Cancer Care Disparities: Research Regarding Timeliness and Potential Coordination

A conceptual framework that recognizes 3 generations of studies in healthcare disparities has been proposed: (1) descriptive studies of disparities in healthcare, (2) analytic studies of mechanisms for these disparities, and (3) interventional studies to reduce disparities.¹ Interventional studies regarding disparities still are relatively rare. The study by Gold et al² in this issue of the Journal fits mostly within the first generation of disparities research, with some insight into what mechanisms do not explain these disparities. Gold et al found that among women age ≥65 years with early-stage breast cancer, those of nonwhite race or Hispanic ethnicity were more likely to have radiation therapy delayed longer than 8 weeks after surgery.

Because of US demographic changes, elderly persons and minorities will be increasingly affected by cancer in the future. By 2030, the projected cancer incidence will increase 67% among older adults (vs an 11% increase for younger adults). The projected incidence will increase 99% among minorities (vs a 31% increase for whites).³ Of course, healthcare disparities among minority groups are important regardless of the population burden; in fact, disparities often are considered to occur because of factors unique to minority status within a society. Yet the impact of persistent disparities, specifically in cancer care, will only become magnified over time.

The study by Gold et al did not directly compare treatment for older women with treatment for women younger than age 65 years. Cancer health services research studies commonly include only older women because of the widespread use of linked Surveillance, Epidemiology and End Results (SEER) and Medicare data. In this particular study, the older cohort was nested in the Breast Cancer Treatment Effectiveness in Older Women Study. Neither the SEER-Medicare data nor the data used by Gold et al allow us to directly understand the comparative vulnerability of an older population to undertreatment.

This study defined minority status broadly: “nonwhite race or Hispanic ethnicity.” That category could include African Americans, Hispanics, Asians, Pacific Islanders, and many other subsets and groups. Defining minority status in this way results in limited understanding of the second-generation causes of these disparities among different population groups with unique cultural identities and challenges, including differences in the perceived benefits of treatment, fatalism, and social norms. Third-generation interventions would likely benefit from tailoring to more narrowly defined racial/ethnic groups.

The minority population studied here was significantly more likely (29%) than white patients (12%) to receive delayed radiation therapy. Timeliness measures, which are increasingly common measures of healthcare quality, are distinct from dichotomous measures, which determine receipt of a recommended service (yes/no). These 2 types of quality measures can provide complementary information, although a dichotomous measure of the receipt of radiation therapy (yes or no) was not provided in these results. The emergence of timeliness measures may be related to the increased adoption of Lean techniques into quality improvement activities.⁴ These techniques commonly apply system principles to workflow in order to remove obstacles that may be associated with delay; timeliness measures fit this paradigm well.

Timeliness measures are especially important when linked to clinical benefit. Gold et al make a case for the benefit of timely radiation therapy. A systematic review found that delayed radiation therapy was associated with higher rates of local recurrence, although there was little evidence about the impact of delay on the probability of metastases or survival.⁵ Patient anxiety associated with long waiting times provides another justification for timely care. Timeliness measures may gain increasing prominence if US healthcare reform proposals characterized by opponents as risking delays in patient care are passed into law.

The delays in radiation therapy among minority women with breast cancer occurred despite full insurance (patient level) and receiving care in an integrated healthcare delivery system (organization level). At the patient level, comorbidity and breast cancer type or size were not related to delays in therapy. Many patient-level explanations could not be explored in this study, including cultural perceptions, patient knowledge, preferences, communication, language concordance, education, and income. An explicit theoretical model may have aided in outlining next steps toward a deeper understanding of patient and organizational behavior.

The breast cancer population for this study was drawn from 5 integrated delivery systems nationwide. The Cancer Research Network has provided national leadership in making substantial contributions to clinical and outcomes research, and has openly discussed participating organizations’ concerns about the confidentiality of quality-of-care data.⁶ The rates of radiation therapy delay in these integrated delivery systems are similar to those in Medicare fee-for-service,⁷ suggesting that the level of coordination within the integrated delivery systems was not exceptional. Yet in the current study, Gold et al² did not measure the construct of care coordination itself, nor many other potential organizational explanations for healthcare disparities including organizational structure (radiation oncologist availability, transportation facilitation), processes (referral procedures, service coordination), and culture.⁸

Observational studies in health services research are limited without additional context regarding the organizations delivering the cancer care, which would enable the findings to be better interpreted. Because of relatively few explanations for the healthcare disparities tested, at either the organizational or the patient level, this study makes its largest contribution to first-generation healthcare disparities research.