The effect of centralizing breast cancer care in an urban public hospital

Discussion

There have been numerous studies reporting on disparities in the treatment of patients with breast cancer based on race or socioeconomic status.^4-18 Many studies have shown inferior survival for black women with breast cancer, but it is not entirely clear whether these differences are the result of the quality of medical care received or biologic differences.^14,19 A moderately large study from a metropolitan medical center in Detroit showed no difference in survival in their patients based on race when all of the patients received equal treatments.¹⁵ A meta-analysis of survival in black and white breast cancer patients showed that the black women had significantly poorer outcomes.¹⁹

Findings from a recent study showed that patients of lower socioeconomic status are more likely to undergo mastectomy than breast conserving therapy.²⁰ The study, which identified 727,927 patients with early-stage breast cancer during 1998-2011, found that the rate of breast conservation increased from 54% to 59% during that time period and that there were significant barriers to women receiving breast-conserving therapy based on their type of insurance and having a lower socioeconomic status.²⁰

The treatment of breast cancer is best delivered in a multimodality setting, but many inner-city public hospitals do not have such a facility for their patients. QHC is the only public hospital in New York City that has established a comprehensive cancer center. The patient population of QHC is overwhelmingly of minority origin (only 5% of patients are white). In addition, it is a safety net hospital, so no patient is turned away because they cannot pay, and most patients are of lower socioeconomic status and do not have insurance. The purpose of the cancer center was to provide a single site at which our patients could receive all their treatment. It was to ensure that our patients had easy access to care and treatment during all phases of their disease trajectory and did not “fall through the cracks” of the system. Those goals were addressed by having all of the center’s physicians in one place. Physicians involved in care included medical, surgical, and radiation oncologists, a gynecologic oncologist, a genitourinary oncologist, and a thoracic surgery oncologist. The support groups organized for the cancer patients included 3 oncology social workers, an oncology navigator, a nutritionist, a pastoral care supporter, and an oncology psychologist, all located in the same area. All of the clerical and financial aspects of care were also placed within the center. This made the experience as seamless as possible for both the patients and the treating physicians. A “survivors clinic” was established so the cancer patients could be seen by integrated primary care providers to address all noncancer-related health issues such as hypertension, diabetes, or heart disease. Finally, a robust clinical oncology research team was established in the same location. The research included several protocols for new drug treatments for breast cancer from pharmaceutical companies as well as the multi-institutional oncology groups.

Part of the mission of the cancer center was to reach out into the community of Queens to provide education about early detection, cancer prevention, and other public health issues such as tobacco cessation. We established a close working relationship with the Queens Public Library System to connect with their users and dispense information about cancer care and early detection. The Queens Library system is the largest in the United States, and everyone who lives in Queens has easy access to one of its 63 branch libraries. We arranged several lectures about breast cancer awareness in some of the branch libraries. We also procured a mobile mammogram unit for free screening events at the lectures, especially in neighborhoods with a large number residents who were of lower socioeconomic status.

To study the possible effect of these changes on our patients with breast cancer, we compared 2 groups of patients. One group was from the year 2000, a year before the cancer center was opened. The other was from the year 2008, the last year we could get real 5-year survival statistics. We explored how establishing the cancer center might have changed the patients’ stage at diagnosis, care, treatment modalities such as type of surgery, and outcomes. It is difficult to compare these 2 groups because of differences in the patients’ cancers, such as their receptor status, as well as differences in treatment options between the two time periods. However, we had no other way to compare the data to see if there were any trends.

There was a migration to earlier-stage cancer at diagnosis during the 6-year period after the cancer center was opened. It is likely that the educational sessions that were done in the community contributed to this migration. We also saw an increase in the number of mammograms done, from 6,300 in 2000 to 8,800 in 2008. This increase in screening also could account for more patients being identified with earlier-stage disease and might be attributable to the community education through the outreach programs.

As a quality control method, the cancer center has been evaluated by the Commission on Cancer every 3 years. At the 2013 evaluation, we received the Gold Commendation – the highest possible recognition for having 8 out of 8 commendations – and a 3-year accreditation.

There was a notable increase in the use of lumpectomy over mastectomy after the establishment of the cancer center, possibly due to the addition of 2 surgical oncologists to the cancer center’s care team. The integration of multimodiality care for each patient may also have increased the use of breast-conserving surgery.

There was a significant increase from 2000 to 2008 in the survival of patients treated for stage III breast cancer. New drugs and new patterns of adjuvant care might have been partly responsible for that change. The establishment of the comprehensive cancer center with access to new protocols ensured that patients received state-of-the-art cancer treatment. Moreover, the facility addressed all aspects of patient care throughout the disease trajectory by including designated social workers, psychologists, a nutritionist, pastoral care, and patient and survivor support groups to ensure that patients would keep coming to the center for their therapy, with no delays and very little loss to follow-up.

Most patients without insurance were able to acquire emergency Medicaid through the cancer center. This was done by having 2 financial counselors who met with every patient and who could facilitate access to Medicaid as needed. As a result of that, the percentage of patients with no coverage went from 86% in 2000 to 16% in 2008. Before this system was set up, patients who were designated self-pay would pay a fee as low as $15 for each visit and received thousands of dollars’ worth of care. Thus, by forming a cancer center and facilitating patient access to Medicaid, we were able to save money for this public institution because of the gain in revenue from Medicaid.

Our findings suggest that the development of comprehensive cancer centers within inner-city health systems can ensure better treatment for patients of lower socioeconomic status. We present evidence that this may result in increased survival, more sophisticated surgical options, and better patient quality of life. Moreover, this can be achieved while effectively increasing revenue for the public hospitals. Correcting the inequality of access to care and better therapeutic options by setting up comprehensive cancer centers could contribute to improved parity of outcomes for underserved populations.