The Breast Cancer Quality of Care Study (BQUAL): A Multi-Center Study to Determine Causes for Noncompliance with Breast Cancer Adjuvant Therapy

Department of Medicine, and Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons, School of Public Health, Columbia University Medical Center, 722 W 168th Street, New York, NY 10032, USA.
The Breast Journal (Impact Factor: 1.41). 04/2012; 18(3):203-13. DOI: 10.1111/j.1524-4741.2012.01240.x
Source: PubMed


In oncology, quality of care is a major issue for patients and providers. Significant variations in care, including nonreceipt of adjuvant systemic therapy, nonadherence to therapy, and/or early discontinuation of therapy, occur frequently and may impact survival. Reasons for these variations are not well understood, but may play a role in the prominent disparity in breast cancer survival between blacks and whites. Since May 2006, the Breast Cancer Quality of Care Study (BQUAL) has recruited 1158 women with nonmetastatic breast cancer from several centers across the country, with completed data on 1057 participants to date. Detailed information on demographic, behavioral, biomedical, and emotional factors related to chemotherapy use was collected on each participant at baseline and at two follow-up interviews during the first 6 months. In addition, for women with ER+ tumors, further questionnaires were completed every 6 months regarding hormonal therapy use. Each participant was also asked to provide a DNA sample, and to allow medical record review. We surveyed physicians providing care to the study participants regarding attitudes toward adjuvant treatment. The mean age of participants was 58 years (SD 11.6), and 15% (n = 160) were black. The majority had an annual household income <$90,000 (n = 683), had college education or higher (n = 802), 55.9% were married, and 57.9% were not currently employed. Seventy-six percent had hormone-receptor-positive tumors, 49.9% initiated chemotherapy and 82.7% started hormonal therapy. Blacks were more likely to have lower annual household income (p < 0001), less education (p = 0.0005), ER negative tumor status (p = 0.02), and poorly differentiated cancer (p = 0.0002). The main endpoints of the study are noninitiation of chemotherapy or hormonal therapy, nonadherence to therapy and early discontinuation of therapy. Treatment and outcomes will be compared on the 15% of participants who are black versus other participants. The BQUAL Study will be a rich ongoing source of information regarding reasons for differences in receipt of both adjuvant chemotherapy and hormonal therapy. This information may be useful in planning interventions to improve quality of care.

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    • "multicenter cohort studies may be able to further investigate these issues for both hormonal therapy and chemotherapy [54] [55], at least for patients treated at larger centers. Our results regarding surgical and radiation therapies and general HRQOL are consistent with several smaller studies [9] [38] [48] [56] [57] including a large US study which found little association of pain with specific treatments [58]. "
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    ABSTRACT: Background Growing numbers of older women receive adjuvant breast cancer therapies, but little is known about the long-term effects of current therapies upon health-related quality of life outside of clinical trials. Methods A population-based cohort of postmenopausal women with incident breast cancer aged sixty-five and older was identified from Medicare claims from four states and followed over five years. General health-related quality of life (HRQOL) was assessed using the Medical Outcomes Study SF-12 Health Survey, and breast cancer-related HRQOL was assessed using the breast cancer subscale of the functional assessment of cancer therapy (FACT-B BCS). The association of HRQOL with sociodemographic variables, comorbidity, and breast cancer variables (stage, treatments, and treatment sequelae) was examined in longitudinal models. Results Among the 3083 older breast cancer survivors, general HRQOL as measured by SF-12 mental and physical component scores was similar to norms for non-cancer populations, and remained stable throughout follow-up. Breast cancer treatments, including surgery and radiation, adjuvant hormonal therapy, and cytotoxic chemotherapy were not associated with worsened general health scores. A similar pattern was seen for breast cancer-related HRQOL scores, except that chemotherapy was associated with slightly worse scores. Lymphedema occurred in 17% of the cohort, and was strongly associated with all measures of HRQOL. Reductions in general HRQOL with lymphedema development were larger than those with an age increase of 10 years. Conclusions There is little association of breast cancer treatment with HRQOL in older breast cancer patients followed for up to five years, but the development of lymphedema is associated with substantial reductions in HRQOL.
    Full-text · Article · Oct 2014 · The Breast
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    • "In addition to the practical, policy-oriented strategies described above, we highlight several ideas for incorporating survivors' employment context into future breast cancer treatment decision making and compliance research. For example, Neugut et al recently completed the multisite, 5-year Breast Cancer Quality of Care Study (BQUAL) to determine causes for non-compliance with breast cancer adjuvant chemotherapy and hormonal therapy.44,47,48 Though their proposed bio-psychosocial model illustrating the causes of treatment noncompliance includes important factors such as physician characteristics, patient-provider communication, provider referrals, biology, and patient characteristics that are known to influence treatment receipt, it does not include an explicit variable focused on employment.44 Longitudinal studies such as BQUAL, with diverse geographic coverage and a large sample of racially diverse working women (42%), serve as prime opportunities to assess patients' employment circumstances and how they may influence treatment decisions. "
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    ABSTRACT: Breast cancer is the leading cause of cancer among women in the United States, costing the healthcare system, employers, and society billions of dollars each year. Despite improvements in screening and treatment, significant breast cancer treatment and survivorship disparities exist among various groups of women. One variable that has not been explored extensively as a possible contributor to breast cancer treatment disparities is employment. This is concerning, given the changing economic and employment trends in the United States favoring low-wage employment. Currently, one-quarter to one-third of all US workers are considered to be working poor, and women are disproportionally represented in this group. Characteristics of low-wage work-limited paid time off, minimal health benefits, schedule inflexibility, and economic insecurity-may become even more significant in the event of a breast cancer diagnosis. To date, there has been limited research into how job conditions inherent to low-wage work may influence working poor survivors' receipt of guideline-recommended breast cancer treatment. Therefore, the purpose of this narrative review was to critically examine the current literature to further our understanding of how employment context may impact treatment decisions and adherence-and therefore receipt of guideline-recommended care-among newly diagnosed, working poor breast cancer survivors. After undertaking a comprehensive review, we failed to identify any published literature that explicitly addressed low-wage employment and receipt of guideline-recommended breast cancer treatment. Four articles reported circumstances where women delayed, missed, or quit treatments due to work interference, or alternatively, developed strategies that allowed them to continue to work and obtain their breast cancer treatment concurrent with medical and economic challenges. An additional five articles, while focused on other cancer and employment outcomes, described the need for increased patient-provider communication about the influence of work on treatment decisions and the development of alternative treatment plans. Due to the paucity of research in this area, future policy, practice, and research efforts should focus on the employment context of working poor breast cancer survivors as a potential contributor to cancer disparities. Engagement of women, employers, oncology providers, healthcare systems, and interdisciplinary researchers is warranted to improve cancer outcomes among this disparate population of working women.
    Full-text · Article · Sep 2013
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    • "Given the increase in the number of oral anti-cancer medications, identifying modifiable barriers to the use of oral therapy, especially in minority women, is critical to improving survival. Prospective studies examining factors associated with non-initiation, non-adherence, and early discontinuation of adjuvant hormone therapy are underway with special attention to ethnic minorities (Neugut et al. 2012). Perceived therapy importance and doctor-patient communication on medication compliance represent modifiable variables which can improve overall cancer survival. "
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    ABSTRACT: Studies have demonstrated lower rates of breast cancer survival for Black versus White women. Factors implicated include later stages at diagnosis, differences in tumor biology, and lower compliance rates to adjuvant hormone therapy (AHT) among Black women with hormone sensitive breast cancer. We examined factors associated with compliance to AHT among Black and White women with invasive breast cancer. Women with estrogen receptor positive (ER+), non-metastatic breast cancer were identified by the cancer registry at the University of Chicago Hospital and asked to complete a mail-in survey. Compliance was defined by self-reported adherence to AHT ≥80% at the time of the survey plus medical record verification of persistence (completion of 5 years of AHT). Logistic regression was used to determine factors associated with compliance to AHT. 197 (135 White and 62 Black) women were included in the analysis. 97.4% of patients reported adherence to therapy. 87.4% were found to be persistent to therapy. Overall compliance was 87.7% with no statistically significant racial difference seen (87.9% in White and 87.0% in Black, P = 0.87). For both Black and White women, compliance was strongly associated with both perceived importance of AHT (OR =2.1, 95% CI:1.21-3.68,P = 0.009) and the value placed on their doctor's opinion about the importance of AHT (OR = 4.80, 95% CI: 2.03-11.4, P < 0.001). In our cohort of Black and White women, perceived importance of AHT and the degree to which they valued their doctor's opinion correlated with overall compliance. This suggests that Black and White women consider similar factors in their decision to take AHT.
    Full-text · Article · Jul 2013 · SpringerPlus
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