Assessing Predictors of Outcomes of Guidelines-Concordant Treatment in Women with Early Stage Breast Cancer Público

Liao, Albert (Spring 2018)

Permanent URL: https://etd.library.emory.edu/concern/etds/rb68xb87r?locale=es
Published

Abstract

Introduction:

Previous studies examining disparities in treatment guideline adherence in early-stage breast cancer have been limited by small study sample sizes, localized geography, unknown causal factors, and lack of diverse populations. To address these issues, we used the National Cancer Data Base to assess socioeconomic, clinical, and facility factors that impact treatment compliance with the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) guidelines.

Methods:

The NCDB file contains 2,246,280 patients diagnosed between January 1st, 2004 to December 31st, 2014. Chi-square tests were used to identify significant differences in rates of guidelines adherence over time for facility type, facility location, quartiles of income, education, insurance status, distance, and tumor staging. Logistic regression modeling was used to compute odds ratios for likelihood of guidelines adherence controlling for these factors. A backward multivariable Cox proportional hazard model was fit and an extended Kaplan-Meier curve plotted. Overall survival was measured in months from date of diagnosis to date of either death or last follow-up.

Results:

Multivariate models revealed decreased use of post-breast conserving surgery (BCS) radiation, chemotherapy, and immunotherapy for women ≥ 75; for lower-volume treatment centers; for patients without private insurance; for patients in the lowest income quartiles; for patients in the lowest education quartile; for patients with higher comorbidities; and for patients having unknown stage tumor. Treatment compliance led to overall mortality reductions for all treatments examined. 

Conclusion:

Certain socioeconomic, clinical, and facility factors influence guideline-concordant care and subsequent outcomes for patients with early-stage breast cancer. Approaches to reducing disparities in breast cancer treatment have had mixed progress; this points to a need for tailored interventions to improve guideline compliance so that non-compliance can be prevented in at-risk populations. With the new emphasis on value-based care, it is important to address these discrepancies in treatment and thus enhance survival for all individuals through better adherence to guideline concordant therapy.  

 

Table of Contents

Table of Contents

Introduction 10

Epidemiology 10

Breast Cancer Staging 12

Figure 1: TNM staging influences the overall AJCC early cancer staging. 15

Treatment 15

Surgery 16

Radiation 17

Chemotherapy 19

Targeted Immunotherapies 21

Why is Guideline Concordant Care Important? 21

Barriers to Guideline Concordant Care 23

Databases 26

Thesis Proposal 27

Methods 27

Data Source and Study Population 27

Study Variables 28

Statistical Analysis 28

Post-Breast Conserving Surgery Radiation 29

Post BCS RT from 2004 to 2013 30

Factors Associated with BCS RT Treatment 30

Impact of BCS RT on OS 31

Discussion 31

Post Breast Conserving Surgery Figures: 34

Figure 2: Selection Criteria for Post-Breast Conserving Surgery Radiation Therapy Study 34

Table 1: Descriptive Statistics for All Variable: Post-Breast Conserving Surgery Radiation 35

Table 2: Univariate Association with Study Cohort: Post Breast Conserving Surgery Radiation 38

Table 3: Multivariable Logistic Regression Model for Post Breast Conserving Surgery Compliance 43

Table 4: Univariate Association with Overall Survival: Post Breast Conserving Surgery Radiation 46

Table 5: Multivariable Cox Proportional Hazard Model for Overall Survival- Post Breast Conserving Surgery Radiation 50

Figure 3: Kaplan Meier Curve for Receipt of Post-Breast Conserving Surgery Radiation Therapy 52

Chemotherapy 53

Chemotherapy Receipt from 2010 - 2013 53

Factors Associated with Chemotherapy Receipt for HER2+/HR- Patient 54

Factors Associated with Chemotherapy Receipt for HER2-/HR+ Patient 55

Factors Associated with Chemotherapy Receipt for HER2+/HR+ Patient 56

Factors Associated with Chemotherapy Receipt for Triple Negative Patients 57

Impact of Chemotherapy on OS 58

Discussion 59

Chemotherapy Figures 63

Figure 4: Selection Criteria for Chemotherapy 63

Table 6: Base Characteristics and Unadjusted Outcomes between Eligible Patients with HER2+/HR- Chemotherapy 63

Table 7: Univariate Association with Chemotherapy HER2+/HR- Patients 66

Table 8: Multivariable Logistic Regression Model for HER2+/HR- Chemotherapy 70

Table 9: Univariate Association with Overall Survival for HER2+/HR- Chemotherapy 72

Table 10: Multivariable Cox Proportional Hazard Model for Overall Survival for HER2+/HR- Chemotherapy 76

Figure 5: Kaplan Meier Curve for HER2+/HR- Breast Cancer 78

Table 11: Descriptive Statistics for All Variables for HER2-/HR+ Chemotherapy 79

Table 12: Univariate Association with HER2-/HR+ Chemotherapy Receipt 82

Table 13: Multivariable Logistic Regression Model for HR+ Chemotherapy 86

Table 14: Univariate Association with Overall Survival for HER2+/HR- Chemotherapy 88

Table 15: Multivariate Cox Proportional Hazard Model for Overall Survival HER2-/HR+ Chemotherapy 92

Figure 6: Kaplan Meier Curve for HER2-/HR+ Breast Cancer 96

Table 16: Descriptive Statistics for All Variables HER2+/HR+ Chemotherapy 97

Table 17: Univariate Association of HER2+/HR+ Chemotherapy 100

Table 18: Multivariable Logistic Regression Model for HER2+/HR+ Chemotherapy 104

Table 19: Univariate Association with Overall Survival for HER2+/HR+ Chemotherapy 108

Table 20: Multivariable Cox Proportional Hazard Ratio for HER2+/HR+ Chemotherapy 112

Figure 7: Kaplan Meier Curve for HER2+/HR+ Breast Cancer 116

Table 21: Descriptive Statistics for All Variables- Triple Negative Chemotherapy 117

Table 22: Univariate Association with Study Cohort- Triple Negative Chemotherapy 120

Table 23: Multivariable Logistic Regression Model for Triple Negative Chemotherapy 124

Table 24: Univariate Association with Overall Survival – Triple Negative Chemotherapy 127

Table 25: Multivariate Cox Proportional Hazard Model for Overall Survival- Triple Negative Chemotherapy 131

Figure 8: Kaplan Meier Curve for Triple Negative Chemotherapy 134

Immunotherapy 135

Immunotherapy Receipt from 2010-2013 136

Univariate Factors Associated with Immunotherapy Underuse in HER2+/HR- Cancers 136

Univariate Factors Associated with Immunotherapy Underuse in HER2+/HR+ Cancers 136

Multivariate Factors Associated with Immunotherapy Underuse in HER2+ Cancers 137

Effectiveness of Immunotherapy Receipt when Recommended by Evidence-Based Guidelines 137

Immunotherapy Figures 138

Table 26: Descriptive Statistics for HER2+/HR- Immunotherapy 138

Table 27: Univariate Association with Study Cohort- HER2+/HR- Immunotherapy 141

Table 28: Baseline Characteristics for Study Cohort: HER2+/HR+ Breast Cancer 145

Table 29: Univariate Association with Study Cohort Immunotherapy- HER2+/HR+ 148

Table 30: Multivariate Logistic Association with Study Cohort: All HER+ Breast Cancer 152

Table 31: Univariate Association with Overall Survival: HER2+/HR- Immunotherapy 154

Table 32: Univariate Associate with Overall Survival: HER+/HR+ Immunotherapy 158

Table 33: Multivariable Cox Proportional Hazard HER2+/HR- Immunotherapy 162

Table 34: Multivariable Cox Proportional Hazard HER2+/HR+ Immunotherapy 164

Figure 9: Kaplan Meier Curve Analysis for HER2+ Breast Cancer 168

Discussion 169

Overall Conclusion 172

List of Figures 176

List of Tables 176

Bibliography 178

 

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