Geographic Disparities in Late-Stage Breast Cancer Diagnosis Rates and Their Persistence Over Time

Association of county level poverty with mortality from primary liver cancers

BACKGROUND

The highly variable occurrence of primary liver cancers across the United States emphasize the relevance of location-based factors. Social determinants such as income, educational attainment, housing, and other factors may contribute to regional variations in outcomes. To evaluate their impact, this study identified and analyzed clusters of high mortality from primary liver cancers and the association of location-based determinants with mortality across the contiguous United States.

METHODS

A geospatial analysis of age-adjusted incidence and standardized mortality rates from primary liver cancers from 2000 to 2020 was performed. Local indicators of spatial association identified hot-spots, clusters of counties with significantly higher mortality. Temporal analysis of locations with persistent poverty, defined as high (>20%) poverty for at least 30 years, was performed. Social determinants were analyzed individually or globally using composite measures such as the social vulnerability index or social deprivation index. Disparities in county level social determinants between hot-spots and non-hot-spots were analyzed by univariate and multivariate logistic regression.

RESULTS

There are distinct clusters of liver cancer incidence and mortality, with hotspots in east Texas and Louisiana. The percentage of people living below the poverty line or Hispanics had a significantly higher odds ratio for being in the top quintile for mortality rates in comparison to other quintiles and were highly connected with mortality rates. Current and persistent poverty were both associated with an evolution from non-hotspots to new hotspots of mortality. Hotspots were predominantly associated with locations with significant levels of socioeconomic vulnerability or deprivation.

CONCLUSIONS

Poverty at a county level is associated with mortality from primary liver cancer and clusters of higher mortality. These findings emphasize the importance of addressing poverty and related socio-economic determinants as modifiable factors in public health policies and interventions aimed at reducing mortality from primary liver cancers.

From Race to Racism and Disparities to Equity: An Actionable Biopsychosocial Approach to Breast Cancer Outcomes

PURPOSE

Racial disparities in outcomes of breast cancer in the United States have widened over more than 3 decades, driven by complex biologic and social factors. In this review, we summarize the biological and social narratives that have shaped breast cancer disparities research across different scientific disciplines in the past, explore the underappreciated but crucial ways in which these 2 strands of the breast cancer story are interwoven, and present 5 key strategies for creating transformative interdisciplinary research to achieve equity in breast cancer treatment and outcomes.

DESIGN

We first review the key differences in tumor biology in the United States between patients racialized as Black versus White, including the overrepresentation of triple-negative breast cancer and differences in tumor histologic and molecular features by race for hormone-sensitive disease. We then summarize key social factors at the interpersonal, institutional, and social structural levels that drive inequitable treatment. Next, we explore how biologic and social determinants are interwoven and interactive, including historical and contemporary structural factors that shape the overrepresentation of triple-negative breast cancer among Black Americans, racial differences in tumor microenvironment, and the complex interplay of biologic and social drivers of difference in outcomes of hormone receptor positive disease, including utilization and effectiveness of endocrine therapies and the role of obesity. Finally, we present 5 principles to increase the impact and productivity of breast cancer equity research.

RESULTS

We find that social and biologic drivers of breast cancer disparities are often cyclical and are found at all levels of scientific investigation from cells to society. To break the cycle and effect change, we must acknowledge and measure the role of structural racism in breast cancer outcomes; frame biologic, psychosocial, and access factors as interwoven via mechanisms of cumulative stress, inflammation, and immune modulation; take responsibility for the impact of representativeness (or the lack thereof) in genomic and decision modeling on the ability to accurately predict the outcomes of Black patients; create research that incorporates the perspectives of people of color from inception to implementation; and rigorously evaluate innovations in equitable cancer care delivery and health policies.

CONCLUSIONS

Innovative, cross-disciplinary research across the biologic and social sciences is crucial to understanding and eliminating disparities in breast cancer outcomes.

Consensus views on an advanced breast cancer education curriculum for cancer nurses: A Delphi study

BACKGROUND

Specialist nursing care is a core indicator of quality care for people living with advanced breast cancer. However, access to and quality of nurse education programmes in advanced breast cancer is variable.

OBJECTIVES

This study aims to define the topics for inclusion in an international curriculum for an advanced breast cancer education programme.

METHODS

A modified four-round Delphi study was undertaken with experts by profession and experience in advanced breast cancer. Thirty-four topics related to advanced breast cancer and six online teaching and learning methods were pre-selected following a systematic review. Between September 2021 and March 2022, the expert panel determined the importance of topics for inclusion in the education programme. Consensus was defined by at least 80 % agreement on the highest three points on a 9-point Likert scale.

RESULTS

A total of 31 experts participated in rounds 1-3 of this study, and 156 experts by profession and experience participated in an additional fourth round, including people living with advanced breast cancer (n = 72, 46 %), healthcare professionals (n = 46, 29 %), family members or caregivers of a person diagnosed with advanced breast cancer (n = 30, 19 %) and advocacy professionals working in the area of advanced breast cancer (n = 8, 5 %). In round 4, 36 topics and five of six learning methods reached consensus.

CONCLUSIONS

The results of this study provide a framework to develop education programmes in advanced breast cancer, defining the essential elements of curriculum content for such programmes. The results highlight the need for advanced breast cancer education programmes to use multiple teaching and learning methods to promote nurses' understanding of person-centred supportive care and the physical, psychosocial and spiritual issues experienced by people living with advanced breast cancer.

Urbanicity, Income, and Mammography-Use Disparities Among American Indian Women

INTRODUCTION

Reported breast cancer screening among American Indian women is consistently below that of White women. The last claims-based trends were from 1991 to 2001. This study updates mammography trends for American Indian women and examines the impact of race, urbanicity, and income on long-term mammography use.

METHODS

This was a multi-year (2005-2019), retrospective study of women aged 40-89 years using a 5% sample of Medicare fee-for-service beneficiaries residing in Arizona, California, New Mexico, Oklahoma, and Washington. This study used multivariable logistic regression to examine the impact of urbanicity and income on receiving mammography for American Indian women compared with that for White women. Analyses were conducted in 2022.

RESULTS

Overall, annual age-adjusted mammography use declined from 205 per 1,000 in 2005 to 165 per 1,000 in 2019. The slope of these declines was significantly steeper (difference = -2.41, p<0.001) for White women (-3.06) than for American Indian women (-0.65). Mammography-use odds across all urbanicity categories were less for American Indian women than for White women compared with those of their respective metropolitan counterparts (e.g., rural: 0.96, 95% CI=0.77, 1.20 for American Indian women and 1.47, 99% CI=1.39, 1.57 for White women). Although residing in higher-income communities was not associated with mammography use for American Indian women, it was 31% higher for White women (OR=1.31, 99% CI=1.28, 1.34).

CONCLUSIONS

The disparity in annual age-adjusted mammography use between American Indian and White women narrowed between 2005 and 2019. However, the association of urbanicity and community income on mammography use differs substantially between American Indian and White women. Policies to reduce disparities need to consider these differences.

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.

Exploring the intersectionality of race/ethnicity with rurality on breast cancer outcomes: SEER analysis, 2000-2016

PURPOSE

Disparities in breast cancer survival have been observed within marginalized racial/ethnic groups and within the rural-urban continuum for decades. We examined whether there were differences among the intersectionality of race/ethnicity and rural residence on breast cancer outcomes.

METHODS

We performed a retrospective analysis among 739,448 breast cancer patients using Surveillance Epidemiology and End Results (SEER) 18 registries years 2000 through 2016. We conducted multilevel logistic-regression and Cox proportional hazards models to estimate adjusted odds ratios (AORs) and hazard ratios (AHRs), respectively, for breast cancer outcomes including surgical treatment, radiation therapy, chemotherapy, late-stage disease, and risk of breast cancer death. Rural was defined as 2013 Rural-Urban Continuum Codes (RUCC) of 4 or greater.

RESULTS

Compared with non-Hispanic white-urban (NH-white-U) women, NH-black-U, NH-black-rural (R), Hispanic-U, and Hispanic-R women, respectively, were at increased odds of no receipt of surgical treatment (NH-black-U, AOR = 1.98, 95% CI 1.91-2.05; NH-black-R, AOR = 1.72, 95% CI 1.52-1.94; Hispanic-U, AOR = 1.58, 95% CI 1.52-1.65; and Hispanic-R, AOR = 1.40, 95% CI 1.18-1.67), late-stage diagnosis (NH-black-U, AOR = 1.32, 95% CI 1.29-1.34; NH-black-R, AOR = 1.29, 95% CI 1.22-1.36; Hispanic-U, AOR = 1.25, 95% CI 1.23-1.27; and Hispanic-R, AOR = 1.17, 95% CI 1.08-1.27), and increased risks for breast cancer death (NH-black-U, AHR = 1.46, 95% CI 1.43-1.50; NH-black-R, AHR = 1.42, 95% CI 1.32-1.53; and Hispanic-U, AHR = 1.10, 95% CI 1.07-1.13).

CONCLUSION

Regardless of rurality, NH-black and Hispanic women had significantly increased odds of late-stage diagnosis, no receipt of treatment, and risk of breast cancer death.