Breast cancer patients' experiences within and outside the safety net

Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature

OBJECTIVE

Diagnostic delay is a pervasive patient safety problem that disproportionately affects historically underserved populations. We aim to systematically examine and synthesise published qualitative studies on patient experiences with diagnostic delay among historically underserved racial and ethnic populations.

DATA SOURCES

PubMed.

ELIGIBILITY CRITERIA

Primary qualitative studies detailing patient or caregiver-reported accounts of delay in the diagnosis of a disease among underserved racial and ethnic populations; conducted in the USA; published in English in a peer-reviewed journal (years 2012-2022); study cohort composed of >50% non-white racial and ethnic populations.

DATA ANALYSIS

Primary outcomes were barriers to timely diagnosis of a disease. Screening and thematic abstraction were performed independently by two investigators, and data were synthesised using the 'Model of Pathways to Treatment' conceptual framework.

RESULTS

Sixteen studies from multiple clinical domains were included. Barriers to timely diagnosis emerged at the socioeconomic and sociocultural level (low health literacy, distrust in healthcare systems, healthcare avoidance, cultural and linguistic barriers), provider level (cognitive biases, breakdown in patient-provider communication, lack of disease knowledge) and health systems level (inequity in organisational health literacy, administrative barriers, fragmented care environment and a lack of organisational cultural competence). None of the existing studies explored diagnostic disparities among Asian Americans/Pacific Islanders, and few examined chronic conditions known to disproportionately affect historically underserved populations.

DISCUSSION

Historically underserved racial and ethnic patients encountered many challenges throughout their diagnostic journey. Systemic strategies are needed to address and prevent diagnostic disparities.

Impact of Safety-Net Hospital Status on Immediate Reconstruction Following Mastectomy: A Contemporary National Analysis

INTRODUCTION

Immediate breast reconstruction (IBR) following mastectomy has been shown to improve quality of life and partially mitigate the adverse psychological impacts associated with the procedure. The present study examined hospital-based and patient-level disparities in utilization and outcomes of IBR following mastectomy.

METHODS

All female adult hospitalizations with a diagnosis of breast cancer undergoing mastectomy were identified in the 2016 to 2020 National Inpatient Sample. Safety-net hospitals (SNH) were defined as those in the top quartile of all Medicaid or self-pay admissions. Patients who underwent mastectomy at SNH comprised the SNH cohort (others: Non-SNH). Multivariable models were developed to examine the impact of SNH status and patient factors on rates of IBR.

RESULTS

Of an estimated 127,740 hospitalizations, 28,330 (22.2%) were treated at SNH. The proportion of patients receiving IBR increased from 46.7% in 2016 to 51.7% in 2020 (nptrend<.001). Compared to others, SNH were younger (57.9 ± 13.5 vs 58.3 ± 13.5 years) and less commonly White (45.6 vs 69.9%) (all P < .001). Additionally, SNH were more likely to receive unilateral mastectomy (67.1 vs 55.2%) but less frequently underwent IBR (37.7 vs 51.5%) (all P < .001). After adjustment, Black and Asian race, SNH, and bilateral mastectomy were associated with decreased odds of IBR. Increasing IBR hospital volume did not eliminate the observed racial disparity at non-SNH or SNH.

CONCLUSION

There are disparities in rates of IBR following mastectomy attributable to SNH status. Future work is needed to ensure all patients have access to reconstructive care irrespective of payer status or the hospital at which they receive care.

Improved Rates of Immediate Breast Reconstruction at Safety Net Hospitals

BACKGROUND

Substantial federal resources have been directed toward ensuring the delivery of high-quality care at safety net hospitals. Although disparities in receipt of breast reconstruction persist at the patient level, the extent to which hospital factors contribute to these differences remains unclear. The rates of immediate breast reconstruction across safety net and non-safety net hospitals were investigated.

METHODS

Women 21 years and older with breast cancer or increased risk of breast cancer undergoing immediate post-mastectomy reconstruction were identified in the Nationwide Inpatient Sample database. Safety net hospitals were defined as hospitals with the highest tertile of Medicaid disproportionate share hospital payment adjustments. Adjusted odds ratios of undergoing reconstruction were calculated.

RESULTS

Thirty-one percent of patients (n = 10,910) at safety net hospitals underwent immediate reconstruction compared with 46 percent of patients (n = 14,619) at non-safety net hospitals (p < 0.001). Logistic regression revealed that women at non-safety net hospitals were significantly more likely to undergo reconstruction (OR, 1.89; 95 percent CI, 1.65 to 2.16). However, analysis by study year revealed that rates of reconstruction at safety net hospitals increased over time.

CONCLUSIONS

After accounting for sociodemographic factors, women undergoing mastectomies at safety net hospitals remain less likely to undergo immediate breast reconstruction. However, the differences in rates of reconstruction between safety net and non-safety net hospitals have narrowed over time. The availability of immediate reconstruction lessens the psychological trauma of mastectomy, and it is critical to continue redirecting federal efforts toward this valuable component of breast cancer care.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Disparities in breast cancer surgery delay: the lingering effect of race

BACKGROUND

Delays to surgical breast cancer treatment of 90 days or more may be associated with greater stage migration. We investigated racial disparities in time to receiving first surgical treatment in breast cancer patients.

METHODS

Insured black (56 %) and white (44 %) women with primary breast cancer completed telephone interviews regarding psychosocial (e.g., self-efficacy) and health care factors (e.g., communication). Clinical data were extracted from medical charts. Time to surgery was measured as the days between diagnosis and definitive surgical treatment. We also examined delays of more than 90 days. Unadjusted hazard ratios (HRs) examined univariate relationships between delay outcomes and covariates. Cox proportional hazard models were used for multivariate analyses.

RESULTS

Mean time to surgery was higher in blacks (mean 47 days) than whites (mean 33 days; p = .001). Black women were less likely to receive therapy before 90 days compared to white women after adjustment for covariates (HR .58; 95 % confidence interval .44, .78). Health care process factors were nonsignificant in multivariate models. Women with shorter delay reported Internet use (vs. not) and underwent breast-conserving surgery (vs. mastectomy) (p < .01).

CONCLUSIONS

Prolonged delays to definitive breast cancer surgery persist among black women. Because the 90-day interval has been associated with poorer outcomes, interventions to address delay are needed.