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Breast cancer is one of the most common types of cancer, and one in which we can readily observe and study disparities in inequalities. It is known that women from lower socioeconomic backgrounds, including those on Medicaid, have lower breast cancer-related survival and are twice as likely to die within 5 years of diagnosis. These populations can sometimes benefit from new lawmaker policies that impact treatment patterns in the hopes of improving outcomes, which in this case would be breast cancer-related mortality.

One such way to accomplish this is to change or eliminate reimbursement incentives for certain facilities, which could help cut costs and improve quality, while addressing disparities. Indeed, in 2009, the state of New York implemented a policy that was applied to its Medicaid beneficiaries, prohibiting low-volume breast centers (defined as fewer than 30 surgeries for breast cancer per year) from being reimbursed for such surgeries in these patients, thus promoting surgical care at high-volume facilities.

A multidisciplinary group led by Ann Nattinger, MD, of Medical College of Wisconsin sought to retrospectively study the women impacted by that policy, in order to determine whether it had an impact on mortality or other outcomes. Hospital discharge and mortality data were reviewed for Medicaid and commercially insured patients, 3 to 4 years before and after the implementation of the New York state policy, from nearly 38,000 women with breast cancer (up to stage III).

As shown in the findings published in a recent issue of the , this group demonstrated that the overall 5-year mortality was slightly lower in post-policy patients, with statistically significant improvement in survival for Medicaid patients in particular who also experienced a greater reduction in breast cancer-specific mortality. However, in Medicaid patients, the adjusted breast cancer mortality was much more dramatic, declining by 2.1% to a value of 4.5% in the years after the policy was initiated, as compared to declining by 0.1% to a value of 3.8% in all other patients.

Interestingly, in the neighboring state of New Jersey in which the above policy was not initiated, there were no similar effects in survival during the same time period amongst breast cancer patients with Medicaid.

This well-conducted analysis aimed to demonstrate how a statewide policy encouraging the centralization of breast cancer surgery to more experienced centers could improve treatment outcomes in terms of improved survival and breast cancer-specific survival, thereby potentially addressing socioeconomic barriers and inequalities.

Though the difference in the outcomes was relatively dramatic and statistically significant, leading the authors to conclude that consolidating breast cancer surgery to higher-volume centers holds merit, there were some limitations to this study including its retrospective nature and broad inclusion criteria.

For example, the non-Medicaid comparator group included some uninsured patients, which could potentially add a confounding effect in interpreting the decreased survival within that group as a whole. Also, the definition of a low-volume breast center by the state policy (< 30 breast cancer surgeries per year) could potentially be regarded as somewhat arbitrary, but it would be interesting to compare outcomes in facilities at low-moderate caseloads (i.e., <50, <100) and higher caseloads perhaps seen at large tertiary or academic centers. With regards to the latter, it would be interesting to see what proportion of patients were sent to such facilities as compared with low/moderate volume community centers or even private practices, and the difference in outcomes.

It would also be interesting to investigate whether the policy created geographical disparities for patients in rural or remote areas, including additional burdens and compliance associated with transportation distance and cost, especially if multiple visits were required. With regard to surveillance and follow-up, it is unclear if this study gathered data regarding whether this state-implemented policy resulted in improved surveillance (and where such surveillance was done) to detect recurrence earlier, which would also likely impact outcomes and survival. It would be interesting to see eventual 10-year follow-up on this population and also whether commercial health plans have started to adopt the strategies learned from this clinical study in order to improve population health outcomes in its patient panels.

Though it may be difficult to power a study like this one for numerous subgroup analyses, it would be interesting to compare stratified data on this population studied, as such analyses could elicit patterns for future hypothesis generation and studies. These subgroup analyses could include the geographical region of the patient, distance to closest experienced breast cancer center, socioeconomic status, race, age, gender (for male breast cancer), germline mutation status, disease stage, histology, molecular markers (ER, PR, HER2), need for neoadjuvant therapy, compliance rates with intended treatment and pre-/post-screening, short-term outcomes including surgical complications, type of surgery performed including any need/referral for reconstruction, "cross-over" rate to other forms insurance or underinsurance, rate of transfer for all care (including medical oncology and radiation oncology) "under one roof" where the surgery was performed, early recurrence or metastatic disease, and lastly the requirement/compliance/completion of any necessary adjuvant radiation, chemotherapy, or endocrine therapy.

With regards to the latter, it is important to consider breast cancer as a multidisciplinary disease and effort, from the time of diagnosis with expert radiology and pathology consultation to ensure an accurate stage and molecular histology, along with the early referral to and involvement of medical oncology and radiation oncology to determine risk factors and considerations for either neoadjuvant chemotherapy and/or post-surgical adjuvant care including endocrine therapy or chemotherapy. In clinical practice, this is often best achieved with physicians from these disciplines working closely together with surgical consultants, often within a tumor board and geographical or relational proximity to ensure coordinated care.

There is also the under-appreciated role of primary care physicians and cancer navigators to ensure timely access to diagnostic mammograms, tissue biopsy, and referrals, to provide clearance for surgery or other therapy, and to ensure implementation of post-treatment surveillance and survivorship.

Overall, this was an excellent study that accomplished several important purposes:

• Quantifying the impact of barriers and disparities in breast cancer care for underprivileged patients

• Analyzing and confirming the positive impact of state-implemented healthcare policies or incentives to address these barriers and disparities

• Potentially lending a template for future design of policies and studies that generate additional data and hypotheses to further analyze the numerous factors and nuances involved in breast cancer care

Indeed, future studies in other states in the U.S. as well as throughout the world, which address the variables and complexity in multidisciplinary breast cancer care, will certainly be warranted to continue investigation and support for the interesting findings and implications from this well-conducted retrospective study.

, is a physician-scientist, educator, author, and speaker, who is involved with cancer care, personalized medicine, and innovation in healthcare. At Palomar Health Medical Group in San Diego, he is the Director of Oncology and Chief Medical Officer of Physician Wellness. He also serves as Alumni Specialty Director at the Cleveland Clinic Lerner College of Medicine and as Clinical Instructor at the University of California San Diego. You can also find him on and .

Read the study here and an interview about it here.