Tracking & Feedback Registry to Reduce Breast Cancer Treatment Disparities

Breast cancer is the second most common cause of cancer death in women. Black women are less
likely than white women to develop breast cancer but, they are more likely to die of the
disease. Some of this survival discrepancy is likely due to underuse of adjuvant therapies
proven to increase survival. Breast cancer treatment often requires coordination among
surgeons, pathologists, primary care physicians, medical and radiation oncologists. In NYC,
black and Hispanic women who accessed care and underwent surgical treatment of their breast
cancer were twice as likely as whites to experience underuse of proven-effective adjuvant
treatment. Disturbingly, 1/3 of these underuse cases were episodes in which the surgeon
recommended treatment, the patient did not refuse and yet, care did not ensue. Underuse in
these circumstances was attributed to system failures rather than to provider or patient
factors. Such system failures occurred more often among minority women and among women
treated at hospitals serving predominantly minority patients. To target these system
failures at 6 NYC hospitals, 4 of which served predominantly minority patients, we used a
quasi-experimental pre-post test design to implement a tracking and feedback registry. The
Tracking and Feedback registry closed the referral loop between surgeons and oncologists,
increased the rate of completed oncology consultations, increased treatment rates and
eliminated the racial disparity in underuse. Its effects were greatest at the 4 hospitals
serving predominantly minority women, sites that had an EMR and patient navigation prior to
and during the T&F implementation. However, the trial was not randomized, tracking and
feedback functions were performed by study personnel and not embedded in the hospital's
workflow and details of what the surgeons did in response to the feedback was not assessed,
resulting in a call for more work in this area.

In this proposed randomized controlled trial, we will implement the Tracking and Feedback
(T&F) innovation in hospitals serving predominantly minority women. We will test the
effectiveness of the Tracking and Feedback registry innovation to increase rates of
completed oncology consultation, reduce underuse of needed adjuvant therapy and racial
disparities in receipt of these treatments. We will also assess the feasibility of
implementing a T&F Registry in these high-risk hospitals by evaluating implementation
effectiveness for this innovation. We have recruited 10 hospitals that serve large
proportions of minority women with breast cancer. We will randomize hospitals and will
recruit 354 women with a new breast cancer, 177 per intervention arm. We choose these "high
risk" hospitals because they serve predominantly minority populations, and such hospitals
have higher rates of the system failure cause of underuse, specifically, the type of
underuse targeted by our Tracking and Feedback Registry. We will: adapt existing
laptop-based Tracking & Feedback software to create a protected web-based format easily
accessible to all participating hospitals; tailor the Tracking & Feedback registry to each
of the participating hospitals' appropriate workflows including the areas of pathology,
surgery, medical and radiation oncology and tumor registry personnel in the process; and
embed the tracking and feedback tasks within existing hospital structures and personnel to
increase likelihood of sustainability beyond the grant. We will include in the web-based T&F
Registry an electronic data capture system to assess responses and actions to the tracking
information that is fed back to the surgeons. To assess the T&F Registry's effectiveness, we
will compare rates of underuse of patients treated at intervention versus control hospitals.
To assess implementation effectiveness at each hospital, we will assess process and outcomes
using qualitative and quantitative methods. Qualitatively, we will conduct pre- &
post-intervention interviews with key stakeholders to assess the implementation climate and
stakeholders' views of the Registry's utility. Quantitatively, we will measure and track
actions taken in response to the feedback information. As there is variability across
hospitals, we will also assess each hospital's treatment rates both pre- (N=540) and
post-intervention (N=354) to provide additional quantitative measures of implementation
effectiveness.

Inclusion Criteria:

- All patients, who are English or Spanish speaking, with a new primary stage 1 or 2
and with tumors > 1 cm or < 1 cm and poorly differentiated breast cancer who have
undergone either breast conserving surgery or mastectomy at 1 of 10 participating
hospitals in the NY Metropolitan Area.

- All surgeons performing breast surgery at study participating hospitals

Exclusion Criteria:

- Patients with a poor prognosis due to end-stage organ failure or other concomitant
conditions such as those undergoing treatment for other cancers