Racial Differences in Time to Breast Cancer Surgery and Overall Survival in the US Military Health System

Structural Racism and Treatment Delay Among Black and White Patients With Breast Cancer

PURPOSE

Structural racism (SR) is a potential driver of health disparities, but research quantifying its impacts on cancer outcomes has been limited. We aimed to develop a multidimensional county-level SR measure and to examine the association of SR with breast cancer (BC) treatment delays among Black and White patients.

METHODS

The cohort included 32,095 individuals from the North Carolina Central Cancer Registry with stage I to III BC diagnosed between 2004 and 2017 and linked to multipayer insurance claims from the Cancer Information and Population Health Resource. County-level data were drawn from multiple public sources aggregated in the Robert Wood Johnson County Health Rankings database. Racial gaps in eight social determinants across five domains were quantified at the county level and ranked on a 0-100 minimum-maximum scale. Domain scores were averaged to create a SR Composite Index (SRCI) score. We used multilevel logistic regression with random intercepts and multiple cross-level interaction terms to evaluate the association between county-level SRCI and patient-level treatment delays, adjusting for patient-level characteristics and stratified by race.

RESULTS

The SRCI score ranged from 21 to 75 with a median (IQR) of 39.0 (31.8, 45.7). For Black patients, a 10-unit increase in SRCI score was associated with increased odds of delay (Adjusted odds ratios [aOR], 1.25; 95% confidence limits [CL], 1.08 to 1.45). No such association was found for White patients (OR, 1.05; 95% CL, 0.97 to 1.15).

CONCLUSION

Area-level SR measured by a composite index is associated with higher odds of BC treatment delays among Black, but not White patients. Increasing county-level SR is associated with increasing Black-White disparities in treatment delay. Further research is needed to refine the measurement of SR and to examine its association with other cancer care disparities.

Dose delay, dose reduction, and early treatment discontinuation in Black and White women receiving chemotherapy for nonmetastatic breast cancer

BACKGROUND

To describe reasons for deviations from planned chemotherapy treatments in women with nonmetastatic breast cancer that contribute to less-than-planned receipt of chemotherapy.

METHODS

Electronic medical records for patients receiving chemotherapy were reviewed for adverse events and treatment modifications. Log-binomial regression models were used to estimate relative risks (RRs) with 95% CIs to examine associations between chemotherapy modifications, patient characteristics, and treatment modalities.

RESULTS

Delays in chemotherapy initiation (7%) were for surgical complications (58%), personal reasons (16%), and other (26%; port malfunction, infections, and obtaining extra imaging). Delays during chemotherapy (38%) were for infections (20%), neutropenia (13%), and personal reasons (13%). Dose reductions (38%) were for neuropathy (36%), unknown causes (9%), anemia (9%), and neutropenia (8%). Early treatment discontinuations (23%) were for neuropathy (29%). Patients receiving paclitaxel/nab-paclitaxel (RR 2.05; 95% CI, 1.47-2.87) and an anthracycline (RR 1.89; 95% CI, 1.39-2.57) reported more dose delays during chemotherapy. Black race (RR 1.46; 95% CI, 1.07-2.00), stage 3 (RR 1.79; 95% CI, 1.09-2.93), and paclitaxel/nab-paclitaxel receipt (RR 1.39; 95% CI, 1.02-1.90) increased the likelihood of dose reduction. Both Black race (RR 2.06; 95% CI, 1.35-3.15) and receipt of paclitaxel/nab-paclitaxel (RR 1.93; 95% CI, 1.19-3.13) increased the likelihood of early discontinuation. Patients receiving anthracyclines had higher rates of hospitalizations during chemotherapy (RR: 1.79; 95% CI, 1.11-2.89).

CONCLUSION

Toxicities are the most common reason for treatment modifications and need close monitoring in high-risk groups for timely intervention. Dose reductions and early treatment discontinuations occurred more for Black patients and need further study.

Racial Disparities in Receipt of Guideline-Concordant Care in Older Adults With Early Breast Cancer

Importance

Racial disparities in receipt of guideline-concordant care (GCC) among older patients with potentially curable breast cancer are understudied.

Objective

To determine whether rates of GCC, time to treatment initiation, and all-cause mortality in stage I to III breast cancer differ by race among older adults.

Design, Setting, and Participants

This cohort study used data from the National Cancer Database and included patients aged 65 years and older with stage I to III breast cancer, diagnosed between 2010 and 2019. Data analysis was conducted between July 2022 to July 2023.

Exposures

Race, defined as non-Hispanic Black or non-Hispanic White.

Main Outcomes and Measures

The primary outcome was nonreceipt of GCC, defined using the National Comprehensive Cancer Network guidelines, and all-cause mortality. The secondary outcome was time to treatment initiation. Univariate and multivariate regression analysis were used to determine association between exposure and outcomes. Models for GCC and all-cause mortality included age, stage, receptor status, year of diagnosis, Charlson-Deyo comorbidity index, insurance, health care setting, and neighborhood-level educational attainment and median income.

Results

The analytic cohort included 258 531 participants (mean [SD] age, 72.5 [6.0] years), with 25 174 participants who identified as non-Hispanic Black (9.7%) and 233 357 participants who identified as non-Hispanic White (90.3%), diagnosed between 2010 and 2017. A total of 4563 non-Hispanic Black participants (18.1%) and 35 374 non-Hispanic White participants (15.2%) did not receive GCC. Non-Hispanic Black race, compared with non-Hispanic White race, was associated with increased odds of not receiving GCC in the multivariate analysis (adjusted odds ratio [aOR], 1.13; 95% CI, 1.08-1.17; P < .001). Non-Hispanic Black race was associated with 26.1% increased risk of all-cause mortality in the univariate analysis, which decreased to 4.7%, after adjusting for GCC and clinical and sociodemographic factors (adjusted hazard ratio, 1.05; 95% CI, 1.01-1.08; P = .006). Non-Hispanic White race, compared with non-Hispanic Black race, was associated with increased odds of initiating treatment within 30 (OR, 1.65; 95% CI, 1.6-1.69), 60 (OR, 2.11; 95% CI, 2.04-2.18), and 90 (OR, 2.39; 95% CI, 2.27-2.51) days of diagnosis.

Conclusions and Relevance

In this cohort study, non-Hispanic Black race was associated with increased odds of not receiving GCC and less timely treatment initiation. Non-Hispanic Black race was associated with increased all-cause mortality, which was reduced after adjusting for GCC and clinical and sociodemographic factors. These findings suggest that optimizing timely receipt of GCC may represent a modifiable pathway to improving inferior survival outcomes among older non-Hispanic Black patients with breast cancer.

Racial and Ethnic Disparity for Cancer Mortality in General and Single-Payer Healthcare Systems in the United States

BACKGROUND

It remains unclear what factors significantly drive racial disparity in cancer survival in the United States (US). We compared adjusted mortality outcomes in cancer patients from different racial and ethnic groups on a population level in the US and a single-payer healthcare system.

PATIENTS AND METHODS

We selected adult patients with incident solid and hematologic malignancies from the Surveillance, Epidemiology, and End Results (SEER) 2011-2020 and Veteran Affairs national healthcare system (VA) 2011-2021. We classified the self-reported NIH race and ethnicity into non-Hispanic White (NHW), non-Hispanic Black (NHB), non-Hispanic Asian Pacific Islander (API), and Hispanic. Cox regression models for hazard ratio of racial and ethnic groups were built after adjusting confounders in each cohort.

RESULTS

The study included 3,104,657 patients from SEER and 287,619 patients from VA. There were notable differences in baseline characteristics in the two cohorts. In SEER, adjusted HR for mortality was 1.12 (95% CI, 1.12-1.13), 1.03 (95% CI, 1.03-1.04), and 0.91 (95% CI, 0.90-0.92), for NHB, Hispanic, and API patients, respectively, vs. NHW. In VA, adjusted HR was 0.94 (95% CI, 0.92-0.95), 0.84 (95% CI, 0.82-0.87), and 0.96 (95% CI, 0.93-1.00) for NHB, Hispanic, and API, respectively, vs. NHW. Additional subgroup analyses by cancer types, age, and sex did not significantly change these associations.

CONCLUSIONS

Racial disparity continues to persist on a population level in the US especially for NHB vs. NHW patients, where the adjusted mortality was 12% higher in the general population but 6% lower in the single-payer VA system.

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study

BACKGROUND

Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy.

STUDY DESIGN

The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge.

RESULTS

The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased.

CONCLUSION

The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Differential response to neoadjuvant endocrine therapy for Black/African American and White women in NCDB

PURPOSE

Compared to White women, there are higher mortality rates in Black/African American (BAA) women with hormone receptor-positive breast cancer (HR + BC) which may be partially due to differences in treatment resistance. We assessed factors associated with response to neoadjuvant endocrine therapy (NET).

METHODS

The National Cancer Database (NCDB) was queried for women with clinical stage I-III HR + BC diagnosed 2006-2017 and treated with NET. Univariate and multivariate analyses described associations between the sample, duration of NET, and subsequent treatment response, defined by changes between clinical and pathological staging.

RESULTS

The analytic sample included 9864 White and 1090 BAA women. Compared to White women, BAA women were younger, had more co-morbidities, were higher stage at presentation, and more likely to have > 24 weeks of NET. After excluding those with unknown pT/N/M, 3521 White and 365 BAA women were evaluated for NET response. On multivariate analyses, controlling for age, stage, histology, HR positivity, and duration of NET, BAA women were more likely to downstage to pT0/Tis (OR 3.0, CI 1.2-7.1) and upstage to Stage IV (OR 2.4, CI 1.002-5.6). None of the women downstaged to pT0/Tis presented with clinical stage III disease; only 2 of the women upstaged to Stage IV disease presented with clinical Stage I disease.

CONCLUSION

Independent of NET duration and clinical stage at presentation, BAA women were more likely to experience both complete tumor response and progression to metastatic disease. These results suggest significant heterogeneity in tumor biology and warrant a more nuanced therapeutic approach to HR + BC.

Time to Cancer Treatment and Chemotherapy Relative Dose Intensity for Patients With Breast Cancer Living With HIV

Importance

Patients with breast cancer and comorbid HIV experience higher mortality than other patients with breast cancer.

Objective

To compare time to cancer treatment initiation and relative dose intensity (RDI) of neoadjuvant and adjuvant chemotherapy among patients with breast cancer with vs without HIV.

Design, Setting, and Participants

A retrospective, matched cohort study enrolled women who received a diagnosis of breast cancer from January 1, 2000, through December 31, 2018. The electronic medical records of 3 urban, academic cancer centers were searched for women with confirmed HIV infection prior to or simultaneous with diagnosis of stage I to III breast cancer. Tumor registry data were used to identify 2 control patients with breast cancer without HIV for each participant with HIV, matching for study site, stage, and year of cancer diagnosis. Statistical analysis was performed from December 2022 to October 2023.

Exposure

HIV infection detected before or within 90 days of participants' breast cancer diagnosis.

Main Outcomes and Measures

The primary outcome was time to breast cancer treatment initiation, defined as the number of days between cancer diagnosis and first treatment. The secondary outcome was overall RDI for patients who received chemotherapy. These outcomes were compared by HIV status using Cox proportional hazards regression and linear regression modeling, respectively, adjusting for confounding demographic and clinical factors. Exploratory outcomes included instances of anemia, neutropenia, thrombocytopenia, and liver function test result abnormalities during chemotherapy, which were compared using Fisher exact tests.

Results

The study enrolled 66 women with comorbid breast cancer and HIV (median age, 51.1 years [IQR, 45.7-58.2 years]) and 132 with breast cancer alone (median age, 53.9 years [IQR, 47.0-62.5 years]). The median time to first cancer treatment was not significantly higher among patients with HIV than those without (48.5 days [IQR, 32.0-67.0 days] vs 42.5 days [IQR, 25.0-59.0 days]; adjusted hazard ratio, 0.78, 95% CI, 0.55-1.12). Among the 36 women with HIV and 62 women without HIV who received chemotherapy, the median overall RDI was lower for those with HIV vs without HIV (0.87 [IQR, 0.74-0.97] vs 0.96 [IQR, 0.88-1.00]; adjusted P = .01). Grade 3 or higher neutropenia during chemotherapy occurred among more women with HIV than those without HIV (13 of 36 [36.1%] vs 5 of 58 [8.6%]).

Conclusions and Relevance

This matched cohort study suggests that patients with breast cancer and HIV may have experienced reduced adjuvant chemotherapy RDI, reflecting greater dose reductions, delays, or discontinuation. Strategies for supporting this vulnerable population during chemotherapy treatment are necessary.

The Military Health System: Minimizing Disparities in Breast Cancer Treatment

BACKGROUND

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population.

METHODS

A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs.

RESULTS

Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004).

CONCLUSIONS

There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.

Timeliness of Breast Diagnostic Imaging and Biopsy in Practice: 15 Years of Collecting, Comparing, and Defining Quality Breast Cancer Care

BACKGROUND

The literature lacks well-established benchmarks for expected time between screening mammogram to diagnostic imaging and then to core needle breast biopsy.

METHODS

Timeliness of diagnostic imaging workup was evaluated using aggregate data from 2005 to 2019 submitted to The National Quality Measures for Breast Centers (NQMBC).

RESULTS

A total of 419 breast centers submitted data for 1,805,515 patients on the time from screening mammogram to diagnostic imaging. The overall time was 7 days with 75th, 25th, and 10th percentile values of 5, 10, and 13.5 days, respectively. The average time in business days decreased from 9.1 to 7.1 days (p < 0.001) over the study period with the greatest gains in poorest-performing quartiles. Screening centers and centers in the Midwest had significantly shorter time to diagnostic imaging. Time from diagnostic imaging to core needle biopsy was submitted by 406 facilities representing 386,077 patients. The average time was 6 business days, with 75th, 25th, and 10th percentiles of 4, 9, and 13.7 days, respectively. Time to biopsy improved from a mean of 9.0 to 6.3 days (p < 0.001) with the most improvement in the poorest-performing quartiles. Screening centers, centers in the Midwest, and centers in metropolitan areas had significantly shorter time to biopsy.

CONCLUSIONS

In a robust dataset, the time from screening mammogram to diagnostic imaging and from diagnostic imaging to biopsy decreased from 2005 to 2019. On average, patients could expect to have diagnostic imaging and biopsies within 1 week of abnormal results. Monitoring and comparing performance with reported data may improve quality in breast care.

Racial disparities in time to laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Disparities in healthcare exist, yet few data are available on racial differences in time from admission to surgery. This study aimed to compare time from admission to laparoscopic cholecystectomy for acute cholecystitis between non-Hispanic Black and non-Hispanic White patients.

METHODS

Patients who underwent laparoscopic cholecystectomy for acute cholecystitis from 2010 to 2020 were identified using NSQIP. Time to surgery and additional preoperative, operative, and postoperative variables were analyzed.

RESULTS

In the univariate analysis, 19.4% of Black patients experienced a time to surgery >1 day compared with 13.4% of White patients (p < 0.0001). In the multivariable analysis, controlling for potential confounding factors, Black patients were found to be more likely than White patients to experience a time to surgery >1 day (OR 1.23, 95% CI 1.17-1.30, p < 0.0001).

CONCLUSIONS

Further investigation is indicated to better define the nature and significance of gender, race, and other biases in surgical care. Surgeons should be aware that biases may adversely impact patient care and should strive to identify and proactively address them to promote health equity in surgery.

MilCanEpi: Increased Capability for Cancer Care Research in the Department of Defense

The Military Health System (MHS) of the US Department of Defense (DoD) provides comprehensive medical care to over nine million beneficiaries, including active-duty members, reservists, activated National Guard, military retirees, and their family members. The MHS generates an extensive database containing administrative claims and medical encounter data, while the DoD also maintains a cancer registry that collects information about the occurrence of cancer among its beneficiaries who receive care at military treatment facilities. Collating data from the two sources diminishes the limitations of using registry or medical claims data alone for cancer research and extends their usage. To facilitate cancer research using the unique military health resources, a computer interface linking the two databases has been developed, called Military Cancer Epidemiology, or MilCanEpi. The intent of this article is to provide an overview of the MilCanEpi data system, describing its components, structure, potential uses, and limitations.

Medicaid expansion, chemotherapy delays, and racial disparities among women with early-stage breast cancer

BACKGROUND

Medicaid expansion under the Affordable Care Act extends eligibility for participating states and has been associated with improved outcomes by facilitating access to care. Delayed initiation of adjuvant chemotherapy is associated with worse outcomes among patients with early-stage breast cancer (BC). The impact of Medicaid expansion in narrowing delays by race and ethnicity has not been studied, to our knowledge.

METHODS

This was a population-based study using the National Cancer Database. Patients diagnosed with primary early-stage BC between 2007 and 2017 residing in states that underwent Medicaid expansion in January 2014 were included. Time to chemotherapy initiation and proportion of patients experiencing chemotherapy delays (>60 days) were evaluated using difference-in-difference and Cox proportional hazards models in preexpansion and postexpansion periods according to race and ethnicity.

RESULTS

A total 100 643 patients were included (63 313 preexpansion and 37 330 postexpansion). After Medicaid expansion, the proportion of patients experiencing chemotherapy initiation delay decreased from 23.4% to 19.4%. The absolute decrease was 3.2, 5.3, 6.4, and 4.8 percentage points (ppt) for Black, Hispanic, White, and Other patients. Compared with White patients, statistically significant adjusted difference-in-differences were observed for Black (-2.1 ppt, 95% confidence interval [CI] = -3.7% to -0.5%) and Hispanic patients (-3.2 ppt, 95% CI = -5.6% to -0.9%). Statistically significant reductions in time to chemotherapy between expansion periods were observed among White patients (adjusted hazard ratio = .11, 95% CI = 1.09 to 1.12) and those belonging to racialized groups (adjusted hazard ratio  = 1.14, 95% CI = 1.11 to 1.17).

CONCLUSIONS

Among patients with early-stage BC, Medicaid expansion was associated with a reduction in racial disparities by decreasing the gap in the proportion of Black and Hispanic patients experiencing delays in adjuvant chemotherapy initiation.

Racial and Ethnic Disparities in Synchronous and Metachronous Bilateral Breast Cancer

INTRODUCTION

Significant racial and ethnic disparities exist in breast cancer treatment and survival. However, studies characterizing these disparities among patients developing bilateral breast cancers (BBC) are lacking. The purpose of this study is to understand the association between race and ethnicity, sociodemographic factors, clinical variables, treatment, and mortality in patients with BBC--synchronous bilateral breast cancer (sBBC) or metachronous bilateral breast cancer (mBBC).

METHODS

Patients diagnosed with mBBC or sBBC in the Surveillance, Epidemiology, and End Results program between 2010 and 2016 were examined. sBBC was defined as contralateral breast cancer <1 year after the initial cancer diagnosis, and mBBC was contralateral cancer ≥1 year. Univariable analysis examined sociodemographic, clinical, and treatment variables. Kaplan-Meier curves and Cox regression models evaluated disease-specific mortality.

RESULTS

Of the 11,493 patients that met inclusion criteria, 9575 (83.3%) had sBBC, and 1918 (16.7%) had mBBC. There were significant racial and ethnic differences in stage, tumor subtype, surgical management, and chemotherapy within sBBC and mBBC groups. On adjusted multivariate analysis of all BBC patients, Black race (HR 1.42; 95%CI 1.11-1.80; p<0.005; Ref White) was associated with a higher disease-specific mortality. Conversely, patients with mBBC had a 25% relative risk reduction in disease-specific mortality (HR 0.75; 95%CI 0.61-0.92; p<0.01) compared to sBBC. Subset analysis suggested Black Race modified the effect of sBBC on mortality (p<0.0001).

CONCLUSIONS

Among patients with BBC, there are racial and ethnic disparities in clinical characteristics, treatment, and mortality. Future studies should focus on strategies to reduce these disparities.

Racial and Ethnic Disparities in Locoregional Recurrence Among Patients With Hormone Receptor-Positive, Node-Negative Breast Cancer: A Post Hoc Analysis of the TAILORx Randomized Clinical Trial

Importance

Whether racial and ethnic disparities in locoregional recurrence (LRR) exist among patients with similar access to care treated in randomized clinical trials is unknown.

Objective

To examine racial and ethnic differences in LRR among patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (ERBB2 [formerly HER2 or HER2/neu])-negative, node-negative breast cancer enrolled in the Trial Assigning Individualized Options for Treatment (TAILORx).

Design, Setting, and Participants

This unplanned retrospective post hoc analysis examined a prospective multicenter clinical trial population of women with breast cancer enrolled between 2006 and 2010, with 9 years of follow-up. The TAILORx investigators randomized patients to treatment based on their Oncotype DX recurrence score, including endocrine therapy alone (recurrence score <11), endocrine therapy alone vs chemotherapy followed by endocrine therapy (recurrence score 11-25), or chemotherapy followed by endocrine therapy (recurrence score >25). Patients with unknown race and ethnicity or lack of follow-up were excluded from this analysis. Data analysis was performed between December 2021 and March 2022.

Main Outcome and Measures

Locoregional recurrence was defined as ipsilateral in breast, skin, chest wall, or regional nodal recurrence without concurrent distant recurrence, and was stratified by racial and ethnic group. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards regression models were used for survival analyses.

Results

Of the 10 273 women enrolled in TAILORx, this analysis included 9369 with T1-2N0 HR-positive, ERBB2-negative breast cancer. Of these patients, 428 (4.6%) were Asian, 886 (9.4%) were Hispanic, 676 (7.2%) were non-Hispanic Black (hereinafter Black), and 7406 (78.8%) were non-Hispanic White (hereinafter White). Assigned treatment receipt was high, with a 9.3% (n = 870) crossover of treatment groups and a median endocrine therapy duration of longer than 60 months, ranging from 61.1 to 65.9 months, across racial and ethnic groups. A total of 6818 patients (72.6%) received radiation (6474 [96.1%] after breast-conserving surgery and 344 [13.0%] after mastectomy). At a median follow-up of 94.8 months (range, 1-138 months), 8-year LRR rates were 3.6% (95% CI, 1.6%-5.6%) in Asian patients, 3.9% (95% CI, 2.2%-5.4%) in Black patients, 3.1% in Hispanic patients (95% CI, 1.7%-4.5%), and 1.8% (95% CI, 1.5%-2.3%) in White patients (P < .001). In survival analyses adjusted for patient, tumor, and treatment factors, Asian race (hazard ratio, 1.91 [95% CI, 1.12-3.29]) and Black race (1.78 [1.15-2.77]) were independently associated with LRR. In adjusted survival analyses for breast cancer mortality, LRR was independently associated with increased breast cancer mortality (hazard ratio, 5.71 [95% CI, 3.50-9.31]).

Conclusions and Relevance

In this post hoc analysis, racial and ethnic differences in LRR were observed among patients with T1-2N0 HR-positive, ERBB2-negative breast cancer despite high rates of treatment receipt in this clinical trial population, with the highest LRR rates in Asian and Black patients. Further study is needed to understand whether failure to rescue after LRR may contribute to racial disparities in breast cancer mortality.

Trial Registration

ClinicalTrials.gov Identifier: NCT00310180.

Mitigating disparities in breast cancer treatment at an academic safety-net hospital

PURPOSE

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital.

METHODS

We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status.

RESULTS

520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5 years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years.

CONCLUSION

Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

Race, geography, and risk of breast cancer treatment delays: A population-based study 2004-2015

BACKGROUND

Treatment delays affect breast cancer survival and constitute poor-quality care. Black patients experience more treatment delay, but the relationship of geography to these disparities is poorly understood.

METHODS

We studied a population-based, retrospective, observational cohort of patients with breast cancer in North Carolina between 2004 and 2017 from the Cancer Information and Population Health Resource, which links cancer registry and sociodemographic data to multipayer insurance claims. We included patients >18 years with Stage I-III breast cancer who received surgery or chemotherapy as their first treatment. Delay was defined as >60 days from diagnosis to first treatment. Counties were aggregated into nine Area Health Education Center regions. Race was dichotomized as Black versus non-Black.

RESULTS

Among 32,626 patients, 6190 (19.0%) were Black. Black patients were more likely to experience treatment delay >60 days (15.0% of Black vs. 8.0% of non-Black). Using race-stratified modified Poisson regression, age-adjusted relative risk of delay in the highest risk region was approximately twice that in the lowest risk region among Black (relative risk, 2.1; 95% CI, 1.6-2.6) and non-Black patients (relative risk, 1.9; 95% CI, 1.5-2.3). Adjustment for clinical and sociodemographic features only slightly attenuated interregion differences. The magnitude of the racial gap in treatment delay varied by region, from 0.0% to 9.4%.

CONCLUSIONS

Geographic region was significantly associated with risk of treatment delays for both Black and non-Black patients. The magnitude of racial disparities in treatment delay varied markedly between regions. Future studies should consider both high-risk geographic regions and high-risk patient groups for intervention to prevent delays.

The impact of race/ethnicity and county-level upward economic mobility on textbook outcomes in hepatopancreatic surgery

BACKGROUND

The impact of upward economic mobility and race/ethnicity on achieving quality metrics such as textbook outcomes remains ill-defined. As such, we sought to define the impact of race and county-level upward economic mobility on the ability to achieve a textbook outcome among patients undergoing hepatic and pancreatic surgery.

METHODS

Patients who underwent hepatic or pancreatic procedures between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The primary outcomes of interest were textbook outcome and its components.

RESULTS

Among 35,403 patients, 17,923 (50.6%) patients were classified as living in a low upward economic mobility county, whereas 17,480 (49.4%) lived in a high upward economic mobility county. Furthermore, 32,981 (93.1%) patients were White, and 2,422 (6.8%) were Black. Overall, a textbook outcome was achieved in 45.6% of patients (n = 16,139), with textbook outcome most likely in patients from a high upward economic mobility county compared with a low upward economic mobility county (low: 44.6% vs high: 46.6%, P < .001). On multivariable analysis, patients in a low upward economic mobility county had 6% lower odds of achieving a textbook outcome compared with a high upward economic mobility county (odds ratio 0.94, 95% confidence interval 0.90-0.98). Furthermore, Black patients were less likely to achieve a textbook outcome (odds ratio 0.91, 95% confidence interval 0.84-0.99) and had 17% and 15% higher odds of developing a complication (odds ratio 1.17, 95% confidence interval 1.07-1.28) and extended length of stay (odds ratio 1.15, 95% confidence interval 1.05-1.27), respectively. Within races, White patients in a high upward economic mobility county had 7% higher odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 1.07, 95% confidence interval 1.02-1.12), although no such effect was observed in Black patients (odds ratio 0.94, 95% confidence interval 0.77-1.15). Furthermore, Black patients in a high upward economic mobility county had similar odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 0.92, 95% confidence interval 0.77-1.09).

CONCLUSION

These results highlight the differential impact of upward economic mobility and race on postoperative outcomes. Due to the health care implications of socioeconomic status, future policy initiatives should target economic mobility as a means to ensure greater health care equity.

Nondisparate Survival of Non-Hispanic Black Women With Breast Cancer Despite Less Favorable Pathology: Effect of Access to and Provision of Care Within a Military Health Care System

Introduction

Breast cancer mortality rates are 40% higher in non-Hispanic Blacks (NHBs) than in non-Hispanic White (NHWs) in the United States. All women treated within the Murtha Cancer Center at Walter Reed National Military Medical Center (MCC/WRNMMC) have health insurance and are provided multidisciplinary health care. Pathological factors and outcomes of NHBs and NHWs treated within the MCC/WRNMMC were evaluated to determine whether equal-access health care reduces disparate phenotypes and survival between the racial groups.

Methods

Between 2001 and 2018, 368 NHB and 819 NHW women were diagnosed with breast cancer at MCC/WRNMMC. Differences between NHBs and NHWs in epidemiological and pathological characteristics were evaluated. Overall and breast cancer-specific 5- and 10-year survival rates were compared between races.

Results

Compared with NHWs, NHBs were significantly more likely to have a body mass index ≥30 kg/m², to be unmarried, to have tumors of higher grade, later stage, with lymph node metastases, and to be hormone receptor negative (HR^-)/human epidermal growth factor receptor 2 positive (HER2⁺) or triple negative. After adjustment for demographic factors, NHBs remained significantly more likely to have tumors diagnosed at a higher grade and later stage, and to be HR^-/HER2⁺ or triple negative. Neither 5- nor 10-year overall or breast cancer-specific survival differed significantly between the racial groups after adjusting for demographic and pathological variables.

Discussion

Despite having tumors with less favorable pathological characteristics, overall and disease-free survival disparities were not observed for NHBs treated at MCC/WRNMMC. These data suggest that survival disparities of NHBs with breast cancer can be diminished with provision of quality care.

Annual report to the nation on the status of cancer, part 1: National cancer statistics

BACKGROUND

The American Cancer Society, the Centers for Disease Control and Prevention, the National Cancer Institute, and the North American Association of Central Cancer Registries collaborate to provide annual updates on cancer occurrence and trends in the United States.

METHODS

Data on new cancer diagnoses during 2001-2018 were obtained from the North American Association of Central Cancer Registries' Cancer in North America Incidence file, which is comprised of data from Centers for Disease Control and Prevention-funded and National Cancer Institute-funded, population-based cancer registry programs. Data on cancer deaths during 2001-2019 were obtained from the National Center for Health Statistics' National Vital Statistics System. Five-year average incidence and death rates along with trends for all cancers combined and for the leading cancer types are reported by sex, racial/ethnic group, and age.

RESULTS

Overall cancer incidence rates were 497 per 100,000 among males (ranging from 306 among Asian/Pacific Islander males to 544 among Black males) and 431 per 100,000 among females (ranging from 309 among Asian/Pacific Islander females to 473 among American Indian/Alaska Native females) during 2014-2018. The trend during the corresponding period was stable among males and increased 0.2% on average per year among females, with differing trends by sex, racial/ethnic group, and cancer type. Among males, incidence rates increased for three cancers (including pancreas and kidney), were stable for seven cancers (including prostate), and decreased for eight (including lung and larynx) of the 18 most common cancers considered in this analysis. Among females, incidence rates increased for seven cancers (including melanoma, liver, and breast), were stable for four cancers (including uterus), and decreased for seven (including thyroid and ovary) of the 18 most common cancers. Overall cancer death rates decreased by 2.3% per year among males and by 1.9% per year among females during 2015-2019, with the sex-specific declining trend reflected in every major racial/ethnic group. During 2015-2019, death rates decreased for 11 of the 19 most common cancers among males and for 14 of the 20 most common cancers among females, with the steepest declines (>4% per year) reported for lung cancer and melanoma. Five-year survival for adenocarcinoma and neuroendocrine pancreatic cancer improved between 2001 and 2018; however, overall incidence (2001-2018) and mortality (2001-2019) continued to increase for this site. Among children (younger than 15 years), recent trends were stable for incidence and decreased for mortality; and among, adolescents and young adults (aged 15-39 years), recent trends increased for incidence and declined for mortality.

CONCLUSIONS

Cancer death rates continued to decline overall, for children, and for adolescents and young adults, and treatment advances have led to accelerated declines in death rates for several sites, such as lung and melanoma. The increases in incidence rates for several common cancers in part reflect changes in risk factors, screening test use, and diagnostic practice. Racial/ethnic differences exist in cancer incidence and mortality, highlighting the need to understand and address inequities. Population-based incidence and mortality data inform prevention, early detection, and treatment efforts to help reduce the cancer burden in the United States.

Disparities in Time to Treatment for Breast Cancer: Existing Knowledge and Future Directions in the COVID-19 Era

Purpose of Review

Despite significant advances in detection and treatment for breast cancer, the breast cancer mortality rate for Black women remains 40% higher than that for White women. Timely work-up and treatment improve outcomes, yet no gold standard exists for which to guide providers.

Recent Findings

A large body of literature demonstrates disparities in time to treatment for breast cancer, and most studies show that Black women receive treatment later than their White counterparts. The COVID-19 pandemic has been projected to worsen these disparities, but the extent of this impact remains unknown.

Summary

In this review, we describe the available evidence on disparities in time to treatment, potential drivers, and possible mitigation strategies. Future research must address how the COVID-19 pandemic has impacted the timely treatment of breast cancer patients, particularly populations vulnerable to disparate outcomes. Improved access to multidisciplinary breast programs, patient navigation services, and establishment of standards for timely treatment are necessary.

Breast Cancer Statistics, 2022

This article is the American Cancer Society's update on female breast cancer statistics in the United States, including population-based data on incidence, mortality, survival, and mammography screening. Breast cancer incidence rates have risen in most of the past four decades; during the most recent data years (2010-2019), the rate increased by 0.5% annually, largely driven by localized-stage and hormone receptor-positive disease. In contrast, breast cancer mortality rates have declined steadily since their peak in 1989, albeit at a slower pace in recent years (1.3% annually from 2011 to 2020) than in the previous decade (1.9% annually from 2002 to 2011). In total, the death rate dropped by 43% during 1989-2020, translating to 460,000 fewer breast cancer deaths during that time. The death rate declined similarly for women of all racial/ethnic groups except American Indians/Alaska Natives, among whom the rates were stable. However, despite a lower incidence rate in Black versus White women (127.8 vs. 133.7 per 100,000), the racial disparity in breast cancer mortality remained unwavering, with the death rate 40% higher in Black women overall (27.6 vs. 19.7 deaths per 100,000 in 2016-2020) and two-fold higher among adult women younger than 50 years (12.1 vs. 6.5 deaths per 100,000). Black women have the lowest 5-year relative survival of any racial/ethnic group for every molecular subtype and stage of disease (except stage I), with the largest Black-White gaps in absolute terms for hormone receptor-positive/human epidermal growth factor receptor 2-negative disease (88% vs. 96%), hormone receptor-negative/human epidermal growth factor receptor 2-positive disease (78% vs. 86%), and stage III disease (64% vs. 77%). Progress against breast cancer mortality could be accelerated by mitigating racial disparities through increased access to high-quality screening and treatment via nationwide Medicaid expansion and partnerships between community stakeholders, advocacy organizations, and health systems.

Temporal trends in Black-White disparities in cancer surgery and cancer-specific survival in the United States between 2007 and 2015

BACKGROUND

The American Society of Clinical Oncology (ASCO) has strived to address racial/ethnic disparities in cancer care since 2009. Surgery plays a pivotal role in cancer care; however, it is unclear whether and how racial/ethnic disparities in cancer surgery have changed over time.

METHODS

This cohort study included 1,113,256 White and Black cancer patients across 9 years (2007-2015) using patient data extracted from the Surveillance, Epidemiology, and End Results (SEER)-18 registries. Patient data were included from 2007 to adjust insurance status and by 2015 to obtain at least a 3-year survival follow-up (until 2018). The primary outcome was a surgical intervention. The secondary outcomes were the use of (neo)adjuvant chemotherapy and cancer-specific survival (CSS). Adjusted associations of the race (Black/White) with the outcomes were measured in each cancer type and year.

RESULTS

The gap between surgery rates for Black and White patients narrowed overall, from an adjusted odds ratio (aOR) of 0.621 (0.592-0.652) in 2007 to 0.734 (0.702-0.768) in 2015. However, the racial gap persisted in the surgery rates for lung, breast, prostate, esophageal, and ovarian cancers. In surgically treated patients with lymph node metastasis, Black patients with colorectal cancer (CRC) were less likely to receive (neo)adjuvant chemotherapy than White patients. Black patients undergoing surgery were more likely to have a worse CSS rate than White patients undergoing surgery. In breast cancer patients, the overall trend was narrow, but continuously present, with an adjusted hazard ratio (aHR) of 1.224 (1.278-1.173) in 2007 and 1.042 (1.132-0.96) in 2015.

CONCLUSIONS

Overall, progress has been made toward narrowing the Black-White gap in cancer surgical opportunity and survival. Future efforts should be directed toward those specific cancers for which the Black-White gap continues. Additionally, it is worth addressing the Black-White gap regarding the use of (neo)adjuvant chemotherapy for CRC treatment.

Impact of Racial Disparities in Preoperative Cardiovascular Evaluation and Surgical Outcomes in Patients Undergoing Metabolic and Bariatric Surgery: A Retrospective Cohort Analysis

Background

We investigated preoperative referral patterns, rates of cardiovascular testing, surgical wait times, and postoperative outcomes in White versus Black, Hispanic, or other racial or ethnic groups of patients undergoing metabolic and bariatric surgery.

Methods and Results

This was a single center retrospective cohort analysis of 797 consecutive patients undergoing metabolic and bariatric surgery from January 2014 to December 2018; 86% (n=682) were Black, Hispanic, or other racial or ethnic groups. White versus Black, Hispanic, or other racial or ethnic groups had similar baseline comorbidities and were referred for preoperative cardiovascular evaluation in similar proportion (65% versus 68%, P=0.529). Black, Hispanic, or other racial or ethnic groups of patients were less likely to undergo preoperative cardiovascular testing (unadjusted odds ratio [OR], 0.56; 95% CI, 0.33–0.95; P=0.031; adjusted for Revised Cardiac Risk Index OR, 0.59; 95% CI, 0.35–0.996; P=0.049). White patients had a shorter wait time for surgery (unadjusted hazard ratio [HR], 0.7; 95% CI, 0.58–0.87; P=0.001; adjusted HR, 0.7; 95% CI, 0.56–0.95; P=0.018). Reduction in body mass index at 6 months was greater in White patients (12.9 kg/m² versus 12.0 kg/m², P=0.0289), but equivalent at 1 year (14.9 kg/m² versus 14.3 kg/m², P=0.330).

Conclusions

White versus Black, Hispanic, or other racial or ethnic groups of patients were referred for preoperative cardiovascular evaluation in similar proportion. White patients underwent more preoperative cardiac testing yet had a shorter wait time for surgery. Early weight loss was greater in White patients, but equivalent between groups at 12 months.

Disparities in time to start of definitive radiation treatment for patients with locally advanced cervical cancer

Background

Chemoradiation or radiation therapy alone are curative standards for patients with locally advanced cervical cancer.

Objective

To investigate factors that influence time to initiation of chemoradiation or radiation and the subsequent impact of time to treatment on recurrence and survival outcomes.

Methods

Patients with locally advanced cervical cancer treated with definitive chemoradiation or radiation at our institution between November 2015 and August 2020 were retrospectively identified. Time to treatment initiation was defined as the number of days from date of diagnosis (via biopsy) to the start date of radiation. The cohort was stratified by the median time to treatment into early (<75 days) and delayed (≥75 days) cohorts. Multivariable logistic regression was conducted to examine factors associated with delayed time to treatment.

Results

We identified 143 patients with locally advanced cervical cancer who underwent definitive chemoradiation or radiation. Median follow-up time was 18 months (range 2–62). A total of 71 (49.7%) patients had time to treatment <75 days and 72 (50.3%) patients had time to treatment ≥75 days. The delayed cohort had a higher proportion of Hispanic patients (51.4% vs 31.0%, p=0.04). In multivariable modeling, Hispanic women were 2.71 times more likely (p=0.04) to undergo delayed time to treatment than non-Hispanic white women. Additionally, patients with stage >IIB disease were less likely to undergo delayed time to treatment (OR 0.26, p=0.02) than patients with stage <IIB disease. There was no interaction between race/ethnicity and disease stage. Delayed time to treatment was not associated with inferior overall survival, loco-regional failure, or distant failure.

Conclusion

Hispanic patients with locally advanced cervical cancer were more likely to receive delayed time to definitive treatment of ≥75 days. Further studies examining the presence of similar disparities in delay to definitive treatment for locally advanced cervical cancer at other institutions and settings are warranted.

Asian Ethnic Subgroup Disparities in Delays of Surgical Treatment for Breast Cancer

Background

As Asian American breast cancer incidence rises, it is necessary to investigate the origins of differential breast cancer outcomes among Asian ethnic subgroups. This study aimed to examine disparities in delays of breast cancer surgery among Asian ethnic subgroups.

Methods

We obtained California Cancer Registry data on female breast cancer diagnoses and treatment from 2012 to 2017. Our main independent variable was patient race and ethnicity, including 6 Asian ethnic subgroups. Dependent variables included time to surgical treatment for breast cancer and receipt of surgical treatment within 30 and 90 days of diagnosis. We conducted multivariable logistic regression to determine the odds of receiving surgery within 30 and 90 days of diagnosis and multivariable Cox proportional hazards regression to determine the risk of prolonged time to surgery.

Results

In our cohort of 93 168 breast cancer patients, Hispanic (odds ratio [OR] = 0.86, 95% confidence interval [CI] = 0.82 to 0.89) and non-Hispanic Black (OR = 0.83, 95% CI = 0.78 to 0.88) patients were statistically significantly less likely than non-Hispanic White patients to receive surgery within 30 days of breast cancer diagnosis, whereas Asian Indian or Pakistani (OR = 1.23, 95% CI = 1.09 to 1.40) and Chinese (OR = 1.30, 95% CI = 1.20 to 1.40) patients were statistically significantly more likely to receive surgery within 30 days of diagnosis.

Conclusions

This large, population-based retrospective cohort study of female breast cancer patients is the first, to our knowledge, to demonstrate that time to surgical treatment is not equal for all Asians. Distinct differences among Asian ethnic subgroups suggest the necessity of further investigating breast cancer treatment patterns to fully understand and target disparities in breast cancer treatment.

A tool to predict disparities in the timeliness of surgical treatment for breast cancer patients in the USA

Purpose

Breast cancer outcomes are impaired by both delays and disparities in treatment. This study was performed to assess their relationship and to provide a tool to predict patient socioeconomic factors associated with risk for delay.

Methods

The National Cancer Database was reviewed between 2004 and 2017 for patients with non-metastatic breast cancer managed with upfront surgery. Times to treatment were measured from the date of diagnosis. Patient, tumor, and treatment factors were assessed with attention paid to sociodemographic variables.

Results

514,187 patients remained after exclusions, with 84.3% White, 10.8% Black, 3.7% Asian, and Hispanics comprising 5.6% of the cohort. Medicaid and uninsured patients had longer mean adjusted time to surgery (≥ 46 days) versus private (36.7 days), Medicare (35.9 days), or other governmental insurance (39.8 days). After adjustment, Black race and Hispanic ethnicity were most impactful, adding 6.0 and 6.4 preoperative days, 10.9 and 11.5 days to chemotherapy, 11.1 and 9.1 days to radiation, and 12.5 and 8.9 days to endocrine therapy, respectively. Income, education, and insurance, among other factors, also affected delay. A nomogram, including race and sociodemographic factors, was created to predict the risk of preoperative delay.

Conclusion

 Significant disparities exist in timeliness of care for factors, including but not limited to, race and ethnicity. Although exact causes cannot be discerned, these data indicate population subsets whose intervals of care risk being longer than those specified by national quality standards. The nomogram created here may help direct resources to those at highest risk of incurring a treatment delay.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06460-9.

Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System

Rationale & Objective

Health-impeding social determinants of health—including reduced access to care—contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care.

Study Design

Cross-sectional study.

Setting & Participants

MHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018.

Predictors

Race, sponsor’s rank (a proxy for socioeconomic status and social class), median household income by sponsor’s zip code, and marital status.

Outcome

CKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype.

Analytical Approach

Multivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor’s service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index).

Results

Of 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators.

Limitations

The cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code–level median household income data.

Conclusions

Racial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.

Identifying Equitable Screening Mammography Strategies for Black Women in the United States Using Simulation Modeling

BACKGROUND

Screening mammography guidelines do not explicitly consider racial differences in breast cancer epidemiology, treatment, and survival.

OBJECTIVE

To compare tradeoffs of screening strategies in Black women versus White women under current guidelines.

DESIGN

An established model from the Cancer Intervention and Surveillance Modeling Network simulated screening outcomes using race-specific inputs for subtype distribution; breast density; mammography performance; age-, stage-, and subtype-specific treatment effects; and non-breast cancer mortality.

SETTING

United States.

PARTICIPANTS

A 1980 U.S. birth cohort of Black and White women.

INTERVENTION

Screening strategies until age 74 years with varying initiation ages and intervals.

MEASUREMENTS

Outcomes included benefits (life-years gained [LYG], breast cancer deaths averted, and mortality reduction), harms (mammographies, false positives, and overdiagnoses), and benefit-harm ratios (tradeoffs) by race. Efficiency (benefits per unit resource), mortality disparity reduction, and equity in tradeoffs were evaluated. Equitable strategies for Black women were defined as those with tradeoffs closest to benchmark values for screening White women biennially from ages 50 to 74 years.

RESULTS

Biennial screening from ages 45 to 74 years was most efficient for Black women, whereas biennial screening from ages 40 to 74 years was most equitable. Initiating screening 10 years earlier in Black versus White women reduced Black-White mortality disparities by 57% with similar LYG per mammogram for both populations. Selection of the most equitable strategy was sensitive to assumptions about disparities in real-world treatment effectiveness: The less effective treatment was for Black women, the more intensively Black women could be screened before tradeoffs fell short of those experienced by White women.

LIMITATION

Single model.

CONCLUSION

Initiating biennial screening in Black women at age 40 years reduces breast cancer mortality disparities and yields benefit-harm ratios that are similar to tradeoffs of White women screened biennially from ages 50 to 74 years.

PRIMARY FUNDING SOURCE

National Cancer Institute at the National Institutes of Health.

Colorectal Cancer Survival in Multiple Sclerosis: A Matched Cohort Study

BACKGROUND AND OBJECTIVES

We tested the hypothesis that overall and cancer-specific survival after a colorectal cancer diagnosis is lower in persons with multiple sclerosis (MS) than in those without MS using a retrospective matched cohort design.

METHODS

Using population-based administrative data in Manitoba and Ontario, we identified persons with MS from a validated case definition and linked these cohorts to cancer registries to identify those with colorectal cancer. We selected persons with colorectal cancer and without MS, matching 4:1 on birth year, sex, cancer diagnosis year, and region. We used Cox proportional hazards regression to compare all-cause survival between cohorts, adjusting for age at cancer diagnosis, cancer diagnosis year, income, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a cause-specific hazards model. We pooled findings across provinces using random-effects meta-analysis. Complementary analyses using a subcohort from Ontario, adjusted for cancer stage and disability status, as measured from the use of home care or long-term care services.

RESULTS

We included 338 MS cases and 1,352 controls with colorectal cancer. The mean (SD) age at cancer diagnosis was 64.7 (11.1) years. After adjustment, MS was associated with an increased hazard for all-cause death that was highest 6 months after diagnosis (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.19-1.76) and then declined over time (HR [95% CI] at 1 year 1.34 [1.09-1.63], 2 years 1.24 [0.99-1.56], 5 years 1.10 [0.80-1.50]). MS was associated with increased cancer-specific death at 6 months after diagnosis only (HR 1.29, 95% CI 1.04-1.61). After adjustment for cancer stage, MS was associated with an increased hazard of death due to any cause (1.60, 95% CI 1.16-2.21) and with cancer-specific death (HR 1.47, 95% CI 1.02-2.12). The association of MS and all-cause death was partially attenuated after adjustment for disability status (HR 1.37, 95% CI 0.97-1.92), as was the association with cancer-specific death (HR 1.34, 95% CI 0.91-1.97).

DISCUSSION

Overall and cancer-specific survival was lower in persons with than without MS in the early period after colorectal cancer diagnosis. Further study is warranted to determine what factors underlie these worse outcomes.

Impact of Inequities on Delay in Breast Cancer Management in Women Undergoing Second Opinions

BACKGROUND

Inequities in breast cancer treatment lead to delay in therapy, decreased survival and lower quality of life. This study aimed to examine demographics and clinical factors impacting time to treatment for second-opinion breast cancer patients.

MATERIALS AND METHODS

We performed a retrospective chart review to analyze patients presenting to one academic institution for second opinion of breast imaging, diagnosis, or breast-related treatment. Data from women with stage I-III breast cancer who received treatment at this institution were evaluated to determine the impact of patient demographics and clinical characteristics on time to first treatment.

RESULTS

Of the 1006 charts reviewed, 307 met inclusion criteria. Low-income patients averaged 58 days from diagnosis to surgery compared to 35 days for high-income patients (incidence rate ratio [IRR] 0.64, P<0.01). Black patients averaged 56 days from diagnosis to surgery compared to 42 days for White patients (IRR 1.37, P<0.01). Latina patients averaged 38 days from initial encounter to neoadjuvant chemotherapy compared to 20 days for White patients (IRR 1.69, P<0.05).

CONCLUSION

Patients with low-income, of Black race and Latina ethnicity experienced increased time to treatment. Additionally, time to mastectomy with and without reconstruction was longer than time to partial mastectomy. Further exploration is needed to determine why certain factors lead to treatment delay and how inequities can be eliminated.

Time to Completion of Breast Cancer Treatment and Survival

BACKGROUND

Breast cancer treatment delays are common. This study was designed to examine the association between the time interval from time of diagnosis to completion of all acute breast cancer treatment modalities (surgery, chemotherapy, and radiation therapy) and survival.

METHODS

A retrospective analysis was performed utilizing data from the National Cancer Database (NCDB) to determine an association between the duration of time from diagnosis to completing all acute breast cancer treatment (surgery, chemotherapy, and radiation therapy) and survival. Secondary survival analysis evaluated whether delay in treatment completion varied by differences in tumor receptor status.

RESULTS

We analyzed 2010 NCDB data of stage I-III breast cancer patients. A subset of 28,284 patients received all three modalities (surgery, chemotherapy, and radiation) as their acute treatment. Median follow-up was 5.8 years. Cox proportional hazards model identified a cut-off showing the risk of delaying completion of all treatment beyond 38 weeks was associated with a decrease in overall survival (hazard ratio [HR] 1.21). This decrease in survival was significant regardless of the major tumor receptor status: triple-negative (HR 1.188, 95% confidence interval [CI] 1.06-1.34), estrogen receptor (ER)+/progesterone receptor (PR)+/human epidermal growth factor receptor 2 (HER2)- (HR 1.22, 95% CI 1.09-1.36), ER-/PR-/HER2+ (HR 1.29, 95% CI 1.004-1.67), and ER+/PR+/HER2+ (HR 1.32, 95% CI 1.01-1.72).

CONCLUSION

Efforts to improve the efficiency of multimodality breast cancer treatment and reduce treatment delays should be a priority to optimize breast cancer patient outcomes.

Breast Cancer Survival in Multiple Sclerosis: A Matched Cohort Study

OBJECTIVE

To test the hypotheses that overall survival and cancer-specific survival after breast cancer diagnosis would be lower in persons with multiple sclerosis (MS) as compared to persons without MS using a retrospective matched cohort design.

METHODS

We applied a validated case definition to population-based administrative data in Manitoba and Ontario, Canada, to identify women with MS. We linked the MS cohorts to cancer registries to identify women with breast cancer. Then we selected 4 breast cancer controls without MS matched on birth year, cancer diagnosis year, and region. We compared all-cause survival between cohorts using Cox proportional hazards regression adjusting for age at cancer diagnosis, cancer diagnosis period, income quintile, region, and Elixhauser comorbidity score. We compared cancer-specific survival between cohorts using a multivariable cause-specific hazards model. We pooled findings between provinces using meta-analysis.

RESULTS

We included 779 patients with MS and 3,116 controls with breast cancer. Most patients with stage data (1,976/2,822 [70.0%]) were diagnosed with stage I or II breast cancer and the mean (SD) age at diagnosis was 57.8 (10.7) years. After adjustment for covariates, MS was associated with a 28% increased hazard for all-cause mortality (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.08-1.53), but was not associated with altered cancer-specific survival (HR 0.98; 95% CI 0.65-1.46).

CONCLUSION

Women with MS have lower all-cause survival after breast cancer diagnosis than women without MS. Future studies should confirm these findings in other populations and identify MS-specific factors associated with worse prognosis.

Factors Associated With Breast Cancer Surgery Delay Within a Coordinated Multihospital Community Health System: When Does Surgical Delay Impact Outcome?

BACKGROUND

Multiple factors influence the time elapsed between diagnosis of breast cancer and surgical extirpation of the primary tumor. The disease-free interval between resection of primary breast cancer and first evidence of recurrence is predictive of mortality. We aimed to determine patient, disease, and treatment factors associated with a delay in time to surgery (TTS) and identify the point when prolonged TTS negatively impacts disease-free survival.

PATIENTS AND METHODS

Cancer registry and electronic medical record data for patients with breast cancer who underwent surgery as first course of treatment during 2006-2016 were retrospectively reviewed. Patients undergoing surgery in ≤30 vs. 31-60 vs. >60 days of initial diagnosis were compared. Kaplan-Meier survival analyses with Cox proportional hazards were performed to evaluate impact of time from breast cancer diagnosis to definitive therapeutic surgery on breast cancer recurrence or death (all-cause).

RESULTS

Overall, 4462 patients were analyzed, 43.4% of whom underwent surgery beyond 30 days. The following factors were associated with TTS >30 days: age <50, non-Hispanic White race/ethnicity, commercial or health exchange/Medicaid insurance, diagnosis of noninvasive disease (i.e., ductal carcinoma in situ), had breast magnetic resonance imaging before definitive surgery, underwent total mastectomy (especially if immediate reconstruction, particularly if autologous, was performed), and did not receive adjuvant therapies (P < .001 for all). After adjusting for relevant variables, significant predictors of recurrence/death included a TTS >60 days, increased patient age, higher breast cancer stage, and triple-negative biomarker expression.

CONCLUSION

Risk of recurrence or death is not compromised until TTS exceeds 60 days after initial breast cancer diagnosis.

Time from breast cancer diagnosis to treatment among Idaho's National Breast and Cervical Cancer Early Detection Program population, 2011-2017

PURPOSE

Idaho's Women's Health Check (WHC) Program provides breast and cervical cancer screening to under- and uninsured women via funding from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Because WHC serves populations with less access to health care, this study evaluated time from breast cancer diagnosis to treatment for women enrolled in the WHC program and linked to Cancer Data Registry of Idaho (CDRI) case data (WHC-linked) and the remainder of female Idaho resident breast cases.

METHODS

Among Idaho residents aged 50-64 years diagnosed during 2011-2017 with ductal carcinoma in situ or invasive breast cancer, we assessed differences in the median time from definitive diagnosis to treatment initiation overall and by demographic and tumor characteristics, and differences in the distribution of demographic and tumor-related variables between 231 WHC-linked and 3,040 non-linked breast cancer cases.

RESULTS

WHC-linked cases were significantly less likely to be non-Hispanic white, and more likely to live in poorer census tracts, be diagnosed at a later stage, and be treated with mastectomy. Most WHC-linked (92%) and non-linked women (94%) began treatment within 60 days of diagnosis; no differences in time to treatment were observed.

CONCLUSION

Disparities in the interval from definitive diagnosis to breast cancer treatment initiation were not observed for women enrolled in the WHC program relative to other Idaho women.

Residential Racial Segregation and Disparities in Breast Cancer Presentation, Treatment, and Survival

OBJECTIVE

To understand the role of racial residential segregation on Black-White disparities in breast cancer presentation, treatment, and outcomes.

SUMMARY OF BACKGROUND DATA

Racial disparities in breast cancer treatment and outcomes are well documented. Black individuals present at advanced stage, are less likely to receive appropriate surgical and adjuvant treatment, and have lower overall and stage-specific survival relative to White individuals.

METHODS

Using data from the Surveillance, Epidemiology, and End Results program, we performed a retrospective cohort study of Black and White patients diagnosed with invasive breast cancer from 2005 to 2015 within the 100 most populous participating counties. The racial index of dissimilarity was used as a validated measure of residential segregation. Multivariable regression was performed, predicting advanced stage at diagnosis (stage III/IV), surgery for localized disease (stage I/II), and overall stage-specific survival.

RESULTS

After adjusting for age at diagnosis, estrogen/progesterone receptor status, and region, Black patients have a 49% greater risk (relative risk [RR] 1.49 95% confidence interval [CI] 1.27, 1.74) of presenting at advanced stage with increasing segregation, while there was no observed difference in Whites (RR 1.04, 95% CI 0.93, 1.16). Black patients were 3% less likely to undergo surgical resection for localized disease (RR 0.97, 95% CI 0.95, 0.99) with increasing segregation, while Whites saw no significant difference. Black patients had a 29% increased hazard of death (RR 1.29, 95% CI 1.04, 1.60) with increasing segregation; there was no significant difference among White patients.

CONCLUSIONS

Our data suggest that residential racial segregation has a significant association with Black-White racial disparities in breast cancer. These findings illustrate the importance of addressing structural racism and residential segregation in efforts to reduce Black-White breast cancer disparities.

Time to surgery among women treated with neoadjuvant systemic therapy and upfront surgery for breast cancer

PURPOSE

Time to surgery (TTS) is a potentially modifiable factor associated with survival after breast cancer diagnosis and can serve as a proxy for quality of oncologic care coordination. We sought to determine whether factors associated with delays in TTS vary between patients who receive neoadjuvant systemic therapy (NST) vs upfront surgery and whether the impact of these delays on overall survival (OS) varies with treatment sequence.

METHODS

Women ≥ 18 years old with Stage I-III breast cancer were identified in the National Cancer Database (2004-2014). Multivariate linear regression stratified by treatment sequence (upfront surgery vs NST [neoadjuvant chemotherapy {NAC}, neoadjuvant endocrine therapy {NAE}, or both {NACE}]) was used to identify factors associated with TTS. Cox proportional hazards models were used to estimate the effect of TTS on overall survival (OS).

RESULTS

Of 693,469 patients, 14.8% (n = 102,326) received NST (NAC n = 85,143, NAE n = 10,004, NACE n = 7179). Non-White race/ethnicity, no or government-issued insurance, more extensive surgery (i.e., mastectomy and contralateral prophylactic mastectomy vs breast-conserving surgery), and post-mastectomy reconstruction were associated with significantly longer adjusted TTS for NAC and upfront-surgery recipients, but only upfront-surgery patients had progressively worse OS with increasing TTS (> 180 vs ≤ 30 days: HR = 1.31, all p < 0.001).

CONCLUSIONS

Surgery extent, race/ethnicity, and insurance were associated with TTS across treatment groups, but longer TTS was only associated with worse OS in upfront-surgery patients. Our findings can help inform surgeon-patient communication, shared decision making, care coordination, and patients' expectations throughout both NST and in the perioperative period.

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills

PURPOSE

Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills.

METHODS

Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16.

RESULTS

A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05).

CONCLUSIONS

At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.

Consolidation of Cancer Registry and Administrative Claims Data on Cancer Diagnosis and Treatment in the US Military Health System

PURPOSE

Linked cancer registry and medical claims data have increased the capacity for cancer research. However, few efforts have described methods to select information between data sources, which may affect data use. We developed a systematic process to evaluate and consolidate cancer diagnosis and treatment information between the linked Department of Defense Central Cancer Registry (CCR) and Military Health System Data Repository (MDR) administrative claims database, called Military Cancer Epidemiology Data System (MilCanEpi).

METHODS

MilCanEpi contains information on cancer diagnosis and treatment of patients receiving care from 1998 to 2014. We used an iterative process guided by knowledge of data features, current literature, and logical comparisons between the CCR and MDR data to evaluate and consolidate cancer diagnosis and treatment received (yes or no) and their dates. We applied the processes to breast cancer data as an example. Agreement between diagnosis and treatment dates in the two data sources was evaluated using Cohen's κ with 95% CIs.

RESULTS

In MilCanEpi, we identified 15,965 patients with a breast cancer diagnosis and 15,145 patients who underwent breast cancer surgery; 97.9% and 84.1% of patients had records in both CCR and MDR for diagnosis and surgery, respectively. Exact agreement was 13.7% for diagnosis dates (Cohen's κ = 0.14; 95% CI, 0.13 to 0.14) and 68.9% for surgery dates (Cohen's κ = 0.69; 95% CI, 0.68 to 0.70) between the two data sources. After applying systematic processes, 98.1% of patients with a breast cancer diagnosis and 99.7% of patients with surgery had information selected for analytic data sets.

CONCLUSION

The developed processes resulted in high consolidation rates of breast cancer data in MilCanEpi and may serve as a data selection template for other tumor sites and linked data sources.

Critical evaluation of factors contributing to time to mastectomy within a single health care system

Increased time to mastectomy (TTM) has significant implications for mortality, well-being, and satisfaction. However, certain populations are subject to disparities that increase TTM. This study examines vulnerable populations and the patient-, disease-, provider-, and system-level factors related to treatment delays. Patients undergoing mastectomy for breast cancer from 2014 to 2018 across 8 hospitals in a single health care system were retrospectively reviewed. Demographics, disease characteristics, and provider- and system-level information were collected. Time from biopsy-proven diagnosis to mastectomy was calculated. Univariate analysis identified variables for inclusion in the multivariable model. One thousand, three hundred thirty patients met inclusion. Median TTM was 55.0 days. Factors from all levels-patient, disease, provider, and systemic-were significantly related to disparities. African-American patients had 11.6% longer TTM compared to white patients (69.0 vs 56.0 days, P < .0001). TTM was 15.5% longer for low-income patients when compared to high-income patients (65.0 vs 49.0 days, P = .0014). Preoperative plastic surgery visits led to 19.3% longer TTM (P = .0012); oncologic appointments for neo-adjuvant chemotherapy led to a 231.0% increase (P < .0001). Average time from last neo-adjuvant treatment to mastectomy was 44.4 days (SD 26.5); average TTM from diagnosis for patients not receiving neo-adjuvant chemotherapy was 58.5 days (SD 13.3). Patients with Medicaid waited 14.5% longer compared to patients with commercial insurance (94.0 vs 62.0 days, P = .0005). In our review of care across a large health care system, we identified multiple levels contributing to disparities in TTM. Identification of these disparities offers valuable insight into process improvement and intervention.

Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System

BACKGROUND AND OBJECTIVES

Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS).

METHODS

Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs).

RESULTS

Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion.

CONCLUSION

Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.