An innovative approach to the multidisciplinary treatment of uninsured breast cancer patients

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Nodora, Jacqueline A. Gilbert, Maria Elena Martinez, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5050432/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Nov, 2024 Read the published version in Cancer Causes & Control → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose A significant proportion of many populations remain uninsured. The aim of the study was to assess differences in breast cancer outcomes before and after the implementation of an innovative approach to the multidisciplinary treatment of uninsured breast cancer patients. Methods Retrospective review was performed of patients seen at a safety net hospital from January 2000 to December 2020. Beginning July 2006 an innovative approach was implemented to lower patient costs to facilitate care of uninsured patients. Results The study included 1,797 patients, 661 patients before the changes (BCS), 1,136 patients after implementation of the new cost saving approach (ACS). The mean age was 53 years. The majority were uninsured (56%) or insured by Medicaid (31%). Only 18% underwent screening mammography. The ACS group had a higher rate of breast conservation (75% vs 47%, p < 0.001). A higher percentage of the ACS group received adjuvant therapy: Chemotherapy (91% vs 70%, p < 0.001), Radiation therapy (91% vs 70%, p < 0.001), and initiated endocrine therapy (87% vs 67%, p < 0.001). After follow up of 8 years, these changes resulted in lower ipsilateral breast tumor recurrence (2% vs 16%, p < 0.001) and chest wall recurrence (5% versus 8%) and improvement in overall survival (90% vs 81%, p < 0.001). Conclusion Peer reviewed literature is replete of studies documenting disparities in breast cancer treatment. The current study describes a successful cost limiting method which takes advantage of existing financial assistance programs to improve care in uninsured patients. Introduction Breast cancer is the most prevalent cancer among women, accounting for about one-third of all cancer diagnoses. It also stands as the second leading cause of cancer-related mortality [1]. Over the past three decades, the integrated approach to breast cancer management has witnessed significant advancements in both diagnostic and therapeutic modalities. Breast cancer management, therefore, requires multidisciplinary care with collaboration of radiologic imaging, pathology, genetic counseling, surgery, radiation oncology, and medical oncology. This has resulted in significantly improved breast cancer survival since 1990 [1]. These advancements, however, come with notable financial implications. A study from 2010 highlighted that the cost of treatment to insurance companies could range from $ 71,000 to $ 190,000 over the first two years, depending on the stage of breast cancer at diagnosis [2]. With further improvement and more available treatments, contemporary cost of therapy has increased to $ 117,000 to $ 435,000 again over the first two years [3]. Access to insurance coverage through the Affordable Care Act (ACA) and other measures have improved coverage, particularly for low-income patients [4,5]. Some studies, however, have shown that the improvement in the rate of early-stage breast cancer was only 1.4% post-ACA [6]. Despite some improvements in access, there remains a significant proportion of the population that remains uninsured. Data from the 2022 National Health Interview Survey indicates that 12.1% of adults aged 18–64 are uninsured, with disparities evident among racial and ethnic groups: 27% of Hispanics, 12.9% of Non-Hispanic Blacks, and 8% of Non-Hispanic Asians lacked insurance, compared to 7.4% of Non-Hispanic Whites [7]. Without insurance most medical expenses become out of pocket costs borne by the patient. Therefore, uninsured and low-income individuals and families, often grappling with socio-economic challenges, face significant barriers in accessing healthcare. For breast cancer patients, these barriers result in poorer outcomes due to delay in diagnosis, presentation at later stages, and decreased compliance with recommended adjuvant therapy [8–16]. These challenges are further magnified in low-resource communities, where factors such as education, limited English proficiency and health literacy, socio-economic constraints, and cultural beliefs can impede effective breast cancer management [11,15,17–20]. While there is literature highlighting the disparities in breast cancer management and outcomes based on socio-economic status and insurance status, there remains a lack of data on effective strategies to bridge these gaps, especially in the uninsured population. The aim of the study was to assess differences in breast cancer outcomes before and after the implementation of an innovative cost limiting approach to the multidisciplinary treatment of breast cancer among uninsured patients. Methods This study was conducted at Maricopa/Valleywise Medical Center and was approved by their Institutional Review Board. Maricopa Medical Center is the safety-net hospital for Maricopa County, which includes the city of Phoenix and the surrounding metropolitan area. Maricopa County is the state’s most populous area with over 4.5 million of Arizona’s 7.4 million inhabitants. Maricopa Medical Center is a teaching institution with seven graduate medical education Residency Programs. Study Patients: The hospital system receives referrals of underinsured patients from around the county. As a result, the patient population was 78% from racial/ethnic minority groups and 87% were underinsured (insured by Arizona Health Care Cost Containment System (AHCCCS)/Medicaid) or uninsured/self-pay. Data Collection: Retrospective chart review was performed from January 1, 2000 to December 31, 2020 of all patients seen in the Breast Clinic. All patients with a diagnosis of breast cancer were included in the study. Baseline data for every patient was compiled prospectively, supplemented by retrospective chart review. The data included sociodemographic information, health literacy assessment, and diagnostic tests. Self-reported household income was also documented. Health literacy was assessed using the Newest Vital Sign (NVS)[21]. Breast cancer treatment, follow up, and mortality were documented. Design of study: Beginning on July 1, 2006, the Chairman of the Department of Surgery felt there was a significant need in the patient population for breast cancer care. As a result, an innovative cost limiting approach to lowering patient costs was implemented to facilitate care of uninsured patients (Table 1 ). The Breast Clinic was located in an adjacent space to the Women’s Imaging Center. A fellowship trained breast surgical oncologist was hired to manage the Breast Clinic. The surgeon had experience with ultrasound and image guided core needle biopsy. These steps were critical to the process because the majority of the patient population did not undergo routine screening mammography. Therefore, many patients presented with palpable masses or findings visible on ultrasound. The Breast Clinic setup, both with staffing and location, allowed patients to have the initial consultation, obtain diagnostic imaging, and undergo diagnostic image guided biopsy at the same initial visit. Table 1 Goals of an innovative approach to setting up a cost limiting breast cancer treatment program 1. Negotiate lower cost radiation therapy with an academic or government funded radiation facility. 2. Apply for treatment grants and fund raising for treatment costs. 3. Negotiate discounted chemotherapeutic medications. 4. Take appropriate steps to minimize number and cost of operations. Utilize preoperative chemotherapy and pathologic complete response. Utilize intraoperative US. Utilize preoperative localization only when location cannot be confidently identified by preoperative US 5. Identify existing programs and paperwork to obtain genetic testing and multigene assays at discounted rates. 6. Consolidate or minimize the number of visits to obtain a diagnosis to lower costs and lessen the possibility of noncompliance and delay in diagnosis. Hire a breast surgical oncologist with experience in breast ultrasound and image guided biopsy. 7. Limit the number of tests ordered according the Choose Wisely Programs (preoperative MRI, metastatic workup in patients without systemic symptoms) This method of “one stop shopping” streamlined the process of obtaining a diagnosis for patients and decreased costs from multiple visits. This also prevented the patient from leaving after diagnostic imaging without a biopsy. Completing the biopsy is important as most patients with breast cancer are asymptomatic and when told that there is a problem on the mammogram, may not return for a biopsy due to other more pressing needs. Following the biopsy, patients were scheduled to return and given an appointment date and time in one week to discuss the pathologic diagnosis. Preoperative breast magnetic resonance imaging was not used, except in the presentation of positive lymph node with an unknown primary. Racial/Ethnic minority patients do get diagnosed at a younger age than non-Hispanic White patients [22,23]. Underinsured patients, however, have difficulty obtaining genetic counseling and paying for genetic testing. The Breast surgical oncologist underwent training in Genetic Cancer Risk Assessment at City of Hope National Medical Center. The training is approximately 13 weeks in duration and the majority of the training was done with online classes [24]. After counseling, if genetic testing was indicated, based on contemporary National Comprehensive Cancer Network (NCCN) guidelines [25], and desired by the patient, blood or sputum was sent to Myriad Genetics. For uninsured patients, Myriad does have a Financial Assistance Program based on the household income of the patient [26]. After consultation and discussion about the diagnosis, if an operation was expected to be the first step in the management, uninsured/self-pay patients met with a financial counselor. Rather than requiring full payment of the planned operation upfront, a down payment was made with a plan for payment in installments of the remainder of the cost. The amount of the down payment varied over the 15 year time period of the study but was approximately $ 2000. If subsequent operations were required for involved margins, another down payment was required. In breast conservation, positive margins are an issue regardless of patient and insurance status [27]. In uninsured/self-pay patients, the cost of additional operations was yet another reason to try to obtain negative margins on the first attempt. For patients undergoing breast conservation for nonpalpable cancer, attempt was made to visualize the cancer with ultrasound. If visible on ultrasound, then breast conservation could be performed with no preoperative localization with wire or tag. For cancers only seen on mammography, the operations were done with wire localization the morning of the planned operation. Radiofrequency tags and magnetic seeds were not used during the study period. Indications for chemotherapy must be individualized. For documentation purposes, all patients with triple negative breast cancer or Her2neu positive (immunohistochemistry 3 + or FISH amplified) at least 1cm or lymph node positive were considered candidates for chemotherapy. Patients with smaller node negative cancers could be considered candidates for chemotherapy based on the recommendation of the treating Oncologist. Generally, patients were treated with anthracycline and taxane based regimens. Patients were often treated with every 3 week taxanes rather than weekly to lessen the number of office visit copays. In patients with luminal breast cancer, a multigene assay was used to determine if chemotherapy was indicated [28]. Prior to July 2019 financial assistance for this assay was available. The multigene assay which was used was purchased by a different company on July 29, 2019. This changed the process and documentation for financial assistance that was used for the majority of the study. There is, however, still a financial assistance program for the multigene assay [29]. When chemotherapy, with or without targeted therapy was indicated, a process was implemented to apply for discounted medications for evidence based regimens with the assistance of Cardinal Health [30]. Some Her2neu targeted therapy and immunotherapy agents could also be used in a similar fashion. The availability and costs depend on discussion at an administrative level of the individual medical center and Cardinal Health. Many of the requirements for financial assistance programs are similar and common requirements include personal identification, household size, and documentation of income. Indications for radiation therapy included any patient who underwent breast conservation, except patients age 70 years and older with luminal breast cancer [31]. In addition, postmastectomy radiation was recommended for all patients with four or more positive lymph nodes. Patients with one to three positive nodes were not offered postmastectomy radiation due to limitations of funding. There are no radiation therapy facilities at Maricopa Medical Center. An agreement was therefore made with a medical specialty group in Phoenix, with radiation oncology facilities, to provide radiation therapy at a significantly discounted cost to uninsured patients. The treatment was paid through treatment grants as well as fundraising activities by the Health Foundation of the hospital For endocrine therapy and risk reduction, due to the lower cost, Tamoxifen was the primary medication used until 2010. After aromatase inhibitors became generic, they were more commonly used in postmenopausal women. Patients were seen semiannually for 5 years and then annually after 5 years. Patients who did not undergo bilateral mastectomy had annual mammography. Statistics Surgical outcomes measured were margin status, re-excision lumpectomy rate, and mastectomy rate. Other outcomes included compliance with recommended adjuvant chemotherapy, radiation therapy, and initiation of endocrine therapy, as well as local recurrence, and overall survival. A two-sample t-test was used to compare the continuous variables between the two groups, before and after the initiative to implement the innovative approach to lower patient costs of treatment. A Fisher’s exact test was used to compare the categorical variables. The outcomes were compared using Fisher’s exact test. Unpaired t-test was used to compare the continuous variables. All statistical tests were two sided and significance levels were set at 5%. Results A total of 1,797 patients were included. Among them, 661 patients were seen before the cost limiting approach (BCS) was started, while 1,136 patients were seen after the implementation of the new cost limiting approach (ACS) was implemented (Table 1 ). The changes made with the implementation of the cost saving approach resulted in a shorter time to operation. These changes also led to a significant reduction in the estimated costs to uninsured patients (Table 2 ). The mean age of the patients was 52 years (Table 3 ) with most patients being Hispanic (56%). On average the patients had 10 years of education and 18% had adequate health literacy. The majority of patients were not employed (70%), had a mean monthly income of $ 1063, and most were uninsured (56%) or insured by Medicaid (31%). Patients seen after the implementation of the cost saving approach were younger and had fewer years of education, but were more likely to be employed and have higher income. Despite this, patients in the ACL group were more likely to be uninsured (65% vs 42%, p < 0.001). Only 18% of patients underwent screening mammography and as a result 71% of patients presented with a palpable mass and 67% of patients presented at stage II or later (Table 4 ). Table 2 Difference in time to operation and cost* after the implementation of the cost saving approach Before Cost Saving Approach After Cost Saving Approach Clinical presentation: Palpable mass/Abnormal mammogram 1/1/2024 1/1/2024 Diagnostic mammogram/US 1–4 weeks (2/1/2024) 0 (63) $ 250 $ 200 Image guided biopsy 1–4 weeks (3/1/2024) 0 (64) $ 1500 $ 0 Consultation for pathologic diagnosis of breast cancer 1 week (3/8/2024) 1 week (1/8/2024) Consultation for genetic counseling/testing 1 week (3/15/2024) 0 (65) $ 1000 $ 0 Genetic testing results 2 weeks (3/29/2024) 2 weeks (1/22/2024) Preoperative Breast MRI 1 week (4/6/2024) Not done (66) $ 1000 $ 0 Operation 2 weeks (4/20/2024) 2 weeks (2/5/2024) $ 11,783 $ 2000 Chemotherapy $ 13,373 x8 $ 0 Radiation therapy (57) $ 14,910 $ 5000 Endocrine therapy per year (67) $ 1080 $ 1080 TOTAL – no chemotherapy $ 31,523 $ 8020 TOTAL – including chemotherapy $ 138,507 $ 8020 *Does not include office copays which are the same in both groups Table 3 Patient sociodemographics of population studied Patients (N = 1797) Before Cost Saving Approach (N = 661) After Cost Saving Approach (N = 1136) p value Age at Diagnosis: Median, Mean Less than 40 40–49 50–59 60–69 70 and greater 52, 52.9 (24–97) 217 (12%) 538 (30%) 543 (30%) 344 (19%) 156 (9%) 54, 54.9 (24–97) 74 (11%) 159 (24%) 207 (31%) 139 (21%) 82 (12%) 51, 51.8 (25–96) 143 (13%) 379 (33%) 336 (30%) 205 (18%) 74 (6%) 0.001 12.72 11.24 Race Non-Hispanic White African American Hispanic Other 503 (28%) 168 (9%) 1011 (56%) 114 (6%) 254 (38%) 64 (10%) 302 (46%) 38 (6%) 249 (22%) 104 (9%) 709 (62%) 76 (7%) 0.001 English speaking 939 (52%) 426 (64%) 513 (45%) 0.001 Education, Mean, yr (SD) Less than 9th Grade Some High School High school graduate Some College Missing 431 (27%) 262 (16%) 391 (25%) 506 (32%) 208 10.6 (3.84) 96 (21%) 81 (18%) 108 (23%) 174 (38%) 202 9.9 (4.21) 335 (30%) 181 (16%) 283 (25%) 332 (29%) 6 0.001 3.84 4.21 Adequate Health Literacy 237/1331 (18%) 71/339 (21%) 166/992 (17%) 0.08 Employment Employed Unemployed Retired Disabled 540 (30%) 965 (54%) 222 (12%) 57 (3%) 172 (26%) 332 (51%) 124 (19%) 20 (3%) 368 (32%) 633 (56%) 98 (9%) 37 (3%) 0.005 Monthly income, $ (SD) 1063.75 (1179.47) 904.60 (753.41) 1149.35 (1167.54) 0.001 Insurance Commercial Medicare Medicaid None 78 (4%) 150 (8%) 554 (31%) 1015 (56%) 36 (5%) 90 (14%) 257 (39%) 278 (42%) 42 (4%) 60 (5%) 297 (26%) 737 (65%) 0.001 Menopause Postmenopausal 1006 (56%) 435 (66%) 571 (50%) 0.001 Married/Domestic partner 767 (43%) 214 (32%) 553 (49%) 0.001 Median Height, meters (SD) Median Weight, kg (SD) Median BMI, kg/m 2 (SD) 1.59 (0.074) 75.6 (79.96) 29.8 (6.67) 1.6 (0.073) 72.8 (18.47) 29.6 (6.78) 1.58 (0.075) 73.5 (17.66) 29.9 (6.60) 0.001 0.42 0.36 Table 4 Clinical presentation, treatment, and breast cancer outcomes All patients (N = 1797) Before Cost Saving Approach (N = 661) After Cost Saving Approach (N = 1136) p value Screening Mammogram within 2 years of presentation (40 + years) 280/1539 (18.2%) 112/555 (20.2%) 168/984 (17.1%) 0.11 Clinical Tumor size, cm (SD) Palpable mass Clinically node positive 1283 (71%) 259/1797 (14%) 3.0 (3.01) 506 (77%) 90/661 (14%) 3.3 (3.60) 777 (68%) 169/1136 (15%) 0.07 0.002 0.49 Stage of Presentation 0 I II III IV 250 (14%) 347 (19%) 852 (47%) 317 (18%) 32 (2%) 69 (10%) 114 (17%) 381 (58%) 90 (14%) 7 (1%) 181 (16%) 233 (20%) 471 (41%) 227 (20%) 25 (2%) 0.001 Preoperative therapy* Chemotherapy Endocrine therapy 539 (38%) 35 (2.5%) 102 (17%) 5 (0.9%) 437 (47%) 30 (3%) 0.001 Operation Breast conservation Mastectomy Mastectomy with reconstruction 882 (63%) 428 (30%) 97 (7%) 287 (47%) 302 (50%) 20 (3%) 595 (75%) 126 (15%) 77 (10%) 0.001 Positive margin Breast conservation Mastectomy 164/882 (19%) 19/525 (4%) 72/287 (25%) 10/322 (3%) 92/595 (15%) 9/203 (4%) 0.001 0.48 Adjuvant therapy Chemotherapy Radiation therapy Endocrine therapy 709/883 (80%) 867/1059 (82%) 766/976 (78%) 317/453 (70%) 303/434(70%) 288/427 (67%) 392/430 (91%) 564/625 (90%) 478/549 (87%) 0.001 0.001 0.001 Recurrence IBTR CW Contralateral Regional Distant 59/882 (6.7%) 36/525 (6.9%) 29/1217 (2.4%) 7/1410 (0.5%) 119/1410 (8.4%) 46/287 (16%) 26/322 (8.1%) 17/586 (2.9%) 2/612 (0.3%) 51/612 (8.3%) 13/595 (2.2%) 10/203 (4.9%) 12/731 (1.6%) 5/798 (0.6%) 68/798 (8.5%) 0.001 0.21 0.13 0.71 0.92 Death 202/1410 (14.3%) 116/612 (19.0%) 86/798 (10.8%) 0.001 *Preoperative therapy for operable stage I – IIIA breast cancer The ACS group underwent a higher percentage of breast conservation procedures than the BCS group (75% vs 47%, p < 0.001). In patients who underwent breast conservation, patients in the ACS group were also less likely to have positive margins and need a second operation as compared to the BCS group (15% vs 25%, p < 0.001). A higher percentage of the ACS group received adjuvant therapy than the BCS group: Chemotherapy (91% vs 70%, p < 0.001), radiation therapy (91% versus 70%, p < 0.001), and initiated endocrine therapy (87% versus 67%, p < 0.001). At a mean follow up of 8 years (Table 4 ), these improvements in adjuvant therapy resulted in a lower incidence of ipsilateral breast tumor recurrence (2% vs 16%, p < 0.001) and similar acceptably low rate of chest wall recurrence (5% versus 8%, p = 0.21). The ACS group had better overall survival compared to the BCS group (90% vs 81%, p < 0.001). Discussion Many studies have been performed to identify disparities in breast cancer care among diverse populations [11–16,18,32,33,34]. Several factors contribute to these disparities including age, race, ethnicity, education. health literacy, employment, household income, insurance status, socioeconomic status, and social/family support. Few studies, however, have provided or attempted to provide solutions on how to improve these disparities. The current study found that after implementation of the cost limiting approach, patients were more likely to undergo breast conservation, have fewer operations, and more likely to undergo adjuvant treatments. These changes resulted in a lower risk for recurrence and death. Our study provides one approach on how to circumvent common breast cancer care barriers to improve outcomes in uninsured and low-income populations. Our study population is like many groups at risk for inadequate breast cancer care. Although the population was a common age seen in breast cancer studies, the majority were racial/ethnic minorities, almost half non-English speaking, and only 43% married/domestic partner. In addition, the population was undereducated and almost 80% had inadequate health literacy. Only 30% were employed and the mean monthly income was $ 1063. This is about 60% below the Federal poverty guideline of $ 31,200 per year [35]. As shown in Table 2 , cost of standard of care breast cancer treatment can be exorbitant for uninsured patients. Even for treatment where chemotherapy is not indicated, the cost would be three times the annual income of the population studied. With chemotherapy, the costs are increased by over $ 100,000. These costs do not include the costs for office visit copays and each additional operation for positive margins. An alarming 56% of the population was uninsured/self-pay and 31% AHCCCS (Medicaid). The rate of uninsured patients in the current study increased in the ACS period despite changes by the Affordable Care Act to increase access to health care. Lack of insurance or being insured by Medicaid both have been associated with poor breast cancer outcomes [11,13]. With the out of pocket costs shown in Table 2 , it was not surprising that compliance with recommended adjuvant therapy was lower prior to the implementation of the cost saving approach for patients. With the cost saving changes, the patient costs decreased by approximately $ 23,000 when chemotherapy was not indicated and by $ 130,000 when chemotherapy was recommended. Delays in breast cancer treatment start with a delay in diagnosis [36]. One study found the time interval from presentation to diagnosis of 23 days and from presentation to first treatment of 65 days. These intervals were longer Hispanic and underinsured patients [37]. The cost saving approach described lessens the likelihood of a patient having a time interval between awareness of an abnormality on breast imaging or physical examination and the biopsy to obtain a diagnosis (Table 2 ). The biopsy on the same day as initial consultation also lowers the costs for the patient because it does not require a separate visit or visit to another location. Racial/ethnic minority groups have been shown to be diagnosed at younger ages and more commonly with triple negative breast cancer than non-Hispanic White women [22,38,39]. Many of these patients are appropriate candidates for genetic counseling and testing. Under most circumstances these services would require a separate appointment. As shown in Table 2 , however, ACS patients eliminate three appointments and save over 2 months from presentation to operation. Many clinicians routinely recommend and order breast MRI on every breast cancer patient. This practice is performed despite studies demonstrating no benefit to lower the need for re-excision lumpectomy, fewer local recurrences, or improved overall survival [40,41,42]. As part of the Choose Wisely Campaign, the American Society of Breast Surgeons recommends against the routine use of MRI in newly diagnosed breast cancer patients [43]. Preoperative breast MRI was not performed on patients in the current study and therefore saved patients out of pocket costs. With an average household come one-third of the Federal poverty threshold, any additional costs are critical. Despite the poor use of screening mammography, presentation with palpable masses and at later stages, once the cost saving approach was implemented, the rate of breast conservation was improved from 47–75%, p < 0.001. This improvement in the rate of breast conservation was likely due to the increased availability of radiation therapy. Without a plan to obtain discounted radiation therapy and funding to support the costs, many patients in the BCS group likely opted for, or were told to have, mastectomy, even if they were appropriate candidates for breast conservation. The rate of breast conservation that was achieved is higher than that reported in most other studies involving underinsured, low-income safety net populations [13,44]. Preoperative breast magnetic resonance imaging was not utilized and the rate of positive margins decreased after the cost saving approach was implemented. The rate of positive margins (15%) was low relative to other reported studies (35%) and even comparable to other studies which utilized intraoperative margin assessment [27,45,46]. The satisfactory rate of breast conservation and positive margins, despite presentation with larger palpable tumors and at later stages, may raise concern that breast conservation was overutilized, possibly putting patients at increased risk for local recurrence and death. The results in Table 4 , however, show a low rate of ipsilateral breast tumor recurrence after breast conservation (2.2%) and death from breast cancer at median follow up of 8.1 years [47]. The low rate of positive margins may be reflective of the increased use of preoperative chemotherapy (47% vs 17%, p < 0.001) after the cost saving approach was implemented. Preoperative chemotherapy results in some percentage of pathologic complete response. In this situation, negative margins are ensured as there is no residual cancer [48,49]. In addition, several studies have demonstrated that intraoperative ultrasound can lower the risk for positive margins, and this technique was used throughout the time after the cost saving approach was implemented [50,51]. Fewer positive margins in an uninsured population are critically important to minimize the number of operations and therefore out of pocket costs. For patients who required or chose mastectomy, there was an increase in the number of patients who were able to undergo reconstruction during the ACS (38% vs 6%, p < 0.001). It is not clear how this change occurred as there was no provision to lessen the cost of reconstruction to the uninsured patients. Two possibilities are that, first reconstruction was offered as an option more often after the cost saving approach was implemented, and second patients may have been more likely to take advantage of the down payment only requirement prior to operations. Overall survival improved to 90% with a majority of patients presenting at stage II or later. Studies have demonstrated that patients insured with Medicaid have outcomes similar to uninsured patients rather than privately insured/commercial insurance patients [52,53,54]. This improvement in survival was likely due to the increased use of all types of adjuvant therapy during the ACS period. Use of recommended chemotherapy increased from 70–91%, p < 0.001. As discussed in the Methods section, for luminal breast cancer, the multigene assay was used to help determine the indication for chemotherapy [29]. Chemotherapeutic medications were obtained through the assistance of Cardinal Health [30]. The level of assistance and process likely varies based on the individual medical centers. Determination of qualification for financial assistance for genetic testing, multigene assay testing, and chemotherapy, however, did have similar requirements. All required patient identification, household size, and documentation of income. The documentation of income was typically with the W-2. If no W-2 was available, then a letter from the clinician and patient could be submitted to explain why no documentation of income was available and the best estimate of the household income. Radiation therapy use increased from 70–90% during the ACS (p < 0.001). The acceptable rate of breast conservation combined with 90% compliance with radiation therapy was an accomplishment compared to a previous study finding 40–65% compliance with radiation therapy [53,55]. Obtaining radiation therapy is the most problematic step in treatment of uninsured patients. Commercial insurance, Medicare, and Medicaid/AHCCCS all cover radiation therapy. Uninsured/self-pay patients must pay out of pocket. Although cost of radiation therapy varies from state to state, a study based on Medicare reimbursements estimated the cost between $ 7300 to $ 10,300 with another study estimating $ 14,910 [56,57]. This cost approaches the average annual income of the population studied. The ability to negotiate a discounted rate for the radiation therapy with a generous radiation oncology group greatly facilitated the treatment. The fund raising and obtainment of treatment grants by the Health Foundation of the hospital also assisted in payment for the treatment. Other studies have reported respectable rates of radiation therapy in safety net populations but had a comparatively very low (9%, 0%, 17% (combined with Medicaid)) percentage of uninsured patients and no explanation as to how the treatment was funded [58,59,60]. Other than the method used in the current study, other potential options include obtaining treatment from government funded facilities such as Veteran’s Administration hospitals or teaching facilities. These type of radiation facilities may be more capable of withstanding lower reimbursement for radiation therapy. Initiation of endocrine therapy was improved by a similar magnitude with the implementation of the cost saving approach. The same indications for endocrine therapy were used in both time periods. Cost of endocrine therapy is small relative to all other facets of breast cancer treatment. One possible explanation for the improvement is that once patients completed other parts of adjuvant therapy, they realized the importance of multidisciplinary treatment and followed through with the endocrine therapy [61]. One limitation is that prolonged compliance with endocrine therapy was not measured. One previous study found higher rates of discontinuation in patients with low income and either Medicaid or self-pay compared to those with private insurance [62]. This study has other limitations as well. Retrospective studies are subject to inherent limitations and biases. Data from prospective studies involving minority uninsured patients, however, are very difficult to obtain even in a disease as common as breast cancer. This study was from one institution, but with a population subject to many disparities. Although outcomes such as local recurrence and survival were reported in this study, the authors feel that the more important aspect of this study is the methodology employed to care for this population. Conclusion Peer reviewed literature is replete of studies documenting disparities in breast cancer treatment and outcomes for many populations. Clearly more studies are needed to provide additional solutions to these problems. The current study describes a successful cost limiting method which streamlines the breast cancer treatment and takes advantage of financial assistance programs to improve access to care in uninsured and low-income, Medicaid insured, patients. While this process may not be fully replicable in many health systems, it provides leaders with clear evidence that improvements in breast cancer care for diverse, low-wealth, individuals are achievable. Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ian Komenaka, Jesse Nodora, and Elena Martnez. The first draft of the manuscript was written by Ian Komenaka and Jesse Nodora and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The datasets generated and analysed during the current study are not publicly available because they were not publicly archived but are available from the corresponding author on reasonable request. Author Contribution JN, EM, IK wrote the main manuscript text. IGK and JN did the statistical analysis and prepared the tables. WA and GR completed the chemotherapy evaluation. JAD and HH completed the radiation therapy evaluation. All authors reviewed the manuscript. References 1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7–33. doi:10.3322/caac.21708 2. Blumen H, Fitch K, Polkus V. Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service. Am Health Drug Benefits. 2016;9(1):23–32. 3. McGarvey N, Gitlin M, Fadli E, Chung KC. Increased healthcare costs by later stage cancer diagnosis. 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Treatment Disparities in Radiation and Hormone Therapy Among Women Covered by Medicaid vs Private Insurance in Cancer Registry and Claims Data. JAMA Health Forum 2023 May 5; 4(5): e230673. doi: 10.1001/jamahealthforum.2023.0673. PMID: 37145688 56. Paravati AJ, Boero IJ, Triplett DP, Hwang L, Matsuno RK, Xu B, Mell LK, Murphy JD. Variation in the Cost of Radiation Therapy Among Medicare Patients With Cancer. J Oncol Pract 2015 Sep; 11(5): 403-9. doi: 10.1200/JOP.2015.005694. Epub 2015 Aug 11. PMID: 26265172 57. Blumen H, Fitch K, Polkus V. Comparison of Treatment Costs for Breast Cancer by Tumor Stage and Type of Service. Am Health Drug Benefits. 2016 Feb; 9(1): 23–32. PMID: 27066193 58. Fefferman A, Beaulieu-Jones BR, Shewmaker G, Zhang T, Sachs T, Merrill A, Ko NY, Cassidy MR. Association of Race, Ethnicity, Insurance, and Language and Rate of Breast-Conserving Therapy Among Women With Nonmetastatic Breast Cancer at an Urban, Safety-Net Hospital. J Surg Res. 2023 Nov; 291: 403–413. doi: 10.1016/j.jss.2023.06.009. Epub 2023 Jul 28. PMID: 37517348 59. Beaulieu-Jones BR, Shewmaker G, Fefferman A, Kenzik K, Zhang T, Drake FT, Sachs TE, Hirsch AE, Merrill A, Ko NY, Cassidy MR. Mitigating disparities in breast cancer treatment at an academic safety-net hospital. Breast Cancer Res Treat 2023 Apr; 198(3): 597–606. doi: 10.1007/s10549-023-06875-6. Epub 2023 Feb 24. PMID: 36826701 60. Parviz M, Cassel JB, Kaplan BJ, Karp SE, Neifeld JP, Penberthy LT, Bear HD. Breast conservation therapy rates are no different in medically indigent versus insured patients with early stage breast cancer. J Surg Oncol. 2003 Oct; 84(2): 57–62. doi: 10.1002/jso.10291. PMID: 14502777 61. Komenaka IK, Hsu CH, Martinez ME, Bouton ME, Low BG, Salganick JA, Nodora J, Hibbard ML, Jha C. Preoperative chemotherapy for operable breast cancer is associated with better compliance with adjuvant therapy in matched stage II and IIIA patients. Oncologist. 2011; 16(6): 742 − 51. doi: 10.1634/theoncologist.2010-0266. Epub 2011 May 9. PMID: 21558134 62. Brezden-Masley C, Fathers KE, Coombes ME, Pourmirza B, Xue C, Jerzak KJ. A population-based comparison of treatment patterns, resource utilization, and costs by cancer stage for Ontario patients with hormone receptor-positive/HER2-negative breast cancer. Breast Cancer Res Treat 2021 Jan; 185(2): 507–515. doi: 10.1007/s10549-020-05960-4. Epub 2020 Oct 16. PMID: 33064230. 63. https://www.goodrx.com/conditions/breast-cancer/free-mammogram 64. https://www.diagnosticimaging.com/view/ultrasound-guided-breast-biopsy-gains-popularity 65. https://www.breastcancer.org/genetic-testing 66. https://www.breastcancer.org/screening-testing/breast-mri 67. https://www.singlecare.com/blog/tamoxifen-without-insurance/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2024 Read the published version in Cancer Causes & Control → Version 1 posted Editorial decision: Revision requested 28 Oct, 2024 Reviews received at journal 29 Sep, 2024 Reviewers agreed at journal 23 Sep, 2024 Reviewers invited by journal 18 Sep, 2024 Editor assigned by journal 11 Sep, 2024 Submission checks completed at journal 11 Sep, 2024 First submitted to journal 07 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Komenaka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYBACgwNgKoGBXwLMkJAhqMWwAapFcgYDI5AtwUNQizEDVIvBDbAWBsJazNi7Ex8X1KTJG99uPv7oRo0FDwP74aMb8Gmx4Tm72XjGsRzDbXeOJTbnHAM6jCct7QZeLRK526R52CoYt93IMWzOYQNqkeAxw6vFTCJ3+2+efxX2m2eAtPwjQosx0BZm3racxA0SQC25bURoMew5u1maty8tecaNtMTZuX0SPGyE/GJwvHfjZ55vybb9M5IPfM75VifHz374GF4tmICNNOWjYBSMglEwCrABAGeYR9TFfr3LAAAAAElFTkSuQmCC","orcid":"","institution":"University of Arizona College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ian","middleName":"K.","lastName":"Komenaka","suffix":""}],"badges":[],"createdAt":"2024-09-07 21:54:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5050432/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5050432/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10552-024-01935-8","type":"published","date":"2024-11-26T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70388901,"identity":"6d293f34-b73b-4772-8085-1921facae5a3","added_by":"auto","created_at":"2024-12-02 17:27:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":604166,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5050432/v1/1fd0f364-783a-4dcf-b760-9fc5b59dbea3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An innovative approach to the multidisciplinary treatment of uninsured breast cancer patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most prevalent cancer among women, accounting for about one-third of all cancer diagnoses. It also stands as the second leading cause of cancer-related mortality [1]. Over the past three decades, the integrated approach to breast cancer management has witnessed significant advancements in both diagnostic and therapeutic modalities. Breast cancer management, therefore, requires multidisciplinary care with collaboration of radiologic imaging, pathology, genetic counseling, surgery, radiation oncology, and medical oncology. This has resulted in significantly improved breast cancer survival since 1990 [1].\u003c/p\u003e \u003cp\u003eThese advancements, however, come with notable financial implications. A study from 2010 highlighted that the cost of treatment to insurance companies could range from \u003cspan\u003e$\u003c/span\u003e71,000 to \u003cspan\u003e$\u003c/span\u003e190,000 over the first two years, depending on the stage of breast cancer at diagnosis [2]. With further improvement and more available treatments, contemporary cost of therapy has increased to \u003cspan\u003e$\u003c/span\u003e117,000 to \u003cspan\u003e$\u003c/span\u003e435,000 again over the first two years [3]. Access to insurance coverage through the Affordable Care Act (ACA) and other measures have improved coverage, particularly for low-income patients [4,5]. Some studies, however, have shown that the improvement in the rate of early-stage breast cancer was only 1.4% post-ACA [6]. Despite some improvements in access, there remains a significant proportion of the population that remains uninsured. Data from the 2022 National Health Interview Survey indicates that 12.1% of adults aged 18–64 are uninsured, with disparities evident among racial and ethnic groups: 27% of Hispanics, 12.9% of Non-Hispanic Blacks, and 8% of Non-Hispanic Asians lacked insurance, compared to 7.4% of Non-Hispanic Whites [7]. Without insurance most medical expenses become out of pocket costs borne by the patient.\u003c/p\u003e \u003cp\u003eTherefore, uninsured and low-income individuals and families, often grappling with socio-economic challenges, face significant barriers in accessing healthcare. For breast cancer patients, these barriers result in poorer outcomes due to delay in diagnosis, presentation at later stages, and decreased compliance with recommended adjuvant therapy [8–16]. These challenges are further magnified in low-resource communities, where factors such as education, limited English proficiency and health literacy, socio-economic constraints, and cultural beliefs can impede effective breast cancer management [11,15,17–20].\u003c/p\u003e \u003cp\u003eWhile there is literature highlighting the disparities in breast cancer management and outcomes based on socio-economic status and insurance status, there remains a lack of data on effective strategies to bridge these gaps, especially in the uninsured population. The aim of the study was to assess differences in breast cancer outcomes before and after the implementation of an innovative cost limiting approach to the multidisciplinary treatment of breast cancer among uninsured patients.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e This study was conducted at Maricopa/Valleywise Medical Center and was approved by their Institutional Review Board. Maricopa Medical Center is the safety-net hospital for Maricopa County, which includes the city of Phoenix and the surrounding metropolitan area. Maricopa County is the state’s most populous area with over 4.5\u0026nbsp;million of Arizona’s 7.4\u0026nbsp;million inhabitants. Maricopa Medical Center is a teaching institution with seven graduate medical education Residency Programs.\u003c/p\u003e\u003cp\u003eStudy Patients: The hospital system receives referrals of underinsured patients from around the county. As a result, the patient population was 78% from racial/ethnic minority groups and 87% were underinsured (insured by Arizona Health Care Cost Containment System (AHCCCS)/Medicaid) or uninsured/self-pay.\u003c/p\u003e\u003cp\u003eData Collection: Retrospective chart review was performed from January 1, 2000 to December 31, 2020 of all patients seen in the Breast Clinic. All patients with a diagnosis of breast cancer were included in the study. Baseline data for every patient was compiled prospectively, supplemented by retrospective chart review. The data included sociodemographic information, health literacy assessment, and diagnostic tests. Self-reported household income was also documented. Health literacy was assessed using the Newest Vital Sign (NVS)[21]. Breast cancer treatment, follow up, and mortality were documented.\u003c/p\u003e\u003cp\u003eDesign of study: Beginning on July 1, 2006, the Chairman of the Department of Surgery felt there was a significant need in the patient population for breast cancer care. As a result, an innovative cost limiting approach to lowering patient costs was implemented to facilitate care of uninsured patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The Breast Clinic was located in an adjacent space to the Women’s Imaging Center. A fellowship trained breast surgical oncologist was hired to manage the Breast Clinic. The surgeon had experience with ultrasound and image guided core needle biopsy. These steps were critical to the process because the majority of the patient population did not undergo routine screening mammography. Therefore, many patients presented with palpable masses or findings visible on ultrasound. The Breast Clinic setup, both with staffing and location, allowed patients to have the initial consultation, obtain diagnostic imaging, and undergo diagnostic image guided biopsy at the same initial visit.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGoals of an innovative approach to setting up a cost limiting breast cancer treatment program\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Negotiate lower cost radiation therapy with an academic or government funded radiation facility.\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Apply for treatment grants and fund raising for treatment costs.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Negotiate discounted chemotherapeutic medications.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Take appropriate steps to minimize number and cost of operations.\u003c/p\u003e \u003cp\u003eUtilize preoperative chemotherapy and pathologic complete response.\u003c/p\u003e \u003cp\u003eUtilize intraoperative US.\u003c/p\u003e \u003cp\u003eUtilize preoperative localization only when location cannot be confidently identified by\u003c/p\u003e \u003cp\u003epreoperative US\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Identify existing programs and paperwork to obtain genetic testing and multigene assays at discounted rates.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Consolidate or minimize the number of visits to obtain a diagnosis to lower costs and lessen\u003c/p\u003e \u003cp\u003ethe possibility of noncompliance and delay in diagnosis.\u003c/p\u003e \u003cp\u003eHire a breast surgical oncologist with experience in breast ultrasound and image guided\u003c/p\u003e \u003cp\u003ebiopsy.\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Limit the number of tests ordered according the Choose Wisely Programs (preoperative\u003c/p\u003e \u003cp\u003eMRI, metastatic workup in patients without systemic symptoms)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis method of “one stop shopping” streamlined the process of obtaining a diagnosis for patients and decreased costs from multiple visits. This also prevented the patient from leaving after diagnostic imaging without a biopsy. Completing the biopsy is important as most patients with breast cancer are asymptomatic and when told that there is a problem on the mammogram, may not return for a biopsy due to other more pressing needs.\u003c/p\u003e\u003cp\u003eFollowing the biopsy, patients were scheduled to return and given an appointment date and time in one week to discuss the pathologic diagnosis. Preoperative breast magnetic resonance imaging was not used, except in the presentation of positive lymph node with an unknown primary. Racial/Ethnic minority patients do get diagnosed at a younger age than non-Hispanic White patients [22,23]. Underinsured patients, however, have difficulty obtaining genetic counseling and paying for genetic testing. The Breast surgical oncologist underwent training in Genetic Cancer Risk Assessment at City of Hope National Medical Center. The training is approximately 13 weeks in duration and the majority of the training was done with online classes [24]. After counseling, if genetic testing was indicated, based on contemporary National Comprehensive Cancer Network (NCCN) guidelines [25], and desired by the patient, blood or sputum was sent to Myriad Genetics. For uninsured patients, Myriad does have a Financial Assistance Program based on the household income of the patient [26].\u003c/p\u003e\u003cp\u003eAfter consultation and discussion about the diagnosis, if an operation was expected to be the first step in the management, uninsured/self-pay patients met with a financial counselor. Rather than requiring full payment of the planned operation upfront, a down payment was made with a plan for payment in installments of the remainder of the cost. The amount of the down payment varied over the 15 year time period of the study but was approximately \u003cspan\u003e$\u003c/span\u003e2000. If subsequent operations were required for involved margins, another down payment was required. In breast conservation, positive margins are an issue regardless of patient and insurance status [27]. In uninsured/self-pay patients, the cost of additional operations was yet another reason to try to obtain negative margins on the first attempt. For patients undergoing breast conservation for nonpalpable cancer, attempt was made to visualize the cancer with ultrasound. If visible on ultrasound, then breast conservation could be performed with no preoperative localization with wire or tag. For cancers only seen on mammography, the operations were done with wire localization the morning of the planned operation. Radiofrequency tags and magnetic seeds were not used during the study period.\u003c/p\u003e\u003cp\u003eIndications for chemotherapy must be individualized. For documentation purposes, all patients with triple negative breast cancer or Her2neu positive (immunohistochemistry 3 + or FISH amplified) at least 1cm or lymph node positive were considered candidates for chemotherapy. Patients with smaller node negative cancers could be considered candidates for chemotherapy based on the recommendation of the treating Oncologist. Generally, patients were treated with anthracycline and taxane based regimens. Patients were often treated with every 3 week taxanes rather than weekly to lessen the number of office visit copays. In patients with luminal breast cancer, a multigene assay was used to determine if chemotherapy was indicated [28]. Prior to July 2019 financial assistance for this assay was available. The multigene assay which was used was purchased by a different company on July 29, 2019. This changed the process and documentation for financial assistance that was used for the majority of the study. There is, however, still a financial assistance program for the multigene assay [29]. When chemotherapy, with or without targeted therapy was indicated, a process was implemented to apply for discounted medications for evidence based regimens with the assistance of Cardinal Health [30]. Some Her2neu targeted therapy and immunotherapy agents could also be used in a similar fashion. The availability and costs depend on discussion at an administrative level of the individual medical center and Cardinal Health. Many of the requirements for financial assistance programs are similar and common requirements include personal identification, household size, and documentation of income.\u003c/p\u003e\u003cp\u003eIndications for radiation therapy included any patient who underwent breast conservation, except patients age 70 years and older with luminal breast cancer [31]. In addition, postmastectomy radiation was recommended for all patients with four or more positive lymph nodes. Patients with one to three positive nodes were not offered postmastectomy radiation due to limitations of funding. There are no radiation therapy facilities at Maricopa Medical Center. An agreement was therefore made with a medical specialty group in Phoenix, with radiation oncology facilities, to provide radiation therapy at a significantly discounted cost to uninsured patients. The treatment was paid through treatment grants as well as fundraising activities by the Health Foundation of the hospital\u003c/p\u003e\u003cp\u003eFor endocrine therapy and risk reduction, due to the lower cost, Tamoxifen was the primary medication used until 2010. After aromatase inhibitors became generic, they were more commonly used in postmenopausal women. Patients were seen semiannually for 5 years and then annually after 5 years. Patients who did not undergo bilateral mastectomy had annual mammography.\u003c/p\u003e\u003cp\u003eStatistics\u003c/p\u003e\u003cp\u003eSurgical outcomes measured were margin status, re-excision lumpectomy rate, and mastectomy rate. Other outcomes included compliance with recommended adjuvant chemotherapy, radiation therapy, and initiation of endocrine therapy, as well as local recurrence, and overall survival. A two-sample t-test was used to compare the continuous variables between the two groups, before and after the initiative to implement the innovative approach to lower patient costs of treatment. A Fisher’s exact test was used to compare the categorical variables. The outcomes were compared using Fisher’s exact test. Unpaired t-test was used to compare the continuous variables. All statistical tests were two sided and significance levels were set at 5%.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,797 patients were included. Among them, 661 patients were seen before the cost limiting approach (BCS) was started, while 1,136 patients were seen after the implementation of the new cost limiting approach (ACS) was implemented (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The changes made with the implementation of the cost saving approach resulted in a shorter time to operation. These changes also led to a significant reduction in the estimated costs to uninsured patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The mean age of the patients was 52 years (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) with most patients being Hispanic (56%). On average the patients had 10 years of education and 18% had adequate health literacy. The majority of patients were not employed (70%), had a mean monthly income of \u003cspan\u003e$\u003c/span\u003e1063, and most were uninsured (56%) or insured by Medicaid (31%). Patients seen after the implementation of the cost saving approach were younger and had fewer years of education, but were more likely to be employed and have higher income. Despite this, patients in the ACL group were more likely to be uninsured (65% vs 42%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Only 18% of patients underwent screening mammography and as a result 71% of patients presented with a palpable mass and 67% of patients presented at stage II or later (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifference in time to operation and cost* after the implementation of the cost saving approach\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore Cost Saving Approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter Cost Saving Approach\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical presentation:\u003c/p\u003e \u003cp\u003ePalpable mass/Abnormal mammogram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/1/2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/1/2024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnostic mammogram/US\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4 weeks (2/1/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImage guided biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;4 weeks (3/1/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultation for pathologic diagnosis of breast cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 week (3/8/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 week (1/8/2024)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsultation for genetic counseling/testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 week (3/15/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetic testing results\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 weeks (3/29/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 weeks (1/22/2024)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Breast MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 week (4/6/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot done\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 weeks (4/20/2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 weeks (2/5/2024)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e11,783\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e2000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e13,373 x8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation therapy (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e14,910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e5000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndocrine therapy per year (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL \u0026ndash; no chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e31,523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTOTAL \u0026ndash; including chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e138,507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e8020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Does not include office copays which are the same in both groups\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient sociodemographics of population studied\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;1797)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore Cost Saving Approach\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;661)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter Cost Saving Approach\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1136)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at Diagnosis: Median, Mean\u003c/p\u003e \u003cp\u003eLess than 40\u003c/p\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003cp\u003e70 and greater\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52, 52.9 (24\u0026ndash;97)\u003c/p\u003e \u003cp\u003e217 (12%)\u003c/p\u003e \u003cp\u003e538 (30%)\u003c/p\u003e \u003cp\u003e543 (30%)\u003c/p\u003e \u003cp\u003e344 (19%)\u003c/p\u003e \u003cp\u003e156 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54, 54.9 (24\u0026ndash;97)\u003c/p\u003e \u003cp\u003e74 (11%)\u003c/p\u003e \u003cp\u003e159 (24%)\u003c/p\u003e \u003cp\u003e207 (31%)\u003c/p\u003e \u003cp\u003e139 (21%)\u003c/p\u003e \u003cp\u003e82 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51, 51.8 (25\u0026ndash;96)\u003c/p\u003e \u003cp\u003e143 (13%)\u003c/p\u003e \u003cp\u003e379 (33%)\u003c/p\u003e \u003cp\u003e336 (30%)\u003c/p\u003e \u003cp\u003e205 (18%)\u003c/p\u003e \u003cp\u003e74 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e12.72\u003c/p\u003e \u003cp\u003e11.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003cp\u003eNon-Hispanic White\u003c/p\u003e \u003cp\u003eAfrican American\u003c/p\u003e \u003cp\u003eHispanic\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e503 (28%)\u003c/p\u003e \u003cp\u003e168 (9%)\u003c/p\u003e \u003cp\u003e1011 (56%)\u003c/p\u003e \u003cp\u003e114 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254 (38%)\u003c/p\u003e \u003cp\u003e64 (10%)\u003c/p\u003e \u003cp\u003e302 (46%)\u003c/p\u003e \u003cp\u003e38 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e249 (22%)\u003c/p\u003e \u003cp\u003e104 (9%)\u003c/p\u003e \u003cp\u003e709 (62%)\u003c/p\u003e \u003cp\u003e76 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnglish speaking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e939 (52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e426 (64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e513 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, Mean, yr (SD)\u003c/p\u003e \u003cp\u003eLess than 9th Grade\u003c/p\u003e \u003cp\u003eSome High School\u003c/p\u003e \u003cp\u003eHigh school graduate\u003c/p\u003e \u003cp\u003eSome College\u003c/p\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e431 (27%)\u003c/p\u003e \u003cp\u003e262 (16%)\u003c/p\u003e \u003cp\u003e391 (25%)\u003c/p\u003e \u003cp\u003e506 (32%)\u003c/p\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.6 (3.84)\u003c/p\u003e \u003cp\u003e96 (21%)\u003c/p\u003e \u003cp\u003e81 (18%)\u003c/p\u003e \u003cp\u003e108 (23%)\u003c/p\u003e \u003cp\u003e174 (38%)\u003c/p\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.9 (4.21)\u003c/p\u003e \u003cp\u003e335 (30%)\u003c/p\u003e \u003cp\u003e181 (16%)\u003c/p\u003e \u003cp\u003e283 (25%)\u003c/p\u003e \u003cp\u003e332 (29%)\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e3.84\u003c/p\u003e \u003cp\u003e4.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate Health Literacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e237/1331 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71/339 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e166/992 (17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployment\u003c/p\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003cp\u003eRetired\u003c/p\u003e \u003cp\u003eDisabled\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e540 (30%)\u003c/p\u003e \u003cp\u003e965 (54%)\u003c/p\u003e \u003cp\u003e222 (12%)\u003c/p\u003e \u003cp\u003e57 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e172 (26%)\u003c/p\u003e \u003cp\u003e332 (51%)\u003c/p\u003e \u003cp\u003e124 (19%)\u003c/p\u003e \u003cp\u003e20 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e368 (32%)\u003c/p\u003e \u003cp\u003e633 (56%)\u003c/p\u003e \u003cp\u003e98 (9%)\u003c/p\u003e \u003cp\u003e37 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly income, \u003cspan\u003e$\u003c/span\u003e (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1063.75 (1179.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e904.60 (753.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1149.35 (1167.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsurance\u003c/p\u003e \u003cp\u003eCommercial\u003c/p\u003e \u003cp\u003eMedicare\u003c/p\u003e \u003cp\u003eMedicaid\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (4%)\u003c/p\u003e \u003cp\u003e150 (8%)\u003c/p\u003e \u003cp\u003e554 (31%)\u003c/p\u003e \u003cp\u003e1015 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (5%)\u003c/p\u003e \u003cp\u003e90 (14%)\u003c/p\u003e \u003cp\u003e257 (39%)\u003c/p\u003e \u003cp\u003e278 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42 (4%)\u003c/p\u003e \u003cp\u003e60 (5%)\u003c/p\u003e \u003cp\u003e297 (26%)\u003c/p\u003e \u003cp\u003e737 (65%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenopause\u003c/p\u003e \u003cp\u003ePostmenopausal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1006 (56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e435 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e571 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/Domestic partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e767 (43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e214 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e553 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Height, meters (SD)\u003c/p\u003e \u003cp\u003eMedian Weight, kg (SD)\u003c/p\u003e \u003cp\u003eMedian BMI, kg/m\u003csup\u003e2\u003c/sup\u003e (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.59 (0.074)\u003c/p\u003e \u003cp\u003e75.6 (79.96)\u003c/p\u003e \u003cp\u003e29.8 (6.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6 (0.073)\u003c/p\u003e \u003cp\u003e72.8 (18.47)\u003c/p\u003e \u003cp\u003e29.6 (6.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.58 (0.075)\u003c/p\u003e \u003cp\u003e73.5 (17.66)\u003c/p\u003e \u003cp\u003e29.9 (6.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.42\u003c/p\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical presentation, treatment, and breast cancer outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1797)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore Cost Saving Approach\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;661)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter Cost Saving Approach\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1136)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening Mammogram within 2 years of presentation (40\u0026thinsp;+\u0026thinsp;years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e280/1539 (18.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112/555 (20.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e168/984 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Tumor size, cm (SD)\u003c/p\u003e \u003cp\u003ePalpable mass\u003c/p\u003e \u003cp\u003eClinically node positive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1283 (71%)\u003c/p\u003e \u003cp\u003e259/1797 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0 (3.01)\u003c/p\u003e \u003cp\u003e506 (77%)\u003c/p\u003e \u003cp\u003e90/661 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.3 (3.60)\u003c/p\u003e \u003cp\u003e777 (68%)\u003c/p\u003e \u003cp\u003e169/1136 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003cp\u003e0.002\u003c/p\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage of Presentation\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003eII\u003c/p\u003e \u003cp\u003eIII\u003c/p\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e250 (14%)\u003c/p\u003e \u003cp\u003e347 (19%)\u003c/p\u003e \u003cp\u003e852 (47%)\u003c/p\u003e \u003cp\u003e317 (18%)\u003c/p\u003e \u003cp\u003e32 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (10%)\u003c/p\u003e \u003cp\u003e114 (17%)\u003c/p\u003e \u003cp\u003e381 (58%)\u003c/p\u003e \u003cp\u003e90 (14%)\u003c/p\u003e \u003cp\u003e7 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e181 (16%)\u003c/p\u003e \u003cp\u003e233 (20%)\u003c/p\u003e \u003cp\u003e471 (41%)\u003c/p\u003e \u003cp\u003e227 (20%)\u003c/p\u003e \u003cp\u003e25 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative therapy*\u003c/p\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003cp\u003eEndocrine therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e539 (38%)\u003c/p\u003e \u003cp\u003e35 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (17%)\u003c/p\u003e \u003cp\u003e5 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e437 (47%)\u003c/p\u003e \u003cp\u003e30 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation\u003c/p\u003e \u003cp\u003eBreast conservation\u003c/p\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003cp\u003eMastectomy with reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e882 (63%)\u003c/p\u003e \u003cp\u003e428 (30%)\u003c/p\u003e \u003cp\u003e97 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e287 (47%)\u003c/p\u003e \u003cp\u003e302 (50%)\u003c/p\u003e \u003cp\u003e20 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e595 (75%)\u003c/p\u003e \u003cp\u003e126 (15%)\u003c/p\u003e \u003cp\u003e77 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive margin\u003c/p\u003e \u003cp\u003eBreast conservation\u003c/p\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164/882 (19%)\u003c/p\u003e \u003cp\u003e19/525 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72/287 (25%)\u003c/p\u003e \u003cp\u003e10/322 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92/595 (15%)\u003c/p\u003e \u003cp\u003e9/203 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant therapy\u003c/p\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003cp\u003eRadiation therapy\u003c/p\u003e \u003cp\u003eEndocrine therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e709/883 (80%)\u003c/p\u003e \u003cp\u003e867/1059 (82%)\u003c/p\u003e \u003cp\u003e766/976 (78%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e317/453 (70%)\u003c/p\u003e \u003cp\u003e303/434(70%)\u003c/p\u003e \u003cp\u003e288/427 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e392/430 (91%)\u003c/p\u003e \u003cp\u003e564/625 (90%)\u003c/p\u003e \u003cp\u003e478/549 (87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003cp\u003eIBTR\u003c/p\u003e \u003cp\u003eCW\u003c/p\u003e \u003cp\u003eContralateral\u003c/p\u003e \u003cp\u003eRegional\u003c/p\u003e \u003cp\u003eDistant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59/882 (6.7%)\u003c/p\u003e \u003cp\u003e36/525 (6.9%)\u003c/p\u003e \u003cp\u003e29/1217 (2.4%)\u003c/p\u003e \u003cp\u003e7/1410 (0.5%)\u003c/p\u003e \u003cp\u003e119/1410 (8.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46/287 (16%)\u003c/p\u003e \u003cp\u003e26/322 (8.1%)\u003c/p\u003e \u003cp\u003e17/586 (2.9%)\u003c/p\u003e \u003cp\u003e2/612 (0.3%)\u003c/p\u003e \u003cp\u003e51/612 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13/595 (2.2%)\u003c/p\u003e \u003cp\u003e10/203 (4.9%)\u003c/p\u003e \u003cp\u003e12/731 (1.6%)\u003c/p\u003e \u003cp\u003e5/798 (0.6%)\u003c/p\u003e \u003cp\u003e68/798 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003cp\u003e0.21\u003c/p\u003e \u003cp\u003e0.13\u003c/p\u003e \u003cp\u003e0.71\u003c/p\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e202/1410 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116/612 (19.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e86/798 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Preoperative therapy for operable stage I \u0026ndash; IIIA breast cancer\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe ACS group underwent a higher percentage of breast conservation procedures than the BCS group (75% vs 47%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In patients who underwent breast conservation, patients in the ACS group were also less likely to have positive margins and need a second operation as compared to the BCS group (15% vs 25%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A higher percentage of the ACS group received adjuvant therapy than the BCS group: Chemotherapy (91% vs 70%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), radiation therapy (91% versus 70%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and initiated endocrine therapy (87% versus 67%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At a mean follow up of 8 years (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), these improvements in adjuvant therapy resulted in a lower incidence of ipsilateral breast tumor recurrence (2% vs 16%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and similar acceptably low rate of chest wall recurrence (5% versus 8%, p\u0026thinsp;=\u0026thinsp;0.21). The ACS group had better overall survival compared to the BCS group (90% vs 81%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMany studies have been performed to identify disparities in breast cancer care among diverse populations [11\u0026ndash;16,18,32,33,34]. Several factors contribute to these disparities including age, race, ethnicity, education. health literacy, employment, household income, insurance status, socioeconomic status, and social/family support. Few studies, however, have provided or attempted to provide solutions on how to improve these disparities. The current study found that after implementation of the cost limiting approach, patients were more likely to undergo breast conservation, have fewer operations, and more likely to undergo adjuvant treatments. These changes resulted in a lower risk for recurrence and death. Our study provides one approach on how to circumvent common breast cancer care barriers to improve outcomes in uninsured and low-income populations.\u003c/p\u003e \u003cp\u003eOur study population is like many groups at risk for inadequate breast cancer care. Although the population was a common age seen in breast cancer studies, the majority were racial/ethnic minorities, almost half non-English speaking, and only 43% married/domestic partner. In addition, the population was undereducated and almost 80% had inadequate health literacy. Only 30% were employed and the mean monthly income was \u003cspan\u003e$\u003c/span\u003e1063. This is about 60% below the Federal poverty guideline of \u003cspan\u003e$\u003c/span\u003e31,200 per year [35]. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, cost of standard of care breast cancer treatment can be exorbitant for uninsured patients. Even for treatment where chemotherapy is not indicated, the cost would be three times the annual income of the population studied. With chemotherapy, the costs are increased by over \u003cspan\u003e$\u003c/span\u003e100,000. These costs do not include the costs for office visit copays and each additional operation for positive margins. An alarming 56% of the population was uninsured/self-pay and 31% AHCCCS (Medicaid). The rate of uninsured patients in the current study increased in the ACS period despite changes by the Affordable Care Act to increase access to health care. Lack of insurance or being insured by Medicaid both have been associated with poor breast cancer outcomes [11,13]. With the out of pocket costs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, it was not surprising that compliance with recommended adjuvant therapy was lower prior to the implementation of the cost saving approach for patients. With the cost saving changes, the patient costs decreased by approximately \u003cspan\u003e$\u003c/span\u003e23,000 when chemotherapy was not indicated and by \u003cspan\u003e$\u003c/span\u003e130,000 when chemotherapy was recommended.\u003c/p\u003e \u003cp\u003eDelays in breast cancer treatment start with a delay in diagnosis [36]. One study found the time interval from presentation to diagnosis of 23 days and from presentation to first treatment of 65 days. These intervals were longer Hispanic and underinsured patients [37]. The cost saving approach described lessens the likelihood of a patient having a time interval between awareness of an abnormality on breast imaging or physical examination and the biopsy to obtain a diagnosis (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The biopsy on the same day as initial consultation also lowers the costs for the patient because it does not require a separate visit or visit to another location. Racial/ethnic minority groups have been shown to be diagnosed at younger ages and more commonly with triple negative breast cancer than non-Hispanic White women [22,38,39]. Many of these patients are appropriate candidates for genetic counseling and testing. Under most circumstances these services would require a separate appointment. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, however, ACS patients eliminate three appointments and save over 2 months from presentation to operation. Many clinicians routinely recommend and order breast MRI on every breast cancer patient. This practice is performed despite studies demonstrating no benefit to lower the need for re-excision lumpectomy, fewer local recurrences, or improved overall survival [40,41,42]. As part of the Choose Wisely Campaign, the American Society of Breast Surgeons recommends against the routine use of MRI in newly diagnosed breast cancer patients [43]. Preoperative breast MRI was not performed on patients in the current study and therefore saved patients out of pocket costs. With an average household come one-third of the Federal poverty threshold, any additional costs are critical.\u003c/p\u003e \u003cp\u003eDespite the poor use of screening mammography, presentation with palpable masses and at later stages, once the cost saving approach was implemented, the rate of breast conservation was improved from 47\u0026ndash;75%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. This improvement in the rate of breast conservation was likely due to the increased availability of radiation therapy. Without a plan to obtain discounted radiation therapy and funding to support the costs, many patients in the BCS group likely opted for, or were told to have, mastectomy, even if they were appropriate candidates for breast conservation. The rate of breast conservation that was achieved is higher than that reported in most other studies involving underinsured, low-income safety net populations [13,44]. Preoperative breast magnetic resonance imaging was not utilized and the rate of positive margins decreased after the cost saving approach was implemented. The rate of positive margins (15%) was low relative to other reported studies (35%) and even comparable to other studies which utilized intraoperative margin assessment [27,45,46]. The satisfactory rate of breast conservation and positive margins, despite presentation with larger palpable tumors and at later stages, may raise concern that breast conservation was overutilized, possibly putting patients at increased risk for local recurrence and death. The results in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, however, show a low rate of ipsilateral breast tumor recurrence after breast conservation (2.2%) and death from breast cancer at median follow up of 8.1 years [47]. The low rate of positive margins may be reflective of the increased use of preoperative chemotherapy (47% vs 17%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) after the cost saving approach was implemented. Preoperative chemotherapy results in some percentage of pathologic complete response. In this situation, negative margins are ensured as there is no residual cancer [48,49]. In addition, several studies have demonstrated that intraoperative ultrasound can lower the risk for positive margins, and this technique was used throughout the time after the cost saving approach was implemented [50,51]. Fewer positive margins in an uninsured population are critically important to minimize the number of operations and therefore out of pocket costs. For patients who required or chose mastectomy, there was an increase in the number of patients who were able to undergo reconstruction during the ACS (38% vs 6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). It is not clear how this change occurred as there was no provision to lessen the cost of reconstruction to the uninsured patients. Two possibilities are that, first reconstruction was offered as an option more often after the cost saving approach was implemented, and second patients may have been more likely to take advantage of the down payment only requirement prior to operations.\u003c/p\u003e \u003cp\u003eOverall survival improved to 90% with a majority of patients presenting at stage II or later. Studies have demonstrated that patients insured with Medicaid have outcomes similar to uninsured patients rather than privately insured/commercial insurance patients [52,53,54]. This improvement in survival was likely due to the increased use of all types of adjuvant therapy during the ACS period. Use of recommended chemotherapy increased from 70\u0026ndash;91%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. As discussed in the Methods section, for luminal breast cancer, the multigene assay was used to help determine the indication for chemotherapy [29]. Chemotherapeutic medications were obtained through the assistance of Cardinal Health [30]. The level of assistance and process likely varies based on the individual medical centers. Determination of qualification for financial assistance for genetic testing, multigene assay testing, and chemotherapy, however, did have similar requirements. All required patient identification, household size, and documentation of income. The documentation of income was typically with the W-2. If no W-2 was available, then a letter from the clinician and patient could be submitted to explain why no documentation of income was available and the best estimate of the household income.\u003c/p\u003e \u003cp\u003eRadiation therapy use increased from 70\u0026ndash;90% during the ACS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The acceptable rate of breast conservation combined with 90% compliance with radiation therapy was an accomplishment compared to a previous study finding 40\u0026ndash;65% compliance with radiation therapy [53,55]. Obtaining radiation therapy is the most problematic step in treatment of uninsured patients. Commercial insurance, Medicare, and Medicaid/AHCCCS all cover radiation therapy. Uninsured/self-pay patients must pay out of pocket. Although cost of radiation therapy varies from state to state, a study based on Medicare reimbursements estimated the cost between \u003cspan\u003e$\u003c/span\u003e7300 to \u003cspan\u003e$\u003c/span\u003e10,300 with another study estimating \u003cspan\u003e$\u003c/span\u003e14,910 [56,57]. This cost approaches the average annual income of the population studied. The ability to negotiate a discounted rate for the radiation therapy with a generous radiation oncology group greatly facilitated the treatment. The fund raising and obtainment of treatment grants by the Health Foundation of the hospital also assisted in payment for the treatment. Other studies have reported respectable rates of radiation therapy in safety net populations but had a comparatively very low (9%, 0%, 17% (combined with Medicaid)) percentage of uninsured patients and no explanation as to how the treatment was funded [58,59,60]. Other than the method used in the current study, other potential options include obtaining treatment from government funded facilities such as Veteran\u0026rsquo;s Administration hospitals or teaching facilities. These type of radiation facilities may be more capable of withstanding lower reimbursement for radiation therapy.\u003c/p\u003e \u003cp\u003eInitiation of endocrine therapy was improved by a similar magnitude with the implementation of the cost saving approach. The same indications for endocrine therapy were used in both time periods. Cost of endocrine therapy is small relative to all other facets of breast cancer treatment. One possible explanation for the improvement is that once patients completed other parts of adjuvant therapy, they realized the importance of multidisciplinary treatment and followed through with the endocrine therapy [61].\u003c/p\u003e \u003cp\u003eOne limitation is that prolonged compliance with endocrine therapy was not measured. One previous study found higher rates of discontinuation in patients with low income and either Medicaid or self-pay compared to those with private insurance [62]. This study has other limitations as well. Retrospective studies are subject to inherent limitations and biases. Data from prospective studies involving minority uninsured patients, however, are very difficult to obtain even in a disease as common as breast cancer. This study was from one institution, but with a population subject to many disparities. Although outcomes such as local recurrence and survival were reported in this study, the authors feel that the more important aspect of this study is the methodology employed to care for this population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePeer reviewed literature is replete of studies documenting disparities in breast cancer treatment and outcomes for many populations. Clearly more studies are needed to provide additional solutions to these problems. The current study describes a successful cost limiting method which streamlines the breast cancer treatment and takes advantage of financial assistance programs to improve access to care in uninsured and low-income, Medicaid insured, patients. While this process may not be fully replicable in many health systems, it provides leaders with clear evidence that improvements in breast cancer care for diverse, low-wealth, individuals are achievable.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ian Komenaka, Jesse Nodora, and Elena Martnez. The first draft of the manuscript was written by Ian Komenaka and Jesse Nodora and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available because they were not publicly archived but are available from the corresponding author on reasonable request.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJN, EM, IK wrote the main manuscript text. IGK and JN did the statistical analysis and prepared the tables. WA and GR completed the chemotherapy evaluation. JAD and HH completed the radiation therapy evaluation. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. 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PMID: 33064230.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e63. https://www.goodrx.com/conditions/breast-cancer/free-mammogram\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e64. https://www.diagnosticimaging.com/view/ultrasound-guided-breast-biopsy-gains-popularity\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e65. https://www.breastcancer.org/genetic-testing\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e66. https://www.breastcancer.org/screening-testing/breast-mri\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e67. https://www.singlecare.com/blog/tamoxifen-without-insurance/\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cancer-causes-and-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caco","sideBox":"Learn more about [Cancer Causes \u0026 Control](https://www.springer.com/journal/10552)","snPcode":"10552","submissionUrl":"https://submission.nature.com/new-submission/10552/3","title":"Cancer Causes \u0026 Control","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5050432/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5050432/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose\u003c/p\u003e\n\u003cp\u003eA significant proportion of many populations remain uninsured. The aim of the study was to assess differences in breast cancer outcomes before and after the implementation of an innovative approach to the multidisciplinary treatment of uninsured breast cancer patients.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eRetrospective review was performed of patients seen at a safety net hospital from January 2000 to December 2020. Beginning July 2006 an innovative approach was implemented to lower patient costs to facilitate care of uninsured patients.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eThe study included 1,797 patients, 661 patients before the changes (BCS), 1,136 patients after implementation of the new cost saving approach (ACS). The mean age was 53 years. The majority were uninsured (56%) or insured by Medicaid (31%). Only 18% underwent screening mammography.\u003c/p\u003e\n\u003cp\u003eThe ACS group had a higher rate of breast conservation (75% vs 47%, p \u0026lt; 0.001). A higher percentage of the ACS group received adjuvant therapy: Chemotherapy (91% vs 70%, p \u0026lt; 0.001), Radiation therapy (91% vs 70%, p \u0026lt; 0.001), and initiated endocrine therapy (87% vs 67%, p \u0026lt; 0.001). After follow up of 8 years, these changes resulted in lower ipsilateral breast tumor recurrence (2% vs 16%, p \u0026lt; 0.001) and chest wall recurrence (5% versus 8%) and improvement in overall survival (90% vs 81%, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003ePeer reviewed literature is replete of studies documenting disparities in breast cancer treatment. The current study describes a successful cost limiting method which takes advantage of existing financial assistance programs to improve care in uninsured patients.\u003c/p\u003e","manuscriptTitle":"An innovative approach to the multidisciplinary treatment of uninsured breast cancer patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-30 14:05:56","doi":"10.21203/rs.3.rs-5050432/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-28T14:13:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-29T17:50:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283745287667668948898996444016796922490","date":"2024-09-23T16:00:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-18T19:35:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-11T14:00:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-11T13:56:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cancer Causes \u0026 Control","date":"2024-09-07T21:53:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cancer-causes-and-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caco","sideBox":"Learn more about [Cancer Causes \u0026 Control](https://www.springer.com/journal/10552)","snPcode":"10552","submissionUrl":"https://submission.nature.com/new-submission/10552/3","title":"Cancer Causes \u0026 Control","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"36d8db32-8ac5-4873-be5b-a58be49ba161","owner":[],"postedDate":"October 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:22:56+00:00","versionOfRecord":{"articleIdentity":"rs-5050432","link":"https://doi.org/10.1007/s10552-024-01935-8","journal":{"identity":"cancer-causes-and-control","isVorOnly":false,"title":"Cancer Causes \u0026 Control"},"publishedOn":"2024-11-26 15:57:54","publishedOnDateReadable":"November 26th, 2024"},"versionCreatedAt":"2024-10-30 14:05:56","video":"","vorDoi":"10.1007/s10552-024-01935-8","vorDoiUrl":"https://doi.org/10.1007/s10552-024-01935-8","workflowStages":[]},"version":"v1","identity":"rs-5050432","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5050432","identity":"rs-5050432","version":["v1"]},"buildId":"pf3fE39SIOqb-0xH_OWvX","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}