Background

Abstractor training is a key element in creating valid and reliable data collection procedures. The choice between in-person vs. remote or simultaneous vs. sequential abstractor training has considerable consequences for time and resource utilization. We conducted a web-based (webinar) abstractor training session to standardize training across six individual Cancer Research Network (CRN) sites for a study of breast cancer treatment effects in older women (BOWII). The goals of this manuscript are to describe the training session, its participants and participants' evaluation of webinar technology for abstraction training.

Findings

A webinar was held for all six sites with the primary purpose of simultaneously training staff and ensuring consistent abstraction across sites. The training session involved sequential review of over 600 data elements outlined in the coding manual in conjunction with the display of data entry fields in the study's electronic data collection system. Post-training evaluation was conducted via Survey Monkey©. Inter-rater reliability measures for abstractors within each site were conducted three months after the commencement of data collection.

Ten of the 16 people who participated in the training completed the online survey. Almost all (90%) of the 10 trainees had previous medical record abstraction experience and nearly two-thirds reported over 10 years of experience. Half of the respondents had previously participated in a webinar, among which three had participated in a webinar for training purposes. All rated the knowledge and information delivered through the webinar as useful and reported it adequately prepared them for data collection. Moreover, all participants would recommend this platform for multi-site abstraction training. Consistent with participant-reported training effectiveness, results of data collection inter-rater agreement within sites ranged from 89 to 98%, with a weighted average of 95% agreement across sites.

Conclusions

Conducting training via web-based technology was an acceptable and effective approach to standardizing medical record review across multiple sites for this group of experienced abstractors. Given the substantial time and cost savings achieved with the webinar, coupled with participants' positive evaluation of the training session, researchers should consider this instructional method as part of training efforts to ensure high quality data collection in multi-site studies.

Objective

To evaluate the effectiveness of methods that control for confounding by indication, we compared breast cancer recurrence rates among women receiving adjuvant chemotherapy versus those who did not.

Study Design and Setting

In a medical record review-based study of breast cancer treatment in older women (n=1798) diagnosed 1990-1994, our crude analysis suggested adjuvant chemotherapy was positively associated with recurrence [hazard ratio (HR)=2.6 (95% confidence interval (CI)=1.9, 3.5)]. We expected a protective effect, so postulated that the crude association was confounded by indications for chemotherapy. We attempted to adjust for this confounding by restriction, multivariable regression, propensity scores [PS], and instrumental variable [IV] methods.

Results

After restricting to women at high-risk for recurrence (n=946), chemotherapy was not associated with recurrence [HR=1.1 (95% CI=0.7, 1.6)] using multivariable regression. PS adjustment yielded similar results [HR=1.3 (95% CI=0.8, 2.0)]. The IV-like method yielded a protective estimate [HR=0.9; (95% CI=0.2, 4.3)]; however imbalances of measured factors across levels of the IV suggested residual confounding.

Conclusion

Conventional methods do not control for unmeasured factors, which often remain important when addressing confounding by indication. PS and IV analysis methods can be useful under specific situations, but neither method adequately controlled confounding by indication in this study.

Little is known about the risk of recurrence more than five years after diagnosis among older breast cancer survivors. A community-based population of women ≥65 years diagnosed with early stage breast cancer who survived disease-free for five years was followed for five additional years or until a diagnosis of breast cancer recurrence, second primary, death or loss to follow-up. These five-year disease-free survivors (N=1277) had primary breast cancers that were node negative (77%) and estrogen receptor positive or unknown (86%). Five percent (N=61) developed a recurrence between five and ten years after diagnosis; 25% local, 9.8% regional, and 66% distant. Women who were node positive (Hazard Ratio [HR]=3.9; 95% Confidence Interval [CI]=1.5,10); had poorly differentiated tumors (HR=2.5; 95% CI=0.9, 6.6); or who received breast conserving surgery without radiation therapy (HR=2.4; 95%CI=1.0, 5.8) had higher recurrence rates compared with node negative, well differentiated, and receipt of mastectomy, respectively. Not receiving adjuvant tamoxifen, compared with receiving adjuvant tamoxifen, was also positively associated with late recurrence among women with estrogen receptor positive/unknown tumors. While relatively few women experience a late recurrence, most recurrences present as advanced disease, which is difficult to treat in older women. This study of late recurrence emphasizes that the risk, although small, is not negligible even in this group at high risk for death due to competing causes.

Background

Annual surveillance mammography is recommended for follow-up of women with a history of breast cancer. We examined surveillance mammography among breast cancer survivors who were enrolled in integrated healthcare systems.

Methods

Women in this study were 65 or older when diagnosed with early stage invasive breast cancer (N = 1,762). We assessed mammography use during 4 years of follow-up, using generalized estimating equations to account for repeated measurements.

Results

Eighty-two percent had mammograms during the first year after treatment; the percentage declined to 68.5% in the fourth year of follow-up. Controlling for age and comorbidity, women who were at higher risk of recurrence by being diagnosed at stage II or receiving breast-conserving surgery (BCS) without radiation therapy were less likely to have yearly mammograms (compared to stage I, odds ratio [OR] for stage IIA 0.72, confidence interval [CI] 0.59, 0.87, OR for stage IIB 0.75, CI 0.57, 1.0; compared to BCS with radiation, OR 0.58, CI 0.43, 0.77). Women with visits to a breast cancer surgeon or oncologist were more likely to receive mammograms (OR for breast cancer surgeon 6.0, CI 4.9, 7.4, OR for oncologist 7.4, CI 6.1, 9.0).

Conclusions

Breast cancer survivors who are at greater risk of recurrence are less likely to receive surveillance mammograms. Women without a visit to an oncologist or breast cancer surgeon during a year have particularly low rates of mammography. Improvements to surveillance care for breast cancer survivors may require active participation by primary care physicians and improvements in cancer survivorship programs by healthcare systems.

Background

Millions of women receive clinical breast examination (CBE) each year, as either a breast cancer screening test or a diagnostic test for breast symptoms. While screening CBE had moderately high specificity (∼94%) in clinical trials, community clinicians may be comparatively inexperienced and may conduct relatively brief examinations, resulting in even higher specificity but lower sensitivity.

Objective

To estimate the specificity of screening and diagnostic CBE in clinical practice and identify patient factors associated with specificity.

Design

Retrospective cohort study.

Subjects

Breast-cancer-free female health plan enrollees in 5 states (WA, OR, CA, MA, and MN) who received CBE (N = 1,484).

Measurements

Medical charts were abstracted to ascertain breast cancer risk factors, examination purpose (screening vs diagnostic), and results (true-negative vs false-positive). Women were considered “average-risk” if they had neither a family history of breast cancer nor a prior breast biopsy and “increased-risk” otherwise.

Results

Among average- and increased-risk women, respectively, the specificity (true-negative proportion) of screening CBE was 99.4% [95% confidence interval (CI): 98.8–99.7%] and 97.1% (95% CI: 95.7–98.0%), and the specificity of diagnostic CBE was 68.7% (95% CI: 59.7–76.5%) and 57.1% (95% CI: 51.1–63.0%). The odds of a true-negative screening CBE (specificity) were significantly lower among women at increased risk of breast cancer (adjusted odds ratio 0.21; 95% CI: 0.10–0.46).

Conclusions

Screening CBE likely has higher specificity among community clinicians compared to examiners in clinical trials of breast cancer screening, even among women at increased breast cancer risk. Highly specific examinations, however, may have relatively low sensitivity for breast cancer. Diagnostic CBE, meanwhile, is relatively nonspecific.

Purpose

A substantial literature describes age-dependent variations in breast cancer treatment, showing that older women are less likely to receive standard treatment than are younger women. We sought to identify patient and tumor characteristics associated with the non-receipt of standard primary tumor and systemic adjuvant therapies.

Methods

We studied 1,859 women aged 65 years or older with stage I and II breast cancer diagnosed between 1990 and 1994 who were cared for in six geographically dispersed community-based health care systems. We collected demographic, tumor, treatment, and comorbidity data from electronic data sources, including cancer registry, administrative, and clinical databases, and from subjects’ medical records.

Results

Women 75 years of age or older and those with higher comorbidy indices were more likely to receive non-standard primary tumor therapy; to not receive axillary lymph node dissection; and to not receive radiation therapy following breast conserving surgery. Asian women were less likely to receive breast conserving surgery and African American women were less likely to be prescribed tamoxifen. Although non-receipt of most therapies was associated with a lower baseline risk of recurrence, an important minority of high risk women (16–30%) did not received guideline therapies.

Conclusions

Age is an independent risk factor for non-receipt of effective cancer therapies, even when comorbidity and risk of recurrence are taken into account. Information regarding treatment effectiveness in this age group and tools that allow physicians and patients to estimate the benefits versus the risks of therapies, taking into account age and comorbidity burden, are critically needed.

Background

Millions of women receive clinical breast examination (CBE) each year, as either a breast cancer screening test or a diagnostic test for breast symptoms. While screening CBE had moderately high specificity (∼94%) in clinical trials, community clinicians may be comparatively inexperienced and may conduct relatively brief examinations, resulting in even higher specificity but lower sensitivity.

Objective

To estimate the specificity of screening and diagnostic CBE in clinical practice and identify patient factors associated with specificity.

Design

Retrospective cohort study.

Subjects

Breast-cancer-free female health plan enrollees in 5 states (WA, OR, CA, MA, and MN) who received CBE (N = 1,484).

Measurements

Medical charts were abstracted to ascertain breast cancer risk factors, examination purpose (screening vs diagnostic), and results (true-negative vs false-positive). Women were considered “average-risk” if they had neither a family history of breast cancer nor a prior breast biopsy and “increased-risk” otherwise.

Results

Among average- and increased-risk women, respectively, the specificity (true-negative proportion) of screening CBE was 99.4% [95% confidence interval (CI): 98.8–99.7%] and 97.1% (95% CI: 95.7–98.0%), and the specificity of diagnostic CBE was 68.7% (95% CI: 59.7–76.5%) and 57.1% (95% CI: 51.1–63.0%). The odds of a true-negative screening CBE (specificity) were significantly lower among women at increased risk of breast cancer (adjusted odds ratio 0.21; 95% CI: 0.10–0.46).

Conclusions

Screening CBE likely has higher specificity among community clinicians compared to examiners in clinical trials of breast cancer screening, even among women at increased breast cancer risk. Highly specific examinations, however, may have relatively low sensitivity for breast cancer. Diagnostic CBE, meanwhile, is relatively nonspecific.

CONTEXT

Women from racial and ethnic minorities in the United States have higher rates of cervical cancer and present with later stage disease compared to whites. Delays in care for abnormal Papanicolaou (Pap) smears can lead to missed cases of cervical cancer or late-stage presentation and may be one explanation for these differences.

OBJECTIVE

To determine if race and ethnicity, health beliefs, and cancer knowledge are associated with delays in care for abnormal Pap smears.

DESIGN, PARTICIPANTS, AND SETTING

We conducted a mailed survey with telephone follow-up of all women with an abnormal Pap smear who received care at Kaiser Permanente Los Angeles Medical Center between October 1998 and October 1999 (n = 1,049).

MEASUREMENTS AND MAIN RESULTS

A delay in care was defined as not attending the first scheduled clinic visit to follow up on an abnormal Pap smear, or requiring multiple contact attempts, including a certified letter, to schedule a follow-up visit. Our response rate was 70% (n = 733) and the sample was 51% Latina. Spanish-speaking Latinas and women of Asian descent were more likely to endorse fatalistic beliefs and misconceptions about cancer. Thirteen percent of the sample delayed follow-up on their abnormal Pap smear. Women who delayed care were more fatalistic and endorsed more misconceptions about cervical cancer. Delays in care were not independently associated with race and ethnicity.

CONCLUSIONS

Health beliefs and cancer knowledge differed by race and ethnicity among women in a large managed care organization. Fatalistic health beliefs and misconceptions about cancer, but not race and ethnicity, were independently associated with delays in care.

Objective

To identify factors associated with delayed radiotherapy (RT) in older women with early stage breast cancer.

Methods

We studied 541 women ages 65+ diagnosed with early stage breast cancer from 1990–1994 at five integrated healthcare delivery systems and treated with breast conserving surgery and RT, but not chemotherapy. We examined whether demographic, tumor, or treatment characteristics were associated with RT delays of >8 weeks post-surgery using chi-square tests and multivariable logistic regression.

Results

Seventy-six women (14%) had delayed RT, with a median delay of 14 weeks. Non-white and Hispanic women were much more likely than White women to have delayed RT (OR=3.3, 95%CI: 1.7, 10) in multivariable analyses that controlled for demographic and clinical variables.

Conclusions

Of women receiving BCS and radiation in this cohort, 14% experienced delayed RT, even though they had insurance and access to care in integrated delivery systems. Women receiving delayed care were more likely to be non-White and Hispanic. Timely RT should be facilitated through physician and patient education, navigation, and notification programs to improve quality of care. Future research should examine modifiable barriers to RT timeliness and whether delays impact long-term outcomes.

Introduction

Randomized trials indicate that adjuvant radiotherapy plus tamoxifen decrease the five-year risk of recurrence among ductal carcinoma in situ patients treated with breast-conserving surgery from about 20% to 8%. The aims of this study were to examine the use and impact of these therapies on risk of recurrence among ductal carcinoma in situ patients diagnosed and treated in the community setting.

Methods

We identified 2,995 patients diagnosed with ductal carcinoma in situ between 1990 and 2001 and treated with breast-conserving surgery at three large health plans. Medical charts were reviewed to confirm diagnosis and treatment and to obtain information on subsequent breast cancers. On a subset of patients, slides from the index ductal carcinoma in situ were reviewed for histopathologic features. Cumulative incidence curves were generated and Cox regression was used to examine changes in five-year risk of recurrence across diagnosis years, with and without adjusting for trends in use of adjuvant therapies.

Results

Use of radiotherapy increased from 25.8% in 1990-1991 to 61.3% in 2000-2001; tamoxifen increased from 2.3% to 34.4%. A total of 245 patients had a local recurrence within five years of their index ductal carcinoma in situ. The five-year risk of any local recurrence decreased from 14.3% (95% confidence interval 9.8 to 18.7) for patients diagnosed in 1990-1991 to 7.7% (95% confidence interval 5.5 to 9.9) for patients diagnosed in 1998-1999; invasive recurrence decreased from 7.0% (95% confidence interval 3.8 to 10.3) to 3.1% (95% confidence interval 1.7 to 4.6). In Cox models, the association between diagnosis year and risk of recurrence was modestly attenuated after accounting for use of adjuvant therapy. Between 1990-1991 and 2000-2001, the proportion of patients with tumors with high nuclear grade decreased from 46% to 32% (P = 0.03) and those with involved surgical margins dropped from 15% to 0% (P = 0.03).

Conclusions

The marked increase in the 1990s in the use of adjuvant therapy for ductal carcinoma in situ patients treated with breast-conserving surgery in the community setting only partially explains the 50% decline in risk of recurrence. Changes in pathology factors have likely also contributed to this decline.