Narrowing racial gaps in breast cancer chemotherapy initiation: the role of the patient–provider relationship

Abstract

Purpose Chemotherapy improves breast cancer survival but is underused more often in black than in white women. We examined associations between patient-physician relationships and chemotherapy initiation and timeliness of initiation among black and white patients. Methods Women with primary invasive, non-metastatic breast cancer were recruited via hospitals (in Washington, DC and Detroit) and community outreach between July 2006 and April 2011. Data were collected via telephone interviews and medical records. Logistic regression models evaluated associations between chemotherapy initiation and independent variables. Since there were race interactions, analyses were race-stratified. Factors associated with time from surgery to chemotherapy initiation and delay of ≥ 90 days were evaluated with linear and logistic regressions, respectively. Results Among eligible women, 82.8% were interviewed and 359 (90.9%)of those had complete data. The odds of initiating chemotherapy were 3.26 times (95% CI: 1.51, 7.06) higher among black women reporting greater communication with physicians (vs. lesser), after considering covariates. In contrast, the odds of starting chemotherapy were lower for white women reporting greater communication (vs. lesser) (adjusted OR .22, 95% CI: .07, .73). The opposing direction of associations was also seen among the sub-set of black and white women with definitive clinical indications for chemotherapy. Among those initiating treatment, black women had longer mean time to the start of chemotherapy than whites (71.8 days vs. 55.0 days, p= .005), but race was not significant after considering trust in oncologists, where initiation time decreased as trust increased, controlling for covariates. Black women were also more likely to delay ≥ 90 days than whites (27% vs. 8.3%; p=.024), but this was not significant after considering religiosity. Conclusion The patient-physician dyad and sociocultural factors may represent leverage points to improve chemotherapy patterns in black women.

Reducing Racial Disparities in Breast Cancer Survivors' Ratings of Quality Cancer Care

“…Because trust in one's healthcare provider is associated with adherence to treatment, health outcomes, and quality of life (Safran et al, 1998), testing strategies to improve patient-provider relationships in cancer patients-particularly Black women-will be important for future studies. When Black women report good communication and higher trust in providers, they are more likely to initiate and have less delay in starting chemotherapy (Sheppard et al, 2013a).…”

“…Therefore, it is crucial that breast cancer patients receive care according to these attributes. Some promising data suggest that when care is patient centered and rated higher among Blacks and other minorities in the United States, outcomes of treatment initiation or adherence (Liu et al, 2013;Sheppard et al, 2013a), quality of life (Kwan et al, 2013), and patient-provider communication (Palmer et al, 2014) improve. Similarly, although data are limited (Palmer et al, 2014;Saha et al, 2003), some studies in the United States suggest that Black patients are less satisfied with their cancer care than White patients (Sorkin et al, 2010;Mead et al, 2013).…”

“…This report is part of a larger study aimed at narrowing racial gaps in breast cancer treatment (Sheppard et al, 2013a). The goal of this study was to assess the ratings of quality care among Black and White breast cancer patients and to evaluate healthcare and psychosocial factors that are associated with these ratings.…”

“…Patient-provider communication, diagnosis and treatment information, and the healthcare facility play important roles in patients' recommendation of their provider and/or facility to others (Kleeberg et al, 2005). There are limited interventions focused on strengthening Black survivors' relationships with their providers (Sheppard et al, 2011;Sheppard et al, 2013b). One decision support intervention found that communication skills training for Black patients improved aspects of the patient-provider relationship (Sheppard et al, 2010).…”

Black-White Differences in Breast Cancer Outcomes Among Older Medicare Beneficiaries

“…These observations support the impression that there may be differences in processes of care that may be markers for suboptimal use of treatment, quality of treatment, or both, not captured in the SEER-Medicare database. In other settings, ratings of patient-physician communication and trust have been related to black women's, but not white women's, patterns of chemotherapy use, 8 further reinforcing the idea that black women may have different cancer care experiences than white women.…”