Ancillary Treatment Referrals and Visits after Breast Cancer Surgery in a Sociodemographically Diverse Population.
Danielle R. Heller2, Vernice Hui Yan Chan1, Elizabeth R. Berger2, Scott Capozza2, Rachel A. Greenup2, Tara B. Sanft2
1The University of Hong Kong, Hong Kong, Hong Kong, 2Yale University, New Haven, Connecticut, United States
Objective(s):
Ancillary therapies with rehabilitative, palliative, and survivorship specialists are known to mitigate the physical and emotional effects of surgical breast cancer treatment. Existing data suggest that patients from disadvantaged backgrounds may be less likely to receive such care. We investigated provider referrals and patient visits at a high-volume urban cancer center in order to identify associated sociodemographic factors and characterize which populations may not be maximally benefiting from ancillary treatments.
Design:
Retrospective cohort study
Setting:
High-volume, urban-based academic cancer center
Patients:
Data was culled from the electronic health records of 5,496 patients with breast cancer treated surgically at the Yale-New Haven Health System between 2010-2017
Main Outcome Measure(s):
Post-operative provider referrals to Physical/Occupational Therapy, Palliative Medicine, and the Survivorship Program were evaluated for associations with demographic and disease variables in univariable and multivariable logistic regression analyses. Patient utilization of referrals, defined as attending as least one consultation, were analysed similarly.
Results:
Among 5,496 patients identified, 2,288 (41.6%) were referred for ancillary treatments and 1,572 (28.6%) attended at least one consultation. Provider referrals were highest among patients with Hispanic and Black ancestry (57.5% and 54.9%, respectively), no health insurance (57.6%), lowest percentage high school degree for zip code (50.5%), and poorest median income bracket for zip code (50.7%). These associations remained significant in multivariable analysis [all p<0.050]. In stark contrast, utilization of referrals was greatest among patients with private insurance (70.7%), highest percentage high school degree (72.8%), and wealthiest median household income (72.2%), in addition to Hispanic ethnicity (73.5%). In multivariable analysis, wealthiest median household income and Hispanic ethnicity remained associated (OR 1.45, p=0.019 and OR 1.50, p=0.048, respectively).
Conclusion:
In a large urban health system serving a demographically diverse population, traditional markers of poor healthcare access were positively associated with provider referral for ancillary services after breast cancer surgery. However, referral did not translate to utilization in this population. This suggests that care access remains a critical barrier to adjunctive therapies that target patients' post-operative morbidity and elevate their quality of life.
Table 1. Multivariable analysis of demographic and disease factors associated with referrals and visits to ancillary care specialists after breast cancer surgery. *Indicates statistical significance
| REFERRAL | VISIT | |||
| OR | P-Value | OR | P-Value | |
| AGE (YEARS) <50 50-64 >65 | - Ref 0.938 0.518 | *<0.001 Ref 0.463 <0.001 | - Ref 1.171 0.828 | 0.060 Ref 0.235 0.268 |
| RACE White Black Hispanic Other/Unknown | - Ref 1.346 1.529 1.373 | *0.001 Ref *0.011 *0.002 0.053 | - Ref 1.297 1.498 1.076 | 0.167 Ref 0.131 *0.048 0.766 |
| INSURANCE None Government Private | - Ref 0.828 0.651 | *0.020 Ref 0.649 0.298 | - Ref 1.036 0.985 | 0.933 Ref 0.948 0.978 |
| MEDIAN HOUSEHOLD INCOME (USD) FOR ZIP CODE <65,000 65,000-79,999 80,000-99,999 ≥$100,000 | - Ref 0.739 0.652 0.798 | *<0.001 Ref *0.001 *<0.001 *0.026 | - Ref 1.200 1.240 1.454 | 0.138 Ref 0.205 0.169 *0.019 |
| RESECTION None/BCS Nipple-sparing Skin-sparing / Simple Modified Radical | - Ref 0.834 1.144 1.068 | 0.377 Ref 0.448 0.251 0.713 | - Ref 1.416 1.245 1.543 | 0.322 Ref 0.383 0.235 0.088 |
| RECONSTRUCTION None/Local tissue arrangement Tissue expander/Implant Autologous | - Ref 0.982 1.123 | 0.658 Ref 0.885 0.433 | - Ref 1.074 1.002 | 0.927 Ref 0.716 0.993 |
| LYMPH NODE HARVEST None Sentinel lymph node biopsy Axillary dissection | - Ref 1.250 1.274 | 0.057 Ref *0.017 0.125 | - Ref 1.265 1.008 | 0.170 Ref 0.133 0.974 |
| CHEMOTHERAPY None Neoadjuvant Adjuvant Neoadjuvant & Adjuvant | - Ref 2.006 1.460 1.364 | *<0.001 Ref *<0.001 *<0.001 0.213 | - Ref 0.683 1.13 1.607 | *0.024 Ref *0.037 0.356 0.232 |
| RADIOTHERAPY No Yes | - Ref 1.358 | *<0.001 Ref *0.001 | - Ref 1.674 | *<0.001 Ref *<0.001 |
| LYMPHEDEMA No Yes | - Ref 5.930 | *<0.001 Ref *<0.001 | - Ref 3.674 | *<0.001 Ref *<0.001 |
| MOTOR DYSFUNCTION No Yes | - Ref 1.886 | *<0.001 Ref *<0.001 | - Ref 1.770 | *<0.001 Ref *<0.001 |
| PAIN/PARAESTHESIA No Yes | - Ref 2.031 | *<0.001 Ref *<0.001 | - Ref 2.041 | *<0.001 Ref *<0.001 |
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