adherence following the reduction in copays due to the introduction of generic AIs., Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 50 054 women diagnosed with incident breast cancer between 2008 and 2013. We compare women whose copays would change and those whose would not, due to the receipt of cost-sharing subsidies before and after generics were introduced using a difference-in-difference (DinD) analysis. To examine primary and secondary nonadherence, we rely on a multistate model with four states (Not yet initiated, User, Not Using, and Death). We adjusted for baseline factors using inverse probability treatment weights and then simulated adherence for 36 months following diagnosis., Results: The generic introduction of AIs resulted in patients initiating AIs faster (DinD = -4.7%, 95%CI = -7.0, -2.3; patients not yet initiating treatment at 6-months), being more adherent (DinD ranging in absolute increase of 8.1%-10.4%) and being less likely to not be using the therapy (DinD range in absolute decrease of 1.2% at 6 months to 8.8% at 24 months) for women that do not receive a subsidy after generics were available., Conclusions: Introduction of generic alternatives to AIs significantly reduced primary and secondary nonadherence., (© 2020 John Wiley & Sons Ltd.)

Purpose: Advanced practice providers (APPs) have increasingly become members of the oncology care team. Little is known about the scope of care that APPs are performing nationally. We determined the prevalence and extent of APP practice and examined associations between APP care and scope of practice regulations, phase of cancer care, and patient characteristics., Methods: We performed an observational study among women identified from Medicare claims as having had incident breast cancer in 2008 with claims through 2012. Outpatient APP care included at least one APP independently billing for cancer visits/services. APP scope of practice was classified as independent, reduced, or restricted. A logistic regression model with patient-level random effects was estimated to determine the probability of receiving APP care at any point during active treatment or surveillance., Results: Among 42,550 women, 6583 (15%) received APP care, of whom 83% had APP care during the surveillance phase and 41% during the treatment phase. Among women who received APP care during a given year of surveillance, the overall proportion of APP-billed clinic visits increased with each additional year of surveillance (36% in Year 1 to 61% in Year 4). Logistic regression model results indicate that women were more likely to receive APP care if they were younger, black, healthier, had higher income status, or lived in a rural county or state with independent APP scope of practice., Conclusions: This study provides important clinical and policy-relevant findings regarding national practice patterns of APP oncology care. Among Medicare beneficiaries with incident breast cancer, 15% received outpatient oncology care that included APPs who were billing; most of this care was during the surveillance phase. Future studies are needed to define the degree of APP oncology practice and training that maximizes patient access and satisfaction while optimizing the efficiency and quality of cancer care.

Background: One-third to one-half of patients prescribed adjuvant endocrine therapy are nonadherent during the recommended 5-year endocrine therapy course. This study investigated whether poor pharmacy synchronization of medication fills (requiring refills on different days) acts as a barrier to adherence., Methods: A cohort of older women with stage 0 to III endocrine receptor-positive breast cancer in 2011 was identified from the Surveillance, Epidemiology, and End Result-Medicare claims-linked cancer registry. Women with endocrine therapy and at least 1 other medication fill were identified, and the 3-month synchronization of their fills was calculated as 1 minus the quotient of the number of pharmacy visits and the number of filled medications. Regression models were used to examine the association between synchronization (in quartiles adjusted for the number of medications) and adherence to endocrine therapy (defined as a medication possession ratio ≥80%) over the subsequent year., Results: During the 3 months after the first endocrine therapy prescription, the study cohort of 3212 women had a mean of 8.6 pharmacy visits (standard deviation, 4.7) with a mean synchronization of 0.3 (standard deviation, 0.2). Those in the third (odds ratio, 1.29; 95% confidence interval, 1.04-1.59) and fourth (most) medication number-adjusted synchronization quartiles (odds ratio, 1.49; 95% confidence interval, 1.19-1.86) were more likely to be adherent than those in the least. Multivariate model predictions showed that the proportion of patients who were adherent over 1 year varied from 68.9% in the least synchronized quartile to 76.6% in the most synchronized one., Conclusions: Prescription refill synchronization is strongly associated with adherence to endocrine therapy. Efforts to improve adherence should address this., (© 2019 American Cancer Society.)

Background: Despite the well-documented association of medication refill synchronization with medication adherence, little is known about how best to measure synchronization at pharmacy visits or about its relationship to number of medications., Objective: To examine the relationship of a commonly cited synchronization measure with the number of prescription medications., Methods: Using a cohort of women aged 66-90 years with stage 0-3 hormone receptor-positive breast cancer from the Surveillance, Epidemiology and End Result (SEER)-Medicare data, we identified women with pharmacy claims for at least 1 endocrine therapy prescription and at least 1 other medication fill. Twelve-month medication refill synchronization was calculated as the quotient of the number of pharmacy visits and the number of filled medications subtracted from 1. Multiple linear regression (including polynomials) was then used to assess the relationship between refill synchronization, number of medications, and other potentially influential factors., Results: Over 47% of cohort subjects took more than 10 unique medications. Subjects made an average (SD) of 29.9 (18.0) pharmacy visits, resulting in a mean (SD) synchronization of 0.28 (0.18, range = 0.0-0.92). The number of medications, including powers through to the fourth, was strongly associated with refill synchronization, with a rapid initial rise followed by a gradual increase after 10 medications. Although patient age and race/ethnicity were not associated with synchronization, there was a significant positive association of receipt of a low-income subsidy and residence in rural areas with synchronization., Conclusions: There is a complex relationship between refill synchronization and number of prescribed medications, and future research into synchronization should account for this., Disclosures: This study was supported by the National Institute on Minority Health and Health Disparities under grant R01 MD010728. The authors have nothing to disclose. This study was presented as an oral abstract at the Society of General Internal Medicine Meeting; April 13, 2018; Denver, CO.

Background: Theoretically, the estrogen deprivation induced by aromatase inhibitors (AIs) might cause ischemic heart disease, but empiric studies have shown mixed results. We aimed to compare AIs and tamoxifen with regard to cardiovascular events among older breast cancer patients outside of clinical trials. We hypothesized that AIs increase the risk of myocardial infarction., Methods: We identified women age ≥67 years diagnosed with breast cancer from June 30, 2006 to June 1, 2008 in the surveillance, epidemiology, and end results (SEER)-Medicare database, treated with either tamoxifen or an AI, and followed through December 31, 2012. To compare myocardial infarction (MI) risk for the treatment groups of AIs vs tamoxifen, we developed and assigned stabilized probability of treatment weights and used the Fine and Gray model for time to MI with death not related to MI as a competing risk., Results: Of the cohort of 5648 women, 4690 were treated with AIs and 958 with tamoxifen; a total of 251 patients developed MI, and 22 patients died of MI during the study period while 476 died of other causes. The hazard for MI was not significantly different between AI vs tamoxifen groups (HR = 1.01, 95% CI 0.72-1.42), after adjusting for the following known MI risk factors at the start of adjuvant therapy: diabetes, ischemic heart disease, congestive heart failure, MI, and peripheral vascular disease., Conclusions: In this SEER-Medicare-based population study, there were no significant differences in the risk of MI between AI and tamoxifen users after adjustment for known risk factors., (© 2018 Wiley Periodicals, Inc.)

Purpose: Although users of aromatase inhibitors have higher total fracture risk in some randomized trials, little is known about their risk outside of clinical trials or in older higher-risk cohorts., Methods: In a population-based retrospective cohort study, we identified all older US Medicare D prescription drug insurance plan-enrolled women who had initial breast cancer surgery in 2006-2008 and began hormonal therapy (an aromatase inhibitor (AI) or tamoxifen) within the subsequent year. Total nonvertebral and hip fractures through 2012 were identified using a validated algorithm. The association of fracture outcomes with hormonal therapy type was assessed using competing risk regression models that accounted for differences in measured baseline covariates. Treatment assignment bias was reduced using inverse probability of treatment weighting computed from propensity scores., Results: Among 23,378 women taking hormonal therapy (23.2% aged 80 or over), there were 3000 total and 436 hip fractures. Although AI users were younger and had lower comorbidity, after propensity score weighting, these and other covariates were balanced. Total nonvertebral risk was higher for users of AIs compared with tamoxifen, HR 1.11 (1.02-1.21), but the small increase in risk for hip fracture was not statistically significant, HR 1.04 (0.84-1.30)., Conclusions: Although total nonvertebral fracture risk was higher among AI users, differences in hip fractures were not significant in a large population-based cohort of older women., Implications for Cancer Survivors: Use of aromatase inhibitors by older women is associated with high risk for nonvertebral fracture that is increased compared with use of tamoxifen. Fracture risk should be assessed among patients taking these medications.

Background: Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity., Objective: Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND., Research Design/subjects: Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009., Measures: Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated., Results: Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases., Conclusions: In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.

Background: Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents., Objectives: Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program., Design: Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D., Subjects: Female Medicare beneficiaries with early-stage breast cancer: 54,772 diagnosed in 2001 and 46,371 in 2007., Measures: SES was based on Medicaid enrollment and zip code per capita income, all-cause mortality from Medicare, and cause of death from National Death Index., Results: Among women diagnosed pre-Part D, 40.5% of poor beneficiaries had died within 5 years compared with 20.3% of high-income women (P<0.0001). Post-Part D, 33.6% of poor women and 18.4% of high-income women died by 5 years. After adjustment for potential confounders, improvement in all-cause mortality post-Part D was greater for poorer women compared with more affluent women (P=0.002). However, absolute improvement in breast cancer-specific mortality was 1.8%, 1.2%, and 0.8% (P=0.88 for difference in improvement by SES), respectively for poor, near-poor, and high-income women, whereas analogous improvement in mortality from other causes was 5.1%, 3.8%, and 0.9% (P=0.067 for difference in improvement by SES)., Conclusions: Large survival disparities by SES exist among breast cancer patients. The Part D program successfully ameliorated SES disparities in all-cause mortality. However, improvement was concentrated in causes of death other than breast cancer, suggesting remaining gaps in care.

Purpose To investigate the role of out-of-pocket cost supports through the Medicare Part D Low-Income Subsidy on disparities in breast cancer hormonal therapy persistence and adherence by race or ethnicity. Methods A nationwide cohort of women age ≥ 65 years with a breast cancer operation between 2006 and 2007 and at least one prescription filled for oral breast cancer hormonal therapy was identified from all Medicare D enrollees. The association of race or ethnicity with nonpersistence (90 consecutive days with no claims for a hormonal therapy prescription) and nonadherence (medication possession rate < 80%) was examined. Survival analyses were used to account for potential differences in age, comorbidity, or intensity of other treatments. Results Among the 25,111 women in the study sample, 77% of the Hispanic and 70% of the black women received a subsidy compared with 21% of the white women. By 2 years, 69% of black and 70% of Hispanic patients were persistent compared with 61% of white patients. In adjusted analyses, patients in all three unsubsidized race or ethnicity groups had greater discontinuation than subsidized groups (white patients: hazard ratio [HR], 1.83; 95% CI, 1.70 to 1.95; black patients: HR, 2.09; 95% CI, 1.73 to 2.51; Hispanic patients: HR, 3.00; 95% CI, 2.37 to 3.89). Racial or ethnic persistence disparities that were present for unsubsidized patients were not present or reversed among subsidized patients. All three subsidized race or ethnicity groups also had higher adherence than all three unsubsidized groups, although with the smallest difference occurring in black women. Conclusion Receipt of a prescription subsidy was associated with substantially improved persistence to breast cancer hormonal therapy among white, black, and Hispanic women and lack of racial or ethnic disparities in persistence. Given high subsidy enrollment among black and Hispanic women, policies targeted at low-income patients have the potential to also substantially reduce racial and ethnic disparities.

Background: Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop "Top Five" lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown., Methods: We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) "basic" public reporting and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely® or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention; and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions., Discussion: The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care., Trial Registration: ClinicalTrials.gov number pending., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Racial health disparities continue to be a serious problem in the United States and have been linked to contextual factors, including racial segregation. In some cases, including breast cancer survival, racial disparities appear to be worsening. Using the Home Mortgage Disclosure Act (HMDA) database, we extend current spatial analysis methodology to derive new, spatially continuous indices of (1) racial bias in mortgage lending and (2) redlining. We then examine spatial patterns of these indices and the association between these new measures and breast cancer survival among Black/African American women in the Milwaukee, Wisconsin metropolitan area. These new measures can be used to examine relationships between mortgage discrimination and patterns of disease throughout the United States., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: Aromatase inhibitors (AIs) are standard adjuvant therapy for postmenopausal women with early-stage, estrogen receptor-positive breast cancer. We designed our study to determine whether women initiating adjuvant therapy with an AI underwent baseline bone mineral density testing, as well as what factors predicted adherence with testing guidelines., Methods: Medicare Parts A, B, and D claims were used to identify a cohort of women aged 67 years and older with incident breast cancer in 2006 and 2007 who started AI therapy. Medicare claims provided information about bone density testing, as well as demographic and other treatment data through 2012. We also ascertained which patients were treated with bisphosphonates and studied the relationship of bisphosphonate therapy with bone density testing., Results: Approximately two-thirds of patients had baseline bone density testing. Older age, comorbidity, low income, and black race were associated with lower rates of baseline bone density testing. Testing rates decreased substantially with increasing age from 73% for women aged 67 to 70 years to 51% for those 85 years of age and older (adjusted odds ratio for not being tested, 2.48 [Cl, 2.17-2.82]). The proportion of women who had neither bone density testing nor bisphosphonate therapy increased with age as well., Conclusions: Despite the importance of age as a risk factor for fractures, older women starting treatment with AIs for treatment of breast cancer are less likely to undergo recommended bone density assessment., (Copyright © 2016 by the National Comprehensive Cancer Network.)

Background: Cancer health disparities by race, ethnicity, socioeconomic status, and geography are a top public health priority. Breast and colorectal cancer, in particular, have been shown to exhibit significant disparities and contribute a large proportion of morbidity and mortality from cancer. In addition, breast and colorectal cancer offer targets for prevention and control, including nutrition, physical activity, screening, and effective treatments to prolong and enhance the quality of survival. However, despite the investment of significant time and resources over many years, breast and colorectal cancer disparities persist, and in some cases, may be growing., Methods: This paper examines breast and colorectal cancer survival disparities in an 8-county region in southeastern Wisconsin, including the City of Milwaukee. Cox proportional hazards models were used to examine survival trends, and a new adaptation of adaptive spatial filtering--a disease mapping method--was used to examine spatial patterns of survival., Results: Disparities by race and ethnicity are revealed, and spatial analyses identify specific areas within the study region that have lower than expected survival rates., Conclusions: Cancer control efforts in southeastern Wisconsin should focus on black/African American and Hispanic/Latina women to reduce breast cancer survival disparities, and black/African American populations to reduce colorectal cancer disparities. Evidence indicates that targeted interventions may be needed to serve populations in the Milwaukee and Kenosha metropolitan areas, as well as areas of Walworth, Ozaukee, and Waukesha counties.

Objective: To reexamine the relationship of hospital and surgical volume to all-cause and breast cancer-specific mortality, taking into account the potential selection bias in patients treated at high-volume centers or by high-volume surgeons., Data Sources: Elderly (65+) women with early-stage, incident breast cancer surgery in 2003., Study Design: A population-based, prospective survey study., Methods: Two-stage, instrumental variable regression models., Principal Findings: Women treated in high-volume hospitals were significantly less likely to die of any cause by 5 years after surgery, even after adjustments for self-selection and a number of other factors. The relationship was larger and more significant for breast cancer-specific mortality. Although the general pattern of better mortality outcomes held for moderately sized hospitals, the relationships were not statistically significant. In contrast, there was no relationship of surgeon volume with all-cause or breast cancer-specific mortality., Conclusions: Hospital volume, but not surgeon volume, is associated with better survival among women with breast cancer. The magnitude of the potential improvement was substantial and comparable with the benefit conferred by many systemic therapies. These findings highlight the importance of accounting for patient self-selection in volume-outcome analyses, and provide support for policy initiatives aimed at regionalizing breast cancer care in the United States.

Background: Aromatase inhibitors (AIs) substantially reduce breast cancer mortality in clinical trials, but high rates of nonadherence to these long-term oral therapies have reduced their impact outside of trials. We examined the association of generic AI availability with AI adherence among a large national breast cancer cohort., Methods: Using a quasi-experimental prepost design, we examined the effect of generic AI introductions (7/2010 and 4/2011) on adherence among a national cohort of women with incident breast cancer in 2006 and 2007 who were enrolled in the Medicare D pharmaceutical coverage program. Medicare D claims were used to calculate AI adherence, defined as a medication possession ratio of 80% or more of eligible days, over 36 months. Multivariable logistic regression models estimated with generalized estimating equations were applied to longitudinal adherence data to control for possible confounders, including receipt of a Medicare D low-income subsidy, and to account for repeated measures. All statistical tests were two-sided., Results: Sixteen thousand four hundred sixty-two Medicare D enrollees were eligible. Adherence declined throughout the study. However, among women without a subsidy, the median quarterly out-of-pocket cost of anastrozole fell from $183 in the fourth quarter of 2009 to $15 in 2011, and declines in adherence were attenuated with generic AI introductions. Regression-adjusted adherence probabilities were estimated to be 5.4% higher after generic anastrozole was introduced in 2010 and 11% higher after generic letrozole/exemestane was introduced in 2011. Subsidy recipients had higher adherence rates throughout the study., Conclusions: The introduction of generic medications attenuated the decline in adherence to AIs over three years of treatment among breast cancer survivors not receiving low-income subsidies for Medicare D coverage., (© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Population-based studies have revealed higher mortality among breast cancer patients treated in low-volume hospitals. Other studies have demonstrated disparities in race and socioeconomic status (SES) in breast cancer survival. The purpose of our study was to determine whether nonwhite or low-SES patients are disproportionately treated in low-volume hospitals., Methods: A population-based cohort of 2,777 Medicare breast cancer patients who underwent breast cancer surgery in 2003 participated in a survey study examining breast cancer outcomes. Information was obtained from survey responses, Medicare claims, and state tumor registry data., Results: On univariate analysis, patients treated at low-volume hospitals were less likely to be white, less likely to live in an urban location, and more likely to have a low SES with less social support and live a greater distance from a high-volume hospital. Education, marital status, total household income, having additional insurance besides Medicare, population density of primary residence, and tangible support were associated with distance to the nearest high-volume hospital. On multivariate analysis, the independent predictors of treatment at a low-volume hospital were being nonwhite (P = 0.003), having a lower household income (P < 0.0001), residence in a rural location (P = 0.01), and living a greater distance from a high-volume hospital (P < 0.0001)., Conclusions: In this large population-based cohort, women who were poorer, nonwhite, and who lived in a rural location or at a greater distance from a high-volume hospital were more likely to be treated at low-volume hospitals. These differences may partially explain racial and SES disparities in breast cancer outcomes.

Health numeracy is associated with increased understanding of cancer risk reduction information and improved control of chronic disease. A cross-sectional survey was conducted among a primary care population to evaluate the effect of health numeracy on breast, cervical, and colorectal cancer screening. No association was found between health numeracy and cancer screening. However, at a baseline screening rate of 85%, increased knowledge (RR 1.06, 95% CI 1.02-1.08) and decreased perceived barriers (RR 0.93, 95% CI 0.92-0.95) were associated with increased screening rates. In conclusion, health numeracy was not predictive of cancer screening among a primary care population.

Background: The authors sought to identify socioeconomic (SES) factors associated with adjuvant hormone therapy (HT) use among a contemporary population of older breast cancer survivors., Methods: Telephone surveys were conducted among women (ages 65-89 years) residing in 4 states (California, Florida, Illinois, and New York) who underwent initial breast cancer surgery in 2003. Demographic, SES, and treatment information was collected., Results: Of 2191 women, 67% received adjuvant HT with either tamoxifen or an aromatase inhibitor (AI); 71% of those women were on an AI. When adjusting for multiple demographic and SES factors, predictors of HT use were better education (high school degree or higher), better informational/emotional support, and younger age (ages 65-79 years). Race/ethnicity, income, and insurance coverage for medication costs were not associated with receiving HT. For those on HT, when adjusting for all other factors, women were more likely to receive an AI if they had insurance coverage for some or all medication costs, if they were wealthier, if they had better informational/emotional support, and if they were younger (ages 65-69 years)., Conclusions: The majority of older women in this population-based cohort received adjuvant HT, and the adoption of AIs was early. The results indicted that providers should be aware that a woman's education level and support system influence her decision to take HT. Given the high cost of AIs, their benefits in postmenopausal women with hormone receptor-positive breast cancer, and the current finding that women with no insurance coverage for medication costs were significantly less likely to receive an AI, we recommend that policymakers address this issue., (Copyright © 2010 American Cancer Society.)

Subject recruitment for epidemiologic studies is associated with major challenges due to privacy laws now common in many countries. Privacy policies regarding recruitment methods vary tremendously across institutions, partly because of a paucity of information about what methods are acceptable to potential subjects. The authors report the utility of an opt-out method without prior physician notification for recruiting community-dwelling US women aged 65 years or older with incident breast cancer in 2003. Participants (n = 3,083) and possibly eligible nonparticipants (n = 2,664) were compared using characteristics derived from billing claims. Participation for persons with traceable contact information was 70% initially (2005-2006) and remained over 90% for 3 follow-up surveys (2006-2008). Older subjects and those living in New York State were less likely to participate, but participation did not differ on the basis of socioeconomic status, race/ethnicity, underlying health, or type of cancer treatment. Few privacy concerns were raised by potential subjects, and no complaints were lodged. Using opt-out methods without prior physician notification, a population-based cohort of older breast cancer subjects was successfully recruited. This strategy may be applicable to population-based studies of other diseases and is relevant to privacy boards making decisions about recruitment strategies acceptable to the public.

Background: A relationship between higher surgeon volume and lower mortality has been described for breast cancer, but selection bias has not been rigorously evaluated. We studied potential bias in the surgeon volume-outcome relationship by comparing the relationship of surgeon volume to breast cancer mortality and to mortality from other causes of death., Methods: We conducted an observational cohort study from tumor registry and Medicare claims data on 12 216 women, 66 years or older, with stage I or II breast cancer, who were operated on by 1856 surgeons. Breast cancer mortality and other-cause mortality were determined from death certificate sources and surgeon volume from Medicare claims., Results: Treatment by a high-volume surgeon was associated with younger patient age, white race, less comorbidity, and residence in a more affluent zip code. Patients treated by low-, medium-, and high-volume surgeons had small differences in breast cancer mortality (17.4, 15.7, and 13.0 deaths per 1000 person-years, respectively; P = .03) but larger differences in non-breast cancer mortality (46.0, 36.8, and 31.7 deaths per 1000 person-years, respectively; P < .001). After adjustment for multiple patient and disease factors, women treated by high-volume surgeons, compared with those treated by low-volume surgeons, were not less likely to die of breast cancer (relative risk, 0.94; 95% confidence interval, 0.76-1.16) but were significantly less likely to die of other causes (relative risk, 0.86; 95% confidence interval, 0.75-0.98)., Conclusions: The surgeon volume-outcome relationship for these patients with breast cancer was attributable not to mortality from breast cancer but to other causes of death. The lack of specificity of this relationship raises the possibility of selection bias as an explanatory factor.

Objectives: We examined the association between number of breast cancer operations performed in a hospital (hospital volume) and all-cause and breast cancer-specific mortality using a national database and statistical methods appropriate for clustering and reducing confounding., Methods: In a retrospective cohort study, we linked Surveillance, Epidemiology, and End Results tumor registry data with Medicare claims data. The cohort included 11225 Medicare patients who had undergone surgery for early-stage breast cancer from 1994 to 1996 in 457 different hospitals. Primary outcomes were all-cause and breast cancer-specific survival rates at a mean follow-up time of 62.5 months., Results: In comparison with treatment in a low-volume hospital, treatment in a high-volume hospital was associated with hazard ratios of 0.83 (95% confidence interval [CI]=0.75, 0.92) for all-cause mortality and 0.80 (CI=0.66, 0.97) for breast cancer-specific mortality., Conclusions: An association between the volume of breast cancer operations performed in a hospital and 5-year survival rates was observed for both all-cause and breast cancer-specific mortality. Further work investigating the aspects of hospital volume that contribute to increased survival is warranted.

Hypothesis: Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics., Design: Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer., Main Outcome Measure: Care adherent to the 1990 National Institutes of Health consensus statement recommendations., Results: Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery., Conclusions: Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.

Objective: To develop and validate a clinically informed algorithm that uses solely Medicare claims to identify, with a high positive predictive value, incident breast cancer cases., Data Source: Population-based Surveillance, Epidemiology, and End Results (SEER) Tumor Registry data linked to Medicare claims, and Medicare claims from a 5 percent random sample of beneficiaries in SEER areas., Study Design: An algorithm was developed using claims from 1995 breast cancer patients from the SEER-Medicare database, as well as 1995 claims from Medicare control subjects. The algorithm was validated on claims from breast cancer subjects and controls from 1994. The algorithm development process used both clinical insight and logistic regression methods., Data Extraction: Training set: Claims from 7,700 SEER-Medicare breast cancer subjects diagnosed in 1995, and 124,884 controls. Validation set: Claims from 7,607 SEER-Medicare breast cancer subjects diagnosed in 1994, and 120,317 controls., Principal Findings: A four-step prediction algorithm was developed and validated. It has a positive predictive value of 89 to 93 percent, and a sensitivity of 80 percent for identifying incident breast cancer. The sensitivity is 82-87 percent for stage I or II, and lower for other stages. The sensitivity is 82-83 percent for women who underwent either breast-conserving surgery or mastectomy, and is similar across geographic sites. A cohort identified with this algorithm will have 89-93 percent incident breast cancer cases, 1.5-6 percent cancer-free cases, and 4-5 percent prevalent breast cancer cases., Conclusions: This algorithm has better performance characteristics than previously proposed algorithms. The ability to examine national patterns of breast cancer care using Medicare claims data would open new avenues for the assessment of quality of care.

Background: Physician volume of at least 15-30 annual breast cancer operations has been associated with higher 5-year survival rates. The authors sought to determine whether surgical volumes for breast cancer in the United States frequently reach this threshold., Methods: The authors conducted a retrospective cohort study of 987 surgeons who operated on 8105 Medicare patients with breast cancer during 1994-1995 in 6 areas in the Surveillance, Epidemiology and End Results tumor registry. The 2-year physician volume of breast cancer operations was estimated among Medicare patients (approximating the on-average annual volumes for patients of all ages) and its association was examined with physician characteristics and with 3 measures of surgical care., Results: The median 2-year Medicare volume for breast cancer surgeons was 6, and 79% of physicians performed < or = 12 operations. Approximately 50% of patients were cared for by physicians who performed < or = 12 operations over 2 years, and 10% of patients were cared for by physicians who performed > or = 30 operations. Surgeon characteristics of age, female gender, general surgery board certification, and academic affiliation were associated with modestly higher volumes of breast cancer surgery. Higher surgeon volumes were associated with higher patient receipt of breast-conserving surgery, testing for hormone receptors, and lymph node dissection during mastectomy., Conclusions: Most physicians who perform breast cancer surgery perform few annual operations in Medicare patients, and lower volumes are associated with differences in surgical processes of care. Because patients in the Medicare age group comprise almost 50% of all incident breast cancer cases, surgical volumes for patients of all ages also are likely to be low. It is likely that only approximately 10% of patients in the United States are treated by surgeons who performing at least 30 annual operations., (Copyright 2004 American Cancer Society.)