Abstract
SAN FRANCISCO: Patients treated for breast cancer at a Miami safety net hospital achieved similar five-year survival outcomes to national averages, despite having a patient population that was largely poor, uninsured, and diagnosed with more advanced disease, according to findings from a pair of studies presented at the American College of Surgeons Clinical Congress 2019.
The promising clinical outcomes were attributed to receipt of treatment in a multidisciplinary breast cancer clinic that streamlines diagnosis, work-up, treatment, and follow-up. "By providing multidisciplinary breast cancer care, we can achieve high-quality clinical outcomes at a safety net hospital that treats patients from an underserved population who tend to present with more advanced disease," said Neha Goel, MD, a surgical oncologist at the University of Miami and senior author of both studies.
"After being seen and discussed by the multidisciplinary team, our patients have a clear treatment plan and follow-up appointments in place. This is crucial given the unique obstacles our patients face to even get to clinic, so we don't want to make navigating the system even more difficult," said Kristin Kelly, MD, MPH, surgical oncology fellow at the University of Miami and primary author of both studies.
The authors believe that the multidisciplinary approach to breast cancer care tackles challenges associated with treating a disparate population. Safety net hospitals are open-door facilities that provide access to care regardless of a patient's ability to pay. Their patients are largely uninsured, Medicaid recipients, or otherwise vulnerable.1 A particular challenge for these facilities is lack of coordination of initial and follow-up diagnostic, surgical, and oncologic care. A study in 2016 found that at safety net hospitals, minority patients were less likely to receive adjuvant therapies that improve survival because they did not have sufficient staff, support, or information technology to coordinate care between surgeons and oncologists.2
The multidisciplinary program described in these studies is held every Tuesday morning. After undergoing an appropriate diagnostic workup, patients with breast cancer are evaluated by surgical and medical oncologists, and their imaging, pathology and treatment is reviewed and discussed by a team of surgical oncologists, medical oncologists, breast radiologists, breast pathologists, and radiation oncologists. A treatment plan is developed and discussed with the patient and any subsequent appointments are made before they leave. "Our goal is to streamline cancer care. By scheduling all the appointments for the same day, we can foresee potential issues that may keep patients from obtaining treatment and help them navigate an otherwise intimidating system" Dr. Goel said.
For one study, researchers compared characteristics and outcomes for 6,344 patients who were treated for breast cancer between 2005 and 2017 at two University of Miami Miller School of Medicine teaching hospitals: the 1550-bed safety net hospital and the NCI-designated cancer center. Both hospitals are accredited by the Commission on Cancer of the American College of Surgeons.
The patients treated in the safety net hospital were younger and more likely to be African American or Hispanic, have Medicaid coverage or no insurance, and belong to the lowest income quartile. More of these patients (33 percent) had advanced stage III or IV disease than patients treated at the comprehensive cancer center (21 percent). Five-year overall survival was nonetheless equivalent for both groups of patients after accounting for the initiation of treatment (HR: 1.12, p=0.301).
For the other study, the researchers reported patient outcomes for all 2,797 patients who presented to the safety net hospital with stages I-IV breast cancer between 2005 and 2017. Patients in this study had more advanced breast cancer than the general population. Nationwide at diagnosis, 62 percent of patients have localized disease, 30 percent have regional disease, and 6 percent have metastatic disease. In contrast, 12 percent of patients treated at the safety net hospital had stage IV disease at presentation. Most had signs of aggressive disease, such as moderate or poorly differentiated tumors.
Five-year survival rates for the safety net patients were comparable to national averages: 94 percent for stage I cancer, 90 percent for stage II, 76 percent for stage III, and 31 percent for stage IV. The five-year overall survival rate is 89.9 percent in the U.S.3
"A key aspect of these studies is the importance of getting patients efficiently through the health care system. Studies like these show that excellent cancer care doesn't occur in a silo. It's more collaborative and requires the multidisciplinary team to work together to create a plan that is individualized for each patient and accounts for their specific circumstances," said Dr. Kelly.
Dr. Goel's and Dr. Kelly's coauthors of the study, "Overcoming Disparities: Multidisciplinary Breast Cancer Care at a Public Safety-Net Hospital," were Emily Ryon, MD; Ahkeel Allen, MD; Dido Franceschi, MD, FACS; Mecker Moller, MD, FACS; Eli Avisar, MD, FACS; Erin N Kobetz, PhD, MPH; Nipun Merchant, MD, FACS; Susan B Kesmodel, MD, FACS.
Their coauthors of the study, "Breast Cancer Survival Outcomes in a Public Safety-Net Hospital Compared to an Adjacent Academic Cancer Center," were Emily Ryon, MD; Francis Igor B Macedo, MD; Dido Franceschi, MD, FACS; Mecker Moller, MD, FACS; Eli Avisar, MD, FACS; Erin N Kobetz, PhD, MPH; Nipun Merchant, MD, FACS; Susan B Kesmodel, MD, FACS.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
