Influence of Race, Insurance, and Rurality on Equity of Breast Cancer Care

Feasibility and acceptability of an online expressive writing intervention for rural breast cancer survivors: A randomized controlled trial

PURPOSE

Rural breast cancer survivors (BCS) have unique unmet psychosocial needs that affect quality of life (QOL). Expressive writing (EW) has been shown to improve QOL in cancer survivors, however, its applicability is unclear among rural individuals. This pilot study explores the feasibility and acceptability of an online expressive writing (EW) intervention among rural breast cancer survivors (BCS).

METHODS

Participants (N = 34) were recruited from a cancer hospital's registry and randomly assigned to either a control group or the EW intervention group to read positive messages and to write about their cancer experience three times, once per week. Health outcomes were assessed at baseline and 1 month after the intervention. Feasibility and acceptability were also assessed.

RESULTS

The study yielded a satisfactory response rate, adherence rate, and completion rate. The majority of the participants reported enjoying the study. Preliminary analyses also demonstrated promising efficacy of the intervention, with improvements (medium effect size) observed for QOL (d = 0.51) and fatigue (d = -0.64) in the intervention group compared to the control group at 1-month follow-up.

CONCLUSIONS

The study demonstrates feasibility and acceptability of an online EW intervention among rural BCS. Future research is warranted to examine the efficacy of the intervention in larger samples of rural cancer survivors.

Association of Socio-Environmental Burden and Inequality With Cancer Screening and Mortality

BACKGROUND AND OBJECTIVES

Social and environmental injustice may influence accessibility and utilization of health resources, affecting outcomes of patients with cancer. We sought to assess the impact of socio-environmental inequalities on cancer screening and mortality rates for breast, colon, and cervical cancer.

METHODS

Data on cancer screening and environmental justice index social and environmental ranking (SER) was extracted from the CDC PLACES and ATSDR, respectively. Mortality rates were extracted using CDC WONDER. Screening targets were defined by Healthy People 2030.

RESULTS

Among census tracts, 14 659 were classified as "low," 29 534 as "moderate," and 15 474 as "high" SER (high SER denoting greater socioenvironmental injustice). Screening targets were achieved by 31.1%, 16.2%, and 88.6% of tracts for colon, breast, and cervical cancers, respectively. High SER tracts were much less likely to reach screening targets compared with low SER tracts for colon (OR: 0.06), breast (OR: 0.24), and cervical cancer (OR: 0.05) (all p < 0.001). Median mortality rates for low and high SER were 16.7, and 21.0, respectively, for colon, 13.4, 14.75, respectively, for breast, and 1.0, 1.6, respectively, for cervical cancer (all p < 0.05).

CONCLUSION

Socioenvironmental disparities negatively influence cancer screening and mortality, underscoring the need to reduce environmental injustices through measures like equitable cancer screening services.

Global, regional, and national trends in the burden of breast cancer among individuals aged 70 years and older from 1990 to 2021: an analysis based on the global burden of disease study 2021

BACKGROUND

Breast cancer poses a substantial health challenge for the world's over-70 population. However, data on the impact and epidemiology of breast cancer in this age group are limited. We aimed to evaluate global, regional, and national breast cancer trends among those aged 70 and older between 1990 and 2021.

METHODS

In this trend analysis based on the 2021 Global Burden of Diseases (GBD), we report on the incidence rates and Global Burden of Diseases (GBD) disability-adjusted life years (DALYs) counts, as well as the incidence rates per 100,000 individuals and average annual percentage changes (AAPCs) for breast cancer among individuals aged 70 and above at the global, regional, and national levels. We analyzed these global trends by age, sex, and socio-developmental index (SDI). Joinpoint regression elucidates pivotal trend shifts.

RESULTS

From 1990 to 2021, the global incidence of breast cancer in the over-70 population modestly increased from 104 to 107 per 100,000, with significant trend changes in 1995, 2005, and 2018. Regionally, High-income North America had the highest incidence in 2021, while North Africa and the Middle East saw the steepest rise in incidence and DALYs. The only decrease was in the High SDI quintile. The 70-74 age group experienced the largest increase globally, with rates rising from 86.3 to 90 per 100,000 (AAPC 0.27).

CONCLUSION

From 1990 to 2021, global breast cancer incidence in the over-70 population saw a slight uptick, contrasted by a significant reduction in DALYs, likely due to progress in endocrine and targeted therapies. This underscores the critical need for enhanced screening and personalized treatments for older patients.

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer

BACKGROUND

Although the rates of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time in the surgical management of early-stage uterine cancer, practice varies significantly in the United States, and there are disparities among low-volume centers and patients of Black race. A significant number of counties in the United States are without a gynecologic oncologist, and almost half of the counties with the highest gynecologic cancer rates lack a local gynecologic oncologist.

OBJECTIVE

This study aimed to evaluate the relationships of distance traveled and proximity to gynecologic oncologists with the receipt of and racial disparities in the quality of surgical care among patients who underwent a hysterectomy for nonmetastatic uterine cancer.

STUDY DESIGN

Patients who underwent a hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in the 2012 to 2018 State Inpatient Database and the State Ambulatory Surgery Services Database files. County-to-county distances were used as the distances traveled to the nearest gynecologic oncologist. Factors associated with the receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models, as was the assessment of the interaction between travel for surgery and patient race.

RESULTS

Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; overall, 55.5% traveled to another county for surgery, including 88% of those who lacked a local gynecologic oncologist. Patients who lacked access to a local gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were affected even more. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had a similar likelihood of undergoing minimally invasive surgery (71%) but had a greater likelihood of undergoing lymph node dissection (64.7% vs 57.2%) than nontravelers. Among those in counties without a gynecologic oncologist, a longer distance traveled was associated with receipt of a lymph node assessment. When compared with non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models that controlled for a diagnosis of fibroids, Black race was an independent risk factor for the receipt of open surgery. There was a significant interaction between Black race and travel for surgery, and Black patients who lived in counties without a gynecologic oncologist who did not travel faced an incrementally lower likelihood of receiving minimally invasive surgery (odds ratio, 0.57 when compared with non-Black patients who traveled for surgery; odds ratio, 0.60 as interaction term; P<.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery.

CONCLUSION

Patients, particularly those of Black race, who lacked local access to gynecologic oncologist specialty care benefitted from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Race norming and biases in surgical oncology care

Disparities in surgical oncology care may be due to race/ethnicity. Race norming, defined as the adjustment of medical assessments based on an individual's race/ethnicity, and implicit bias are specifically explored in this focused systematic review. We aim to examine how race norming and bias impact oncologic care and postsurgical outcomes, particularly in Black patient populations, while providing potential strategies to improve equitable and inclusive care.

Understanding and tackling cancer inequities: What opportunities does intersectionality offer researchers, policymakers, and providers? A scoping review

PROBLEM IDENTIFICATION

We summarised the international evidence relating to the role of intersectionality in patients' lived experience of inequities along the cancer care pathway. We produced guidance to use intersectionality in future research.

LITERATURE SEARCH

We included 42 articles published between 1989 to 2023 that used intersectionality to guide the study and interpretation of inequities in cancer care.

DATA EVALUATION/SYNTHESIS

Articles predominantly comprised North American (n = 37), followed by European (n = 4) and Asian (n = 1) studies. Similar compounding effects of racism, homophobia, and discrimination across countries exacerbated inequities in cancer care experience and cancer outcomes particularly for women of color and sexual/gender minority groups. Professionals' knowledge, attitudes, and behaviors toward minoritised groups affected patient-provider relationships and influenced cancer patients' psychosocial responses.

CONCLUSION

Intersectionality provides a framework to assess the personal, interpersonal, and structural processes through which cancer inequities manifest within and across countries.

Residential Redlining, Neighborhood Trajectory, and Equity of Breast and Colorectal Cancer Care

OBJECTIVE

To determine the influence of structural racism, vis-à-vis neighborhood socioeconomic trajectory, on colorectal and breast cancer diagnosis and treatment.

BACKGROUND

Inequities in cancer care are well-documented in the United States but less is understood about how historical policies like residential redlining and evolving neighborhood characteristics influence current gaps in care.

METHODS

This retrospective cohort study included adult patients diagnosed with colorectal or breast cancer between 2010 and 2015 in 7 Indiana cities with available historic redlining data. Current neighborhood socioeconomic status was determined by the Area Deprivation Index. Based on historic redlining maps and the current Area Deprivation Index, we created 4 "neighborhood trajectory" categories: advantage stable, advantage reduced, disadvantage stable, and disadvantage reduced. Modified Poisson regression models estimated the relative risks (RRs) of neighborhood trajectory on cancer stage at diagnosis and receipt of cancer-directed surgery (CDS).

RESULTS

A final cohort derivation identified 4862 cancer patients with colorectal or breast cancer. Compared with "advantage stable" neighborhoods, "disadvantage stable" neighborhood was associated with a late-stage diagnosis for both colorectal and breast cancer [RR = 1.30 (95% CI: 1.05-1.59); RR = 1.41 (1.09-1.83), respectively]. Black patients had a lower likelihood of receiving CDS in "disadvantage reduced" neighborhoods [RR = 0.92 (0.86-0.99)] than White patients.

CONCLUSIONS

Disadvantage stable neighborhoods were associated with late-stage diagnoses of breast and colorectal cancer. "Disadvantage reduced" (gentrified) neighborhoods were associated with racial inequity in CDS. Improved neighborhood socioeconomic conditions may improve timely diagnosis but could contribute to racial inequities in surgical treatment.

Impact of Empowerment Theory-Based Nursing Intervention on the Quality of Life and Negative Emotions of Patients Diagnosed with Brain Metastasis Post Breast Cancer Surgery

Objective

This study explores the impact of a nursing intervention grounded in empowerment theory, focusing on behavioral change, on brain metastasis patients post-breast cancer surgery.

Methods

Between June 2021 and June 2023, 102 patients diagnosed with brain metastasis after breast cancer surgery at Bao Ding No.1 Central Hospital were randomized into two groups. The control group (51 patients) received standard nursing care, while the observation group (51 patients) participated in a behavioral change nursing intervention influenced by empowerment theory. The evaluation metrics included measures of negative emotions, compliance with treatment protocols, overall quality of life, and nursing satisfaction, assessed at multiple time points during the study period.

Results

The intervention led to significant reductions in negative emotions for all patients when compared to their pre-intervention statuses, with the observation group exhibiting notably lower depression and anxiety scores at one and three months post-intervention (P < 0.05). Additionally, this group achieved higher compliance scores and demonstrated greater improvements in quality of life than the control group (P < 0.05). Nursing satisfaction was also significantly higher in the observation group, with 96.08% reporting high satisfaction compared to 80.39% in the control group (P < 0.05).

Conclusion

Implementing a nursing intervention that emphasizes behavioral changes and leverages empowerment theory significantly enhances the quality of life, reduces negative emotions, boosts compliance with treatment, and increases nursing satisfaction among patients with brain metastasis following breast cancer surgery. This suggests that such interventions could be a valuable component of postoperative care for this patient population.

Inequity in Cancer and Cancer Care Delivery in the United States

Inequity exists along the continuum of cancer and cancer care delivery in the United States. Marginalized populations have later stage cancer at diagnosis, decreased likelihood of receiving cancer-directed care, and worse outcomes from treatment. These inequities are driven by historical, structural, systemic, interpersonal, and internalized factors that influence cancer across the pathologic and clinical continuum. To ensure equity in cancer care, interventions are needed at the level of policy, care delivery, interpersonal communication, diversity within the clinical workforce, and clinical trial accessibility and design.

The Impact of Health Inequities on Population-Based Breast Cancer Survival in a Colombian Population, 2008-2015

OBJECTIVE

To obtain breast cancer survival estimates in Manizales, Colombia, considering socioeconomic level, health insurance regime and residential area, while adjusting for age, histology and stage at diagnosis.

METHODS

Analytical cohort study based on breast cancer incident cases recorded by the Population-based Manizales Cancer Registry between 2008-2015. Patients were followed-up for 60 months. Cause-specific survival was calculated using the Kaplan-Meier method for variables of interest, with the Wilcoxon-Breslow-Gehan test for differences. Cox multivariate regression models were fitted.

RESULTS

856 breast cancer cases were included. The 5-year cause-specific survival for the entire cohort was 78.2%. It was higher in women with special/exception health insurance, high socioeconomic level, <50 years old, ductal carcinoma, and stages I and II. Residential area did not impact survival. In Cox models, the subsidized health insurance regime (HR: 4.87 vs contributory) and low socioeconomic level (HR: 2.45 vs high) were predictors of the hazard of death in women with breast cancer, adjusted for age, histology, stage and interactions age-stage and insurance-stage. A positive interaction (synergistic effect modification) between health insurance regime and stage regarding to survival was observed.

CONCLUSION

Socioeconomic factors significantly contribute to the inequities in breast cancer survival, independent of the stage at diagnosis. This suggests the need for comprehensive interventions to remove barriers to accessing the health system. This research provides evidence of survival gaps mediated by certain social determinants of health and generates data on the overall performance of the Colombian health system.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia

BACKGROUND

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis.

METHODS

Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis.

RESULTS

Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors.

CONCLUSIONS

Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Cancer Disparities Experienced by People with Disabilities

People with disabilities, who represent a rapidly growing and seriously disadvantaged segment of the U.S. population, face unremitting barriers to equal and accessible healthcare and a high prevalence of chronic health conditions. A slowly growing body of research suggests multiple cancer-related disparities between people with and without disabilities. This commentary identifies multiple aspects of the cancer experience and highlights ways cancer is impacted by disability. This includes vulnerabilities to risk factors, barriers to accessing healthcare, and disparities in screening, diagnosis, and treatment. The authors offer six essential pathways for reducing cancer disparities faced by people with disabilities. It is clear that reducing cancer health disparities experienced by people with disabilities will require the commitment and cooperation of a wide range of stakeholders.