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Background: Emergency department (ED) overuse is a large contributor to healthcare spending in the USA. We examined the rate of and risk factors for ED visits following outpatient breast cancer surgery., Patients and Methods: Using linked data from the Surveillance, Epidemiology, and End Results (SEER) program and Medicare, we identified women who underwent curative breast cancer surgery between 2003 and 2015. Our outcome of interest was ED visits within 30 days of surgery. Multivariate regression was used to evaluate the odds of ED visit while controlling for clinical and socioeconomic variables. Secondary analyses assessed admission from the ED as well as costs., Results: Of the 78,060 included patients, 5.1% returned to the ED, of which only 29.8% required hospital admission. Rate of ED visits increased with patient age. A higher percentage of Black patients returned to the ED compared with white patients (7.0% versus 5.0%, p < 0.001). Patients with higher income were less likely to visit the ED compared with those with lower income (OR 0.76, p < 0.001). Predictors of ED visits included: being unmarried (OR 1.18, p < 0.001), having stage 2 (OR 1.20, p < 0.001) or stage 3 cancer (OR 1.38, p < 0.001), and those with Charlson comorbidity score of 1 (OR 1.39, p < 0.001) or ≥ 2 (OR 2.29, p < 0.001)., Conclusion: While a substantial number of patients return to the ED following outpatient breast surgery, most do not require hospital admission, which indicates that a large proportion of these visits could have been avoided. We identified several clinical and socioeconomic predictors of postoperative ED visits, which will aid in the development of patient risk profiling tools., (© 2022. Society of Surgical Oncology.)

Background: Tamoxifen and aromatase inhibitors (AIs) are used as adjuvant hormonal therapy (AHT) for early-stage hormone receptor-positive (HR+) breast cancer. Treatment for 5 years reduces cancer mortality by 30%. Despite this benefit, adherence to AHT has been suboptimal. Here, we evaluated AHT initiation and patient adherence in women with private health insurance., Materials and Methods: Female patients with breast cancer ≥ 18 years of age who underwent mastectomy or lumpectomy between 1999 and 2015 were identified in the IBM MarketScan Research Database. AHT initiation and adherence rates were estimated for all AHT users regardless of HR+ status. Initiation rates were standardized using HR+ breast cancer incidence rates in the Surveillance, Epidemiology, and End Results (SEER) program. Adherence was defined as medication possession ratio ≥ 80%. Risk ratios, odds ratios, and their 95% CIs were calculated for factors associated with patients' initiation and adherence., Results: Among 80,224 patients, the raw initiation rate was 71.8% and the standardized rate was 87.5%. We found 61.2% patients initiated treatment with AIs and 38.8% with tamoxifen. Patients' 1-year adherence rate was 84.4% and the 5-year rate was 65.2%. Prescription by mail-in order, using a single AHT regimen, 50 to 69 years of age, monthly out-of-pocket drug payment ≤ $11, in US dollars, no depression, no comorbidity, living in the Northeast, treatment in recent years, and receipt of a combination of chemotherapy, radiation, and surgery were associated with better adherence., Conclusion: Five-year AHT adherence rates are low among female patients with breast cancer with private health insurance. Effective approaches to improve AHT adherence are needed., Competing Interests: Mariana Chavez-MacGregorEmployment: MD Anderson Physician’s NetworkHonoraria: Pfizer, EisaiConsulting or Advisory Role: Roche/Genentech, AstraZeneca, Novartis, Pfizer, Asofar, Genomic HealthResearch Funding: NovartisExpert Testimony: Abbott Laboratories, PfizerTravel, Accommodations, Expenses: PfizerNo other potential conflicts of interest were reported.

Background: There is limited literature on patterns of everolimus use and subsequent hospitalizations and emergency room (ER) visits in real-world clinical practice. In this study, we describe patterns of everolimus use and hospitalizations and ER visits in a large cohort of patients with breast cancer (BC)., Materials and Methods: Patients with BC treated with everolimus were identified in the MarketScan database from 2009 to 2016. The pattern of everolimus use and frequency of associated ER visits and hospitalizations during treatment (between the first claim and 30 days after the last claim for everolimus) were identified. Descriptive statistics and regression models were used., Results: A total of 3,556 everolimus users were identified (median age of 60 years; median days of use, 112). The initial prescribed dose was 10 mg in 74.8% of the patients. Compared with the initial dose, 23.5% of patients had a dose change. Forty-six percent of patients were hospitalized or had an ER visit during the treatment with everolimus. Age greater than 71, higher comorbidity score, treatment year prior to 2012, and lower initial dose were found to be significantly associated with ER visit/hospitalization in the regression models., Conclusions: A significant proportion of patients receiving everolimus had an ER visit or hospitalization during the use of everolimus. These results provide data regarding risks and benefits of treatment with everolimus. These results will be helpful in identifying patients at higher risk of hospitalizations or ER visits and facilitate evidence-based decision making to avoid serious complications., Implications for Practice: Everolimus, a mammalian target of rapamycin inhibitor, is approved in combination with exemestane in patients with hormone receptor-positive tumors previously treated with anastrozole or letrozole. As new drugs become available, it is crucial to understand the adverse events and potential complications associated with the use of such drugs in the general population, outside of the controlled clinical trial setting. This study describes the patterns of everolimus use and adverse events, including hospitalization and emergency room visits, in a large cohort of patients with metastatic breast cancer in routine practice., (© AlphaMed Press 2020.)

Background: Rates of anthracycline adherence in breast cancer (BC) patients are unknown, but noncompletion of chemotherapy is associated with worse outcomes., Methods: Using the Surveillance, Epidemiology, and End Results-Medicare database, we obtained demographics, comorbidities, tumor characteristics, and treatment and hospitalization data from stage I-III BC patients diagnosed at age ≥66 years in 1996-2005 treated with surgery who had anthracycline claims. We compared variables between patients with claims for less than four cycles, considered nonadherent cases, and those with claims for four or more cycles using logistic regression analyses., Results: The sample included 7,399 patients, of whom 1,222 (16.5%) were nonadherent cases. Two hundred forty-three (3.3%) patients had one claim, 298 (4.0%) had two claims, and 681 (9.2%) had three claims. The multivariate regression model showed statistically significant associations between nonadherence and older age, black race, unmarried status, diagnosis before the year 2001, and hospitalizations., Conclusions: Eighty-three percent of older patients with early-stage BC completed at least four cycles of an anthracycline-based chemotherapy regimen. We identified a subset of patients with a higher likelihood of not adhering to the course of treatment. Further research is warranted to develop interventions to enhance adherence.

Background: For patients with Stage II breast cancer with one to three positive lymph nodes, controversy exists about whether radiation as a component of treatment provides a survival benefit., Methods and Materials: We analyzed data from patients with Stage II breast cancer with one to three positive lymph nodes diagnosed from 1988-2002 in the Surveillance, Epidemiology, and End Results registry and compared the outcome of 12,693 patients treated with breast-conservation therapy with radiation (BCT + XRT) with the 18,902 patients treated with mastectomy without radiation (MRM w/o XRT)., Results: Patients treated with BCT + XRT were younger, were more likely to be treated in recent years of the study period, more commonly had T1 primary tumors, and had fewer involved nodes compared with those treated with MRM w/o XRT (p < 0.001 for all differences). The 15-year breast cancer-specific survival rate for the BCT + XRT group was 80% vs. 72% for the MRM w/o XRT group (p < 0.001). Cox regression analysis showed that MRM w/o XRT was associated with a hazard ratio for breast cancer death of 1.19 (p < 0.001) and for overall death of 1.25 (p < 0.001). The survival benefit in the BCT + XRT group was not limited to subgroups with high-risk disease features., Conclusions: Radiation use was independently associated with improved survival for patients with Stage II breast cancer with one to three positive lymph nodes. Because multivariate analyses of retrospective data cannot account for all potential biases, these data require confirmation in randomized clinical trials., Competing Interests: Notification: No relationships to disclose

Background: Optimal treatment for breast cancer often involves lengthy multimodality care including 5 to 6 weeks of radiotherapy, but few studies have evaluated adherence to radiotherapy outside the context of a therapeutic clinical trial., Methods: Using a SEER-Medicare database, the authors identified women age 66 years or older with Stage I to III breast cancer diagnosed between 1992 and 2002. They evaluated rates of completion of radiotherapy, defined as a minimum of 25 sessions. Multivariate logistic regression analyses were performed to determine factors associated with completion of radiotherapy, and Cox multivariate models were used to determine the impact of radiotherapy completion on local recurrence., Results: Some 24,510 patients were included in the study. Eighty-seven percent of patients completed 25 or more radiotherapy sessions. In multivariate logistic regression models, mastectomy (HR 1.26, 95% CI 1.10-1.43), hospitalization during treatment (2.87, 2.49-3.31), earlier year of diagnosis, and black race (1.36, 1.14-1.63) were associated with increased risk of non-completion of radiotherapy. Among 21,269 patients treated with breast conservation, incomplete radiotherapy was associated with higher risk of local recurrence. A total of 96.6% [corrected] of patients who did not complete radiation therapy were free of recurrence at 5 years vs. 97.5% of patients who completed radiation therapy (HR 1.46, CI 1.09-1.95)., Conclusion: This study demonstrates relatively high rates of completion of radiation therapy among a population of older woman with breast cancer. However, those who did not complete a full course of radiotherapy had small but statistically significant higher risk of breast cancer recurrence. Future efforts should focus on intervening with women at high risk of not receiving adjuvant radiotherapy and increasing rates of radiotherapy completion., ((Copyright) 2008 American Cancer Society.)

Purpose: Screening mammography guidelines for patients age 80 years and older are variable. We determined the effect of mammography use on stage at breast cancer diagnosis and survival among women of this age range., Patients and Methods: We used the linked Surveillance, Epidemiology, and End Results-Medicare database to evaluate 12,358 women >or= 80 years of age diagnosed with breast cancer between 1996 and 2002. Patients were grouped according to number of mammograms during the 60 months before diagnosis: nonusers (0 mammograms), irregular users (one to two mammograms), and regular users (three or more mammograms). Effects of mammography on disease stage (I to IIa v IIb to IV) and survival were determined by logistic regression and Cox proportional hazards analyses., Results: Percentages of women with nonuse, irregular use, and regular use of mammography during the 5 years preceding diagnosis were 49%, 29%, and 22%, respectively. On multivariate analysis, patients were 0.37 times less likely to present with late-stage cancer for each mammogram obtained (odds ratio, 0.63; 95% CI, 0.63 to 0.67). Breast cancer-specific 5-year survival among nonusers was 82%, that among irregular users was 88%, and that among regular users was 94%. However, survival from causes other than breast cancer was also associated with mammography use, suggesting a bias for healthier patients to undergo mammography., Conclusion: Regular mammography among women >or= 80 years of age was associated with earlier disease stage, although improved survival remains difficult to demonstrate. Health care providers should consider discussing the potential benefits of screening mammography with their older patients, particularly for those without significant comorbidity.

Introduction: i.v. bisphosphonates reduce skeletal events in women with bone metastases from breast cancer, but little is known about the prevalence and duration of bisphosphonate use., Methods: Patients were identified from the Surveillance, Epidemiology, and End Results-Medicare database who were aged > or =65 years and were diagnosed with invasive breast cancer in 1995-2002. Healthcare Common Procedure Coding System codes were used to identify patients treated with pamidronate and zoledronic acid. Descriptive statistics were used to describe patterns of use. Multivariate analyses were performed to determine the predictors of bisphosphonate use., Results: In total, 55,864 women with breast cancer were included, with 307,467 person-years of follow-up. Overall, 1.26% of women with all stages of breast cancer received i.v. bisphosphonates. In 2004, 2% of all breast cancer patients and 32% of patients with distant stage disease received bisphosphonates. Approximately two thirds of patients treated with bisphosphonates received zoledronic acid and one third received pamidronate in 2004. Multivariate analyses showed that patients who were > or =75 years old were less likely to receive bisphosphonates (75-79 years versus 65-69 years: odds ratio [OR], 0.81; 95% confidence interval [CI], 0.70-0.93; 80+ years versus 65-69 years: OR, 0.49; 95% CI, 0.42-0.57). The use of bisphosphonates dramatically increased over time. The majority of living patients were continued on i.v. bisphosphonates once started (83% at 1 year, 64% at 3 years, 50% at 5 years), but the median survival time after initiation of i.v. bisphosphonates was only 21 months., Conclusions: i.v. bisphosphonates appear to be underused in patients with metastatic breast cancer, particularly among those patients >75 years of age.

Purpose: Limited data are available on long-term cardiac safety of adjuvant anthracycline chemotherapy in breast cancer patients over age 65 years. We evaluated rates and predictors of congestive heart failure (CHF) in this population., Patients and Methods: We used the Surveillance, Epidemiology, and End Results Medicare database and included women with no history of CHF who were age 66 to 80 years and diagnosed with stage I to III breast cancer from 1992 to 2002. Cumulative rates of CHF were estimated, and multivariable Cox regression analysis was used to determine factors associated with the development of CHF., Results: A total of 43,338 women were included. Anthracycline-treated women were younger, with fewer comorbidities and more advanced disease than women who received nonanthracycline or no chemotherapy (P < .001 for each). The adjusted hazard ratio (HR) for CHF was 1.26 (95% CI, 1.12 to 1.42) for women aged 66 to 70 treated with anthracycline compared with other chemotherapy. For women aged 71 to 80, adjuvant chemotherapy type was not associated with CHF. The following baseline characteristics were significant predictors of CHF: age (HR, 1.79 per 10 years; 95% CI, 1.66 to 1.93), black race (HR, 1.40; 95% CI, 1.30 to 1.50), trastuzumab treatment (HR, 1.46; 95% CI, 1.21 to 1.77), hypertension (HR, 1.45; 95% CI, 1.39 to 1.52), diabetes (HR, 1.74; 95% CI, 1.66 to 1.83), and coronary artery disease (HR, 1.58; 95% CI, 1.39 to 1.79). Left-sided radiotherapy did not confer an elevated risk of CHF (HR, 1.04; 95% CI, 0.98 to 1.11)., Conclusion: Women aged 66 to 70 years who received adjuvant anthracyclines had significantly higher rates of CHF. The difference in rates of CHF continued to increase through more than 10 years of follow-up.

Purpose: The purpose of this study was to determine the risk of developing acute myeloid leukemia (AML) after adjuvant chemotherapy for breast cancer in older women., Patients and Methods: Data from the Surveillance, Epidemiology, and End Results-Medicare linked database were used for women diagnosed with nonmetastatic breast cancer from 1992 to 2002. The primary end point was a claim with an inpatient or outpatient diagnosis of AML (International Classification of Diseases ninth revision, codes 205 to 208), comparing patients treated with and without adjuvant chemotherapy, and by differing chemotherapy regimens. The cumulative hazard of AML was estimated using the Kaplan-Meier method. Cox proportional hazards models were used to determine factors independently associated with the development of AML., Results: In this observational study, there were 64,715 patients: 10,130 received adjuvant chemotherapy and 54,585 did not. The median patient age was 75.6 years (range, 66 to 104 years). The mean follow-up was 54.8 months (range, 13 to 144 months). The absolute risk of developing AML at 10 years after any adjuvant chemotherapy for breast cancer was 1.8% versus 1.2% for women who had not received chemotherapy. The adjusted hazard ratio for AML with adjuvant chemotherapy versus none was 1.53 (95% CI, 1.14 to 2.06). Granulocyte colony-stimulating factor (G-CSF) within the first year of diagnosis did not convey a significantly increased risk of AML (hazard ratio, 1.14; 95% CI, 0.67 to 1.92)., Conclusion: There is a small but real increase in AML after adjuvant chemotherapy for breast cancer in older women. This study may underestimate the true incidence because myelodysplastic syndrome cannot be identified through claims. G-CSF use within the first year of diagnosis does not convey an increased risk of AML in older women.

Purpose: This study was undertaken to determine patterns and outcomes of adjuvant chemotherapy use in a population-based cohort of older women with primary breast cancer., Patients and Methods: Women were identified from the Surveillance, Epidemiology, and End Results-Medicare-linked database who met the following criteria: age > or = 65 years, stage I to III breast cancer, and diagnosis between 1991 and 1999. Adjuvant chemotherapy use was ascertained by Common Procedural Terminology J codes. Logistic regression analysis was performed to determine factors associated with chemotherapy use. Multivariate Cox proportional hazards models were used to calculate the hazard of death for women with and without chemotherapy., Results: A total of 41,390 women met study criteria, of whom 4,500 (10.9%) received chemotherapy. The use of adjuvant chemotherapy more than doubled during the 1990s, from 7.4% in 1991 to 16.3% in 1999 (P < .0001), with a significant shift toward anthracycline use. Women who were younger, white, with lower comorbidity scores, more advanced stage disease, and estrogen receptor (ER) -negative disease were significantly more likely to receive chemotherapy. Chemotherapy was not associated with improved survival among women with lymph node-negative (LN) disease or LN-positive, ER-positive disease (hazard ratio [HR], 1.05; 95% CI, 0.85 to 1.31). However, among women with LN-positive, ER-negative breast cancer, chemotherapy was associated with a significant reduction in breast cancer mortality (HR, 0.72; 95% CI, 0.54 to 0.96). A similar significant benefit of chemotherapy was seen in the subset of women age 70 years or older (HR, 0.74; 95% CI, 0.56 to 0.97)., Conclusion: In this observational cohort, chemotherapy was associated with a significant reduction in mortality among older women with ER-negative, LN-positive breast cancer.

Background: Modern radiation techniques, which limit the radiation dose to the heart during treatment for breast cancer, have greatly reduced the risk of radiation-induced cardiac injury. However, the risk of radiation damage to the carotid artery, which is often incidentally included in the supraclavicular radiation field for breast cancer treatment, is not routinely examined, and the technique used to treat this field has not changed significantly from early radiation trials. The purpose of the current study was to compare the incidence of hospitalization for stroke among women with breast cancer treated with supraclavicular radiation with those who received radiation therapy to the breast but not the supraclavicular fossa., Methods: Data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for 5752 women who were diagnosed with American Joint Committee on Cancer (AJCC) Stage I-III nonmetastatic breast cancer between 1988 and 1997 were analyzed. Women included were age > or = 66 years, had known lymph node (LN) status, had tumors measuring < or = 5 cm, underwent breast surgery, and received adjuvant radiation therapy (with or without supraclavicular irradiation). Patients with < 5 years of follow-up were excluded because events in the first 5 years after radiation were unlikely to be radiation induced. A Cox proportional hazards model was used to compare patients with 0 positive LNs (surrogate group for no supraclavicular radiation, n = 5281) with patients with > 4 positive LNs (surrogate for supraclavicular radiation group, n = 471) for the endpoint of hospitalization for stroke. Time-to-event curves were calculated using the conditional Kaplan-Meier method., Results: The median follow-up for the 0 and 4+ LN cohorts were 92 months and 90 months, respectively (minimum of 60 months). The 10-year and 15-year actuarial freedom from hospitalization for stroke was 91% (0 LN) versus 89.5% (4+ LN) and 79% (0 LN) versus 81.6% (4+ LN), respectively (P = .28). Estrogen receptor status was balanced between the 2 cohorts. As expected, the 4+ cohort had more advanced tumors, higher stage, larger tumor size, and higher grade (P < .0001). In multivariate analysis including LN group, year of diagnosis, age, race, type of surgery, stage, tumor size, grade, estrogen receptor status, and Charlson comorbidity score, only increased age (hazard ratio [HR] for ages 70-74 years, 1.6; HR for ages 75-79 years, 2.1; and HR for age 80 + years, 2.7) and increasing comorbidity score were predictive of an increased risk of hospitalization for stroke., Conclusions: Although patients with nonbreast malignancies treated with higher doses to the carotid arteries have been shown to have an increased risk of carotid injury, no evidence was found that radiation to the carotid delivered during supraclavicular irradiation for breast cancer increases the risk of hospitalization for stroke., (Copyright 2006 American Cancer Society.)

Background: The publication of results from randomized clinical trials can have a dramatic effect on treatment patterns, but the impact of oral presentations at national scientific meetings is unknown. We investigated the temporal association between the oral presentation of the results from the Cancer and Leukemia Group B (CALGB) Study 9344 at the May 1998 meeting of the American Society of Clinical Oncology, which showed that paclitaxel improves survival of women with lymph node-positive breast cancer, and use of taxane chemotherapy for breast cancer., Methods: We studied chemotherapy use in 3341 women identified through the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stage I-III breast cancer in 1994-1999 at age 65 years or older and received adjuvant chemotherapy, as identified through claims data, within 1 year of diagnosis. We assessed the temporal association between the CALBG presentation and taxane use with piecewise regression analysis. Multivariable logistic regression analysis was used to determine which patient characteristics were associated with taxane use., Results: The use of taxanes increased substantially after the CALGB presentation, with absolute rates of taxane use of 5.2% before May 1998 and 23.6% in May 1998 and later. Initially, this increase was confined to patients with lymph node-positive disease (40% of whom were receiving taxanes by the end of 1999), but over time it extended to patients with lymph node-negative disease (15% of whom were receiving taxanes by the end of 1999). In multivariable analysis, patients who were treated in May 1998 or later were statistically significantly more likely to have received a taxane than patients treated before this date (estimated relative risk = 6.84, 95% confidence interval = 5.71 to 8.07). Younger patient age, larger number of lymph nodes involved, higher tumor grade, and larger tumor size were also independently associated with adjuvant taxane use., Conclusions: The oral presentation of a single study at a national conference was temporally associated with an increase in the use of taxanes for primary breast cancer, even before study publication or Food and Drug Administration approval.

Purpose: Squamous cell carcinoma (SCC) of the breast is rare and generally aggressive. In this study, we analyzed 33 patients treated at The University of Texas M.D. Anderson Cancer Center (Houston, TX) and a series of 137 patients identified through the Surveillance, Epidemiology, and End Results (SEER) database to make therapy recommendations., Methods: Records of The University of Texas M.D. Anderson Cancer Center were searched for patients diagnosed with breast SCC from 1985 to 2001. All biopsy material was reviewed by a dedicated breast pathologist who performed immunohistochemistry for hormone receptors and the epidermal growth factor receptor (EGFR). We searched the SEER database for patients with breast SCC diagnosed between 1988 and 2001., Results: We identified 33 patients with breast SCC, of whom two patients had metastatic disease at diagnosis. The median relapse-free survival (RFS) of 31 patients with localized disease was 20 months (range, 1 to 108 months), with a 26% RFS rate at 5 years. The median overall survival in these patients was 37 months (range, 12 to 108 months), with 40% surviving at 5 years. Median survival from the time recurrent disease was recognized was 14 months (range, 2 to 86 months). Tumors were usually hormone receptor-and HER2/neu-negative, though EGFR was frequently overexpressed. Information from the SEER database was consistent with most of our findings., Conclusion: SCC of the breast is aggressive and often treatment-refractory. The role of platinum salts, EGFR inhibitors, and other novel agents needs to be explored.