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Compliance with Breast Cancer Post-Therapy Surveillance

11/01/2016
Compliance with Breast Cancer Post-Therapy Surveillance

A study measures compliance rates of patients with state and federal safety-net funding

BY MELISSA CARANDANG, MD; WESLEY BABARAN, MD; LAWRENCE WAGMAN, MD; LIANNE NACPIL, MPH, CTR; TIMOTEA LARA, RN, MSN, NP-C; NORMA CASTRO; AND SHANNIN GREENE

IN BRIEF

The multidisciplinary breast cancer clinic at St. Joseph Hospital, Center for Cancer Prevention and Treatment (CCPT), Orange, Calif., was designed with a specific infrastructure to serve women with state and federal safety net funding. In 2011 CCPT initiated a study to measure patient compliance with post-therapy surveillance in this population, conducting a descriptive retrospective chart review on previously diagnosed breast cancer patients seen at the multidisciplinary breast cancer clinic during the two years from 2011 to 2013. Post-therapy surveillance compliance was assessed in three categories: clinic appointments (n=82), annual mammography for patients with one or both breasts intact (n=75), and yearly evaluation for those prescribed anti-hormone therapy (n=61). CCPT compared compliance rates based on patient characteristics: age, stage, distance from the clinic, insurance carrier, race, and ethnicity. Study results found the average per patient combined compliance for all post-therapy surveillance to be 92.5 percent at 12 months, 54.4 percent at 18 months, and 82.4 percent at 60 months. When comparing characteristic groups by test categories, CCPT found no clinically significant patterns or trends; however, overall annual mammogram compliance was consistently higher than both clinic appointment and anti-hormone therapy compliance.

The St. Joseph Hospital, Center for Cancer Prevention and Treatment established its multidisciplinary breast cancer clinic in 2008 as a component of the National Cancer Institute Community Cancer Centers Program (NCCCP) grant. The goal: to serve women with a confirmed breast cancer diagnosis and “safety net” financial status—the patient population for the study discussed in this article.

Clinic components include scheduling, nursing, culturally geared navigation, operating services, breast imaging, electronic health records, translation services, and research (Table 1, page 37). As the breast cancer clinic is staffed by both hospital-employed and private practice multispecialty oncologic physicians, CCPT has developed guidelines for physician participation in the cancer program. Some physicians treat patients in the hospital’s outpatient department and bill under 1206(d) in the Outpatient Prospective Payment System (OPPS), while others see patients in their private physician practice offices and bill for services under the Physician Fee Schedule (PFS).

The CCPT multidisciplinary breast cancer clinic follows National Comprehensive Cancer Network (NCCN) guidelines for breast cancer post-therapy surveillance, including clinic appointments, mammograms, and confirmation of anti-hormone therapy use. During this study period, the standard practice was to advise patients in accordance with NCCN post-therapy surveillance. Note: this analysis precedes the multidisciplinary breast cancer clinic’s consistent distribution of a formal breast-cancer- specific treatment summary survivorship plan, which is currently required by the Commission on Cancer (CoC).

Study Methods
In 2014 CCPT conducted a retrospective, descriptive chart review on 82 previously diagnosed breast cancer patients seen at the multidisciplinary breast cancer clinic between 2011 and 2013. Post therapy surveillance consisted of:

  • Clinic appointments every 4 to 6 months for the first 5 years after treatment.
  • Annual mammograms for the first 5 years after treatment.
  • Annual compliance with recommended anti-hormone therapy use for the first 5 years after treatment.

As is expected in the breast cancer patient population, CCPT believed that primary care providers, in a variety of settings, would potentially assume patients’ long-term cancer surveillance.

Individual patient and test results were tallied and analyzed for compliance. All 82 patients were evaluable for clinic appointment compliance. For annual mammograms, the patients who were included in the study had one or both breasts intact (n=75), while patients with a history of bilateral total mastectomies were excluded. CCPT also assessed the compliance of all patients who had been prescribed anti-hormone therapy (e.g., aromatase inhibitors or tamoxifen); data was collected to document evidence of assessment and adherence at the follow-up appointments (n=61). Patients who were not prescribed anti-hormone therapy were excluded.

CCPT then compared compliance for the three main parameters based on subject characteristics:

  • Age
  • Stage at diagnosis
  • Distance from home to clinic
  • Type of insurance
  • Race
  • Ethnicity

Table 2, page 38, shows the subject characteristics of the study.

Study Results
Overall, during the 5-year study period, the compliance rate for attending scheduled clinic appointments for all 82 patients ranged from 54.3 percent to 96.3 percent. Patient compliance with
mammograms completed for 75 patients ranged from 78.6 percent to 97.3 percent. Finally, compliance with reported anti-hormone therapy use for 61 patients ranged from 62.5 percent to 93.3 percent. CCPT saw a large dropoff in the average per patient combined compliance for the three parameters 18 months post-treatment, but compliance increased and remained consistently higher after 2-years post-treatment (see Figure 1, page 40).

During analysis of the compliance with clinic appointments based on patient age, the average was approximately 70 percent throughout the groups. The average compliance of reported anti-hormone therapy use based on age groups was slightly higher at 81 percent, while mammogram compliance was the highest overall, with averages ranging from about 80 percent to 90 percent.

All patients in the study were newly diagnosed and staged at their initial multidisciplinary breast cancer clinic evaluation. When measuring the compliance with clinic appointment based on stage at diagnosis, the range was large—59.3 percent at Stage 0 to 80.6 percent at Stage III. The compliance with reported anti-hormone use based on stage at diagnosis was slightly higher with a range of 75.1 percent (Stage 0) to 87.5 percent (Stage IV). Mammograms completed showed the highest compliance, ranging from 85.1 percent (Stage II) to 91.7 percent (Stage IV).

As the distance from the clinic increased, the average compliance of all three post-therapy surveillance measurements did show a slight downward trend. For clinic appointments, the compliance was highest for patients who traveled 0.0 to 9.9 miles for treatment (76.6 percent), whereas the patients who traveled more than 20 miles had a slightly lower average (67.6 percent). The compliance with reported anti-hormone therapy use was around 77 percent. Again, mammograms completed were the highest all around, ranging from 81 percent (patients traveling 10 to 19.9 miles) to 93.5 percent (patients traveling 0 to 9.9 miles).

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Categories: Cancer,News