Time-sensitive advance directive (AD) completion rates were improved for most patient groups with the use of the right info/care/patient/time (4R care sequence) care planning and delivery model coupled with health educator follow-up, according to results of a study presented at the 2022 ASCO Annual Meeting.

AD is an important aspect of care planning but there remains a lack of effective tools to improve AD rates among patients undergoing surgery for breast cancer.

This quality improvement project implemented the 4R oncology intervention at a community-based center. The intervention comprised a multi-modal 4R care sequence plan with follow-up workflows. Patients with newly diagnosed, nonmetastatic breast cancer who were undergoing surgical treatment between October 2019 and September 2020 (140 patients) received usual care; those undergoing surgical treatment between October 2020 and September 2021 (141 patients) received the 4R oncology intervention. AD completion rates were compared between cohorts.

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Baseline demographic and clinical characteristics were well balanced between the cohorts.

The AD completion rate improved from 15% with usual care to 73.8% with the intervention (P <.01).

Stratified by patient characteristics, the intervention associated with improved AD completion among White (76% vs 16%; P <.01), Asian or Pacific Islander (80% vs 17%; P <.01), and Black (79% vs 17%; P =.019) patients. Significance was not reached among Hispanic patients (27% vs 5%) or patients with other ethnicities (67% vs 20%), likely due to small sample sizes.

Stratified by level of distress, no significant trends in AD completion among the intervention cohort were observed between patients with high or low levels of distress.

The study authors concluded that delivery of a 4R care sequence with health educator follow-up improved AD completion among patients with breast cancer undergoing surgical treatment. This type of intervention may be an effective tool for ensuring standardized delivery of equitable care.

Disclosure: Some authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Ossowski S, Lyon L, Linehan ES, et al. Increasing advance directive completion within the 4R oncology model in breast cancer patients prior to surgery in a racially diverse patient population. J Clin Oncol. 2022;40(suppl 16; abstr e13511). doi:10.1200/JCO.2022.40.16_suppl.e13511