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Purpose: Accounting for endocrine therapy use for breast cancer treatment is important for studies of survivorship. We evaluated the accuracy of Surveillance, Epidemiology, and End Results (SEER) breast cancer endocrine therapy data compared with pharmacy dispensings from an integrated health system., Methods: We included women with non-metastatic hormone receptor positive primary breast cancer diagnosed between 1995 and 2017 enrolled in Kaiser Permanente Washington, linking their data with SEER. We used pharmacy dispensings for endocrine therapy within one year following diagnosis as our reference standard. We calculated kappa (concordance), positive predictive value (PPV), and negative predictive values (NPV) overall and stratified by woman and tumor characteristics of interest., Results: Of 5,055 women, mean age at diagnosis was 62 years (interquartile range = 53-71); 53% had localized stage, 56% received lumpectomy with radiation, and 31% received chemotherapy. SEER data alone identified 67% of women as having received endocrine therapy; this increased to 75% with pharmacy dispensings. SEER's concordance with pharmacy dispensings was 0.68 (PPV = 91%; NPV = 76%). PPV did not vary by tumor or women characteristics; however, NPV declined with younger age at diagnosis (64% in < 45 years vs. 86% in 75+ years), increasing tumor stage (49% in regional stage vs. 91% in DCIS), and chemotherapy treatment (41% in those with chemotherapy vs. 83% in those without chemotherapy)., Conclusion: Pharmacy dispensings enable more complete endocrine therapy capture, particularly in women with more advanced tumors or who receive chemotherapy. We determined woman, tumor, and treatment characteristics that contribute to underascertainment of endocrine therapy use in tumor registries., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objectives: To measure changes in primary care physician (PCP) ordering rates for 4 global resource use measures before and after dissemination of physician feedback reports that provided peer-comparison resource use rates. We also explored whether physician practice characteristics (panel size, clinic size, and years of experience) were associated with resource use changes., Study Design: Pre-post implementation study measuring physician resource use in an integrated healthcare system (2011-2014)., Methods: Kaiser Permanente Washington PCPs (N = 210) were provided annual feedback reports showing their personal ordering rates compared with those of their peers. Monthly physician ordering was measured from November 2011 to September 2014 (including prereport and postreport periods). We examined 4 physician ordering rates (specialty referrals, high-end imaging, laboratory tests, and 30-day prescriptions) per 1000 patients, adjusted for patient age, gender, and clinical complexity., Results: After accounting for physician practice characteristics, monthly PCP ordering rates for high-end imaging significantly decreased by 0.8 images per 1000 patients (P <.01). In contrast, orders for laboratory tests and 30-day prescriptions significantly increased by 15.0 tests and 84.7 prescriptions per 1000 patients (both P <.01). We observed greater changes following feedback in physicians with fewer years of experience (≤10 years), who had 4.2 fewer specialty referrals (P = .01) and 101.3 more 30-day prescriptions (P <.01) compared with those with more experience (>20 years)., Conclusions: Physician feedback reports may be associated with changes in physician resource use, and physicians with fewer years of experience may be more responsive to feedback reports. Better understanding of factors associated with changes in resource use is necessary for future targeted development of physician interventions.

Breast cancer tends to occur in an older age group of women also burdened with comorbidities such as cardiovascular disease (CVD). Numerous medications used to manage CVD (e.g., statins and antihypertensives) are hypothesized to alter breast cancer risk, but there are few studies on breast cancer outcomes. The COmmonly used Medications and Breast Cancer Outcomes (COMBO) cohort was developed to study how medications and co-morbidities influence breast cancer prognosis. Cohort study among adult women, diagnosed with incident early stage breast cancer, and enrolled in an integrated health plan. Data sources included health plan administrative databases, Surveillance, Epidemiology, and End Results tumor registry, and medical records. Statins, angiotensin-converting enzyme inhibitors (ACEI), beta blockers (BB), calcium blockers, and diuretics were the exposures of interest. The outcome was second breast cancer events (SBCE) defined as recurrence or second primary breast cancer. We used multivariable Cox proportional hazards models to estimate hazard ratios (HR) and 95 % confidence intervals (CI) for SBCE, and components of SBCE. 4,216 women were followed for a median of 6.3 years, and 13.2 % experienced a SBCE (first of: n = 415 recurrences and n = 143 s primary breast cancers). Compared to non-users, we observed an increased risk of second primary breast cancer with ACEI use (HR = 1.66; 95 % CI, 1.06-2.58) and an increased risk of recurrence with BB use (HR = 1.29; 95 % CI, 1.01-1.64). There was suggestion of a reduced risk of SBCE with statin use (HR = 0.82; 95 % CI, 0.62-1.08) and second primary breast cancer with BB use (HR = 0.77; 95 % CI, 0.50-1.19). No differences in outcomes were observed by duration of medication use. A majority of CVD medications evaluated in this study appear safe with respect to SBCE, but ACEI and BB use warrant further evaluation. The study presented is one example of the questions that can be addressed using the COMBO cohort.

Objectives: To examine uptake patterns of the electronic health risk assessment (eHRA) and compare characteristics of early adopters among adults in 1 healthcare system with those of the potentially eligible population., Study Design: Retrospective cohort study (September 2006-March 2009)., Methods: We designed and implemented an integrated eHRA to improve individual health plan members' self-management of their health risks and chronic illness. We included individuals aged 21 to 85 years who had been enrolled at Group Health Cooperative for 12 or more months before September 2006, when the eHRA was first introduced. Study participants had to be registered users of the health plan's secure Web portal by March 2009 in order to complete the eHRA., Results: A total of 332,381 adults were potentially eligible; of these 39.3% were eligible to complete the eHRA. One or more eHRAs were completed by 22.4% of registered Web portal users over the study period with slow but consistent uptake. Completers were more likely to be women, to be middle-aged (41-65 years), and to have had a recent well-care visit and fewer comorbid conditions., Conclusions: Significant additional outreach, engagement strategies, and incentives are likely required by health systems to increase adoption and ongoing use of an eHRA among target populations. Future research on eHRA uptake in primary care should focus on whether the use of these tools leads to patient action and provider engagement that improve health outcomes in moderate-risk and high-risk individuals, as well as on modalities to reach broader audiences for higher completion rates.

Introduction: Because receipt of breast imaging likely occurs in nonrandom patterns, selection bias is an important issue in studies that attempt to elucidate associations between imaging and breast cancer outcomes. The purpose of this study was to analyze use of advanced diagnostic imaging in a cohort of patients with breast cancer insured by commercial, managed care, and public health plans by demographic, health insurance, and clinical variables from 2002 to 2009., Methods: We identified women with breast cancer diagnoses from a Surveillance Epidemiology and End Results (SEER) registry whose data could be linked to claims from participating health plans. We examined imaging that occurred between cancer diagnosis and initiation of treatment and classified patients according to receipt of (1) mammography or ultrasound only; (2) breast magnetic resonance imaging (MRI); and (3) other advanced imaging (computed tomography [CT] of the chest, abdoment, and pelvis; positron emission tomography [PET]; or PET-CT). We used logistic regression to identify factors associated with receipt of breast MRI as well as other advanced imaging., Results: Commercial health plan, younger age, and later year of diagnosis were strongly associated with receipt of breast MRI and other advanced imaging. Women with prescription drug plans and those who had less comorbidities were more likely to have received breast MRI., Conclusion: Use of breast MRI and other advanced imaging is increasing among patients newly diagnosed with breast cancer; individual patient and insurance-related factors are associated with receipt of these imaging tests. Whether use of diagnostic advanced imaging affects outcomes such as re-excision, cancer recurrence, mortality rates, and costs of breast cancer treatment remains to be determined.

Purpose: Many studies suggest increased body mass index (BMI) is associated with worse breast cancer outcomes, but few account for variability in screening, access to treatment, and tumor differences. We examined the association between BMI and risk of breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality, and evaluated whether tumor characteristics differ by BMI among a mammographically screened population with access to treatment., Methods: Using a retrospective cohort study design, we followed 485 women aged ≥40 years diagnosed with stage I/II breast cancer within 24 months of a screening mammogram occurring between 1988 and 1993 for 10-year outcomes. BMI before diagnosis was categorized as normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Tumor marker expression was assessed via immunohistochemistry using tissue collected before adjuvant treatment. Medical records were abstracted to identify treatment, recurrence, and mortality. We used Cox proportional hazards to separately model the hazard ratios (HR) of our three outcomes by BMI while adjusting for age, stage, and tamoxifen use., Results: Relative to normal-weight women, obese women experienced increased risk of recurrence (HR 2.43; 95 % CI 1.34-4.41) and breast cancer death (HR 2.41; 95 % CI 1.00-5.81) within 10 years of diagnosis. There was no association between BMI and all-cause mortality. Obese women had significantly faster growing tumors, as measured by Ki-67., Conclusions: Our findings add to the growing evidence that obesity may contribute to poorer breast cancer outcomes, and also suggest that increased tumor proliferation among obese women is a pathway that explains part of their excess risk of adverse outcomes.

Background: Approximately 20% to 50% of women diagnosed with hormone receptor-positive breast cancer discontinue endocrine therapy early; most reports come from automated pharmacy data or small self-report evaluations. We conducted a larger self-report evaluation of endocrine therapy discontinuation associated with patient characteristics and therapy-related adverse effects., Methods: We surveyed 538 women from a single health plan who were diagnosed with early-stage breast cancer from 2002 to 2008 and received endocrine therapy. Women reported adverse effects and reasons for discontinuation via mailed survey; tumor characteristics were obtained via registry linkage. We classified women as discontinuers if they self-reported stopping therapy and their self-reported duration of tamoxifen plus aromatase inhibitor (AI) use was < 5 years, and nondiscontinuers if they self-reported ≥ 5 years use or current use. We estimated odds ratios (ORs) with 95% CIs for discontinuation versus continuation by using logistic regression adjusted for age and year of diagnosis., Results: Among 538 women, 98 (18.2%) discontinued endocrine therapy early. Women with positive lymph nodes (v negative) were significantly less likely to discontinue therapy (odds ratio [OR] = 0.54; 95% CI, 0.31 to 0.93). Almost all women (94%) experienced adverse effects. Experiencing headaches was associated with discontinuation of AIs (OR = 4.16; 95% CI, 2.16 to 8.01) and tamoxifen (OR = 2.34; 95% CI, 1.24 to 4.41); few other individual adverse effects were related to discontinuation despite most discontinuers reporting they "did not like adverse effects" (AIs: 66.7%, tamoxifen: 59.1%)., Conclusion: Few individual adverse effects or patient characteristics were significantly associated with endocrine therapy discontinuation, yet adverse effects were prevalent and were the most common reason women reported for discontinuing therapy.

Objective: Reminder letters are effective at prompting women to schedule mammograms. Less well studied are reminders addressing multiple preventive service recommendations. We compared the effectiveness of a mammogram-specific reminder sent when a woman was due for a mammogram to a reminder letter addressing multiple preventive services and sent on a woman's birthday on mammography receipt., Methods: The study included 48,583 women 52-74 years enrolled in Group Health Cooperative, a health plan in Washington State. From 2005 to 2009, women were mailed 88,605 mammogram-specific or birthday letters. In this one group pretest-posttest study, we modeled the odds of obtaining a screening mammogram after receiving a letter by reminder type using logistic regression, controlling for demographic and healthcare use characteristics and stratifying by whether women were overdue or up-to-date with mammography at the mailing., Results: Among women up-to-date with screening, birthday letters were negatively associated with mammography receipt compared to mammogram-specific letters (birthday letters with 1-2 recommendations: OR=0.73; 95% CI:0.68-0.79; 3 recommendations: OR=0.74; 95% CI:0.69-0.78; 4-8 recommendations: OR=0.62 95% CI:0.55-0.68) after. Among overdue women, birthday letters with 4-8 recommendations were negatively associated with mammography receipt., Conclusions: Transitioning from mammogram-specific reminder letters to multiple preventive service birthday letters was associated with decreased mammography receipt., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Studies of breast cancer outcomes rely on the identification of second breast cancer events (recurrences and second breast primary tumors). Cancer registries often do not capture recurrences, and chart abstraction can be infeasible or expensive. An alternative is using administrative health-care data to identify second breast cancer events; however, these algorithms must be validated against a gold standard., Methods: We developed algorithms using data from 3152 women in an integrated health-care system who were diagnosed with stage I or II breast cancer in 1993-2006. Medical record review served as the gold standard for second breast cancer events. Administrative data used in algorithm development included procedures, diagnoses, prescription fills, and cancer registry records. We randomly divided the cohort into training and testing samples and used a classification and regression tree analysis to build algorithms for classifying women as having or not having a second breast cancer event. We created several algorithms for researchers to use based on the relative importance of sensitivity, specificity, and positive predictive value (PPV) in future studies., Results: The algorithm with high specificity and PPV had 89% sensitivity (95% confidence interval [CI] = 84% to 92%), 99% specificity (95% CI = 98% to 99%), and 90% PPV (95% CI = 86% to 94%); the high-sensitivity algorithm had 96% sensitivity (95% CI = 93% to 98%), 95% specificity (95% CI = 94% to 96%), and 74% PPV (95% CI = 68% to 78%)., Conclusions: Algorithms based on administrative data can identify second breast cancer events with high sensitivity, specificity, and PPV. The algorithms presented here promote efficient outcomes research, allowing researchers to prioritize sensitivity, specificity, or PPV in identifying second breast cancer events.

Aims: This paper describes our process to engage regional stakeholders for prioritizing comparative effectiveness research (CER) in cancer diagnostics. We also describe a novel methodology for incorporating stakeholder data and input to inform the objectives of selected CER studies., Materials & Methods: As an integrated component to establishing the infrastructure for community-based CER on diagnostic technologies, we have assembled a regional stakeholder group composed of local payers, clinicians and state healthcare representatives to not only identify and prioritize CER topics most important to the western Washington State region, but also to inform the study design of selected research areas. A landscape analysis process combining literature searches, expert consultations and stakeholder discussions was used to identify possible CER topics in cancer diagnostics. Stakeholders prioritized the top topics using a modified Delphi/group-nominal method and a standardized evaluation criteria framework to determine a final selected CER study area. Implementation of the selected study was immediate due to a unique American Recovery and Reinvestment Act funding structure involving the same researchers and stakeholders in both the prioritization and execution phases of the project. Stakeholder engagement was enhanced after study selection via a rapid analysis of a subset of payers' internal claims, coordinated by the research team, to obtain summary data of imaging patterns of use. Results of this preliminary analysis, which we termed an 'internal analysis,' were used to determine with the stakeholders the most important and feasible study objectives., Results: Stakeholders identified PET and MRI in cancers including breast, lung, lymphoma and colorectal as top priorities. In an internal analysis of breast cancer imaging, summary data from three payers demonstrated utilization rates of advanced imaging increased between 2002 and 2009 in the study population, with a great deal of variability in use between different health plans. Assessing whether breast MRI affects treatment decisions was the top breast cancer study objective selected by the stakeholders. There were other high-priority research areas including whether MRI use improved survival that were not deemed feasible with the length of follow-up time following MRI adoption., Conclusion: Continuous stakeholder engagement greatly enhanced their enthusiasm for the project. We believe CER implementation will be more successful when undertaken by regional stakeholders.

Background: A prostate-specific antigen (PSA) level above 4 ng/mL has historically been recognized as an appropriate threshold to recommend biopsy; however the risk of high-grade disease observed among men with lower PSA levels in the Prostate Cancer Prevention Trial has led to calls to change the criteria for biopsy referral., Purpose: To aid providers when discussing aggressiveness of biopsy by cataloging available community biopsy patterns and determine whether lower PSA thresholds are being used to recommend biopsy., Methods: Laboratory and biopsy records were reviewed among 59,764 men in a large Washington State health plan between 1998 and 2007. Follow-up in the 12-month period after a test was categorized as biopsy, urology visit without biopsy, additional PSA testing with no urology visit, or no PSA-related follow-up. Data analysis occurred between 2010 and 2011., Results: Twenty-eight percent of tests with PSA levels ≥4.0 ng/mL, 2.9% of tests with levels between 2.5 and 4.0 ng/mL, and 0.4% of tests with levels <2.5 ng/mL were followed with a biopsy within 12 months. More than 40% of elevated tests (≥4.0 ng/mL) were followed by a urologist visit without a biopsy, and more than 30% of tests ≥4.0 did not have any PSA-related follow-up within 12 months. PSA velocity, defined as annualized rate of change in PSA level, was strongly associated with biopsy, especially when absolute PSA was <4.0 ng/mL. There appear to be no discernable temporal trends in biopsy thresholds or practice patterns based on PSA lower levels or velocity., Conclusions: Despite recent calls to more aggressively recommend biopsy at lower PSA thresholds, the practice in this large health plan has remained consistent over time., (Published by Elsevier Inc.)

Objective: To evaluate woman-level characteristics associated with timing of follow-up after abnormal mammograms in an integrated healthcare system with an active breast health program., Study Design: Retrospective cohort study., Methods: The study included women aged 40-84 years who had an abnormal mammogram (20,060 screening and 3184 diagnostic) recommended for follow-up. We compared characteristics of women who received any follow-up evaluation within <7, 8 to 14, 15 to 21, and 22 to 180 days. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate ordinal logistic regression., Results: The proportion of women seeking care within 7 days was 23% for screening and 69% for diagnostic mammograms. Characteristics associated with later follow-up (>8 days vs <7 days) after an abnormal screening mammogram included being older (OR=1.15; 95% CI, 1.04-1.26 [age 70-79 years]; OR=1.31; 95% CI, 1.14-1.51 [age 80+ years]), Asian (OR=1.18; 95% CI, 1.04-1.33), or having a college degree (OR=1.10; 95% CI, 1.01-1.19). Characteristics associated with earlier follow-up included family history of breast cancer (OR=0.93; 95% CI, 0.88-0.98), symptoms at time of mammogram (OR=0.79; 95% CI, 0.70-0.88), or extremely dense breasts (OR=0.82; 95% CI, 0.69-0.96). For diagnostic mammograms, symptoms at time of mammogram (OR=0.47; 95% CI, 0.39-0.56) and being obese (OR=0.79; 95% CI, 0.65-0.98) were associated with earlier follow-up., Conclusions: Several woman-level characteristics were associated with timely follow-up after an abnormal screening exam, but only presence of symptoms and being obese was associated with timely follow-up after an abnormal diagnostic exam.

Purpose: Although screening with fecal occult blood testing (FOBT) reduces colorectal cancer (CRC) mortality, its effectiveness may diminish if patients do not adhere with repeated screenings. Among patients who had previously engaged in FOBT screening, we assessed subsequent adherence with FOBT screening., Methods: We assessed longitudinal adherence with biennial FOBT screening (every other year) within a cohort of patients enrolled in an integrated Washington State health plan. Among 11,110 patients who participated in FOBT screening during a 2-year baseline period (2000-2001), we ascertained CRC screening use during a subsequent 2-year observation period (2002-2003). We used multinomial logistic regression to identify patient characteristics associated with higher incidence of repeat CRC screening (with or without FOBT) relative to patients who received no CRC screening., Results: Despite prior participation in FOBT screening, less than one-half of patients (44.4%; 95% CI, 42.9%-45.8%) completed FOBT screening during the 2-year observation period. Although 8.8% of patients (95% CI, 8.0%-9.7%) received other CRC tests without FOBT during the observation period, nearly one-half, 46.8% (95% CI, 45.3%-48.4%), received no CRC screening. After adjustment for other patient characteristics, receipt of a preventive health examination was strongly associated with FOBT adherence relative to no CRC screening (adjusted relative rate ratio = 11.16; 95% CI, 9.61-12.96)., Conclusions: Longitudinal adherence with FOBT screening was low in this insured population, potentially compromising its effectiveness in population CRC mortality reduction. Interventions to promote adherence may be necessary to achieve high effectiveness in population-based FOBT screening programs.

Background: The purpose of this report is to examine the correlates of quality of life (QOL) of a well-defined group of long-term breast cancer survivors diagnosed between the ages of 40 and 49., Methods: Women were eligible if they were diagnosed with invasive breast cancer or ductal carcinoma in situ 5 to 10 years before June 30, 1998 and were enrolled at Group Health Cooperative, a health maintenance organization in western Washington State. A questionnaire was mailed to 290 women; 216 were included in this analysis. The questionnaire included standardized measures of QOL [e.g., the Cancer Rehabilitation Evaluation System (CARES-SF) and SF-36] as well as general demographic and medical information. ANOVA and logistic regression were used to estimate correlates of self-reported QOL., Results: The mean age at diagnosis was 44.4 years, and the average time since diagnosis was 7.3 years. Women reported high levels of functioning across several standardized QOL scales; mild impairment was found on the CARES-SF Sexual Scale. The presence of breast-related symptoms at survey, use of adjuvant therapy, having lower income, and type of breast surgery were significantly associated with lower QOL 5 to 10 years post-diagnosis on one or more of the scales., Conclusions: Our results emphasize that younger long-term survivors of breast cancer have a high QOL across several standardized measures. However, the long-term consequences of adjuvant therapy and the management of long-term breast-related symptoms are two areas that may be important for clinicians and women with breast cancer in understanding and optimizing long-term QOL.