e12129 Background: Interest in the use of neoadjuvant endocrine therapy (NET) has increased over the past decade, and recent studies have demonstrated similar response rates compared to neoadjuvant chemotherapy. We examined the associations between duration of NET and type of surgery and change from clinical stage to pathologic stage. Methods: We used the National Cancer Data Base to identify women diagnosed with stage II-III, ER and/or PR positive breast cancer who received endocrine therapy from 2004-2014 and underwent surgery. We classified patients according to timing and duration of NET. We performed logistic regression to examine the impact of NET duration on likelihood of 1) receiving breast conserving surgery (BCS) versus mastectomy and 2) being downstaged. Downstaging was defined as pathologic stage lower than clinical stage and upstaging as pathologic stage higher than clinical stage. Results: In our sample of 159,676 patients, 6584 received NET (4.1%). NET was more frequently used in older women with multiple comorbid conditions, larger tumors, and higher nodal stage. The highest rates of NET were in academic/research or integrated network cancer programs. Of patients who underwent NET, 26.5% received it for ≤3 months, 41.0% for 3-6 months, 27.7% for 6-12 months, and 4.9% for 12-24 months. Patients who received NET for 3-6, 6-12, and 12-24 months were all significantly more likely to receive BCS versus mastectomy than patients who did not receive NET (Table). Patients who underwent NET compared to adjuvant endocrine therapy were more likely to be downstaged (Table). Conclusions: The most common duration of NET was 3-6 months, but >26% of patients received NET for less than 3 months. Longer durations of NET were strongly associated with BCS and downstaging. Further research is needed to determine the population of patients mostly likely to benefit from NET and the optimal length of treatment. [Table: see text]
The aim of the study was to compare costs associated with excision of routine cavity shave margins (CSM) versus standard partial mastectomy (PM) in patients with breast cancer.Excision of CSM reduces re-excision rates by more than 50%. The economic implications of this is, however, unclear.Between October 21, 2011 and November 25, 2013, 235 women undergoing PM for Stage 0-III breast cancer were randomized to undergo either standard PM ("no shave", n = 116) or have additional CSM taken ("shave", n = 119). Costs from both a payer and a hospital perspective were measured for index surgery and breast cancer surgery-related care through subsequent 90 days.The 2 groups were well-matched in terms of baseline characteristics. Those in the "shave" group had a longer operative time at the initial surgery (median 76 vs 66 min, P < 0.01), but a lower re-excision rate for positive margins (13/119 = 10.9% vs 32/116 = 27.6%, P < 0.01). Actual direct hospital costs associated with operating room time ($1315 vs. $1137, P = 0.03) and pathology costs ($1195 vs $795, P < 0.01) were greater for the initial surgery in patients in the "shave" group. Taking into account the index surgery and the subsequent 90 days, there was no significant difference in cost from either the payer ($10,476 vs $11,219, P = 0.40) or hospital perspective ($5090 vs $5116, P = 0.37) between the "shave" and "no shave" groups.Overall costs were not significantly different between the "shave" and "no shave" groups due to significantly fewer reoperative surgeries in the former.
Following diagnosis of breast cancer, many women experience serious psychological distress, which can adversely affect their cancer care and outcomes. We conducted this study to examine the association between mental health conditions and hospital outcomes and costs among women undergoing mastectomy for invasive breast cancer. Using nationally representative data from the 2005 to 2008 Nationwide Inpatient Sample, we identified women aged ≥18 years with invasive breast cancer who underwent inpatient mastectomy (N = 40,202). Individuals with a psychiatric diagnosis (major depressive, posttraumatic stress, panic, adjustment, or generalized anxiety disorder) or substance abuse were compared with those without a mental health condition. Outcomes included risk of complications, prolonged hospitalization (>3 days), and direct costs of care. Multivariable logistic and linear regression analyses were performed to control for sociodemographic and clinical characteristics. Overall, 4.5% of patients had a mental health condition. Patients with substance abuse were more likely than those without to experience both complications (8.5% versus 4.8%; adjusted odds ratio [AOR] = 1.61 [1.30-2.00]) and prolonged hospitalization (26.4% versus 13.6%; AOR = 2.25 [1.95-2.59]), and to have higher average costs ($9,855 versus $9,128, p = 0.009). Presence of psychiatric diagnoses was also significantly associated with increased complications (5.9% versus 4.8%; AOR = 1.21 [1.10-1.34]), prolonged hospitalization (8.5% versus 4.8%; AOR = 1.40 [1.32-1.49]), and higher average costs ($9,723 versus $9,108, p < 0.001). Mental health conditions are associated with poorer outcomes and higher costs in breast cancer patients undergoing inpatient mastectomy. Greater efforts are needed to identify and manage these patients with psychiatric and substance use disorders during the perioperative period.
e13541 Background: Recent evidence suggests that black cohosh (Cimicifuga racemosa) may prevent and treat breast cancer through anti-proliferative, pro-apoptotic, anti-estrogenic, and anti-inflammatory effects. We sought to determine the efficacy of black cohosh (BC) as a potential chemoprevention agent by evaluating its ability to decrease the cell proliferation biomarker Ki67 in a pre-operative window trial of ductal carcinoma in situ (DCIS) patients. Methods: Patients were treated pre-operatively with commercial standardized isopropanolic black cohosh extract (20 mg orally twice daily) for 2-5 weeks. Ki67 in DCIS regions was measured using automated quantitative immunofluorescence (AQUA) pre- and post-operatively. A sample size of 22 patients, assuming a 10% drop-out rate, was estimated to achieve 91% power to detect a 0.8 standard deviation of difference with a two-sided significance level at 0.05 using Wilcoxon signed-rank test. Eligible subjects were women newly diagnosed with DCIS on core biopsy, prior to definitive excision (NCT01628536). Results: Of 32 patients enrolled, 24 patients were available for Ki67 analysis; 5 patients’ samples were unevaluable by AQUA and 3 patients lacked DCIS post-treatment. Mean duration of BC therapy was 23 days (range; 13-35 days). Among evaluable patients, we found no significant change in Ki67 values in areas of DCIS with pre-operative exposure to BC (Z = -.9714, p = .33), though a downward trend was observed. Eleven of the 32 patients (34%) were found to have invasive disease at the time of surgery, nine of whom had grade 2-3 DCIS at biopsy; these observations are similar to expected DCIS upgrade rates published in the literature. BC was well tolerated; no related adverse events were above grade 1. Conclusions: Pre-operative exposure to BC did not significantly decrease Ki67 in patients with DCIS, although a downward trend was seen. Our findings suggest that BC is safe for use in breast cancer patients and could be explored as a potential chemoprevention agent. Clinical trial information: NCT01628536.Disease # of patients Avg. Ki67 pre Avg. Ki67 post % decrease p-value DCIS 14 1700 1327 21.94 .68 Invasive 10 1413 1076 23.82 .28 All patients 24 1581 1223 22.64 .33
Objective To characterize Medicare expenditures on initial breast cancer care and examine variation in expenditures across hospital referral regions ( HRR s). Data Source We identified 29,110 women with localized breast cancer diagnosed in 2005–2008 and matched controls from the Surveillance, Epidemiology, and End Results‐Medicare linked database. Study Design Using hierarchical generalized linear models, we estimated per patient Medicare expenditure on initial breast cancer care across HRR s and assessed the contribution of patient, cancer, and treatment factors to regional variation via incremental models. Principal Findings Mean Medicare expenditure for initial breast cancer care was $19,255 per patient. The average expenditures varied from $15,053 in the lowest‐spending HRR quintile to $23,480 in the highest‐spending HRR quintile. Patient sociodemographic, comorbidity, and tumor characteristics explained only 1.8 percent of the difference in expenditures between the lowest‐ and highest‐spending quintiles, while use of specific treatment modalities explained 14.5 percent of the difference. Medicare spending on radiation therapy differed the most across the quintiles, with the use of intensity modulated radiation therapy increasing from 1.7 percent in the lowest‐spending quintile to 11.6 percent in the highest‐spending quintile. Conclusions Medicare expenditures on initial breast cancer care vary substantially across regions. Treatment factors are major contributors to the variation.
e17802 Background: Demand for price transparency in healthcare is growing, empowering employers and beneficiaries to better understand what they pay for services. Variation in surgeon payments for oncologic resection has not been well studied, especially in the private-payer sector. We therefore assessed (1) geographic variation of private payer expenditures to surgeons for cancer resection, (2) variation within geographical regions for these expenditures. Methods: We use data based on fee-for-service allowed amounts, billed by a mix of private-payer providers for the year 2013, obtained in partnership with Fair Health, Inc. FAIR Health (FH) is an independent, not-for-profit corporation that collects and compiles claims data from insurers nationwide. We selected surgical resections frequently used for treating breast, lung and prostate cancer with CPT codes for simple mastectomy (SM), open lobectomy (LB), and robotic radical prostatectomy (RP). We evaluated surgeon reimbursement, as derived by FH through an ‘allowed medical benchmark’ (AMB) based on the maximum allowable payments for the submitted procedure codes and relative value units of the procedure. The data is grouped into 491 geographical regions based on zip code. To assess variation across regions, we compared the median AMB between regions. To assess intra-region variability, we evaluated regional inter-quartile ranges of AMB. Results: For each surgical procedure, the surgeon’s median AMB varied substantially across regions: For SM, the median AMB ranged from $487 in the least expensive region to $1,364 in the costliest region. For LB the median AMB ranged from $498 to $5,047; for RP from $1,716 to $5,775. Even standard deviations for the 50thpercentile of AMB were high (LB $1,450, RP $1,173). There was also substantial variation within geographic regions. The AMB means of the 25th & 75thpercentile within regions were as follows: for SM $552 & $1,088, LB $997 & $3,061, and RP $2,350 & $3,567. Conclusions: We found a wide range of variation both across and within geographic regions in the allowed reimbursement for these common surgical procedures. Transparency about surgical payment may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care.
