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What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata

Durand, Marie-Anne; Yen, Renata W; O'Malley, A James; Schubbe, Danielle; Politi, Mary C; Saunders, Catherine H; Dhage, Shubhada; Rosenkranz, Kari; Margenthaler, Julie; Tosteson, Anna N A; Crayton, Eloise; Jackson, Sherrill; Bradley, Ann; Walling, Linda; Marx, Christine M; Volk, Robert J; Sepucha, Karen; Ozanne, Elissa; Percac-Lima, Sanja; Bergin, Emily; Goodwin, Courtney; Miller, Caity; Harris, Camille; Barth, Richard J; Aft, Rebecca; Feldman, Sheldon; Cyr, Amy E; Angeles, Christina V; Jiang, Shuai; Elwyn, Glyn
BACKGROUND:Women of lower socioeconomic status (SES) with early-stage breast cancer are more likely to report poorer physician-patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices. METHODS:We conducted a 3-arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon-level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence-based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre-consultation) to T5 (1-year after surgery. RESULTS:Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self-reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety. CONCLUSIONS:Paper-based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients. LAY SUMMARY/UNASSIGNED:The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices. Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text-only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education. Conversation aids with pictures and text helped women make better breast cancer surgery choices.
PMID: 33170506
ISSN: 1097-0142
CID: 4689292

Imaging and Management of Internal Mammary Lymph Nodes

Samreen, Naziya; Dhage, Shubhada; Gerber, Naamit Kurshan; Chacko, Celin; Lee, Cindy S.
Internal mammary lymph nodes (IMLNs) account for approximately 10%-40% of the lymphatic drainage of the breast. Internal mammary lymph nodes measuring up to 10 mm are commonly seen on high-risk screening breast MRI examinations in patients without breast cancer and are considered benign if no other suspicious findings are present. Benign IMLNs demonstrate a fatty hilum, lobular or oval shape, and circumscribed margins without evidence of central necrosis, cortical thickening, or loss of fatty hilum. In patients with breast cancer, IMLN involvement can alter clinical stage and treatment planning. The incidence of IMLN metastases detected on US, CT, MRI, and PET-CT ranges from 10%-16%, with MRI and PET-CT demonstrating the highest sensitivities. Although there are no well-defined imaging criteria in the eighth edition of the American Joint Committee on Cancer Staging Manual for Breast Cancer, a long-axis measurement of ≥ 5 mm is suggested as a guideline to differentiate benign versus malignant IMLNs in patients with newly diagnosed breast cancer. Abnormal morphology such as loss of fatty hilum, irregular shape, and rounded appearance (which can be quantified by a short-axis/long-axis length ratio greater than 0.5) also raises suspicion for IMLN metastases. MRI and PET-CT have good sensitivity and specificity for the detection of IMLN metastases, but fluorodeoxyglucose avidity can be seen in both benign conditions and metastatic disease. US is helpful for staging, and US-guided fine-needle aspiration can be performed in cases of suspected IMLN metastasis. Management of suspicious IMLNs identified on imaging is typically with chemotherapy and radiation, as surgical excision does not provide survival benefit and is performed only in rare cases.
ISSN: 2631-6110
CID: 4733442

Understanding surgical education needs in Zambian residency programs from a Resident's perspective

Wang, David E; Sultan, Darren; Ismail, Hebah; Robinson, Elizabeth; Zulu, Robert; Musowoya, Joseph; Munthali, James C; Hopkins, Mary Ann; Dhage, Shubhada
INTRODUCTION/BACKGROUND:Approximately 100 surgeons in Zambia serve a population of 16 million, a severe shortage in basic surgical care. Surgical education in Zambia and other low-middle income countries has not been well characterized. The aim of this study was to evaluate surgical training resources from a resident perspective. METHODS:6 of 8 COSECSA-accredited major medical centers were included. We developed a Surgical Education Capacity Tool to evaluate hospital characteristics including infrastructure, education, and research. The questionnaire was completed by administrators and trainees. RESULTS:18 of 45 trainees were surveyed. Caseloads and faculty-to-trainee ratio varied by location. No sites had surgical skills, simulation, or research labs. Most had medical libraries, lecture halls, and internet. Outpatient clinics, bedside teaching, M&M conferences, and senior supervision were widely available. Despite some exposure, research mentorship, basic science, and grant application guidance were critically limited. CONCLUSIONS:Lack of access to proper infrastructure, research, and personnel all impact surgical training and education. The Surgical Education Capacity Tool offers insights into areas of potential improvement, and is applicable to other LMICs.
PMID: 30654918
ISSN: 1879-1883
CID: 3595432

Surgical treatment of young women with breast cancer: Public vs private hospitals

Patel, Ami; Wang, Wen-Jie; Warnack, Elizabeth; Joseph, Kathie-Anne; Schnabel, Freya; Axelrod, Deborah; Dhage, Shubhada
Disparities in breast cancer treatment have been documented in young and underserved women. This study aimed to determine whether surgical disparities exist among young breast cancer patients by comparing cancer treatment at a public safety-net hospital (BH) and private cancer center (PCC) within a single institution. This was a retrospective study of young women (<45) diagnosed with invasive breast cancer (stage I-III) from 2011-2016. Patient information was abstracted from the breast cancer database at BH and PCC. Demographic variables, surgery type, method of presentation, and stage were analyzed using Pearson's chi-square tests and binary logistic regression. A total of 275 patients between ages 25-45 with invasive breast cancer (Stage I-III) were included in the study. There were 69 patients from BH and 206 patients from PCC. At PCC, the majority of patients were Caucasian (68%), followed by Asian (11%), Hispanic (10%), and African American (8.7%). At BH, patients were mostly Hispanic (47.8%), followed by Asian (27.5%), and African American (10.1%). At PCC, 82% had a college/graduate degree versus 18.6% of patients at BH (P < 0.001). All patients at PCC reported English as their primary language versus 30% of patients at BH (P < 0.001). Patients at PCC were more likely to present with lower stage cancer (P = 0.04), and less likely to present with a palpable mass (P = 0.04). Hospital type was not a predictor of receipt of mastectomy (P = 0.5), nor was race, primary language, or education level. Of patients who received a mastectomy, 87% at BH and 76% at PCC had immediate reconstruction. Surgical management of young women with breast cancer in a public hospital versus private hospital setting was equivalent, even after controlling for race, primary language, stage, and education level.
PMID: 31074047
ISSN: 1524-4741
CID: 3900922

The Use of Breast MRI for Patients With Preoperative Breast Cancer in an Underserved Population

Warnack, Elizabeth; Dhage, Shubhada; Johnson, Elaheh; Horowitz, Elizabeth; Joseph, Kathie Ann
BACKGROUND:Use of MRI for preoperative evaluation of newly diagnosed breast cancer has become more common, despite questionable impact on outcomes. We sought to determine how often and in what manner preoperative breast MRI changed surgical management in an underserved patient population. MATERIALS AND METHODS/METHODS:We examined the use of preoperative MRI at Bellevue Hospital Center (BHC), a public, tertiary hospital in lower Manhattan with a large underserved population. The BHC breast clinic database was used to identify patients who received preoperative MRI for breast cancer between January 2015 and December 2016. MRI was defined as changing surgical management in a positive manner if an MRI-detected abnormality had verification of malignancy in the final surgical specimen, confirming the MRI indication for wider excision or mastectomy, while MRI was defined to change surgical management in a negative manner if final pathology was discordant with MRI. Chi-square test was used to analyze characteristics of those who received MRI versus those who did not. RESULTS:A total of 208 patients underwent breast surgery at BHC, and 62 patients underwent MRI for preoperative planning purposes. There were significant differences between the MRI and no MRI group in terms of ethnicity (P = 0.05), age (P < 0.01), and type of surgery (P = 0.03). 50% of the biopsies performed as a result of MRI were benign. MRI changed surgical management in 35 % of patients, most commonly by converting lumpectomy to mastectomy. Of cases in which MRI changed surgical management, most were positive changes. However, 4 patients underwent surgery and 11 patients underwent biopsy for benign pathology as a result of MRI findings. CONCLUSIONS:MRI requires significant hospital and patient resource utilization. Especially in an underserved population, decision for MRI must be individualized, taking into account the risks and benefits of ordering this test.
PMID: 30527468
ISSN: 1095-8673
CID: 3800632

Contralateral prophylactic mastectomy in an underserved population

Warnack, Elizabeth; Wu, Flora; Dhage, Shubhada; Joseph, Kathie-Ann
PMID: 30600570
ISSN: 1524-4741
CID: 3563392

Factors affecting the treatment of young women with breast cancer at tertiary referral public and private hospitals [Meeting Abstract]

Patel, Ami; Dhage, Shubhada
ISSN: 1055-9965
CID: 3331092

Age disparities in breast cancer management: A multi-institutional study [Meeting Abstract]

Warnack, Elizabeth; Ma, Shaoying; Asumeng, Charles; Wang, Jason; Wang, Wen-Jie; Depaz, Hector; Castaneda, Monti; Hillyer, Grace Clarke; Schmitt, Karen; Dhage, Shubhada
ISSN: 1068-9265
CID: 3156232

Adapting the Breast Cancer Surgery Decision Quality Instrument for Lower Socioeconomic Status: Improving Readability, Acceptability, and Relevance

Durand, Marie-Anne; Song, Julia; Yen, Renata West; Sepucha, Karen; Politi, Mary C; Dhage, Shubhada; Rosenkranz, Kari; Margenthaler, Julie; Tosteson, Anna N A; Crayton, Eloise; Jackson, Sherrill; Bradley, Ann; O'Malley, A James; Volk, Robert J; Ozanne, Elissa; Percac-Lima, Sanja; Acosta, Jocelyn; Mir, Nageen; Scalia, Peter; Ward, Abigail; Elwyn, Glyn
Introduction. Breast cancer is the second most common malignancy in women. The Decision Quality Instrument (DQI) measures the extent to which patients are informed and involved in breast surgery decisions and receive treatment that aligns with their preferences. There are limited data on the performance of the DQI in women of lower socioeconomic status (SES). Our aims were to 1) examine (and if necessary adapt) the readability, usability, and acceptability of the DQI and 2) explore whether it captures factors important to breast cancer surgery decisions among women of lower SES (relevance). Methods. We conducted semistructured cognitive interviews with women of lower SES (based on insurance status, income, and education) who had completed early-stage breast cancer treatments at three cancer centers. We used a two-step thematic analysis with dual independent coding. The study team (including Patient Partners and a Community Advisory Board) reviewed and refined suggested changes. The revised DQI was presented in two focus groups of breast cancer survivors. Results. We conducted 39 interviews. Participants found most parts of the DQI to be helpful and easy to understand. We made the following suggested changes: 1) added a glossary of key terms, 2) added two answer choices and an open text question in the goals and concerns subscale, 3) reworded the treatment intention question, and 4) revised the knowledge subscale instructions since several women disliked the wording and were unsure of what was expected. Discussion. The readability, usability, acceptability, and relevance of a measure that was primarily developed and validated in women of higher SES required adaptation for optimal use by women of lower SES. Further research will test these adaptations in lower SES populations.
PMID: 30515461
ISSN: 2381-4683
CID: 3520312

Surgical registrars' perceptions of surgical training and capacity in Zambia: Results from three COSECSA affiliated training hospitals

Freitas, Derek M; Munthali, James; Musowoya, Joseph; Ismail, Hebah; Herbst, Allyson; Chikoya, Laston; Dhage, Shubhada; Hopkins, Mary Ann
BACKGROUND: Surgery is a vital component of a comprehensive health system, but there are often personnel limitations in resource constrained areas. Zambia provides post graduate surgical training through two systems to help address this shortage. However, no studies have analyzed surgical trainees' perceptions of these programs. METHODS: Surgical registrars at COSECSA affiliated hospitals in Zambia were surveyed about their programs. Responses were analyzed to identify key strengths and challenges across several categories including: operative training, clinical training, educational experiences, and career plans. RESULTS: Registrars report having significant independence and receiving broad and high quality operative training. They note specific challenges including limitations in specialty training, resources, and infrastructure. CONCLUSIONS: Zambian training programs have the potential to increase number of surgeons in Zambia by a significant amount in the coming years. These programs have many strengths but also face challenges in their goal to expand surgical access in the country.
PMID: 28764850
ISSN: 1879-1883
CID: 2655722