Race and delays in breast cancer treatment across the care continuum in the Carolina Breast Cancer Study

Abstract

Background After controlling for baseline disease factors, researchers have found that black women have worse breast cancer survival, and this suggests that treatment differences may contribute to poorer outcomes. Delays in initiating and completing treatment are one proposed mechanism. Methods Phase 3 of the Carolina Breast Cancer Study involved a large, population‐based cohort of women with incident breast cancer. For this analysis, we included black women (n = 1328) and white women (n = 1331) with stage I to III disease whose treatment included surgery with or without adjuvant therapies. A novel treatment pathway grouping was used to benchmark the treatment duration (surgery only, surgery plus chemotherapy, surgery plus radiation, or all 3). Models controlled for the treatment pathway, age, and tumor characteristics and for demographic factors related to health care access. Exploratory analyses of the association between delays and cancer recurrence were performed. Results In fully adjusted analyses, blacks had 1.73 times higher odds of treatment initiation more than 60 days after their diagnosis in comparison with whites (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.04‐2.90). Black race was also associated with a longer treatment duration. Blacks were also more likely to be in the highest quartile of treatment duration (OR, 1.69; 95% CI, 1.41‐2.02), even after adjustments for demographic and tumor characteristics (OR, 1.31; 95% CI, 1.04‐1.64). A nonsignificant trend toward a higher recurrence risk was observed for patients with delayed initiation (hazard ratio, 1.44; 95% CI, 0.89‐2.33) or the longest duration (hazard ratio, 1.17; 95% CI, 0.87‐1.59). Conclusions Black women more often had delayed treatment initiation and a longer duration than whites receiving similar treatment. Interventions that target access barriers may be needed to improve timely delivery of care.

Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women

“…In fact, few studies have examined how characteristics of the health system affect racial differences in treatment. 51 We previously took initial steps toward addressing health care factors by assessing treatment delay by Area Health Education Center (AHEC) region, 27 and future work should capture more complex care-coordination variables such as distance to care, type of care center, and workload associated with treatment. 52 In conclusion, there are many dimensions of treatment delay, from diagnosis to treatment completion.…”

“…[22][23][24][25][26] Moreover, many studies have focused on delayed treatment initiation without considering other delays on the care continuum. 27 We have previously reported a more comprehensive approach to the definition and measurement of breast cancer treatment delays 27 and sought to apply this conceptualization of treatment delays in combination with latent class variables for SES and access to care. As reviewed by Palumbo et al, 28 latent class analysis (LCA) has distinct advantages compared with area-level SES and continuous measurements of SES.…”

“…Previous research on White–Black differences in treatment delay has been limited because many studies have used area‐level socioeconomic status (SES) proxy variables and/or are single‐institution or hospital‐based studies, and most studies that use individual level data use a single variable to assess SES 22‐26 . Moreover, many studies have focused on delayed treatment initiation without considering other delays on the care continuum 27 . We have previously reported a more comprehensive approach to the definition and measurement of breast cancer treatment delays 27 and sought to apply this conceptualization of treatment delays in combination with latent class variables for SES and access to care.…”

“We get double slammed!”: Healthcare experiences of perceived discrimination among low-income African-American women

“…Racial/ethnic discrimination resulting from implicit bias has been shown to have significant impact on provider communication, patient perception of care, and health outcomes for persons of color. 30 – 32 While there is mixed evidence on the impact of healthcare provider implicit bias on health outcomes, 33 some studies have demonstrated the influence of healthcare provider implicit bias on clinical assessment, decision-making, and treatment recommendations for Black women 34 Implicit bias among healthcare providers has also been associated with lower quality of care. 35 All of these suggest that discrimination, whether explicit or implicit, contributes significantly to the health disparities that AA women continue to experience.…”

Health System Factors That Influence Treatment Delay in Women With Breast Cancer in Sub-saharan Africa: A Systematic Review

“…This would indicate two major conclusions: rst, our phenomenon of interest is no longer a real problem for them, and second, there has been a clear advancement in the management of women with breast cancer in high-income countries compared to low-and middle-income countries. However, recent studies conducted in these countries have shown inequalities in access to breast cancer diagnosis and care for vulnerable populations such as immigrant women, residents of rural areas and black individuals [62][63][64].…”