Background: (Neo) Adjuvant chemotherapy decreases the risk of recurrence and improves overall survival among breast cancer patients, however, delays in chemotherapy initiation are associated with adverse outcomes. While the determinants of such delays are not clearly understood, delays are more likely to occur in those: with additional comorbidities, belonging to a low social economic status, without a partner, enrolled in public health insurance, or who identify as Latino/Hispanic or Black/African Americans. The causes of disparities in the delivery of care among breast cancer patients are complex and include interrelated social, economic, cultural, environmental, and health system factors. The goal of Project Start was to conduct a qualitative investigation to assess and identify the multilevel factors contributing to the barriers and facilitators of initiating chemotherapy in the context of breast cancer treatment.
Methods: We enrolled English or Spanish speaking women, ≥18 years, diagnosed with primary invasive breast cancer who experienced a ≥ 60 days delay to chemotherapy initiation, whether adjuvant or neoadjuvant (determined from the date of surgery or the date of histopathologic diagnosis). Participants were identified through electronic medical record review and approached in clinic to participate. Semi-structured interviews were conducted in-person or over the phone to explore participants’ perceptions about individual, community, and system level barriers and facilitators contributing to starting chemotherapy. Interviews were audio-recorded, transcribed verbatim, and coded using the Sort and Sift, Think and Shift qualitative approach to identify concepts and topics within and across transcripts. Participants completed brief questionnaires collecting sociodemographic characteristics, health literacy and numeracy, physician trust, and social support to supplement the qualitative data. Quantitative data were summarized using descriptive statistics.
Results: Seventeen participants completed semi-structured interviews and questionnaires (mean age 49.9 years; range 30-70 years). Participants identified as: Latina (n=7); Black (n=2); and non-Latina White (n=8). Most completed interviews in English (n=15) and over half had lower educational attainment (i.e., middle school, high school, associate’s degree; n=10). While the interview included questions addressing chemotherapy delays, explicit insight into chemotherapy delay was rare among participants. When discussing their process to chemotherapy, participants described barriers and facilitators at the patient, family, medical, and community levels contributing to their timeline to start chemotherapy. At the patient level, participants discussed their fear and anxiety, the command over their diagnosis, and the importance of playing an active role in treatment. Within the family realm, participants described their family roles (e.g., caregiving, income), treatment costs, and the need for emotional support (e.g., not shutting family members out). Participants sought out and relied heavily on support from their communities (e.g., churches, other patients, survivors). Finally, patients described their reliance on the medical team for information, the trust needed to navigate their treatment process, and the challenge of managing information associated with their treatment.
Conclusions: Women expressed the importance of managing individual stressors, family roles and support, medical information, and community support. Activating women to be engaged in the treatment process at multiple levels appeared to facilitate initiating chemotherapy. Multilevel interventions that engage the patient, family, medical team, and community may provide the supports to enable the initiation of timely chemotherapy.
Citation Format: Ashley J. Housten, Edna Paredes, Cassandra L. Harris, Mariana Chavez-MacGregor. Why do women experience a delay to chemotherapy? A qualitative analysis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-75.