Abstract
Purpose:
This study aimed to evaluate whether comprehensive multidisciplinary care (cMDC) for breast cancer patients affected time from diagnosis to treatment, compliance with appointments and to assess for racial disparities.
Methods:
This institutional review board approved retrospective study included adult patients diagnosed with invasive breast cancer between February 2015 and February 2017 and treated at an academic health system where the cMDC program was implemented in February 2016. The cMDC and non-cMDC groups as well as black and white patients were compared to assess time from diagnosis (date of pathology result indicating invasive breast cancer) to treatment (date of surgery or chemotherapy). Compliance was measured by appointments characterized as “no shows” or “canceled due to personal reasons” in the electronic medical record.
Results:
Of 541 patients (419 cMDC and 122 non-cMDC), mean time from diagnosis to treatment was significantly longer for blacks than whites in the non-cMDC group (46.9 ± 64.6 days vs 28.2 ± 14.8 days, p = 0.024) and the cMDC group (39.9 ± 34.1 days vs 31.4 ± 16.3 days, p = 0.001). Of 38 (7.2%) patients who started treatment > 60 days after diagnosis, 25 (65.8%) were black. Implementation of cMDC significantly improved patient compliance (missed appointments 4.9 ± 7.6 non-cMDC vs 3.2 ± 4.6 cMDC, p = 0.029).
Conclusion:
Use of cMDC for invasive breast cancer at our institution highlighted an area for improvement for care administered to blacks and improved patient compliance with appointments.
Keywords: Multidisciplinary care, Racial disparity, Breast cancer management, Compliance, Standard of care
INTRODUCTION
Care provided for breast cancer patients has evolved to include a multidisciplinary approach.1–4 Multidisciplinary care (MDC) involves representation from all health professionals who contribute to decision-making on management plans.5 Studies assessing adherence to multidisciplinary tumor board recommendations indicate strong adherence and less deviance over time.6 Results on the effect of MDC on patients are mixed. Some studies found no changes in patient mortality or cost of care, while others demonstrated improved quality of life for people with advanced disease.7–11 In lung cancer management, MDC led to decreased time from presentation to initiation of treatment.12,13 More favorable outcomes are associated with shorter times to diagnosis and treatment.14 To make recommendations, various cancer providers must evaluate and assess each patient, which increases the number of visits required per patient. Formation of MDC teams has led to fewer provider visits and decreased resources used to diagnose and stage cancer.12,13 Unfortunately, challenges still exist in the management of breast cancer patients, including addressing disparities based on race and socioeconomic status.15,16 Limited data exist on the effect of multidisciplinary tumor board recommendations on patient compliance in breast cancer management.
Our academic health system implemented a comprehensive multidisciplinary care (cMDC) program for invasive breast cancer in February 2016. The program involves two sites, one urban and one suburban, with tumor board discussion held weekly on different days by site, and scheduling patients to see each provider recommended by the tumor board on the same day that their case is discussed. This study aimed to evaluate whether cMDC for breast cancer patients affected time from diagnosis to treatment, compliance with appointments and to assess for racial disparities.
MATERIALS AND METHODS
This retrospective study included patients, 18 and older, diagnosed with invasive breast cancer and treated between February 2015 and February 2017 at our institution’s suburban and urban sites. The cMDC program was implemented in February 2016, thus patients diagnosed with invasive breast cancer after its implementation were assigned to the cMDC group and patients diagnosed prior to its implementation were assigned to the non-cMDC group. Exclusion criteria included patients treated at outside institutions or other satellite sites within the health system, and those with metastatic and noninvasive disease. The study was approved by the health system’s institutional review board.
Patients were also subcategorized by race/ethnicity. The primary outcome, time of diagnosis to treatment, was compared across both groups. Time of diagnosis was defined as the date of the pathology result indicating invasive breast cancer, and time of treatment was defined as the date of an initial surgical procedure or chemotherapy infusion. The secondary outcome, patient compliance, was measured by missed appointments using the proxy of the number of appointments characterized as “no shows” or “canceled due to personal reasons” in the electronic medical record.
Statistical analysis
To attain a two-sided power of 80% allowing for a 5% type 1 error rate, a minimum sample size of 163 patients was calculated for this study. Group comparisons were made using chi-square tests for the non-sparse categorical data, Fisher’s exact test for the sparse categorical data, and Wilcoxon signed rank test for the non-normally distributed numerical data. Analyses used SPSS Statistics (IBM, Armonk, NY) with significance set at p < 0.05.
RESULTS
Of the 541 patients who met inclusion criteria, the cMDC group included 419 patients and the non-cMDC group included 122 patients. Overall, 242 patients were treated at the suburban site and 299 patients at the urban site. Average age was 61 years old. Race was self-reported by 540 patients: 280 white, 233 black, 18 Asian, 6 Hispanic, 1 Middle Eastern, and 2 “other.” Race analyses included only white and black patients.
Time from diagnosis to treatment
The mean time from diagnosis to treatment for cMDC vs non-cMDC groups was not significantly different (34.7 ± 25.6 days vs 36.7 ± 46.4 days, respectively; p = 0.130) (Table 1). When analyzing by race, the mean time from diagnosis to treatment was significantly longer for blacks than whites in both groups: non-cMDC group was 46.9 ± 64.6 days vs 28.2 ± 14.8 days (p = 0.024; Table 2) and cMDC group was 39.9 ± 34.1 days vs 31.4 ± 16.3 days (p = 0.001; Table 3). No significant difference in mean time to treatment was found when assessing only white patients across both groups (Table 4) or only black patients (Table 5) across both groups.
Table 1.
Patient demographics and characteristics.
| All Study Patients | ||
|---|---|---|
| Age, years (mean ± SD) | 61.7 ± 13.3 | |
|
| ||
| Number of live births (mean ± SD) | 2.2 ± 1.6 | |
|
| ||
| Insurance | Public | 183 (34.0%) |
| Private | 356 (66.0%) | |
|
| ||
| Family history of cancer | No | 282 (52.3%) |
| Yes | 257 (47.7%) | |
|
| ||
| Group (n = 541) | Non-cMDC | 122 (22.6%) |
| cMDC | 419 (77.4%) | |
|
| ||
| Race (n = 512) | White | 280 (54.6%) |
| Black | 232 (42.9%) | |
|
| ||
| Diagnosis to initial treatment (n = 526) | ≤30 days | 270 (51.3%) |
| 31–60 days | 218 (41.4%) | |
| >60 days | 38 (7.2%) | |
|
| ||
| Diagnosis to initial treatment (n = 526) | ≤30 days | 270 (51.3%) |
| >30 days | 256 (48.7%) | |
|
| ||
| Diagnosis to initial treatment (n = 526) | ≤60 days | 488 (92.8%) |
| >60 days | 38 (7.2%) | |
|
| ||
| Diagnosis to initial treatment, days (mean ± SD) | 35.1 ± 31.4 | |
| Median | 30.0 | |
|
| ||
| Number of missed/cancelled appointments (mean ± SD) | 3.6 ± 5.5 | |
| Median | 2.0 | |
SD, standard deviation; cMDC, comprehensive multidisciplinary care.
Race status is known for 540 of 541 patients; 27 patients not included in analyses self-reported as Asian (18), Hispanic (6), Middle Eastern (1), and “other” (2). Days from diagnosis to initial treatment known for 526 patients; the other 16 did not pursue that form of treatment following diagnosis.
Table 2.
Non-cMDC group race comparisons.
| Race | ||||
|---|---|---|---|---|
| Whites | Blacks | p-value | ||
| Diagnosis to initial treatment | ≤30 days | 37 (63.8%) | 28 (50.0%) | 0.034 (F)a |
| 31–60 days | 20 (34.5%) | 20 (35.7%) | ||
| >60 days | 1 (1.7%) | 8 (14.3%) | ||
| n = 58 | n = 56 | |||
|
| ||||
| Diagnosis to initial treatment | ≤30 days | 37 (63.8%) | 28 (50.0%) | 0.137 (C) |
| >30 days | 21 (36.2%) | 28 (50.0%) | ||
| n = 58 | n = 56 | |||
|
| ||||
| Diagnosis to initial treatment | ≤60 da ys | 57 (98.3%) | 48 (85.7%) | 0.016 (F)a |
| >60 da ys | 1 (1.7%) | 8 (14.3%) | ||
| n = 58 | n = 56 | |||
|
| ||||
| Diagnosis to initial treatment, days (mean ± SD) | 28.2 ± 14.8 | 46.9 ± 64.6 | 0.024 (W)a | |
| Median | 26.5 | 31.5 | ||
|
| ||||
| Missed/cancelled appointments (mean ± SD) | 4.2 ± 5.5 | 5.4 ± 9.1 | 0.993 (W) | |
| Median | 2.5 | 2.0 | ||
C, chi-square test; F, Fisher’s exact test; SD, standard deviation; W, Wilcoxon rank sum test.
2 Black patients did not pursue treatment
Statistically significant, p < 0.05.
Table 3.
cMDC group race comparisons.
| Race | ||||
|---|---|---|---|---|
| Whites | Blacks | p-value | ||
| Diagnosis to initial treatment | ≤30 days | 114 (53.5%) | 71 (41.8%) | 0.044 Ia |
| 31–60 days | 87 (40.8%) | 82 (48.2%) | ||
| >60 days | 12 (5.6%) | 17 (10.0%) | ||
| n = 213 | n = 170 | |||
|
| ||||
| Diagnosis to initial treatment | ≤30 days | 114 (53.5%) | 71 (41.8%) | 0.022 (C)a |
| >30 days | 99 (46.5%) | 99 (58.2%) | ||
| n = 213 | n = 170 | |||
|
| ||||
| Diagnosis to initial treatment | ≤60 days | 201 (94.4%) | 153 (90.0%) | 0.109 (C) |
| >60 days | 12 (.6%) | 17 (10.0%) | ||
| n = 213 | n = 170 | |||
|
| ||||
| Diagnosis to initial treatment, days (mean ± SD) | 31.4 ± 16.3 | 39.9 ± 34.1 | 0.001 (W)a | |
| Median | 30.0 | 33.0 | ||
|
| ||||
| Missed/cancelled appointments (mean ± SD) | 2.7 ± 4.8 | 3.9 ± 4.6 | <0.001 (W)a | |
| Median | 2.0 | 2.5 | ||
C, chi-square test; cMDC, comprehensive multidisciplinary care; SD, standard deviation; W, Wilcoxon rank sum test.
Statistically significant, p < 0.05.
Table 4.
Non-cMDC versus cMDC group comparisons for whites only.
| White Non-cMDC | White cMDC | p-value | ||
|---|---|---|---|---|
| Diagnosis to initial treatment | ≤30 days | 37 (63.8%) | 114 (53.5%) | 0.249 (C) |
| 31–60 days | 20 (34.5%) | 87 (40.8%) | ||
| >60 days | 1 (1.7%) | 12 (5.6%) | ||
| n = 58 | n = 213 | |||
|
| ||||
| Diagnosis to initial treatment | ≤30 days | 37 (63.8%) | 114 (53.5%) | 0.163 (C) |
| >30 days | 21 (36.2%) | 99 (46.5%) | ||
| n = 58 | n = 213 | |||
|
| ||||
| Diagnosis to initial treatment | ≤60 days | 57 (98.3%) | 201 (94.4%) | 0.311 (F) |
| >60 days | 1 (1.7%) | 12 (5.6%) | ||
| n = 58 | n = 213 | |||
|
| ||||
| Diagnosis to initial treatment, days (mean ± SD) | 28.2 ± 14.8 | 31.4 ± 16.3 | 0.129 (W) | |
| Median | 26.5 | 30.0 | ||
|
| ||||
| Missed/cancelled appointments (mean ± SD) | 4.2 ± 5.5 | 2.7 ± 4.8 | 0.010 (W)a | |
| Median | 2.5 | 2.0 | ||
C, chi-square test; F, Fisher’s exact test; cMDC, comprehensive multidisciplinary care; SD, standard deviation; W, Wilcoxon rank sum test.
Statistically significant, p < 0.05.
Table 5.
Non-cMDC versus cMDC group comparisons for blacks only.
| Black Non-cMDC | Black cMDC | p-value | ||
|---|---|---|---|---|
| Diagnosis to initial treatment | ≤30 days | 28 (50.0%) | 71 (41.8%) | 0.245 (C) |
| 31–60 days | 20 (35.7%) | 82 (48.2%) | ||
| >60 days | 8 (14.3%) | 17 (10.0%) | ||
| n = 56 | n = 170 | |||
|
| ||||
| Diagnosis to initial treatment | ≤30 days | 28 (50.0%) | 71 (41.8%) | 0.281 (C) |
| >30 days | 28 (50.0%) | 99 (58.2%) | ||
| n = 56 | n = 170 | |||
|
| ||||
| Diagnosis to initial treatment | ≤60 days | 48 (85.7%) | 153 (90.0%) | 0.375 (C) |
| >60 days | 8 (14.3%) | 17 (10.0%) | ||
| n = 56 | n = 170 | |||
|
| ||||
| Diagnosis to initial treatment, days (mean ± SD) | 46.9 ± 64.6 | 39.9 ± 34.1 | 0.602 (W) | |
| Median | 31.5 | 33.0 | ||
|
| ||||
| Missed/cancelled appointments (mean ± SD) | 5.4 ± 9.1 | 3.9 ± 4.6 | 0.918 (W) | |
| Median | 2.0 | 2.5 | ||
C, chi-square test; cMDC, comprehensive multidisciplinary care; SD, standard deviation; W, Wilcoxon rank sum test.
When categorizing time from diagnosis to treatment as ≤ 60 days or >60 days, 488 patients (92.8%) started treatment within 60 days compared to 38 (7.2%) who started treatment after 60 days from diagnosis (Table 6). Of those 38 patients, 25 (65.8%) were black.
Table 6.
Group comparisons for all patients.
| Group | ||||
|---|---|---|---|---|
| Non-cMDC | cMDC | p-value | ||
| Race | White | 58 (50.0%) | 222 (56.1%) | 0.249 (C) |
| Black | 58 (50.0%) | 174 (43.9%) | ||
| n = 110 | n = 396 | |||
|
| ||||
| Diagnosis to initial treatment | ≤30 days | 69 (58.0%) | 200 (49.3%) | 0.198 (C) |
| 31–60 days | 41 (34.5%) | 177 (43.6%) | ||
| >60 days | 9 (7.6%) | 29 (7.1%) | ||
| n = 119 | n = 406 | |||
|
| ||||
| Diagnosis to initial treatment | ≤30 days | 69 (58.0%) | 200 (49.3%) | 0.094 (C) |
| >30 days | 50 (42.0%) | 206 (50.7%) | ||
| n = 119 | n = 406 | |||
|
| ||||
| Diagnosis to initial treatment | ≤60 days | 110 (92.4%) | 377 (92.9%) | 0.876 (C) |
| >60 days | 9 (7.6%) | 29 (7.1%) | ||
| n = 119 | n = 406 | |||
|
| ||||
| Diagnosis to initial treatment, days (mean ± SD) | 36.7 ± 46.4 | 34.7 ± 25.6 | 0.130 (W) | |
| Median | 28.0 | 31.0 | ||
|
| ||||
| Missed/cancelled appointments (mean ± SD) | 4.9 ± 7.6 | 3.2 ± 4.6 | 0.029 (W)a | |
| Median | 2.0 | 2.0 | ||
C, chi-square test; cMDC, comprehensive multidisciplinary care; SD, standard deviation; W, Wilcoxon rank sum test.
Statistically significant, p < 0.05.
In the non-cMDC group, there were significantly more white patients treated ≤60 days (57 [98.3%]) than black patients (48 [85.7%]), and significantly more black patients were treated > 60 days (white 1 [1.7%] vs black 8 [14.3%]) (p = 0.016; Table 2). This difference was no longer noted in the cMDC group.
Missed appointments/compliance
Using the mean number of missed appointments, patient compliance significantly improved after implementation of cMDC (3.2 ± 4.6 vs non-cMDC 4.9 ± 7.6, p = 0.029; Table 2). For the cMDC group, white patients missed significantly less appointments than black patients (2.7 ± 4.8 vs 3.9 ± 4.6, p = 0.001; Table 3) whereas no difference was found between the races in missed appointments in the non-cMDC group. When comparing each race separately, white patients missed significantly less appointments in the cMDC group (2.7 ± 4.8 vs non-cMDC 4.2 ± 5.5, p = 0.010; Table 4) but no significant change was noted for black patients (non-cMDC 5.4 ± 9.1 vs cMDC 3.9 ± 4.6, p = 0.918) (Table 4).
DISCUSSION
This retrospective review of over 500 patients who received breast cancer care before and after implementation of a cMDC program found no statistically significant improvement in time from diagnosis to treatment associated with cMDC. Although there is no exact recommended time from diagnosis to initial treatment, research has demonstrated that treatment initiated within 60 days of diagnosis is associated with better prognosis.14,17 The majority of our patients received treatment within 60 days before (92.4%) and after (92.9%) implementation of cMDC. The variance of the cMDC group was less than that of the non-cMDC group, indicating that distribution of the time frame to start treatment was much narrower following implementation of cMDC. This may indicate a more uniform approach to management of breast cancer patients with cMDC.
Racial disparities have been noted in the management of breast cancer.16 Of our 38 patients who started treatment >60 days after diagnosis, the majority were black. While implementation of cMDC showed a 4.3% decrease for black patients with >60 days time to treatment, this improvement was not statistically significant. Black patients in both the non-cMDC and cMDC groups showed significantly longer times from diagnosis to treatment than whites. The gap in time to treatment between the races shortened with implementation of cMDC (18.7 days–8.5 days), but this improvement was not significant (two-way analysis of variance, p = 0.371). Therefore, although the difference across races moved from a clinically significant time frame of diagnosis to treatment of >60 days, to a non-clinically significant timeframe of >30 days in the cMDC group, these findings highlight an opportunity to improve our cMDC program.
While black patients missed more appointments than white patients after implementation of cMDC, our study did not assess whether the first appointments for treatment were missed, affecting time to treatment, or why appointments were missed. Further studies are needed to assess the barriers that contribute to the delay to treatment found among black patients.
Use of a multidisciplinary cancer care program has been associated with better clinical outcomes with evidence of improved survival among breast cancer patients.18 The impact of MDC on patient compliance in cancer management has not been widely studied. Evidence shows that a multidisciplinary team improves patient compliance in the management of other chronic diseases such as diabetes.19–21 Like ours, most multidisciplinary teams involve nurses or mid-level providers who telephone patients to ensure appropriate follow-up. Based on the number of missed/cancelled appointments in our study, overall patient compliance improved significantly following cMDC implementation.
A surprising finding in regards to patient compliance was that no racial differences occurred in missed appointments before implementation of cMDC, only after. Why the cMDC approach might affect missed or cancelled appointments for black patients requires study to identify barriers to overcome.
Strengths of the study include adequate sample size to assess for significant differences. Weaknesses include not further analyzing if the missed appointments were sporadic or occurring in clusters as well as if it was the first appointment to initiate treatment. Missed/cancelled appointments may be overestimated because if the patient rescheduled and subsequently attended the rescheduled visit, then that action does not imply noncompliance.
CONCLUSION
This single-institution study demonstrated that implementation of cMDC for patients with invasive breast cancer did not affect time from diagnosis to treatment but significantly improved patient compliance overall. Our findings showed racial disparity with blacks having longer times from diagnosis to treatment and more missed or cancelled appointments than whites. Further studies are needed to assess factors contributing to the racial disparity and strategies to alleviate them.
IMPLICATIONS
Multidisciplinary care programs do improve clinical outcomes and this study demonstrated it improves compliance as well. It did not overcome racial disparities observed in the time from treatment to diagnosis; further investigation of the barriers that exist is needed in order to propose strategies to alleviate them.
Acknowledgments:
The authors would like to thank Lindsey Petersen, MD, Myah Bell, MD, Vini Chopra, MD, and Lisa Newman, MD, for support in formulating and collecting data for this project as well as Gordon Jacobsen, MS, for statistical support.
Abbreviations:
- cMDC
comprehensive multidisciplinary care
- MDC
multidisciplinary care
Footnotes
FINANCIAL DISCLOSURE
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CONFLICT OF INTEREST STATEMENT
No competing financial interests exist.
Contributor Information
Samfee Doe, Department of Women’s Health Services, Breast Surgical Oncology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
Shariska Petersen, Department of Women’s Health Services, Breast Surgical Oncology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
Thomas Buekers, Department of Women’s Health Services, Breast Surgical Oncology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
Monique Swain, Department of Women’s Health Services, Breast Surgical Oncology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA; Department of General Surgery, Breast Surgical Oncology, Henry Ford Hospital, 2799 W. Grand Blvd, Detroit, MI, 48202, USA
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