Faculty Bibliography

Advances in breast cancer screening and systemic therapies have been credited with profound improvements in breast cancer outcomes; indeed, 5-year relative survival rate approaches 91% in the USA (U.S. National Institutes of Health NCI. SEER Training Modules, Breast). While breast cancer mortality has been declining, oncologic outcomes have not improved equally among all races and ethnicities. Many factors have been implicated in breast cancer disparities; chief among them is limited access to care which contributes to lower rates of timely screening mammography and, once diagnosed with breast cancer, lower rates of receipt of guideline concordant care (Wu, Lund, Kimmick GG et al. in J Clin Oncol 30(2):142-150, 2012). Hospitals with a safety-net mission, such as the essential hospitals, historically have been dedicated to providing high-quality care to all populations and have eagerly embraced the role of caring for the most vulnerable and working to eliminate health disparities. In this article, we review landmark articles that have evaluated the role safety-net hospitals have played in providing equitable breast cancer care including to those patients who face significant social and economic challenges.

INTRODUCTION: The pulmonary embolism severity index (PESI) score is a well-known and validated clinical tool, utilized to predict 30-day mortality in patients with pulmonary embolism (PE). It is used to identify low-risk individuals (PESI < =85) who can be safely started on novel oral anticoagulation agents (NOAC) and discharged from the Emergency Department (ED). After calculating the PESI score in all patients admitted for PE within a 3-year period at a community hospital, this study first estimated the fraction of low-risk patients who ended up getting admitted. Additionally, this study compared the prevalence of right heart strain (RHS), incidence of bleeding events, and mortality rates between the low-risk and high-risk (PESI >85) cohorts.
METHOD(S): This study is a retrospective chart review of patients admitted with a primary diagnosis of PE to Mercy Fitzgerald Hospital from January 2018 to March 2021. The Fisher test was used to compare odds ratios (OR) of RHS on initial CT angiogram of the chest, bleeding events after initiation of the anticoagulation (drop in hemoglobin > 2 g/dL, positive hemoccult status, episodes of overt bleeding), and death rates between low-risk and high-risk groups. PRISM statistical software was used for statistical analysis.
RESULT(S): 211 patients were included in this study. 102 (48.3%) patients were categorized as low-risk and 109 (51.7%) as high-risk. RHS was present in 16 patients of the low-risk group (2 of which had saddle PE) versus 41 in the high-risk group (OR 0.39, CI [0.2-0.76], p 0.005). Bleeding after initiation of anticoagulation was observed in 2 patients in the low-risk versus 5 patients in the high-risk group (OR 0.42, CI [0.08-2], p 0.45). None of the patients in the low-risk group died during the admission compared to 6 patients from the high-risk group (OR non reported, CI [0-0.74], p 0.03).
CONCLUSION(S): When factoring in patients with RHS on initial imaging, 40.7% of the patients hospitalized for PE potentially could have been discharged safely for outpatient management based on this study. The patients who were identified as high risk had a higher occurrence of RHS and had significantly higher mortality compared to the low-risk group. The rate of bleeding events after initiation of anticoagulation among both groups was not statistically different

PURPOSE/UNASSIGNED:The recruitment of underserved patients into therapeutic oncology trials is imperative. The National Institutes of Health mandates the inclusion of minorities in clinical research, although their participation remains under-represented. Institutions have used data mining to match patients to clinical trials. In a public health care system, such expensive tools are unavailable. METHODS/UNASSIGNED:The NYU Clinical Trials Office implemented a quality improvement program at Bellevue Hospital Cancer Center to increase therapeutic trial enrollment. Patients are screened through the electronic medical record, tumor board conferences, and the cancer registry. Our analysis evaluated two variables: number of patients identified and those enrolled into clinical trials. RESULTS/UNASSIGNED:Two years before the program, there were 31 patients enrolled. For a period of 24 months (July 2017 to July 2019), we identified 255 patients, of whom 143 (56.1%) were enrolled. Of those enrolled, 121 (84.6%) received treatment, and 22 (15%) were screen failures. Fifty-five (38.5%) were referred to NYU Perlmutter Cancer Center for therapy. Of the total enrollees, 64% were female, 56% were non-White, and overall median age was 55 years (range: 33-88 years). Our participants spoke 16 different languages, and 57% were non-English-speaking. We enrolled patients into eight different disease categories, with 38% recruited to breast cancer trials. Eighty-three percent of our patients reside in low-income areas, with 62% in both low-income and Health Professional Shortage Areas. CONCLUSION/UNASSIGNED:Prescreening at Bellevue has led to a 4.6-fold increase in patient enrollment to clinical trials. Future research into using prescreening programs at public institutions may improve access to clinical trials for underserved populations.

OBJECTIVE:To determine the role of race and gender in the career experience of Black/AA academic surgeons and to quantify the prevalence of experience with racial and gender bias stratified by gender. SUMMARY OF BACKGROUND DATA/BACKGROUND:Compared to their male counterparts, Black/African American (AA) women remain significantly underrepresented among senior surgical faculty and department leadership. The impact of racial and gender bias on the academic and professional trajectory of Black/AA women surgeons has not been well-studied. METHODS:A cross-sectional survey regarding demographics, employment, and perceived barriers to career advancement was distributed via email to faculty surgeon members of the Society of Black American Surgeons (SBAS) in September 2019. RESULTS:Of 181 faculty members, 53 responded (29%), including 31 women (58%) and 22 men (42%). Academic positions as a first job were common (men 95% vs women 77%, p = 0.06). Men were more likely to attain the rank of full professor (men 45% vs women 7%, p = 0.01). Reports of racial bias in the workplace were similar (women 84% vs men 86%, NS); however, reports of gender bias (women 97% vs men 27%, p < 0.001) and perception of salary inequities (women 89% vs 63%, p = 0.02) were more common among women. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Despite efforts to increase diversity, high rates of racial bias persist in the workplace. Black/AA women also report experiencing a high rate of gender bias and challenges in academic promotion.

Global disparities in breast cancer care become particularly evident when patients seek definitive care in the United States (USA) after receiving a breast cancer diagnosis and initiating care in low- and middle-income countries (LMICs). We performed a retrospective review of 26 patients with breast cancer who immigrated from LMICs and received care at Bellevue Hospital. Fifteen (58%) presented with advanced disease (stage III or IV), including 7 (27%). All 26 patients required diagnostic work-up in the USA, and all 19 (73.1%) patients with stage 0-III disease underwent surgical excision. Patients from LMICs frequently present with advanced disease and in varying stages of breast cancer treatment. Improving communication with previous providers and fostering a collaborative approach with the international community are essential to developing efficacious treatment plans and improving oncologic outcomes.

OBJECTIVE:To determine the representation of Black/AA women surgeons in academic medicine among U.S. medical school faculty and to assess the number of NIH grants awarded to Black/AA women surgeon-scientists over the past 2 decades. SUMMARY OF BACKGROUND DATA/BACKGROUND:Despite increasing ethnic/racial and sex diversity in U.S. medical schools and residencies, Black/AA women have historically been underrepresented in academic surgery. METHODS:A retrospective review of the Association of American Medical Colleges 2017 Faculty Roster was performed and the number of grants awarded to surgeons from the NIH (1998-2017) was obtained. Data from the Association of American Medical Colleges included the total number of medical school surgery faculty, academic rank, tenure status, and department Chair roles. Descriptive statistics were performed. RESULTS:Of the 15,671 U.S. medical school surgical faculty, 123 (0.79%) were Black/AA women surgeons with only 11 (0.54%) being tenured faculty. When stratified by academic rank, 15 (12%) Black/AA women surgeons were instructors, 73 (59%) were assistant professors, 19 (15%) were associate professors, and 10 (8%) were full professors of surgery. Of the 372 U.S. department Chairs of surgery, none were Black/AA women. Of the 9139 NIH grants awarded to academic surgeons from 1998 and 2017, 31 (0.34%) grants were awarded to fewer than 12 Black/AA women surgeons. CONCLUSION/CONCLUSIONS:A significant disparity in the number of Black/AA women in academic surgery exists with few attaining promotion to the rank of professor with tenure and none ascending to the role of department Chair of surgery. Identifying and removing structural barriers to promotion, NIH grant funding, and academic advancement of Black/AA women as leaders and surgeon-scientists is needed.

BACKGROUND:Breast reconstruction can help restore the shape and appearance of breasts after surgery. Studies have shown that minority and uninsured patients are less likely to receive breast reconstruction after mastectomy. OBJECTIVE:We sought to determine if post-mastectomy reconstruction varied by patient ethnicity and insurance status in a medically underserved population. METHODS:This was a retrospective study of mastectomy patients seen at Bellevue Hospital Center, a safety-net hospital in New York City, between January 2010 and December 2015. The Chi square test was used to compare patient characteristics versus type of reconstruction chosen and likelihood of reconstruction. Logistic regression was used to examine likelihood of reconstruction, controlling for patient insurance status, race, age, stage at presentation, and contralateral prophylactic mastectomy. RESULTS:Of the 750 patients included in the database, 220 underwent mastectomy. Overall, 73.6% of our patient population received breast reconstruction. Patients with Medicare insurance were less likely to get reconstruction compared with patients with other types of insurance (37.5%, p = 0.04). Hispanic patients were most likely to receive reconstruction (89.1%), followed by Black patients (80%) and Asian patients (66.7%) [p = 0.03]. There were no significant associations between patient race or stage at presentation and type of reconstruction. In a multivariate logistic regression, advancing age was associated with a decreased likelihood of reconstruction (adjusted odds ratio 0.91, p < 0.001). CONCLUSIONS:In our underserved patient population, patients received breast reconstruction at rates higher than the national average. Institutional availability of patient navigators and preoperative counseling may contribute to more equal access to breast reconstruction.