Alerting surgeons when their breast cancer patients did not attend a follow-up consultation with a medical oncologist was associated with a reduction in racial disparities in adjuvant therapy, according to a non-randomized study published in the November 25 online issue of the Journal of the National Cancer Institute.
Black and Hispanic women with early stage breast cancer are less likely to consult a medical oncologist than their white counterparts. To reduce system failures in which the surgeon recommends a consultation and the patient does not refuse but still does not receive the consultation, Nina Bickell, M.D., of the Mount Sinai School of Medicine in New York and colleagues implemented a tracking and feedback system in six New York hospitals.
In the current study, Bickell and colleagues compared the rate of completed consultations with a medical oncologist and the use of adjuvant therapy among 639 women with early stage breast cancer who were treated between 1999 and 2000, prior to implementation of the system, with 300 women treated between 2004 and 2006 after implementation.
The researchers found that the tracking and feedback registry was associated with a 14 percentage point increase in consultations with oncologists, from 83 percent in the pre-implementation group to 97 percent in the post-implementation group. There was a statistically significant decrease in the underuse of adjuvant treatment, from 23 percent in the earlier cohort to 14 percent in the later cohort. The decline in underuse of adjuvant care was more pronounced in black (34 percent to 14 percent) and Hispanic women (23 percent to 13 percent) than in white women (17 percent to 14 percent).
"The tracking and feedback registry, designed to target the system failure cause of underuse, was most effective at municipal hospitals that had greater frequencies of underuse due to system failure," the authors write. "Especially in such settings, this simple intervention appeared to eliminate previously detected racial disparities in adjuvant treatment underuse."
In an accompanying editorial, Rachel Freedman, M.D., and Eric P. Winer, M.D., of the Dana-Farber Cancer Institute in Boston note that because breast cancer care requires patients to see multiple specialists over the course of their therapy, there are opportunities for patients to get lost in the system. Navigator programs have already been implemented in numerous hospitals to help patients move through health care systems as smoothly as possible. A tracking and feedback system, such as the one used in the Bickell study, may have the potential to improve care, but randomized studies need to be performed to more definitively demonstrate the effectiveness of such programs.
"We believe that the work described by Bickell et al., albeit promising, needs to be replicated using a prospective, randomized design," the editorialists write. "Disparities in cancer care represent one of the most important challenges facing the oncological community, and although we need to act quickly, we cannot rush to implement approaches that have not been thoroughly evaluated through rigorous investigation."
Contact:
Article: Ian Michaels, ian.michaels@mountsinai.org, (212) 241-9200
Editorial: Bill Schaller, William_Schaller@dfci.harvard.edu, (617) 632-5357
Citation:
Article: Bickell NA, et al. A Tracking and Feedback Registry to Reduce Racial Disparities in Breast Cancer Care. J Natl Cancer Inst 2008; 100:1717-1723
Editorial: Freedman RA, Winer EP. Reducing Disparities in Breast Cancer Care — A Daunting but Essential Responsibility. J Natl Cancer Inst 2008; 1661-1663
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