Turning the Page on Breast Cancer in Ohio: Lessons learned from implementing a multilevel intervention to reduce breast cancer mortality among Black women

BACKGROUND

Turning the Page on Breast Cancer (TPBC) uses a multilevel approach to reduce breast cancer (BC) mortality among Black women. TPBC intervenes by (1) improving health care facilities' ability to conduct effective BC screening, follow-up, and treatment; (2) involving community-based organizations; and (3) providing education and personal risk information through a culturally relevant website. Ohio has among the worst BC mortality rates in the United States for Black women. TPBC is in its third year of providing targeted interventions in 12 Ohio counties with particularly high BC rates among Black women.

METHODS

TPBC enrolls health care facilities, collects organizational and patient data, and conducts key informant interviews to inform the provision of appropriate evidence-based interventions. TPBC engages Black communities through community-based organizations and social media advertising. The TPBC website offers BC information, connects Black women to community BC resources, and provides access to a risk-assessment tool.

RESULTS

TPBC has provided tailored information packets, evidence-based interventions, and systematic support for improving the tracking and follow-up of breast health care among patients in 10 clinical partnerships. The project has provided education at community events monthly since mid-2021. The TPBC website (http://endbreastcancerohio.org) is promoted through social media (primarily Facebook) and community events to reach Black women aged 25-70 years. To date, 4108 unique users have visited the website, of whom 15.9% completed the risk assessment.

CONCLUSIONS

Novel strategies are needed to address persistent disparities in BC outcomes among Black women. TPBC demonstrates the potential effectiveness of multiple methods of community-based, clinic-based, and web-based engagement.

PLAIN LANGUAGE SUMMARY

Turning the Page on Breast Cancer (TPBC) aims to reduce breast cancer mortality among Black women in Ohio by conducting multilevel, community-engaged interventions in 12 counties. Women are provided risk information and education at virtual and in-person community events and through a community-friendly website that was launched in November 2020. Almost 4000 women have visited the website, which offers community-targeted information, urges screening for individuals at elevated risk, and offers access to patient navigation services; 655 users have used a breast cancer risk-assessment tool on the site. Community-based organizations conduct educational efforts. TPBC partners with health care facilities, which are taught to improve their ability to conduct effective breast cancer screening, follow-up, and treatment. So far, TPBC has provided educational information, evidence-based intervention lists, tailored information packets, and ongoing quarterly support to partners in 10 counties. Evaluation will focus on aggregated data for screening and genetic testing referral at the clinic level.

Loss of TSC1 in secondary angiosarcoma of the breast

Key Clinical Message

Post-radiation angiosarcoma of the breast is a rare complication associated with a poor prognosis. This case reports the first loss of function mutation in TSC1 in breast radiation-induced angiosarcoma and illustrates the utility of evaluating these markers to identify potential therapeutic targets.

Abstract

Post-radiation angiosarcoma of the breast is rare and associated with a poor prognosis. This case presents the first loss of function mutation in TSC1 in breast radiation-induced angiosarcoma. Evaluation of these markers can aid in identifying potential therapeutic targets.

Abstract P4-02-17: Impact of low hormone receptor expression on neoadjuvant chemotherapy response and patterns of care in early-stage HER2-negative breast cancer: a US National Cancer Database analysis

Background: Hormone receptor (HR) low (1-10%) HER2-negative breast cancer (BC) is emerging as a distinct subtype with similarities in clinical outcomes to triple-negative BC. However, there is a lack of consensus on treatment recommendations for chemo-immunotherapy and endocrine therapy in this subset. Here, we present results from a US National Cancer Database (NCDB) analyses of patients with HER2-negative BC evaluating response to neoadjuvant chemotherapy (NAC) and patterns of care by HR expression.

Methods: Patients with stage I-III HER2-negative BC diagnosed in 2018 were identified in NCDB, a nationwide oncology outcomes database in the US. Quantitative HR expression was unavailable prior to 2018. Data were categorized into four groups by estrogen receptor (ER) and progesterone receptor (PR) expression: ER< 1% & PR< 1% (HR-Neg), ER 1-10% and/or PR 1-10% (HR-Low), ER >11-30% and/or PR>11-30% (HR-Int), ER> 30% and/or PR > 30% (HR-High). Those with undocumented HR status (3%) or without curative intent surgery (5%) were excluded. The primary outcome was pathologic complete response (pCR) by HR expression in those undergoing neoadjuvant chemotherapy. Key secondary objectives included assessment of clinicopathologic characteristics and practice patterns. The categorical variables were compared between the four groups using a Chi-square test. Age was compared using a Kruskal-Wallis test.

Results: Out of 104,205 incident cases, 2541 (2.4%) were HR-Low and 1241 (1.2%) were HR-Int. Significant differences were found between HR groups with higher grade, clinical stage, and Ki-67 in HR-Low vs. HR-Int or HR-High groups (Table 1). Patients with HR-Low and HR-Int BC were more likely to receive chemotherapy than HR-High (74%, 70% vs. 20%; p < 0.001) and the use of adjuvant endocrine therapy correlated with HR expression. Only half of patients in the HR-Low group received any endocrine therapy compared to higher rates in the HR-Int and HR-High groups (52% vs. 74%, 92%; p< 0.001). pCR rates in those receiving neoadjuvant chemotherapy were significantly different by HR status, with higher pCR rates in HR-Low vs. HR-High groups (p< 0.001) (Table 2). NAC utilization significantly differed between groups. A higher proportion of patients with HR-Low BC received NAC than other HR-positive groups (p < 0.001). Additionally, there was an increased use of NAC in patients with HR-Low BC treated at academic vs. community cancer centers (p< 0.001).

Conclusions: This is one of the largest real-world analyses comparing key differences in biology and practice patterns of HR-Low, HER2-negative BC. Consistent with prior studies, we report HR-Low BC to be a rare and distinct subtype with higher pCR rates compared to HR-High BC. Practice patterns show wide variability in utilization of neoadjuvant chemotherapy and endocrine therapy for these patients. Future studies should address this disparity and enhance representation of patients with HR-Low BC in clinical trials to improve long-term outcomes.

Table 1: Patient demographics

Table 2: Neoadjuvant chemotherapy response amongst differing HR expression levels

Citation Format: Dionisia Quiroga, Michael Grimm, Julie Stephens, Kai Johnson, Nicole Williams, Preeti K. Sudheendra, Mathew A. Cherian, Daniel Stover, Ashley C. Pariser, Margaret Gatti-Mays, Robert Wesolowski, Jose G. Bazan, Sasha Beyer, Ko Un Park, Bridget Oppong, Bhuvaneswari Ramaswamy, Julia White, Sachin R. Jhawar, Sagar Sardesai. Impact of low hormone receptor expression on neoadjuvant chemotherapy response and patterns of care in early-stage HER2-negative breast cancer: a US National Cancer Database analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-02-17.

Inflammatory breast cancer, trimodal treatment, and mortality: Does where you live matter?

BACKGROUND

The objective of this study is to examine the associations among neighborhood socioeconomic status, trimodal treatment, and disease-specific mortality among inflammatory breast cancer patients using data from the Surveillance, Epidemiology, and End Results program.

METHODS

Patients diagnosed with inflammatory breast cancer (T4d) from 2010 to 2016 were identified in the Surveillance, Epidemiology, and End Results program. The cohort was stratified into neighborhood socioeconomic status groups (low, middle, high) based on National Cancer Institute census tract-level index. Trimodal treatment was defined as receipt of modified radical mastectomy, chemotherapy, and radiation therapy. Bivariable analysis, log-rank test, and a Cox proportional hazards model (hazard ratio, 95% confidence interval) were conducted to evaluate the relationship between neighborhood socioeconomic status, trimodal treatment, and disease-specific mortality.

RESULTS

In total, 4,374 patients met study criteria. There was no difference between the neighborhood socioeconomic status groups in receipt of trimodal treatment (P = .19). On multivariable analysis, there was no association between low neighborhood socioeconomic status (hazard ratio 1.13, 0.98-1.30; ref high neighborhood socioeconomic status) or middle neighborhood socioeconomic status (hazard ratio 1.01, 0.88-1.64; ref high neighborhood socioeconomic status) and disease-specific mortality. Notably, triple negative subtype (hazard ratio 2.66, 2.21-3.20; ref luminal A) and Black race (hazard ratio 1.41, 1.16-1.72; ref White) were associated with a higher disease-specific mortality.

CONCLUSION

For inflammatory breast cancer patients in the Surveillance, Epidemiology, and End Results program, disease-specific mortality appears to be driven by tumor biology and patient characteristics instead of treatment disparities or neighborhood socioeconomic status.

Abstract P5-14-05: Are neighborhood and community factors associated with refusing breast cancer surgery?

Background: The importance of an individual’s community impacts cancer disparities and is intimately related to social determinants of health. Surgery refusal is associated with a high disease-specific mortality. Studies of factors associated with refusal of treatment for potentially curable breast cancer show personal factors including age, marital status, and insurance are at play. However, few studies have investigated whether community or area-based characteristics may affect receipt of surgery. Methods: We selected all women diagnosed with non-metastatic (Stage I-III) breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database. We focused on those who refused surgery comparing racial and ethnic differences between Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic all races. Yost index calculated as neighborhood socio-economic status (nSES- divided into tertiles) and RUCA code-derived rural-urban status were based on an NCI census tract-level index, a composite score that includes income, education, housing, and employment; the remaining community factor measures were based on county-level index. Sociodemographic and community differences were analyzed using Pearson’s Chi-Square tests and analysis of variance. Multivariate logistic regression of predictors of refusal of surgery and Cox-proportional hazard model of disease-specific mortality were performed. A p-value of 0.05 was considered statistically significant. Results: 2,155 (0.7%) of 322,538 people refused surgery (NHW: 1,435 (66.6%), NHB: 353(16.3%), Hispanic all races: 166(7.7%)). Surgery refusers were more likely to live in areas with high poverty (<200% level), lower education attainment, lower unemployment, higher percentage urban population, higher percentage foreign-born, higher rates of language isolation, and lower rates of women over 40 having undergone mammography in the previous two years. Multivariate analysis shows surgery refusal is associated with high percentage of having a bachelor’s degree or higher (OR: 1.29, 95% CI:1.05-1.60, p-value <0.05), high percentage of poverty (<200% of poverty) (OR: 1.50, 95% CI:1.04-2.16, p-value <0.05), and high percentage of urban population (OR: 1.26, 95% CI:1.06-1.49, p-value <0.01). Surgery refusal rates declined with increasing nSES. Breast cancer-specific mortality increased significantly for those who refused surgery (HR:3.92, 95% CI: 3.41-4.51, p-value <0.01). Conclusion: Risk of refusing surgery for an otherwise curable breast cancer is associated with residence in communities with the lowest nSES. These are communities disproportionately populated by racial and ethnic minorities. Given the high mortality associated with refusing surgery, further investigation into the reasons why women decline treatment is necessary. For women living in impoverished communities, culturally sensitive education on benefits of care may be appropriate, while women of means may face different challenges such as utilization of alternative medicine.

Citation Format: Theresa Relation, Oindrila Bhattacharyya, Jay Fisher, Yaming Li, Allan Tsung, Ahmad Hamad, Amara Ndumele, Bridget Oppong. Are neighborhood and community factors associated with refusing breast cancer surgery? [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-05.

From street address to survival: Neighborhood socioeconomic status and pancreatic cancer outcomes

BACKGROUND

Neighborhood factors may influence cancer care through physical, economic, and social means. This study assesses the impact of neighborhood socioeconomic status on diagnosis, treatment, and survival in pancreatic cancer.

METHODS

Patients with pancreatic adenocarcinoma were identified in the 2010-2016 Surveillance Epidemiology and End Results database. Neighborhood socioeconomic status (divided into tertiles) was based on an National Cancer Institute census tract-level composite score, including income, education, housing, and employment. Multivariate models predicted metastasis at time of diagnosis and receipt of surgery for early-stage disease. Overall survival compared via Kaplan-Meier and Cox proportional hazards.

RESULTS

Fifteen thousand four hundred and thirty-six patients (29.7%) lived in low neighborhood socioeconomic status, 17,509 (33.7%) in middle neighborhood socioeconomic status, and 19,010 (36.6%) in high neighborhood socioeconomic status areas. On multivariate analysis, neighborhood socioeconomic status was not associated with metastatic disease at diagnosis (low neighborhood socioeconomic status odds ratio 1.02, 95% confidence interval 0.97-1.07; ref: high neighborhood socioeconomic status). However, low neighborhood socioeconomic status was associated with decreased likelihood of surgery for localized/regional disease (odds ratio 0.60, 95% confidence interval 0.54-0.68; ref: high neighborhood socioeconomic status) and worse overall survival (low neighborhood socioeconomic status hazard ratio 1.18, 95% confidence interval 1.15-1.21; ref: high neighborhood socioeconomic status).

CONCLUSION

Patients from resource-poor neighborhoods are less likely to receive stage-appropriate therapy for pancreatic cancer and have an 18% higher risk of death.

Access Denied: Inequities in Clinical Trial Enrollment for Pancreatic Cancer

BACKGROUND

The influence of social determinants of health (SDH) on participation in clinical trials for pancreatic cancer is not well understood. In this study, we describe trends and identify disparities in pancreatic cancer clinical trial enrollment.

PATIENTS AND METHODS

This is a retrospective study of stage I-IV pancreatic cancer patients in the 2004-2016 National Cancer Database. Cohort was stratified into those enrolled in clinical trials during first course of treatment versus not enrolled. Bivariate analysis and logistic regression were used to understand the relationship between SDH and clinical trial participation.

RESULTS

A total of 1127 patients (0.4%) enrolled in clinical trials versus 301,340 (99.6%) did not enroll. Enrollment increased over the study period (p < 0.001), but not for Black patients or patients on Medicaid. The majority enrolled had metastatic disease (65.8%). On multivariate analysis, in addition to year of diagnosis (p < 0.001), stage (p < 0.001), and Charlson score (p < 0.001), increasing age [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.96-0.97], non-white race (OR 0.54, CI 0.44-0.66), living in the South (OR 0.42, CI 0.35-0.51), and Medicaid, lack of insurance, or unknown insurance (0.41, CI 0.31-0.53) were predictors of lack of participation. Conversely, treatment at an academic center (OR 6.36, CI 5.4-7.4) and higher neighborhood education predicted enrollment (OR 2.0, CI 1.55-2.67 for < 7% with no high school degree versus > 21%).

DISCUSSION

Age, race, insurance, and geography are barriers to clinical trial enrollment for pancreatic cancer patients. While overall enrollment increased, Black patients and patients on Medicaid remain underrepresented. After adjusting for cancer-specific factors, SDH are still associated with clinical trial enrollment, suggesting need for targeted interventions.

Cancer Care in the Incarcerated Population: Barriers to Quality Care and Opportunities for Improvement

Importance

Cancer is the leading cause of mortality in incarcerated individuals older than 45 years and the fourth leading cause of mortality overall. Health care professionals face increasing challenges to provide high-quality care under the confines of prison regulations and procedures.

Observations

Adjusted for age, race, sex, and year of diagnosis, the standardized incidence ratio for all cancers is more than 2-fold higher in incarcerated vs general populations. Among deaths occurring in state and federal prison systems, cancer is the overall leading cause of mortality with lung cancer being the leading cause of cancer-related mortality followed by liver, colon, and pancreatic cancers, respectively. Access to high-quality oncological services remains variable; however, cost of care represents about a fifth of overall annual prison expenditures. Given the enormous patient burden, coupled with the rushed discretionary screenings performed by jail and prison nursing staff, early cancer symptoms are often missed altogether or misdiagnosed as a chronic illness or as acute infections. As such, many incarcerated individuals present with more advanced cancer stage. Incarcerated individuals have limited, if any, access to the internet, social media, and other sources of information, which severely limits their ability to research treatment options. Within the prison setting, access to professionals with special skills in assisting with social and spiritual concerns is also generally limited, and less than 4% of prisons have hospice programs. There are no uniform quality-of-care monitoring standards for correctional systems and facilities, nor are there mechanisms for reporting comparable performance data to enforce quality control within correctional health care systems.

Conclusions and Relevance

There is a growing trend in cancer incidence among incarcerated patients, which is multifactorial including barriers in access to care, increased burden of chronic medical conditions, and decreased screening tests. Efforts are needed to ensure quality health care outcomes for incarcerated patients with cancer.

Hispanic Ethnicity and Breast Cancer: Disaggregating Surgical Management and Mortality by Race

OBJECTIVE

Breast cancer is the leading cause of cancer death among Hispanic women. Unfortunately, few studies disaggregate Hispanic patients by race to understand its implications on treatment and clinical outcomes such as mortality. The aim of this study is to examine surgical management and overall mortality among different subgroups of women who self-identify as Hispanic.

METHODS

Hispanic female patients, ages 18-90, stages I-III, diagnosed with breast cancer between 2010 and 2015 from the National Cancer Data Base were identified. The study cohort was divided into three ethnoracial categories: (1) Hispanic White (HW), 2) Hispanic Black (HB), and 3) Hispanic Other (HO). Descriptive statistics and multivariate models were constructed to determine the relationship between sociodemographic factors, clinical variables, surgical management, and mortality when disaggregated by race.

RESULTS

There were 56,675 Hispanic women who met the study criteria. Most where HW (n=50,599, 89.3%) and the rest were HB (n=1,334, 2.4%) and HO (n=4,742, 8.3%). There was no difference between the three groups on receipt of breast conservation therapy (P=0.12). HB (48.5%) and HO (46.6%) women were more likely to undergo reconstruction than those who identified as HW (38.7%) (P<0.001). Additionally, HB (38.3%) women were more likely to undergo tissue-based reconstruction than HW (29.0%) and HO women (30%) (P=0.0008). There was no difference between the groups in the utilization of contralateral prophylactic mastectomy (CPM) (P=0.078). On multivariable analysis, there was no difference in mortality between HB and HW patients (HR 1.18, 95%CI 0.92-1.51; Ref HW). However, HO women had a 24% relative risk reduction in mortality (HR 0.76, 95% CI 0.63-0.92; HW ref).

CONCLUSION

Findings from this study suggest there are ethnoracial disparities in reconstruction utilization and mortality among Hispanic women. Future studies should examine how culture, language, healthcare access, and patient preferences contribute to these disparities.

Abstract PS7-10: Hormone receptor positive breast cancers and Black race: Does gender matter?

Introduction: Male breast cancer (MBC) patients present with later disease stages and have higher mortality rates than female breast cancer (FBC) patients. Additionally, black breast cancer patients, regardless of gender, consistently have worse clinical outcomes than their white counterparts. To date, there are few studies exclusively comparing clinical outcomes between black MBC and black FBC patients. The objective of this study is to understand the differences in presentation, treatment and mortality between black MBC and black FBC patients with hormone receptor positive breast cancer using the National Cancer Database (NCDB).

Methods: The NCDB was queried for all black MBC and FBC patients, ages 18-90, with hormone receptor positive breast cancer diagnosed between 2010-2016. Hormone receptor positivity was defined as estrogen receptor positive, progesterone positive and HER 2-negative cancer. Sociodemographic and clinical variables were compared between MBC and FBC patients on univariate analysis. For stages I-III patients, a propensity score (PS) was generated by a logistic regression model including the following covariates: age at diagnosis, tumor size, nodes removed, node positivity, resection margin status, hormonal treatment, chemotherapy treatment, and radiation treatment. MBC patients were matched to FBC patients using PS 2:1 nearest-neighbor matching. A log rank test was used to determine differences in survival between the matched cohort.

Results: There were 994 black MBC and 65,931 black FBC patients that met study criteria. MBC patients were older at diagnosis than women (age, MBC 63 ± 12.5, FBC 60.6± 13.3). Compared to FBC patients, more MBC patients had lower oncotype scores (RS 0-10, MBC 39.7%, FBC 24%, p&lt;0.001). Additionally, MBC patients were more likely to present with metastatic disease (stage 4, MBC 4.4%, FBC 2.6%, p&lt;0.001), had fewer smaller tumors (tumor size &lt;2cm, MBC 32.1, FBC 49.1%, p&lt;0.001) and a higher percentage of poorly differentiated tumors (grade 3, MBC 28.5%, FBC 21.4%, p&lt;0.001). Notably, MBC patients had lower rates of hormone therapy (MBC 66.4%, FBC 80.7%, p&lt;0.001) and neoadjuvant chemotherapy (MBC 5.8%, FBC 7.5%, p=0.05) utilization than their female counterparts. On propensity score matched analysis black MBC patients had a higher overall mortality compared to FBC patients (p=0.026).

Conclusion: Hormone receptor positive black MBC patients in the NCDB present with more advanced stages of disease, are less likely to receive endocrine therapy and have worse overall mortality compared to their black FBC counterparts. These results indicate that significant gender-based disparities exist in presentation, treatment and mortality among black breast cancer patients. Future studies should evaluate how biologic sex and tumor biology intersect to affect these intra-racial differences in clinical outcomes.

Citation Format: Mariam Eskander, Yaming Li, Bridget Oppong, Oindrila Bhattacharyya, Allan Tsung, Samilia Obeng-Gyasi. Hormone receptor positive breast cancers and Black race: Does gender matter? [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-10.

The implications of neighborhood socioeconomic status on surgical management and mortality in malignant phyllodes patients in the Surveillance, Epidemiology, and End Results program

BACKGROUND

Neighborhood socioeconomic status has been implicated in breast cancer incidence and mortality. However, there are no studies on the impact of neighborhood socioeconomic status on clinical outcomes or surgical management among patients with phyllodes tumors. The objective of this study is to understand the relationship between neighborhood socioeconomic status, surgical management and disease specific mortality in malignant phyllodes tumor patients in the Surveillance, Epidemiology, and End Results program.

METHODS

Surveillance, Epidemiology, and End Results program was queried for malignant phyllodes tumor patients diagnosed between 2000 and 2016. Using the National Cancer Institute census tract-level index for neighborhood socioeconomic status the data were stratified into low neighborhood socioeconomic status, middle neighborhood socioeconomic status, and high neighborhood socioeconomic status. Bivariate intergroup analysis was conducted. Disease specific mortality was evaluated using a Cox proportional hazards model.

RESULTS

Of the 651 patients with malignant phyllodes tumor in the sample, the disease specific mortality was 7.6% and 7.9% at 5 and 10 years, respectively. On bivariate analysis, there were no differences between the neighborhood socioeconomic status groups and surgery type (P = .794). On multivariable analysis, older age (≥71 years; hazard ratio 9.9; 95% confidence interval, 2.84-34.57; P < .001) and larger tumor size (≥40 mm; hazard ratio 2.20; 95% confidence interval, 1.09-4.44; P = .027) were associated with a higher disease specific mortality compared with younger age (≤ 40 years) and smaller tumor size (<40 mm). There was no association between neighborhood socioeconomic status and disease specific mortality (low neighborhood socioeconomic status-ref, middle neighborhood socioeconomic status hazard ratio 0.87 (95% confidence interval, 0.71-1.78; P = .71), high hazard ratio 0.91 (95% confidence interval, 0.44-1.90, P = .81).

CONCLUSION

Among malignant phyllodes tumor patients in the Surveillance, Epidemiology, and End Results program, disease specific mortality and surgical management are mostly driven by tumor characteristics and not social determinants of health.

Purposeful surgical delay and the coronavirus pandemic: how will black breast cancer patients fare?

Purpose

The Coronavirus pandemic has exposed substantial racial and ethnic health and healthcare disparities. Black breast cancer patients face significant disparities in stage of presentation, surgical management, and mortality. The objective of this editorial is to examine the possible implications of the surgical delay imposed by the pandemic on black breast cancer patients.

Methods

The American College of Surgeons, the Society of Surgical Oncology, and the American Society of Breast Surgeons recommendations for surgical delay during the Coronavirus Disease 2019 (COVID-19) were evaluated and discussed.

Results

Guidelines by major surgical organizations on surgical delay for breast cancer patients may inadvertently exacerbate disparities in time to surgery for black breast cancer patients. Our recommendations to better characterize the impact of these guidelines on surgical delay among vulnerable populations include the following: (1) track time from biopsy-proven diagnosis to surgery by race and ethnicity, (2) document patient and institution-related reasons for surgical delay, (3) record patient and disease-related variables/reasons for the selection of breast conservation surgery, mastectomy, and reconstruction by race and ethnicity, and (4) collect data on impactful social determinants of health such as financial reserve, housing conditions, stress, and transportation.

Conclusions

The COVID-19 pandemic may exacerbate delays in time to surgery among black breast cancer patients. Surgeons should incorporate collection of social determinants of health into their clinical practice to better understand the impact of COVID-19 on racial and ethnic disparities in surgical management.

Developing a Mass Media Campaign to Promote Mammography Awareness in African American Women in the Nation's Capital

This study developed and examined the reach and impact of a culturally appropriate mass media campaign pilot, designed to increase awareness about the importance of mammography screening and the available community mammography services for low-income African American women ages 40 and above. We conducted formative research using focus groups to inform campaign development, resulting in five emergent themes-good breast health, holistic views of healthiness, cancer fatalism, fear of mammogram machines, and mammogram affordability. The campaign targeted specific low-income African American communities in the District of Columbia via print ads in Metro stations and on buses, print ads in the Washington Informer, and online ads on a local TV network website. Data were collected before, during, and after campaign implementation to assess reach and impact. Reach was measured by number of impressions (number of people exposed to the campaign), while impact was assessed via online ad click-through rates, website use and referrals, and mammography center calls. The campaign was successful in reaching the target audience, with a total combined reach from all media of 9,479,386 impressions. In addition, the mammography center received significant increases in new website visitors (1482 during the campaign, compared to 24 during the preceding period) as well as 97 calls to the dedicated phone line. Further research involving a more long-term investment in terms of funding and campaign run time, coupled with a more robust evaluation, is needed to assess if culturally appropriate mass media campaigns can generate increased mammography screening rates and decrease breast-cancer-related mortality.

A Community-Based Outreach Navigator Approach to Establishing Partnerships for a Safety Net Mammography Screening Center

Washington, DC, has one of the highest incidence and mortality rates for breast cancer in the USA. Patient navigation coupled with informational and community resources are important strategies that assist patients' access and help them understand the complex world of cancer care. The Georgetown Lombardi Comprehensive Cancer Center's Capital Breast Care Center (CBCC) is a safety net mammography screening center that utilizes a community-based navigation program. In addition to providing assistance with coordination of clinical services, navigators at CBCC are integral in establishing intra-community partnerships to educate members of the community about breast cancer screening. The aim of this study was to detail the role of patient navigation at the CBCC, with an emphasis on community engagement and community-based partnerships. We describe the process by which CBCC established partnerships with multiple community organizations between 2004 and 2015 and analyzed data of women screened in relationship to the evolution of the patient navigation services. Application of the CBCC navigation model that integrates individual patient outreach with community engagement has yielded viable and lasting community partnerships that have resulted in an increase in mammography uptake, especially among medically underserved minority women.

Abstract A40: Capital Breast Care Center: A Patient Navigation Exemplar

Introduction. Breast cancer is the second leading cause of cancer deaths for American women. Washington, DC, has one of the highest incidence and mortality rates for breast cancer in the U.S. Patient navigation coupled with informational and community resources are important strategies that assist patients' access and help them understand the complex world of cancer care.

Aims.The Georgetown Lombardi Comprehensive Cancer Center's Capital Breast Care Center (CBCC) serves as an exemplary community-embedded facility that develops multiple intra community partnerships to improve patient access to health care. The aim of this study is to detail the role of patient navigation at the Capital Breast Care Center, with an emphasis on community engagement and community-based partnerships.

Program process description. We describe the development and application of the CBCC patient navigation process and navigation components: (a) creating partnerships; (b) educating members of the community about mammograms; (c) providing patient navigation into screening assistance; and (d) helping women with coordination of diagnostic follow-up. Data were collected from 2004-2015 and analyzed in 2015.

Program process evaluation results. CBCC established 41 community partnerships categorized by different organizational types that include transitional housing facilities, health service providers, neighborhood associations, churches, senior centers, and local neighborhood recreation centers. Application of the CBCC navigation model yielded important lessons; in general, partnerships and patient navigation.

Discussion. Partnerships, community engagement, and informational resources are all crucial to the patient navigation process in providing access to quality care for all patients.

Citation Format: Sherrie Flynt Wallington, Bridget Oppong, Chiranjeev Dash, Tesha Coleman, Holly Greenwald, Tanya Torres, Marquita Iddirisu, Lucile Adams-Campbell. Capital Breast Care Center: A Patient Navigation Exemplar. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A40.

Stereotactic Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Rationale, Feasibility, and Early Experience Using the CyberKnife Radiosurgery Delivery Platform

PURPOSE

The efficacy of accelerated partial breast irradiation (APBI) utilizing brachytherapy or conventional external beam radiation has been studied in early-stage breast cancer treated with breast-conserving surgery. Data regarding stereotactic treatment approaches are emerging. The CyberKnife linear accelerator enables excellent dose conformality to target structures while adjusting for target and patient motion. We report our institutional experience on the technical feasibility and rationale for stereotactic accelerated partial breast irradiation (SAPBI) delivery using the CyberKnife radiosurgery system.

METHODS

Ten patients completed CyberKnife SAPBI (CK-SAPBI) in 2013 at Georgetown University Hospital. Four gold fiducials were implanted around the lumpectomy cavity prior to treatment under ultrasound guidance. The synchrony system tracked intrafraction motion of the fiducials. The clinical target volume was defined on contrast enhanced CT scans using surgical clips and post-operative changes. A 5 mm expansion was added to create the planning treatment volume (PTV). A total dose of 30 Gy was delivered to the PTV in five consecutive fractions. Target and critical structure doses were assessed as per the National Surgical Adjuvant Breast and Bowel Project B-39 study.

RESULTS

At least three fiducials were tracked in 100% of cases. The Mean treated PTV was 70 cm(3) and the mean prescription isodose line was 80%. Mean dose to target volumes and constraints are as follows: 100% of the PTV received the prescription dose (PTV30). The volume of the ipsilateral breast receiving 30 Gy (V30) and above 15 Gy (V > 15) was 14 and 31%, respectively. The ipsilateral lung volume receiving 9 Gy (V9) was 3%, and the contralateral lung volume receiving 1.5 Gy (V1.5) was 8%. For left-sided breast cancers, the volume of heart receiving 1.5 Gy (V1.5) was 31%. Maximum skin dose was 36 Gy. At a median follow-up of 1.3 years, all patients have experienced excellent/good breast cosmesis outcomes, and no breast events have been recorded.

CONCLUSION

CyberKnife stereotactic accelerated partial breast irradiation is an appealing technique for partial breast irradiation offering improvements over existing APBI techniques. Our early findings indicate that CK-SAPBI delivered in five daily fractions is feasible, well tolerated, and is a reliable platform for delivering APBI.

Weight Changes in Black and White Women Receiving Chemotherapy Treatment for Breast Cancer

PURPOSE

Weight gain after a breast cancer diagnosis is associated with poor cancer outcomes. Limited research describes patterns of weight change by race. The goal of this study was to assess and compare the percent of weight change and change in body mass index (BMI) after chemotherapy in Black and White breast cancer patients.

METHODS

Black and White women diagnosed with invasive non-metastatic breast cancer were recruited from two metropolitan areas. Medical records were abstracted to obtain clinical (e.g. cancer stage) and treatment variables (e.g. chemotherapy regimen). Weight change was examined in 98 women who underwent chemotherapy. Differences in baseline characteristics by race were evaluated using the chi-square or Fisher's exact test for categorical variables and t-test for continuous variables. We performed bivariate associations between study variables and relative weight change.

RESULTS

Most (62%) participants maintained their pre-treatment weight; 38% gained more than 5% of their baseline weight by the end chemotherapy. Normal weight women had the highest mean increase (3.57; 1.05, 6.10) compared to those that were overweight/obese. Fifteen percent of women shifted to a higher BMI category; 26% of those that were normal became overweight; 17% of overweight patients became obese. Blacks were more likely than whites to shift to a higher BMI (P=0.06).

CONCLUSIONS

Results underscore the need for integrating weight control within cancer treatment plans to prevent weight gain in patients undergoing chemotherapy. Future studies that help to elucidate behaviors and/or biological factors that contribute to weight gain overall and in blacks will be important.

Abstract C06: Temporal changes in characteristics of women receiving screening mammograms at a community-based breast cancer screening center

The American Cancer Society recommends annual mammography screening for women over 40 years old, however, screening uptake is lower among African American, Hispanic, and Asian Americans than Whites. Socioeconomic factors such as income, lack of insurance, low education level, and immigrant status are also associated with lower mammography screening rates. Among uninsured/under-insured and medically underserved populations, community clinics are important providers for breast cancer screening services. The Capital Breast Care Center (CBCC) of the Georgetown-Lombardi Comprehensive Cancer Center was established in 2004 to deliver breast and cervical cancer screening to all women in the District of Columbia (D.C.) metropolitan region regardless of ability to pay. We examined the characteristics of women presenting to CBCC for screening mammograms from 2010-2012 and investigated temporal changes in selected demographic and socioeconomic characteristics during this period.

Data was abstracted from the electronic medical records at CBCC and analyzed. Patient characteristics were described in frequencies and the statistical significance was determined using chi-square tests. From 2010 to 2012, 4,604 women were screened at CBCC. Patient volume increased each year, with a greater number of returning patients than each previous year. In 2010, 1428 women were seen, 46% of whom were new. In 2011 and 2012, 1581 and 1594 patients were seen, with 43% and 38% as new patients, respectively. About 40% of the women screened at CBCC each year were below the age of 50. The age distribution of the women remained relatively constant over the 3 year study period. African-American and Hispanic women accounted for about 90% of those screened at CBCC over the 3 year period. However, between 2010 and 2012, the racial/ethnic composition of the screenees shifted with a 9% decrease in the number of African-Americans and an increase of 6% among Latinas (P&lt;0.0001). A small increase in the number of Asian-American women was also noted (2%). Corresponding changes in the primary language spoken by the patients were also observed with the proportion of native English speakers decreasing and native Spanish speakers increasing by 6% from 2010 to 2012 (P &lt; 0.01). More than half of the women seen at CBCC were uninsured. The proportion of uninsured women screened at CBCC increased by 13% from 2010 (46%) to 2012 (59%), with corresponding declines in the proportion of screenees with private insurance (-3.52%), Medicaid (-5.49%), and Medicare (-1.98%) (P&lt;0.0001). 73% of the women screened between 2010 and 2012 had completed high school or higher education. Temporal changes in education levels of the participants were not evident in our data.

Reasons for the temporal changes in racial/ethnic composition and native language of the women seen at CBCC could be related to the demographic changes in the Washington D.C. metropolitan area and/or a demographic shift in the age distribution of Latinas thereby resulting in a greater percentage of them being eligible for mammograms. In addition, over the past three years, CBCC outreach efforts have increased in the Latino community with hiring of Spanish-speaking health educators and patient navigators. Results from our study underscore the importance of community-based clinics in increasing cancer screening uptake in un-/under-served communities.

Citation Format: Holly S. Greenwald, Chiranjeev Dash, Bridget Oppong, Tesha Coleman, Vivian Watkins, Lucile L. Adams-Campbell. Temporal changes in characteristics of women receiving screening mammograms at a community-based breast cancer screening center. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C06.

Abstract 140: Weight changes in African American and White breast cancer patients undergoing chemotherapy

PURPOSE: Weight gain after a breast cancer diagnosis is associated with cancer recurrence, worse cancer prognosis, higher comorbidity, and increased likelihood of inaccurate chemotherapy dose reductions during treatment. This health problem is especially relevant for African Americans, as they are more likely to be obese and to present comorbid conditions compared to their White counterparts. However, limited research describes patterns of weight change by race. The goal of this study was to assess and compare weight change after chemotherapy in Black and White breast cancer patients.

METHODS: Ninety-eight Black and White women diagnosed with invasive non-metastatic breast cancer were recruited from two metropolitan areas. Medical records were abstracted to obtain clinical (e.g. cancer stage) and treatment variables (e.g. chemotherapy regimen). Weight change was examined in women who underwent chemotherapy and it was conceptualized as the relative percent of weight change and change in body mass index (BMI - kg/m2) categorized as normal, overweight, and obese. Differences in baseline characteristics by race were evaluated using the chi-square or Fisher's exact test for categorical variables and t-test for continuous variables. We performed bivariate associations between study variables and relative weight change.

RESULTS: African-American women had higher BMI at baseline (at the start of therapy) as compared to Whites (p&lt;0.001). African American women were also more likely to have at least one comorbid condition compared to Whites. Most (62%) participants maintained their pre-treatment weight. About a third of the sample (29%) experienced a weight gain of more than 5% of their baseline weight after treatment for breast cancer.

Only 9% of women lost more than 5% of their pre-treatment weight. Normal weight women had the highest mean relative weight increase (3.57%; 95% CI: 1.05%, 6.10%) compared to those that were overweight or obese. Fifteen percent of women shifted to a higher BMI category; 26% of those that were normal became overweight; 17% of overweight patients became obese. Blacks were more likely than whites to shift to a higher BMI (p=0.006).

CONCLUSIONS: The American Cancer Society guidelines recommend cancer survivors to maintain a normal weight and avoid weight gain. We found that women in all BMI categories were likely to gain weigh with those in the normal category having the highest risk of weight gain. Results underscore the need for integrating weight control within cancer treatment plans to prevent weight gain and promote weight maintenance in patients undergoing chemotherapy. Interventions that address dietary habits and promote increased physical activity to maintain fat-free mass may be warranted. Future studies that help to elucidate behaviors and/or biological factors that contribute to weight gain overall and in blacks will be important.

Citation Format: Vanessa B. Sheppard, Chiranjeev Dash, Bridget Oppong, Fikru Hirpa, Elizabeth Dennis, Lucile L. Adams-Campbell. Weight changes in African American and White breast cancer patients undergoing chemotherapy. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 140. doi:10.1158/1538-7445.AM2013-140