Economic factors may affect getting guideline-recommended breast cancer treatment

Women with interruptions in health insurance coverage or with low income levels had a significantly increased likelihood of failing to receive breast cancer care that is in concordance with recommended treatment guidelines, according to results presented here at the Sixth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved, held Dec. 6-9.

Women with a break in their insurance coverage had a 3.5-fold higher likelihood of nonconcordance with National Comprehensive Cancer Network (NCCN) guidelines for radiation therapy and chemotherapy compared with women with uninterrupted coverage.

"We found that women who had no insurance at some point during treatment, women with lower incomes compared with those in the highest income categories, and women who held more debt at the time of diagnosis were less likely to receive all of the recommended treatments," said Jean A. McDougall, Ph.D., M.P.H., a postdoctoral fellow at the Fred Hutchinson Cancer Research Center in Seattle, Wash. "Documenting and understanding these disparities is important for connecting women who are at high risk for not receiving all of their treatment with a patient navigator or social worker ahead of time so that we might increase the likelihood that they will get recommended treatment."

McDougall and colleagues conducted a population-based cohort study of 1,344 women from the Seattle-Puget Sound area diagnosed with breast cancer between 2004 and 2011. Using data from the cancer registry records, pathology reports, and patient self-reports, the researchers assessed whether or not the treatment received was in concordance with guidelines issued by the NCCN.

The researchers found that women with an annual family income of less than $50,000 were more than twice as likely to have received care that was not in concordance with guidelines for radiation therapy compared with women with an income of greater than $90,000 per year. In addition, they had an almost five times higher likelihood for nonconcordance with chemotherapy guidelines, and an almost four times higher likelihood for nonconcordance with endocrine therapy guidelines.

They also found that women who had consistent financial insecurity or who had debt at the time of cancer diagnosis had an increased likelihood for nonconcordance with American Society of Clinical Oncology/NCCN Quality Measures.

In addition, women who had problems talking to a doctor, women who did not have anyone to accompany them for their hospital visits, and who did not have anyone to take care of them and their household chores, were less likely to receive NCCN guideline-recommended chemotherapy.

"Surprisingly, we found that education or the facility where a woman was treated was not associated with receipt of guideline-recommended care," McDougall said. "Our results suggest that further studies are needed to address the root cause of these inequities, and to develop effective interventions."

More information: Abstract Number: PR08

Presenter: Jean A. McDougall, Ph.D., M.P.H.

Title: Socioeconomic determinants of the receipt of guideline-concordant breast cancer treatment

Authors: Jean A. McDougall, Noel S. Weiss, Kenneth J. Kopecky, Beti Thompson, Hannah M. Linden, Christopher I. Li.

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.

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