Comparison of characteristics in Mexican women with breast cancer according to healthcare coverage

Objective:

To compare the sociodemographic, diagnostic, clinical, and treatment-related characteristics and outcomes of patients with breast cancer in two hospitals in Mexico according to type of healthcare coverage.

Methods:

A retrospective cohort study of women with breast cancer according to public or private healthcare coverage in two hospitals was done. Patients were treated by the same group of physicians and healthcare infrastructure. Groups were compared using the chi-square test for categorical variables, Mann–Whitney U-test and Student’s t-test for quantitative variables, and Kaplan–Meier estimator and log-rank test for time dependent outcomes (including recurrence-free and overall survival). A value of p < 0.05 was considered statistically significant.

Results:

A total of 282 women were included. Mean age at diagnosis was 52 years. Women with public healthcare coverage were diagnosed more frequently with self-detected tumors (82.8% vs 47.9%, p < 0.001) and advanced clinical stage (III and IV) (31.1% vs 17.8%, p = 0.014). More women with public healthcare insurance underwent initial systemic treatment (41.1% vs 17.8%, p < 0.001) and mastectomy (70.1% vs 54.9%, p = 0.020), and received more chemotherapy (79.4% vs 43.8%, p < 0.001) and adjuvant radiotherapy (68.9% vs 53.4%, p = 0.017). Overall, no differences were found in survival outcomes according to healthcare coverage. Trends suggesting worse recurrence-free and overall survival were observed in patients with public coverage at 3 years follow-up in stage III (85.7% vs 67.3% and 100% vs 84.6%, respectively) and triple negative disease (83.3% vs 74.5% and 100% vs 74.1%, respectively).

Conclusion:

Strategies to promote preventive medicine, diagnostic mammograms, and prompt diagnosis of breast cancer in Mexican women with public health coverage are needed. Access to the main treatment modalities by Seguro Popular and good quality care by an experienced group of physicians likely explains the similar outcomes between patients with private and public healthcare coverage. However, trends suggesting worse survival for patients with public medical coverage with stage III and triple-negative disease should encourage close follow-up.

Abstract P6-11-11: Comparison of demographic, diagnostic, pathological, and treatment characteristics in Mexican women with breast cancer according to type of healthcare coverage

Background: Breast cancer (BC) represents the most frequent neoplasm and cause of cancer death in Mexican women. Previous studies have reported that BC patients with public healthcare coverage present with more advanced stage disease and worse clinical outcomes than those with private healthcare coverage. However, differences between BC patients with public versus private healthcare coverage regarding general characteristics, disease presentation, and treatment have not been investigated in Mexico.

Methods: A retrospective comparative analysis of women with BC diagnosed and treated at two hospitals by the same group of physicians with the same healthcare infrastructure, according to type healthcare coverage was done. Demographic, clinical, and treatment characteristics were retrieved from medical records. Groups were compared using the chi square test for qualitative variables and U Mann-Whitney and T-student for quantitative variables. A p value of &lt; 0.05 was considered statistically significant.

Results: A total of 268 women were included. Median age at diagnosis was 52.5 years. Comparisons of main demographic, diagnostic, pathological, and treatment characteristics by type of healthcare coverage are presented in Table 1. Women with public healthcare were more frequently diagnosed with self-detected tumors (82.6% vs. 47.9%, p &lt; 0.001) and with more locally advanced disease (51.3% vs. 23.3%, p = 0.026), whereas women with private healthcare presented with more early disease (64.4% vs. 42.6%, p = 0.026). Patients with public healthcare coverage have a significantly longer period of diagnostic and total delay. Globally, hormone receptor (HR) positive (HR+) / HER2 negative (HER2-) disease was the most prevalent molecular subtype (69.4%), with no difference among BC subtypes by type of coverage. More women with public healthcare coverage underwent initial systemic treatment (32.8% vs. 17.8%, p = 0.001), mastectomy (68.1% vs. 54.9%, p = 0.048), chemotherapy (79% vs. 43.8%, p &lt; 0.001), and adjuvant radiotherapy (68.7% vs. 53.5%, p = 0.02), probably related to more advanced disease. Women from both groups with HR+ and HER2 positive (HER2+) disease received hormonal therapy and HER2 targeted therapy equally.

Conclusion: In Mexico, patients with BC with public health coverage present with more advanced disease than those with private coverage, despite being similarly diagnosed and managed within the same healthcare framework. This is possibly explained by the higher rates of self-detected lesions vs. smaller screening-detected tumors and translates into superior rates of initial systemic treatment, mastectomy, chemotherapy use and adjuvant radiotherapy. Strategies to increase BC awareness, screening and early detection in the general population are urgently needed to promote timely diagnosis of BC in Mexican women with public healthcare coverage.

Table 1CharacteristicsPrivatePublicn = 73%n = 195%pPartnered (married, domestic partnership)5676.711156.00.003Unpartnered (single, divorced, widowed)1723.38443.1Homemaker4257.515780.50.001Unemployed11.421Employed3041.13618.5Self-detected3547.916182.6&lt;0.001BC screening3852.13417.4Diagnosis delay (months)0.46 (0-16.5)2.1 (0-59.6)&lt;0.001Total delay (months)1.22 (0.07-24.6)3.2 (0-59.89)&lt;0.001Treatment delay (months)0.62 (0-24.5)0.66 (0-36.9)0.183Clinical stage- In situ (0)68.284.10.026- Early (I, IIA)4764.48342.6- Locally advanced (IIB, IIIA-IIIC)1723.310051.3- Metastatic (IV)34.142.1Molecular subtype- RH- (in situ)22.710.50.568- HR+/HER2-5169.913569.2- HR+/HER2+45.5168.2- HR-/HER2+8112010.3- HR-/HER2-8112311.8Initial treatment- Local6082.212061.50.001- Systemic1317.88832.8Breast conserving surgery3245.16131.90.048Mastectomy3954.913068.1Axillary dissection2128.87940.50.121Sentinel lymph node466310855.4NA68.284.1Breast reconstruction3446.62412.3&lt;0.001Radiotherapy3953.413468.70.020Chemotherapy3243.815479&lt;0.001- Neoadjuvant1031.36944.80.199— Complete pathologic response3301927.50.029Anti-HER2 therapy (HER2+, n = 48)121003597.20.560Hormonal therapy (HR+, n = 206)5498.214797.40.7312

Citation Format: Bertha A Martinez-Cannon, Tania Zertuche-Maldonado, Sylvia de la Rosa-Pacheco, Servado Cardona-Huerta, Mauricio Canavati-Marcos, Gabriela S Gomez-Macias, Cynthia Villarreal-Garza. Comparison of demographic, diagnostic, pathological, and treatment characteristics in Mexican women with breast cancer according to type of healthcare coverage [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-11.

Palliative Care Needs in an Acute Internal Medicine Ward in Mexico

BACKGROUND

Palliative care is an evolving but underdeveloped practice in Mexico.

OBJECTIVE

The primary end point of this prospective observational study was to identify internal medicine inpatients fulfilling advanced criteria within a second-level hospital. Secondary end points were symptom burden, treatment, resource utilization, and one-year survival.

DESIGN AND MEASUREMENTS

The 390-sample size calculation was based on previous studies where 15% of inpatients fulfilled palliative care needs. Consecutive admissions were assessed to identify patients with any of the following: cancer, cardiac, renal, hepatic insufficiency, COPD, AIDS, stroke, or fragility until sample size was completed. After obtaining informed consent, interview to patient, attending physician, and chart review was completed to identify any of the following advanced disease criteria in each patient: (1) Surprise question to attending physician of the possibility of the patient dying in the following year, (2) Palliative Performance Scale (PPS) <50, and (3) Advanced disease specific criteria. Interview also included presence of symptoms, functional capacity, and previous resource utilization. Treatment offered was analyzed only on day of admission. One-year follow-up to assess survival was done through the state death certificates.

RESULTS

Out of 390 patients, 131 (34%) had any of the diseases studied. Out of 131 patients, 86 (66%) had at least one of the three inclusion criteria for advanced disease. Out of 86 patients, 70 (81%) advanced disease patients died after one-year follow-up. Comparison between patients with no advanced disease (no criteria) versus advanced disease (at least one criteria) showed a significant difference in mean PPS, nutrition status, survival days, inhospital death, weight loss, dependency on activities of daily living, and previous multiple emergency room visits. Advanced disease patients with no death at one year follow-up had significantly more new admissions to that hospital.

CONCLUSIONS

The number of patients requiring palliative care in internal medicine wards may be excessive to the current palliative care structures available.

Unusual presentation of Gilbert disease with high levels of unconjugated bilirubin. Report of two cases

Gilbert's syndrome is a benign condition characterized by asymptomatic sporadic episodes of jaundice, due to a mild unconjugated hyperbilirubinemia caused by a deficiency in bilirubin glucoronidation. Under certain physiologic or pathologic events bilirubin level rises but according to literature it does not reach out more than 3 mg/dl. We report 2 cases of Gilbert's syndrome, genetically tested, which presented with bilirubin levels above 6 mg/dl without any trigger or coexisting condition. In conclusion, bilirubin levels higher than 6 mg/dL in Gilbert syndrome are rare, hemolytic and other metabolism diseases must be ruled out, and genetic testing may be necessary in some cases.