Abstract
Background: Guidelines for the management of early stage invasive breast cancer include locoregional and systemic treatments that, on average, prolong disease-free and overall survival. Yet, a considerable proportion of women do not receive some or all of the guideline recommended breast cancer care. Disparities in the receipt of radiation therapy, chemotherapy, and endocrine therapy by patient and treatment facility characteristics may contribute to demographic differences in breast cancer survival.
Methods: This population-based cohort study enrolled women aged 20 – 69 years, diagnosed with stage I, II, or IIIA breast cancer in the Seattle-Puget Sound area between 2004 and 2011, who were identified through the local Surveillance Epidemiology and End Results cancer registry. Concordance with National Comprehensive Cancer Network (NCCN) guideline recommendations and American Society of Clinical Oncology (ASCO)/NCCN Quality Measures (QMs) was assessed for 1,344 women using data collected from cancer registry records, pathology reports, and patient self-report from a telephone interview. Multivariable logistic regression was used to estimate the association between patient and facility characteristics, barriers and facilitators to care, and non-concordance with NCCN guidelines and QMs.
Results: Compared to women with uninterrupted insurance coverage, women who did not have insurance at some point during their breast cancer treatment had a 3.5-fold (95% CI: 1.0-10.5) higher likelihood of non-concordance with NCCN guidelines for radiation therapy, and a 3.5-fold (95 % CI 1.2-10.5) higher likelihood of non-concordance with NCCN guidelines for chemotherapy. Low income was consistently associated with risk of non-concordance, with multivariate odds ratios of 2.3 (95% CI: 1.0-4.9) for radiation therapy guidelines, 4.6 (95% CI: 1.8-11.6) for chemotherapy guidelines, and 3.7 (95% CI: 1.4-9.7) for endocrine therapy guidelines associated with an annual family income of <$50,000 relative to that of ≥$90,000. We also observed consistent associations between financial insecurity and both NCCN guidelines and QMs and the amount of debt that a woman held at the time of breast cancer diagnosis was associated with a suggestion of an increased likelihood of non-concordance across all QMs. In addition, women who stated in the interview that they had problems talking to doctors or their staff (OR 2.7, 95% CI 1.1-6.4), women who stated that they did not have someone to go with them to appointments and drive them home (OR 3.3, 95% CI 1.4-7.9), and women who stated that they did not have someone to help them with daily chores and care for them if they were sick or tired (OR 2.2, 95% CI 1.0-4.7) were all at increased risk of non-concordance with NCCN chemotherapy guidelines. No clear pattern of non-concordance by education or treatment facility characteristics was observed.
Conclusions: Economic factors were associated with non-receipt of most forms of recommended treatment. Our results and those of previous studies documenting socioeconomic disparities in the receipt of guideline recommended chemotherapy warrant further study of the root causes of these inequities, and of the effectiveness of interventions, such as patient navigation, designed to improve guideline concordance among uninsured, underinsured, and low-income women.
This abstract is also presented as Poster A85.
Citation Format: Jean A. McDougall, Noel S. Weiss, Kenneth J. Kopecky, Beti Thompson, Hannah M. Linden, Christopher I. Li. Socioeconomic determinants of the receipt of guideline-concordant breast cancer treatment. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr PR8. doi:10.1158/1538-7755.DISP13-PR8
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