Susan Kraenzle’s research while affiliated with Barnes Jewish Hospital and other places

Background: Breast cancer (BC) is the most commonly diagnosed cancer in women. The American Cancer Society (ACS) guidelines recommend annual screening mammography for women of average risk beginning at age 40. Objective: Based on the ACS recommendation, we sought to determine whether women aged 40 years and older who had annual screening mammogram before BC diagnosis incurred lower healthcare costs after BC diagnosis compared to those who did not follow the guidelines. Methods: We used data from a large private health insurance claims database (Thomson Reuters Marketscan Research Databases), 2006-2010. Our sample included women aged at least 40 years with a BC diagnosis between January 2009 and May 2010 and excluded women with cancer other than BC. The study period was chosen to allow for (1) the observation of their screening behavior (3 years) before BC diagnosis and (2) the determination of their metastatic status. A woman was determined to have metastasis upon diagnosis if within the period of 1 month before and 7 months after BC diagnosis, she had at least two metastasis codes and chemotherapy (algorithm adapted from Schootman et al. 2009). The outcome variable was total healthcare costs after BC diagnosis. Costs in MarketScan are defined as adjudicated reimbursement amounts from insurer claims data. Women who had annual mammogram screening (ACS guidelines followers) were defined as women who had a screening mammogram every calendar year from January 2006 until their BC diagnosis. Multivariable regression analyses of log-transformed total costs were conducted, adjusting for age, months between BC diagnosis and December 2010, employee classification (e.g., salary union), employment status, geographic location (e.g., northeast, south, etc.), metastatic status, and whether they received wire localization, lumpectomy, partial mastectomy, radical mastectomy, breast reconstruction, chemotherapy, and radiotherapy. Results: 7,892 women with BC were identified. Among them, 27% had screening mammography every calendar year before their BC diagnosis. In the multivariable analysis, women who had annual mammogram screening were associated with a 4.6% higher cost (p=0.03). Women with metastatic diseases at diagnosis increased healthcare costs by 143.8% (p<.0001). Health care costs increased by 0.9% each month after diagnosis (p<.0001). Wire localization incurred 40.4% higher costs (p<.0001). Lumpectomy increased healthcare costs by 45% (p<.0001). Partial mastectomy was associated with 42.3% more costs (p<.0001). BC patients undergoing radical mastectomy had 34.6% more costs (p<.0001). Breast reconstruction increased costs by 62.6%. Patients who received chemotherapy had 189.8% higher healthcare costs compared to those who did not receive chemotherapy (p<.0001). Radiotherapy was associated with 95.9% more costs (p<.0001). Conclusion: This study provides evidence suggesting that even amongst an insured population, it appears that less than 30% of breast cancer patients had annual mammogram screening before diagnosis and that these patients were associated with higher healthcare costs in the early stage after their BC diagnosis. Future studies need to be conducted to further examine total healthcare costs throughout breast cancer survivors’ life span. Citation Format: Su-Hsin Chang, Lauren T Steward, Bettina F Drake, Sarah Lyons, Susan Kraenzle, Melody S Goodman. Does annual mammogram screening incur lower healthcare costs for breast cancer women after diagnosis? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-07-16.

Background: Among women, breast cancer is the most common noncutaneous cancer and second most common cancerous cause of death. The American Cancer Society recommends that all healthy women over age 40 have a mammogram annually because early detection and treatment of tumors has been associated with a 15% decrease in breast cancer mortality. African American women have higher mortality rates than white women and, in general, uninsured women have low rates of screening. To increase screening rates, mobile mammography has been implemented in many cities. Previous studies have investigated women’s self-reported adherence to screening guidelines at the time of participation in mobile mammography, but no study has examined if women use it as an annual screening tool. Objective: The purpose of this study was to determine if women are using mobile mammography vans as their established source of medical care for breast cancer screening and the factors that predict repeat visits to these vans. Methods: A prospective cohort study was conducted from 2006 to 2013 in which 8450 women who received a mammogram as part of Siteman Cancer Center’s Breast Health Outreach Program responded to surveys and provided access to their clinical records. Only visits on the mammography van were included. The predictor variables explored in this study were: urban status, insurance coverage, age group, race, marital status, mammography experience at baseline visit, employment status, and year of screening. Data were analyzed using chi-square tests, logistic regression, and negative binomial regression. Results: Among the study participants, 25.3% (N=2134) had multiple visits to the mobile mammography van. Of these women, 57.2% had good mammography experiences at baseline, 48.2% were from urban settings, 70.6% were uninsured, 51.2% were ages 50-65, 69.7% were Black, 76.4% were not currently married, and 63.3% were unemployed. Women who were ages 50-65, uninsured, or Black had a higher odds of a repeat visit to the mobile mammography van compared to women who were ages 40-50, insured, or White (OR=1.135, 95% CI: 1.013-1.271; OR=1.302, 95% CI: 1.146-1.479; OR=1.281, 95% CI: 1.125-1.457), respectively. However, the odds of having a repeat visit to the van was lower among women who reported a rural zip code or were unemployed compared to women who provided a suburban zip code or were employed (OR=.503, 95% CI: .411-.616; OR=.868, 95% CI: .774-.972), respectively. Conclusion: This study has identified key characteristics of women who are either more or less likely to use mobile mammography vans as their primary source of medical care for breast cancer screening and have repeat visits. It is important that mobile mammography is maintained and remains easily accessible to women who continuously use the service. Further research should be done to discover ways to make mobile mammography a more effective resource for those more likely to use it for routine screening. Citation Format: Bettina F Drake, Salmafatima S Abadin, Sarah Lyons, Su-Hsin Chang, Lauren T Steward, Susan Kraenzle, Melody S Goodman. Mammograms on-the-go: Predictors of repeat visits to mobile mammography vans in St. Louis, Missouri [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-06.

Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium; December 9-13, 2014; San Antonio, TX Background: Mobile mammography has been used to reach underserved women in a diverse number of settings. In this work, we demonstrate similarities and differences between rural and urban communities served by a single mobile mammography unit (MMU) affiliated with a comprehensive cancer center in Missouri. Methods: An outreach registry of patients serviced by the MMU was created and includes data from medical records and responses to a brief questionnaire completed at each visit. Data was examined by point of care (urban/rural) to assess the efficacy of mobile mammography as an outreach strategy in each of these environments. Bivariate analyses were used to examine the relationships between demographic characteristics such as age, income, race/ethnicity, education, employment status, marital status, insurance status, and living environment proxy. Results: Between 2006 and 2013, 9480 women received their care on the mobile mammography van. The sample was stratified by point of care (urban vs. rural) served, with majority of the women (86%) residing in urban/suburban St. Louis City/County, and 14% in rural regions. Urban zip codes had a lower percentage of women with income greater than $20,000 (12$10,000 (49% v. 37%) in comparison to rural communities(p=0.01). There were higher proportions of black women in urban communities (63%) compared to rural communities (10%; p<0.001). Almost half (47%) the women that received mobile mammography in rural zip code were married compared to less than a quarter of women from urban zip codes (24%; p<0.001). Rural communities (83%) had a higher percentage of uninsured women compared to urban communities (67%; p<0.001). Women in urban and rural communities were similar in respect to age, employment status, and education. Conclusions: Mobile mammography has the potential to reach a large population of women with limited educational, financial, and healthcare resources. Future studies will be needed to determine if increasing the range and extent of mobile units, such as this one, would be effective in increasing the screening rates of not only women in Missouri, but also in other portions of this country. Citation Format: Lauren Steward, Susan Kraenzle, Bettina Drake, Sarah Lyons, Melody Goodman. An evaluation of mobile mammography outreach in urban and rural communities [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-13.

Objectives Among women, breast cancer is the most common non-cutaneous cancer and second most common cause of cancer-related death. The purpose of this study was to determine the extent to which women use mobile mammography vans for breast cancer screening and what factors are associated with repeat visits to these vans. Design A case–control study. Cases are women who had a repeat visit to the mammography van. (n=2134). Participants Women who received a mammogram as part of Siteman Cancer Center's Breast Health Outreach Program responded to surveys and provided access to their clinical records (N=8450). Only visits from 2006 to 2014 to the mammography van were included. Outcome measures The main outcome is having a repeat visit to the mammography van. Among the participants, 25.3% (N=2134) had multiple visits to the mobile mammography van. Data were analysed using χ2 tests, logistic regression and negative binomial regression. Results Women who were aged 50–65, uninsured, or African-American had higher odds of a repeat visit to the mobile mammography van compared with women who were aged 40–50, insured, or Caucasian (OR=1.135, 95% CI 1.013 to 1.271; OR=1.302, 95% CI 1.146 to 1.479; OR=1.281, 95% CI 1.125 to 1.457), respectively. However, the odds of having a repeat visit to the van were lower among women who reported a rural ZIP code or were unemployed compared with women who provided a suburban ZIP code or were employed (OR=0.503, 95% CI 0.411 to 0.616; OR=.868, 95% CI 0.774 to 0.972), respectively. Conclusion This study has identified key characteristics of women who are either more or less likely to use mobile mammography vans as their primary source of medical care for breast cancer screening and have repeat visits.

Background To investigate perceived barriers to mammography among underserved women, we asked participants in the Siteman Cancer Center Mammography Outreach Registry – developed in 2006 to evaluate mobile mammography’s effectiveness among the underserved – why they believed women did not get mammograms. Methods The responses of approximately 9000 registrants were analyzed using multivariable logistic regression. We report adjusted odds ratios (OR) and 95% confidence intervals (CI) significant at two-tailed p<0.05. Results Fears of cost (40%), mammogram-related pain (13%), and bad news (13%) were the most commonly reported barriers. Having insurance was associated with not perceiving cost as a barrier (OR 0.44, 95%CI 0.40-0.49) but with perceiving fear of both mammogram-related pain (OR 1.39, 95%CI 1.21-1.60) and receiving bad news (OR 1.38, 95%CI 1.19-1.60) as barriers. Conclusion Despite free services, underserved women continue to report experiential and psychological obstacles to mammography, suggesting the need for more targeted education and outreach in this population.

Background: Despite the wide use of mobile mammography in outreach efforts there is a dearth of literature on effectiveness, best practices, and the evaluation of mobile mammography outreach programs. An outreach registry of patients serviced by the Breast Health Center (BHC) was created for program evaluation and planning purposes. Registry includes medical record data and responses to a brief questionnaire completed at each visit. Methods: We evaluate the BHC outreach program to determine, population served, barriers to mammography, and effectiveness of mobile mammography efforts. We examined data from the first screening visit of women enrolled in the BHC registry between 2006 and 2011. Data are examined by point of care (van/onsite, and urban/suburban/rural). Results: In the six year period 9,079 women were enrolled in the registry; 33% white, 54% black, 4% Hispanic and 8% other race/ethnicity. The majority of women are uninsured (74%), were screened on the van (83%), have an annual income less than $20,000 (87%), reside in St. Louis City (44%) or County (40%); over a quarter had more than high school education (27%), 24% reside in one of the eight high breast cancer mortality zip codes, and 5% in the rural bootheel region of Missouri. Discussion: Despite receiving free services most women reported cost as a major barrier to mammography. Without this type of outreach service most of these women reported they would not have a mammogram next year. Additional barriers include being afraid suggesting that breast health education may be needed to increase screening rates.

13 Background: An outreach registry of Breast Health Center patients was developed in 2006 to evaluate the effectiveness of mobile mammography among the medically underserved. Registry included collection of medical record data, demographic data, and answers to a questionnaire about perceptions of breast cancer screening. Here, we examine barriers to mammography. Methods: Between April 2006 and May 2011, 9,082 women were registered. Data from registrants’ first screening visit (n= 8,916) were analyzed using multivariable logistic regression examining three outcomes identified as barriers to mammography: cost, fear of pain during the procedure, and fear of receiving bad news. Two-tailed p<0.05 was considered significant. Results: The majority of registrants were black (54%), uninsured (74%), screened on a van (83%), resided in the greater St. Louis region (84%), had an annual income <$20,000 (87%), and reported a good or excellent experience as part of the outreach program (92%). Fears of cost, mammogram-r...