Patient-reported causes of distress predict disparities in time to evaluation and time to treatment after breast cancer diagnosis

Factors influencing psychological distress among breast cancer survivors using machine learning techniques

Breast cancer is the most commonly diagnosed cancer among women worldwide. Breast cancer patients experience significant distress relating to their diagnosis and treatment. Managing this distress is critical for improving the lifespan and quality of life of breast cancer survivors. This study aimed to assess the level of distress in breast cancer survivors and analyze the variables that significantly affect distress using machine learning techniques. A survey was conducted with 641 adult breast cancer patients using the National Comprehensive Cancer Network Distress Thermometer tool. Participants identified various factors that caused distress. Five machine learning models were used to predict the classification of patients into mild and severe distress groups. The survey results indicated that 57.7% of the participants experienced severe distress. The top-three best-performing models indicated that depression, dealing with a partner, housing, work/school, and fatigue are the primary indicators. Among the emotional problems, depression, fear, worry, loss of interest in regular activities, and nervousness were determined as significant predictive factors. Therefore, machine learning models can be effectively applied to determine various factors influencing distress in breast cancer patients who have completed primary treatment, thereby identifying breast cancer patients who are vulnerable to distress in clinical settings.

The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach

BACKGROUND

Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies.

METHODS

We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and > 60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and > 60-day adjuvant delay.

RESULTS

We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25).

CONCLUSIONS

Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.

Psychological distress in adult women of reproductive age at different stages after breast cancer diagnosis: A qualitative study

AIM

To explore the actual experience of psychological distress of adult women of reproductive age at different stages after breast cancer diagnosis.

DESIGN

Qualitative.

METHODS

Eighty-one patients with breast cancer-related distress thermometer scores >4 were selected using a purposive sampling method. Patients were divided into newly diagnosed and 1-, 3-, 6-, 9- and 12-month groups according to time since diagnosis and then interviewed. A phenomenological approach was adopted to analyse interview content, and different themes were extracted.

RESULTS

Women exhibited different levels of psychological distress depending on the time since diagnosis, with newly diagnosed patients showing the highest distress. Within 1 year post-diagnosis, different events caused patients distress. Themes extracted at new diagnosis and 1-, 3-, 6-, 9- and 12 months post-diagnosis included sadness and disbelief, loss of control, optimistic but concerned, physical and mental exhaustion, difficulties returning to society and limited sexual intimacy, respectively; all groups expressed reproductive concerns.

CONCLUSION

Clinical nurses should focus on different psychologically distressing events to provide targeted interventions at distinct phases. For women of childbearing age, clinical nurses should pay particular attention to patients' marriage and reproductive concerns.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

During the year after a breast cancer diagnosis, patients of childbearing age experience events that cause psychological distress that differ depending on time since diagnosis. Nurses should focus on core stressful events and perform specific nursing interventions.

IMPACT

To provide holistic care, nurses should consider the psychological and emotional changes patients may undergo. For women of childbearing age, clinical nurses should pay particular attention to patients' marriage and fertility concerns, and be able to provide evidence-based professional guidance on reproductive preservation techniques.

REPORTING METHOD

The study was reported using the consolidated criteria for reporting qualitative research guidelines.

PATIENT OR PUBLIC CONTRIBUTION

Patients contributed to data collection through interviews.

Transcultural Adaptation of the Breast Cancer Awareness Measure in a Rural Border Area of Greece

BACKGROUND

Breast cancer awareness is a concept suggesting that awareness of signs and symptoms and early seeking of medical advice may decrease mortality, especially in limited resource settings.

METHODS

A modified questionnaire based on the breast cancer awareness measure (BCAM) by Cancer Research UK was translated into Greek and used for the first time. Participants were women residing in a rural border area in Greece. For statistical analysis the χ2 goodness-of-fit and Cramer's V test for categorical comparisons were used and Cronbach's alpha for reliability analysis.

RESULTS

In total, 110 women filled out and returned the questionnaire. Respondents appeared to be inappropriately informed regarding the less common warning signs of breast cancer, the most common age of breast cancer occurrence, the national screening program, and the less important risk factors of breast cancer. On the other hand, most women appeared to be confident in recognizing breast changes and seeking medical advice if needed.

CONCLUSIONS

The translated modified BCAM tool can be used to evaluate breast cancer awareness in Greek women. Future campaigns developed by policymakers should focus on improving breast cancer awareness, especially in socioeconomically deprived areas.

Disparities and barriers in the assessment of psychological distress, access to and use of psycho-oncological support in Europe: current perspectives

The implementation of psycho-oncological support has shown important results in positively influencing treatment outcomes and quality of life in cancer patients and survivors. In the last few decades, the importance of mental health has been brought to attention to the general public and healthcare professionals on a national, institutional and organisational level. Official guidelines, policies, and training programs have been developed suggesting that psycho-oncological support should be considered as a non-negotiable requirement for quality cancer care in many hospitals and clinical centres across Europe. Health organisations, associations, institutions, and societies, such as the International Psycho-Oncology Society (IPOS) and the European Partnership for Action Against Cancer (EPAAC), are forming alliances, funding research projects and organising congresses in order to study, understand, and discuss the reasons for barriers and disparities in psycho-oncological support and, eventually, to overcome the existing cancer divide. Nevertheless, the World Health Organization's (WHO) estimations indicate that the cancer burden is still increasing, and relevant barriers and disparities in accessing psycho-oncological support continue to exist and influence the health conditions and quality of life of cancer patients and survivors. The present work will present the current disparities and barriers regarding assessment, access to and use of psycho-oncological support in the countries of the European Union, making suggestions for further research and possible solutions.

Modifiable Barriers and Facilitators for Breast Cancer Care: A Thematic Analysis of Patient and Provider Perspectives

INTRODUCTION

We sought to examine patient and provider perspectives regarding modifiable contributors to breast cancer treatment and to assess perceptual alignment between these two groups.

MATERIALS

Participants were women≥18 y with stage 0-IV breast cancer who received all oncologic care in a single health system and physicians and advanced practice providers who provided medical, radiation, or surgical oncology care for breast cancer. All completed ∼45-min semistructured interviews that were recorded and transcribed verbatim. A 5-stage approach to thematic analysis was conducted, with emergent themes and exemplar quotes placed into clinical, psychological, social/logistical, financial, and lifestyle categories using a multilevel conceptual framework.

RESULTS

Eighteen patients (9 Black, 9 White, and median age 60 y) and 10 providers (6 physicians and 4 advanced practice providers) were interviewed from May to November 2018. Both patients and providers perceived suboptimal communication, parking and transportation, and competing family-caregiving responsibilities as modifiable barriers to care. Treatment costs were cited by patients as barriers that were inadequately addressed even with referrals to financial counselors, but providers did not raise the issue of cost unless prompted by patients and did not feel prepared to discuss the topic when it arose. Providers cited obesity as a barrier to treatment, a view not shared by patients.

CONCLUSIONS

Several modifiable factors were recognized by both patients and providers as either promoting or detracting from treatment receipt, but there was also significant incongruence and asymmetry. Alignment of provider and patient perceptions regarding contributors to guideline-concordant care receipt could mitigate disparities in breast cancer treatment and outcomes.

Psychological distress in breast cancer patients during oncological inpatient rehabilitation: incidence, triggering factors and correlation with treatment-induced side effects

As a result of the cancer diagnosis and the mostly multimodal, stressful therapy, psychological distress is a common symptom in breast cancer patients. As part of this prospective study, 1400 patients who were admitted to the hospital for oncological rehabilitation were screened for distress and somatic, therapy-induced secondary disorders. Mean distress in the screened population was 5.6 ± 2.56 (range 0-10). In 942 cases (67.3%) a significant distress score (≥ 5) was detected and in 587 cases (41.9%) very high levels of distress (≥ 7) was observed. Psychological distress significantly correlated with younger age, presence of triple negative breast cancer (TNBC), tumor recurrence and metastasis, and inability to work. Treatment-induced side effects such as lymphedema, CIPN or extensive tumor resection (mastectomy) showed a (not significant) trend for higher distress. The high incidence of distress underscores the importance of psycho-oncological therapy offers and the great importance of occupational measures during oncological rehabilitation such as the importance of a successful return to work for a better quality of life in breast cancer patients.

Psychometric properties of the perceived stress scale (pss-10) with breast cancer patients

Breast cancer diagnosis is one of the most difficult events that a woman can experience during her life and it usually produces high levels of stress. Global measures of perceived stress are useful for screening and for comparing stress levels between cancer patients and other clinical and nonclinical populations. One such instrument that is widely used is the Perceived Stress Scale (pss-10), but its psychometric properties have scarcely been analysed with breast cancer patients. The aim of this study was to provide validity evidence regarding the use of the 10-item version of the pss-10 as a tool for measuring perceived stress in this context. Participants were 215 Spanish breast cancer patients who completed the PSS-10 and the DASS-21, a measure of affective distress (depression, anxiety, and stress). The internal structure of the PSS-10 was examined through confirmatory factor analysis (CFA), and the reliability of test scores was estimated using McDonald's omega coefficient. Validity evidence based on relationships with other variables was also obtained using correlation analysis. The CFA supported a correlated two-factor structure: perceived helplessness (six negatively worded items) and perceived self-efficacy (four positively worded items). Reliability coefficients for scores on these two factors were 0.87 and 0.73, respectively. Scores on affective distress (DASS-21) were strongly and positively correlated with perceived helplessness and moderately and negatively correlated with perceived self-efficacy. The PSS-10 is an adequate tool for measuring perceived stress in the breast cancer context and it may be useful for identifying women at risk of psychological maladjustment.

A detailed description of the distress trajectory from pre- to post-treatment in breast cancer patients receiving neoadjuvant chemotherapy

PURPOSE

To characterize the distress trajectory in patients with newly diagnosed, non-metastatic breast cancer from pre-neoadjuvant chemotherapy until 12 months after onset of treatment and to identify demographic and clinical predictors of distress in these patients.

METHODS

In a retrospective, longitudinal study, chart review data were abstracted for 252 eligible patients treated at a comprehensive cancer care center. The center screens for distress at least monthly with the distress thermometer; the highest distress score per month was included in the analyses. The growth trajectory was established using mixed modeling and predictors were added to the initial growth model in subsequent models.

RESULTS

Distress showed a cubic growth trajectory with highest distress prior to treatment onset followed by a steep decline in the first three months of treatment. A slight increase in distress was apparent over months 6-10. Being Hispanic was associated with a stronger increase in distress in the second half of the year (p = 0.012). NACT was associated with lower distress and surgery with higher distress (both: p < 0.001).

CONCLUSION

Distress is at its peak prior to treatment onset and rapidly decreases once treatment has started. Oncologist should be aware that both completion of NACT and undergoing surgery are associated with increases in distress and Hispanic patients may be more at risk for an increase in distress at these times; this suggests that careful monitoring of distress during the treatment trajectory and in Hispanic patients in particular in order to provide timely support.

Socioeconomic Disparities in Neoadjuvant Chemotherapy for Early-Stage Breast Cancer

Background

Neoadjuvant chemotherapy (NCT) is often used for patients with early-stage breast cancer. Disparities in the use of NCT based on clinical, demographic, and socioeconomic factors have not been evaluated.

Methods

Data from the National Cancer Database was analyzed for patients with T1-2, N0-1 breast cancer from 2006 to 2015. Univariate and multivariate analysis determined which factors predicted for the receipt of NCT.

Results

We found 159 946 eligible patients. Factors associated with receipt of NCT included T2 vs. T1 disease, N1 vs. N0, and treatment at an academic facility. Race itself was not significant; however, a higher level of education amongst Black populations correlated with the receipt of NCT.

Discussion

Clinical factors are the greatest determinants for receipt of NCT in early-stage breast cancer. Disparities exist that cannot be explained by race alone; socioeconomic and demographic factors are important. Cancer care should be evaluated in the context of the intersectionality of these health determinants.

In search of lost time: Delays in adjuvant therapy for pancreatic adenocarcinoma among under-resourced patient populations

BACKGROUND

The initiation of adjuvant chemotherapy for pancreatic adenocarcinoma within 12 weeks after surgery is recommended by the National Comprehensive Cancer Network. This study seeks to identify factors associated with delayed adjuvant chemotherapy and whether delays impact survival in under-resourced populations.

METHODS

Patients with nonmetastatic pancreatic adenocarcinoma who received a definitive resection followed by adjuvant chemotherapy between 2006 and 2017 were queried from the National Cancer Database. Multivariate logistic regression models were constructed to determine the relationship between socioeconomic/clinical variables and delayed adjuvant chemotherapy. Kaplan Meier curves compared survival between under-resourced patients receiving delayed versus timely adjuvant chemotherapy.

RESULTS

Among 25,008 patients, timely adjuvant chemotherapy varied by stage (stage 1: 67.9% vs stage 2: 75.8% vs stage 3: 89.2%; P < .001). Older age (odds ratio 1.02, 95% confidence interval 1.02-1.03; P < .001), Non-Hispanic Black race (odds ratio 1.25, 95% confidence interval 1.11-1.41; P < .001), increasing comorbidity score (odds ratio 1.18, 95% confidence interval 1.12-1.23; P < .001), 30-day readmission (odds ratio 1.45, 95% confidence interval 1.28-1.63; P < .001), and undergoing a Whipple (odds ratio 1.30, 95% confidence interval 1.16-1.44; P < .001) were associated with delayed adjuvant chemotherapy. Conversely, the highest neighborhood median income quartile (odds ratio 0.84, 95% confidence interval 0.73-0.97; P = .021), private insurance (odds ratio 0.59, 95% confidence interval 0.46-0.76; P < .001), Medicare (odds ratio 0.68, 95% confidence interval 0.52-0.88; P = .003), and receipt of neoadjuvant therapy (odds ratio 0.05, 95% confidence interval 0.04-0.06; P < .001) were associated with timely adjuvant chemotherapy. Non-Hispanic Black patients and patients with the lowest neighborhood education had worse overall survival when receiving delayed versus timely adjuvant chemotherapy.

CONCLUSION

Timely adjuvant chemotherapy for pancreatic adenocarcinoma was only achieved in 73.3% of patients. Age, race, comorbidities, median income, and insurance were identified as barriers. Delayed adjuvant chemotherapy was associated with worse survival among under-resourced populations.

Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries

BACKGROUND

Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood.

METHODS

We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence.

RESULTS

Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays.

CONCLUSIONS

Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban status.

Disparities in timely treatment among young women with breast cancer

BACKGROUND

Although evidence suggests worse breast cancer-specific survival associated with treatment delay beyond 90 days, little is known regarding the sociodemographic predictors of delays in cancer-directed surgery among young women with breast cancer. This is particularly notable, given that 5-10% of new diagnoses occur in younger women aged <40 years, commonly with more aggressive features than in older women.

METHODS

We used the National Cancer Database (2004-2017) to assess sociodemographic disparities in delay of upfront surgery beyond 90 days among young women with non-metastatic breast cancer, using multivariable logistic regression and predictive marginal modeling.

RESULTS

Black women experienced treatment delays more frequently than white women (aOR: 1.93 [95% CI: 1.76-2.11], p < 0.001). Adjusted rates of treatment delay were 4.91% [95% CI: 4.51%-5.30%] and 2.60% [95% CI: 2.47%-2.74%] for Black and white women, respectively, and 2.97% [95% CI: 2.83%-3.12%], 2.36% [95% CI: 2.03%-2.68%], and 1.18% [95% CI: 0.54%-1.81%] for women from metro, urban, and rural areas, respectively.

CONCLUSION

These results suggest that improving access to timely treatment may be leveraged as a means through which to lessen the breast cancer disparities experienced by Black women.

Social Disparities in Thoracic Surgery Database Research: Implications and Impact

A complex relationship exists between health care disparities and large databases among the thoracic surgical patient population. Using the example of thoracic malignancies, the ability of investigations leveraging large databases and novel analytical approaches to highlight disparate access to care and discordant outcomes following treatment is illustrated. Large, widely used databases may not be representative of the thoracic surgical patient population as a whole, and caution must be used when interpreting and generalizing results gleaned from such database analyses. Ensuring appropriate representation of all relevant patient subgroups in research databases will improve external generalizability and scientific validity of future investigations.

Uncovering Barriers to Screening for Distress in Patients With Cancer via Machine Learning

BACKGROUND

Psychologic distress and manifest mental disorders are overlooked in 30-50% of patients with cancer. Accordingly, international cancer treatment guidelines recommend routine screening for distress in order to provide psychologic support to those in need. Yet, institutional and patient-related factors continue to hinder implementation.

OBJECTIVE

This study aims to investigate factors, which are associated with no screening for distress in patients with cancer.

METHODS

Using machine learning, factors associated with lack of distress screening were explored in 6491 patients with cancer between 2011 and 2019 at a large cancer treatment center. Parameters were hierarchically ordered based on statistical relevance. Nested resampling and cross validation were performed to avoid overfitting and to comply with assumptions for machine learning approaches.

RESULTS

Patients unlikely to be screened were not discussed at a tumor board, had inpatient treatment of less than 28 days, did not consult with a psychiatrist or clinical psychologist, had no (primary) nervous system cancer, no head and neck cancer, and did have breast or skin cancer. The final validated model was optimized to maximize sensitivity at 83.9%, and achieved a balanced accuracy of 68.9, area under the curve of 0.80, and specificity of 53.9%.

CONCLUSION

Findings of this study may be relevant to stakeholders at both a clinical and institutional level in order to optimize distress screening rates.

Characterization of Clinical Symptoms by Race Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer Before Starting Chemotherapy

IMPORTANCE

Race disparities persist in breast cancer mortality rates. One factor associated with these disparities may be differences in symptom burden, which may reduce chemotherapy tolerance and increase early treatment discontinuation.

OBJECTIVES

To compare symptom burden by race among women with early-stage breast cancer before starting chemotherapy and quantify symptom differences explained by baseline characteristics.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of symptom burden differences by race among Black and White women with a diagnosis of stage I to III, hormone receptor-positive breast cancer who had a symptom report collected before chemotherapy initiation in a large cancer center in the southern region of the US from January 1, 2007, through December 31, 2015. Analyses were conducted from November 1, 2019, to March 31, 2021. Blinder-Oaxaca decomposition was used, adjusting for baseline sociodemographic and clinical characteristics.

MAIN OUTCOMES AND MEASURES

Four symptom composite scores with a mean (SD) of 50 (10) were reported before starting chemotherapy (baseline) and were derived from symptom items: general physical symptoms (11 items), treatment adverse effects (8 items), acute distress (4 items), and despair (7 items). Patients rated the severity of each symptom they experienced in the past week on a scale of 0 to 10 (where 0 indicates not a problem and 10 indicates as bad as possible).

RESULTS

A total of 1338 women (mean [SD] age, 54.6 [11.6] years; 420 Black women [31.4%] and 918 White women [68.6%]) were included in the study. Before starting chemotherapy, Black women reported a statistically significantly higher (ie, worse) symptom composite score than White women for adverse effects (44.5 vs 43.8) but a lower acute distress score (48.5 vs 51.0). Decomposition analyses showed that Black patients' characteristics were associated with higher symptom burden across all 4 scores. However, these differences were offset by relatively greater, statistically significant, unexplained physical, distress, and despair symptom reporting by White patients.

CONCLUSIONS AND RELEVANCE

In this study, before starting chemotherapy, Black patients with early-stage breast cancer reported significantly higher burden for symptoms that may be exacerbated with chemotherapy and lower distress symptoms compared with White patients. Future studies should explore how symptoms change before and after treatment and differ by racial/ethnic groups and how they are associated with treatment adherence and mortality disparities.

Characterizing participants in the North Carolina Breast and Cervical Cancer Control Program: A retrospective review of 90,000 women

BACKGROUND

The North Carolina Breast and Cervical Cancer Control Program (NC BCCCP) provides breast cancer screening services to underserved women to mitigate disparities in access to care. The authors sought to characterize this understudied population.

METHODS

Women 21 years old or older who underwent their first breast cancer screen through NC BCCCP from 2008 to 2018 were included. Demographic factors associated with the timeline of care and odds of a breast cancer diagnosis were identified with negative binomial and logistic regression, respectively.

RESULTS

Of the 88,893 women identified, 45.5% were non-Hispanic (NH) White, 30.9% were NH Black, 19.6% were Hispanic, 1.7% were American Indian, and 1.1% were Asian. Breast cancer was diagnosed in 2.5% of the women (n = 2255). Hispanic women were the least likely to be diagnosed with breast cancer (odds ratio vs NH White women, 0.40; 95% confidence interval [CI], 0.34-0.47). Among patients with breast pathology, the median time to diagnosis was 19 days (interquartile range [IQR], 10-33 days), and the time to treatment was 33 days (IQR, 19-54 days). After adjustments, a longer time to diagnosis was significantly associated with age (incidence rate ratio [IRR], 1.01; 95% CI, 1.01-1.02) and being NH Black (vs NH White; IRR, 1.17; 95% CI, 1.06-1.29). A longer time to treatment was significantly associated with age (IRR, 1.01; 95% CI, 1.01-1.01), being NH Black (vs NH White; IRR, 1.20; 95% CI, 1.10-1.31), and being Hispanic (vs NH White; IRR, 1.22; 95% CI, 1.05-1.41).

CONCLUSIONS

NC BCCCP participants with breast cancer received treatment within approximately 1 month of presentation, and this finding aligns with quality care benchmarks. Nevertheless, racial/ethnic disparities in timeliness of care persist, and this suggests opportunities for improvement.

LAY SUMMARY

This review of approximately 90,000 participants in a breast cancer screening program for uninsured and underinsured women highlights the importance of safety net programs in providing timely care to underserved patients. The authors found that the North Carolina Breast and Cervical Cancer Control Program met timeliness benchmarks from the Centers for Disease Control and Prevention across all racial/ethnic groups. However, non-Hispanic Black women experienced relative delays in the time to diagnosis, and both non-Hispanic Black women and Hispanic women experienced relative delays in the time to treatment. These findings demonstrate how racial/ethnic disparities in the timeliness of care can persist even within a program intended to reduce barriers to access.