Local practice variations and payer differences underlie state-wide disparities in oncoplastic breast surgery.

BACKGROUND: Little is known about disparities in oncoplastic breast surgery delivery. METHODS: The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy. RESULTS: We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001). CONCLUSION: Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.

The Effect of Black Cohosh on Ki67 expression and Tumor Volume: A Pilot Study of Ductal Carcinoma in Situ Patients.

BACKGROUND: Black cohosh (BC) (Cimicifuga racemosa) may prevent and treat breast cancer through anti-proliferative, pro-apoptotic, anti-estrogenic, and anti-inflammatory effects. This study sought to evaluate the effect of BC on tumor cellular proliferation, measured by Ki67 expression, in a pre-operative window trial of ductal carcinoma in situ (DCIS) patients. METHODS: Patients were treated pre-operatively for 2 to 6 weeks with BC extract. Eligible subjects were those who had DCIS on core biopsy. Ki67 was measured using automated quantitative immunofluorescence (AQUA) pre/post-operatively. Ki67, tumor volume, and hormone changes were assessed with 2-sided Wilcoxon signed-rank tests, α = .05. RESULTS: Thirty-one patients were treated for an average of 24.5 days (median 25; range 15-36). Ki67 decreased non-significantly (n = 26; P = .20; median pre-treatment 1280, post-treatment 859; range pre-treatment 175-7438, post-treatment 162-3370). Tumor volume, estradiol, and FSH did not change significantly. No grade 3 or 4 adverse events were reported. CONCLUSIONS: BC use showed no significant impact on cellular proliferation, tumor volume, or invasive disease upgrade rates in DCIS patients. It was well-tolerated, with no observed significant toxicities. Further study is needed to elucidate BC's role in breast cancer treatment and prevention.ClinicalTrials.gov Identifier: NCT01628536https://clinicaltrials.gov/ct2/show/NCT01628536.

Insulin resistance and racial disparities in breast cancer prognosis: a multi-center cohort study.

The survival for breast cancer (BC) is improving but remains lower in Black women than White women. A number of factors potentially drive the racial differences in BC outcomes. The aim of our study was to determine if insulin resistance (defined as homeostatic model assessment for insulin resistance (HOMA-IR)), mediated part of the relationship between race and BC prognosis (defined by the improved Nottingham prognostic index (iNPI)). We performed a cross-sectional study, recruiting self-identified Black and White women with newly diagnosed primary invasive BC from 10 US hospitals between March 2013 and February 2020. Survey, anthropometric, laboratory, and tumor pathology data were gathered, and we compared the results between Black and White women. We calculated HOMA-IR as well as iNPI scores and examined the associations between HOMA-IR and iNPI. After exclusions, the final cohort was 1206: 911 (76%) White and 295 (24%) Black women. Metabolic syndrome and insulin resistance were more common in Black than White women. Black women had less lobular BC, three times more triple-negative BC, and BCs with higher stage and iNPI scores than White women (P < 0.001 for all comparisons). Fewer Black women had BC genetic testing performed. HOMA-IR mediated part of the association between race and iNPI, particularly in BCs that carried a good prognosis and were hormone receptor (HR)-positive. Higher HOMA-IR scores were associated with progesterone receptor-negative BC in White women but not Black women. Overall, our results suggest that HOMA-IR contributes to the racial disparities in BC outcomes, particularly for women with HR-positive BCs.

Perioperative magnetic resonance imaging in breast cancer care: Distinct adoption trajectories among physician patient-sharing networks.

BACKGROUND: Despite no proven benefit in clinical outcomes, perioperative magnetic resonance imaging (MRI) was rapidly adopted into breast cancer care in the 2000's, offering a prime opportunity for assessing factors influencing overutilization of unproven technology. OBJECTIVES: To examine variation among physician patient-sharing networks in their trajectory of adopting perioperative MRI for breast cancer surgery and compare the characteristics of patients, providers, and mastectomy use in physician networks that had different adoption trajectories. METHODS AND FINDINGS: Using the Surveillance, Epidemiology, and End Results-Medicare database in 2004-2009, we identified 147 physician patient-sharing networks (caring for 26,886 patients with stage I-III breast cancer). After adjusting for patient clinical risk factors, we calculated risk-adjusted rate of perioperative MRI use for each physician network in 2004-2005, 2006-2007, and 2008-2009, respectively. Based on the risk-adjusted rate, we identified three distinct trajectories of adopting perioperative MRI among physician networks: 1) low adoption (risk-adjusted rate of perioperative MRI increased from 2.8% in 2004-2005 to 14.8% in 2008-2009), 2) medium adoption (8.8% to 45.1%), and 3) high adoption (33.0% to 71.7%). Physician networks in the higher adoption trajectory tended to have a larger proportion of cancer specialists, more patients with high income, and fewer patients who were Black. After adjusting for patients' clinical risk factors, the proportion of patients undergoing mastectomy decreased from 41.1% in 2004-2005 to 38.5% in 2008-2009 among those in physician networks with low MRI adoption, but increased from 27.0% to 31.4% among those in physician networks with high MRI adoption (p = 0.03 for the interaction term between trajectory group and time). CONCLUSIONS: Physician patient-sharing networks varied in their trajectory of adopting perioperative MRI. These distinct trajectories were associated with the composition of patients and providers in the networks, and had important implications for patterns of mastectomy use.

Comparing complications in irradiated and non-irradiated free-flaps in patients with bilateral immediate breast reconstruction and unilateral post-mastectomy radiotherapy.

BACKGROUND: Numerous studies have evaluated the effect of post-mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free-flaps are compared to non-irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. METHODS: Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free-flaps were compared to those on the contralateral non-irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free-flaps. RESULTS: Seventy-three women were included. There was no significant difference between complication rates for the irradiated and non-irradiated free-flaps (39.7% vs. 38.4%, p = .78), although irradiated free-flaps were more likely to have fibrosis (17.0% vs. 0.0%; p < .0001) and multiple complications (9.6% vs. 0.0%; p = .02). Both groups underwent a similar number of revision surgeries (42.5% vs. 41.1%; p = .29). Looking at the irradiated free-flaps, internal mammary node (IMN) irradiation was the only factor predictive of complications (IRR 3.80, CI 1.32-10.97; p = .01). CONCLUSIONS: PMRT may contribute to free-flap fibrosis, but does not appear to affect the overall risk of complications or revision surgeries. However, additional counseling is warranted if IMN irradiation is likely, as it is potentially associated with increased complications.

Characteristics and Long-Term Risk of Breast Angiosarcoma.

BACKGROUND: Angiosarcoma of the breast is rare and aggressive. It can occur as a de novo tumor or secondary to breast cancer treatment. The purpose of this study is to analyze differences between patients with primary and secondary angiosarcoma of the breast and investigate potential risk factors for its development. PATIENTS AND METHODS: The Surveillance, Epidemiology, and End Results program of the National Cancer Institute database was queried to identify patients with angiosarcoma of the breast, trunk, shoulder, and upper arm. The population-based incidence was analyzed. Primary and secondary angiosarcoma cases were identified and compared. Breast cancer characteristics of secondary angiosarcoma patients were compared with all breast cancer patients in the database who did not develop angiosarcoma. RESULTS: Overall, 904 patients were included, and 65.4% were secondary angiosarcomas. These patients had worse survival, were older, more likely to be White, more likely to have regionally advanced disease, and had angiosarcoma tumors of higher pathologic grade. Independent factors associated with development of secondary angiosarcoma among breast cancer patients included White race, older age, invasive tumor, lymph node removal, lumpectomy, radiation treatment, and left-sided tumor. Although the mean time to develop angiosarcoma after breast cancer diagnosis was 8.2 years, the risk continues to increase up to 30 years after breast cancer treatment. CONCLUSION: Angiosarcoma is rare but increasing in incidence. Secondary angiosarcomas are more common and exhibit more aggressive behavior. Several factors for angiosarcoma after breast cancer treatment could be identified, which may help us counsel and identify patients at risk.

Surgical Outcomes of Mastectomy with Immediate Autologous Reconstruction Followed by Radiation.

INTRODUCTION: Timing of autologous reconstruction relative to postmastectomy radiation therapy (PMRT) is debated. Benefits of immediate reconstruction must be weighed against a possibly heightened risk of complications from flap irradiation. We reviewed flap outcomes after single operation plus PMRT in a large institutional cohort. METHODS: Medical records were reviewed for women who underwent simultaneous mastectomy-autologous reconstruction with PMRT from 2007 to 2016. Primary endpoints were rates and types of radiation-related flap complications and reoperations, whose predictors were assessed by multivariable analysis. A p value < 0.10 was deemed significant to avoid type II error. Non-parametric logistic regression generated a model of PMRT timing associated with probabilities of complications and reoperations. RESULTS: One-hundred and thirty women underwent 208 mastectomy reconstruction operations, with a median follow up of 35.1 months (interquartile range 23.6-56.5). Forty-seven (36.2%) women experienced radiation-related complications, commonly fat necrosis (44.1%) and chest wall asymmetry (28.8%). Complications were higher among women who received PMRT < 3 months after surgery (46.8% for < 3 months vs. 29.3% for ≥ 3 months; p = 0.06), most of whom received neoadjuvant chemotherapy, and among women treated with internal mammary nodal (IMN) radiation (65.2% vs. 26.4%; p < 0.01); IMN radiation remained strongly associated in multivariable analysis (odds ratio [OR] 5.24; p < 0.01). Thirty-two (24.6%) women underwent 70 reoperations, commonly fat grafting (51.9%) and fat necrosis excision (17.1%). Reoperations were higher among women who received PMRT < 3 months after surgery (48.9 for < 3 months vs. 36.6 for ≥ 3 months; p = 0.19), which was significantly associated in multivariable analysis (OR 0.42; p = 0.08 for ≥ 3 months). The probabilities of complications and reoperations were lowest when PMRT was administered ≥ 3 months after surgery. CONCLUSIONS: Among a large institutional cohort, immediate autologous reconstruction was associated with similar rates of adverse flap outcomes as historically reported alternatively sequenced protocols. IMN radiation increased risk, while PMRT ≥ 3 months after surgery decreased risk. Additional studies are needed to elaborate the impact of IMN radiation and early PMRT in immediate versus delayed autologous reconstruction.

Is there variation in private payor payments to cancer surgeons? A cross-sectional study in the USA.

OBJECTIVES: Although demand for price transparency in healthcare is growing, variation in private payors' payments to surgeons for oncologic resection has not been well characterised. Our aim was to assess variation of private payors' payments to surgeons for cancer resection using data based on fee-for-service allowed amounts, billed by a large mix of commercial payors and third-party administrators. SETTING: Fair Health (FH), an independent, not-for-profit organisation that collects and compiles claims data from payors nationwide. FH maintains the nation's largest repository of privately billed medical and dental claims representing over 125 million covered lives in the USA. PARTICIPANTS: We performed a cross-sectional study assessing private payer data for five common types of cancer surgery: simple mastectomy (SM), modified radical mastectomy (MRM), open lobectomy, video-assisted thoracoscopic surgery (VATS) lobectomy and radical prostatectomy during 2012 and 2013. PRIMARY AND SECONDARY OUTCOME MEASURES: To assess variation across regions, we compared regional median allowed payments. To assess intraregion variability, we evaluated the distribution of regional IQRs of allowed payments. RESULTS: Median allowed payments varied substantially across regions. For SM, median allowed payments ranged from $550 in the least expensive to $1380 in the costliest region. For MRM, the range was $842-$1760, for lobectomy $326-$3066, for VATS $317-$3307 and for prostatectomy $1716-$4867. There was also substantial variation within geographic areas. For example, the mean IQRs in surgeon payment within regions were: SM $577 (25th percentile) to $1132 (75th percentile); MRM $850-$1620; lobectomy $861-$2767; VATS $1024-$3122; and prostatectomy $2286-$3563. CONCLUSIONS: There is a wide range of variation both across and within geographic regions in allowed amounts of surgeon payments for common oncologic resections. Transparency about these allowed amounts may have a profound impact on patient and employer choice and facilitate future assessments of value in cancer care.

Insulin resistance contributes to racial disparities in breast cancer prognosis in US women.

BACKGROUND: Racial disparities in breast cancer survival between Black and White women persist across all stages of breast cancer. The metabolic syndrome (MetS) of insulin resistance disproportionately affects more Black than White women. It has not been discerned if insulin resistance mediates the link between race and poor prognosis in breast cancer. We aimed to determine whether insulin resistance mediates in part the association between race and breast cancer prognosis, and if insulin receptor (IR) and insulin-like growth factor receptor (IGF-1R) expression differs between tumors from Black and White women. METHODS: We conducted a cross-sectional, multi-center study across ten hospitals. Self-identified Black women and White women with newly diagnosed invasive breast cancer were recruited. The primary outcome was to determine if insulin resistance, which was calculated using the homeostatic model assessment of insulin resistance (HOMA-IR), mediated the effect of race on prognosis using the multivariate linear mediation model. Demographic data, anthropometric measurements, and fasting blood were collected. Poor prognosis was defined as a Nottingham Prognostic Index (NPI) > 4.4. Breast cancer pathology specimens were evaluated for IR and IGF-1R expression by immunohistochemistry (IHC). RESULTS: Five hundred fifteen women were recruited (83% White, 17% Black). The MetS was more prevalent in Black women than in White women (40% vs 20%, p < 0.0001). HOMA-IR was higher in Black women than in White women (1.9 ± 1.2 vs 1.3 ± 1.4, p = 0.0005). Poor breast cancer prognosis was more prevalent in Black women than in White women (28% vs 15%. p = 0.004). HOMA-IR was positively associated with NPI score (r = 0.1, p = 0.02). The mediation model, adjusted for age, revealed that HOMA-IR significantly mediated the association between Black race and poor prognosis (ß = 0.04, 95% CI 0.005-0.009, p = 0.002). IR expression was higher in tumors from Black women than in those from White women (79% vs 52%, p = 0.004), and greater IR/IGF-1R ratio was also associated with higher NPI score (IR/IGF-1R >  1: 4.2 ± 0.8 vs IR/IGF-1R = 1: 3.9 ± 0.8 vs IR/IGF-1R < 1: 3.5 ± 1.0, p < 0.0001). CONCLUSIONS: In this multi-center, cross-sectional study of US women with newly diagnosed invasive breast cancer, insulin resistance is one factor mediating part of the association between race and poor prognosis in breast cancer.

How We Do It: Creation of a Workforce Development-Focused Track at a Surgical Hackathon.

OBJECTIVE: Healthcare hackathons are fast-paced, mentored events that bring together individuals with diverse skillsets to identify clinical needs and propose solutions. Traditionally geared toward device development and workflow optimization, platforms that address women and minorities in surgery are rare. We aimed to expand the traditional healthcare hackathon model to include a novel workforce development (WD) track to address concerns faced by surgeons and trainees. DESIGN: The WD track was created as part of the first surgical hackathon at our academic institution. In a single-day event, participants identified concerns (pain points) of diversity and sustainability in surgery, formed interdisciplinary teams, and pitched solutions. Pain points, project themes, and postevent survey results were analyzed and compared between WD and other tracks. SETTING: Participants were surveyed at Yale School of Medicine, an academic medical tertiary center, in September 2018. PARTICIPANTS: Thirty-one total participants. Twenty-five (80.6%) responded to the survey. RESULTS: Of 57 problem pitches, 23 (40.4%) were related to WD. Issues highlighted 5 themes: training and career exploration, leadership and communication of skills, mental health and burnout prevention, surgeon discrimination and harassment, and work-life balance. Participants formed 6 groups, with 1 focused on WD. There was no difference between participants in the WD track and non-WD track counterparts with regard to excitement for continuing their project beyond the hackathon (4.00, standard deviation [SD] 0.89, vs. 3.63, SD 1.12, p = 0.43), and in their perception of the mentorship they received (4.00, SD 1.00, vs. 4.11, SD 0.78, p = 0.84). The project presented within the WD track, on culturally sensitive scrub wear, was 1 of 3 prize-winners. CONCLUSIONS: The first WD track at a healthcare hackathon identified 5 themes of unmet workforce needs. The pilot demonstrated that WD tracks can be implemented in hackathons with similar results to traditional tracks and create innovative and sustainable solutions to surgical workforce concerns.

"Radiotherapy for older women (ROW)": A risk calculator for women with early-stage breast cancer.

OBJECTIVE: Among older adult women with early-stage breast cancer who undergo lumpectomy, the benefits of radiotherapy vary according to tumor characteristics and life expectancy. We aimed to develop a risk calculator to predict individualized probability of long-term survival and local recurrence, accounting for these factors. METHODS: We developed a simulation model to estimate an individual patient's risk of local recurrence and all-cause mortality according to age, comorbidities, functional status, tumor characteristics, and radiotherapy status. We integrated two existing prediction models, the Early Breast Cancer Trialist's Collaborative Group prediction model for breast cancer specific outcomes and ePrognosis for life expectancy. An online risk calculator "Radiotherapy for Older Women (ROW)" was developed through an iterative multi-stage process, that included individual consultation and group meetings with an advisory committee (AC) comprised of patients, advocates, clinicians, and researchers. RESULTS: We developed the tool over 40 months and had 15 group meetings. The risk calculator developed as a simulation model with 16 factors (5 tumor-related, 3 demographic, 4 comorbidities, and 4 functional statuses). Across 56,700 simulated scenarios, the benefit of RT in terms of absolute 10-year local recurrence reduction, ranged from 0% to 34%, depending on individual characteristics. Based on feedback from the AC, overall survival and local recurrence were chosen as the output for ROW, with these outcomes displayed numerically (percentages and natural frequencies) and graphically (pictographs). CONCLUSIONS: This tool "ROW" could facilitate shared decision making regarding receipt of radiotherapy for older women with early breast cancer. Additional studies to examine usability testing are underway.

Association between perceived benefits and receipt of radiotherapy among older breast cancer patients.

While radiotherapy can be safely omitted in many older women with early-stage breast cancer after lumpectomy, approximately two-thirds of eligible women still undergo this treatment. We surveyed 63 older women with stage I (T1N0M0), estrogen-receptor-positive breast cancer who underwent lumpectomy, and were considering/receiving radiotherapy. Participants perceived that radiotherapy would reduce their 10-year risk of local recurrence by an average of 18.7%, which is significantly higher than the 8% risk reduction reported in literature. Multivariate analyses demonstrated that participants who reported a large perceived benefit were significantly more likely to undergo radiotherapy treatment (odds ratio 10.34; 95% confidence interval: 1.66-66.35).

Income disparities in needle biopsy patients prior to breast cancer surgery across physician peer groups.

OBJECTIVE: Evaluate income disparities in receipt of needle biopsy among Medicare beneficiaries and describe the magnitude of this variation across physician peer groups. METHODS: The Surveillance, Epidemiology and End Results (SEER)-Medicare database was queried from 2007-2009. Physician peer groups were constructed. The magnitude of income disparities and the patient-level and physician peer group-level effects were assessed. RESULTS: Among 9770 patients, 65.4% received needle biopsy. Patients with low income (median area-level household income < $33K) were less likely to receive needle biopsy (58.5%) compared to patients with high income (≥ $50K) (68.6%; adjusted odds ratio 0.77; 95% confidence interval (CI) 0.65-0.91). Needle biopsy varied substantially across physician peer groups (interquartile range 43.4-81.9%). The magnitude of the disparity ranged from an odds ratio (OR) of 0.50 (95% CI 0.23-1.07) for low vs. high income patients to 1.27 (95% CI 0.60-2.68). The effect of being treated by a physician peer group that treated mostly low-income patients on receipt of needle biopsy was nearly three times the effect of being a low-income patient. CONCLUSIONS: Needle biopsy continues to be underused and disparities by income exist. The magnitude of this disparity varies substantially across physician peer groups, suggesting that further work is needed to improve quality and reduce inequities.

Utilization, duration, and outcomes of neoadjuvant endocrine therapy in the United States.

PURPOSE: To evaluate if real-world utilization of neoadjuvant endocrine therapy (NET) is associated with similar rates of response and breast conservation surgery (BCS) compared to neoadjuvant chemotherapy (NAC). METHODS: Our population-based assessment used the National Cancer Data Base to identify women diagnosed with stage II-III, hormone receptor (HR)-positive BC who underwent surgery and received endocrine therapy from 2004 to 2014. Women were categorized by receipt of NET, NAC or no neoadjuvant therapy. We used logistic regression to assess differences in outcomes between therapies using inverse propensity score weighting to adjust for potential selection bias. RESULTS: In our sample of 211,986 women, 6584 received NET, 52,310 received NAC, and 153,092 did not receive any neoadjuvant therapy. After adjusting for multiple relevant covariates and cofounders, there was no significant difference between NET and NAC with regard to BCS [odds ratio (OR) 0.91; 95% confidence interval (CI) (0.82-1.01)]; however, women who received NET were significantly less likely to achieve pCR [OR 0.34; 95% CI (0.23-0.51)] or a decrease in T stage [OR 0.39; CI (0.34-0.44)] compared to women treated with NAC. Patients who received NET for ≥ 3 months had higher odds of BCS (OR 1.59; 95% CI 1.46-1.73) and downstaging (OR 1.79; 95% CI 1.63-1.97) compared to patients who did not receive neoadjuvant therapy. CONCLUSIONS: Women who received NET had similar rates of BCS compared to women who received NAC. Those who received NET for longer treatment durations had increased odds of BCS and downstaging compared to women who did not receive neoadjuvant therapy.

The effect of modifiable risk factors on breast cancer aggressiveness among black and white women.

INTRODUCTION: Although breast cancer incidence is higher among white women, black women are more likely to have aggressive tumors with less favorable histology, and to have a worse prognosis. Obesity and alcohol consumption have been identified as two modifiable risk factors for breast cancer, while physical activity may offer protection. Little however is known about the association of these factors with race on the severity of breast cancer. METHODS: Data collected as part of a large prospective study looking at insulin resistance and race among women with breast cancer was queried for patient characteristics, lifestyle factors and tumor characteristics. The association with Nottingham Prognostic Index (NPI) was assessed with different models using univariate and multivariate linear regression. RESULTS: Among 746 women in our cohort, 82% (n = 615) were white and 18% (n = 131) were black, mean age 58 years. Black patients were more likely to have high BMI (31.0 vs. 26.7, p < 0.0001), comorbidities (69% vs 55%, p = 0.01), self-reported poor diet (70% vs 42%, p < 0.001), be sedentary (56% vs 46%, p = 0.03) and were less likely to consume alcohol (8% vs 32%, p < 0.0001) compared to white patients. Overall, 137 (18%) of the patients had poorer prognosis (NPI > 4.4), which was significantly associated with younger age (55.6 vs 58.5 years, p = 0.02), black race (27% vs 15%, p = 0.001), triple negative cancer (15% vs 6%, p = 0.003), and poor diet (54% vs 45%, p = 0.046) compared to patients with better prognosis (NPI ≤ 4.4). On multivariate analysis, (model R2 = 0.12; p < 0.001), age (ß = -0.011 per year, p = 0.002), healthy diet (ß = -0.195, p = 0.02), and exercise (ß = -0.004, p = 0.02) were associated with better prognosis, while black race (ß = 0.247, p = 0.02) and triple negative cancer (ß = 0.908, p < 0.0001) were associated with poor prognosis. Neither alcohol use nor BMI was significantly associated with NPI. CONCLUSION: Among modifiable risk factors, diet and exercise are associated with NPI. Unmodifiable factors including race and biologic subtype remain the most important determinants of prognosis.