Breast Cancer Treatment Disparities Impact Survival Based on Race, Age, Socioeconomics

Racial and ethnic disparities in breast cancer treatment decline—meaning treatment was refused—are linked to older age, being on public insurance, being uninsured, or having lower median household income, comorbidities, nonmetastatic disease, and lower tumor grade. These factors emphasize the importance of targeted health equity interventions that focus on overall survival (OS) through treatment benefits, along with improved communication methods, shared decision-making, and disparity reduction.

Researchers conducted a retrospective cross-sectional study using data from the National Cancer Database (NCDB) between 2004 to 2020.¹ The study assessed 4 types of treatment: chemotherapy, hormone therapy (HT), radiotherapy, and surgery. Patients in the chemotherapy cohort had stage I to IV disease, patients undergoing HT had stage I to IV hormone receptor–positive disease, and patients undergoing radiotherapy and surgery had stage I to III disease.

Primarily, the study aimed to examine trends and factors associated with reductions in the 4 treatment modalities. Secondarily, they aimed to assess the OS of patients with breast cancer stratified by race, ethnicity, and treatment decision.

In addition to race and ethnicity, patient characteristics included age at diagnosis, sex assigned at birth, type of health insurance (uninsured, private, Medicaid, Medicare, and other government or unknown), median household income quartile, rural-urban residence, facility type, cancer stage group, histology, molecular subtype, tumor grade, and year of initial diagnosis. Survival was tracked until either death (from any cause) or the last date of follow-up with the patient.

Overall, the study included 2,837,446 patients with an average age of 61.6 years; 99.1% of participants were female patients. Most patients reported a White ethnicity (78%), followed by Black (11.2%), Hispanic (5.6%), Asian/Pacific Islander (3.5%), and American Indian/Alaskan Native/other participants (1.7%). Almost half of enrolled patients had private insurance or managed care coverage (49.9%), while other patients had Medicare (39.3%) or Medicaid (6.3%). A majority of patients had stage I disease (55.6%), and 74% of the population had hormone receptor–positive/ERBB2-negative disease.

The prevalence of treatment decline and the trends presented were examined thoroughly. Patients declined chemotherapy the most (9.6%), followed by radiotherapy (6.1%), HT (5%), and surgery (0.6%). Identifiable patterns found patients declined all treatment options they were eligible for (0.4%) while others declined 1 to 3 therapies (9.8%). Most of the patient population received all forms of suggested treatments (89.9%). Throughout the data collection period, patterns of decline in HT, radiotherapy, and surgery were identified for 2004 to 2020, whereas chemotherapy decreased over time.

Additionally, associations were identified between refusing chemotherapy and racial/ethnic disparities. More White patients (10.3%) declined chemotherapy vs American Indian/Alaska Native/other (8.7%), Asian or Pacific Islander (8.8%), Black (8.1%), and Hispanic (5.7%) patients. After covariate adjustments were made, American Indian/Alaska Native/other patients, Asian/Pacific Islander patients, and Black patients were more likely to decline chemotherapy while Hispanic patients were less likely than White patients to decline chemotherapy. The older the patient was, the more likely they were associated with treatment refusal.

Socioeconomic factors, like insurance, influenced treatment decline, too. Privately insured patients were less likely to decline compared with uninsured patients and those with Medicaid. Also, greater odds of chemotherapy decline were present in patients with lower median household incomes or tumor grade. Patients with late-stage disease were less likely to decline chemotherapy.

Danielle Roman, PharmD, BCOP, manager of clinical pharmacy services at Allegheny Health Network, explained in a webinar from the Academy of Managed Care Pharmacy, "Innovations in Women’s Health: Bridging Disparities in Breast Cancer," “There are known racial disparities in breast cancer. When comparing to non-Hispanic White women, we do see that there's a higher incidence of breast cancer within that non-Hispanic White population. When compared to non-Hispanic White patients, the non-Hispanic Black patients have earlier onset of disease, often more aggressive disease or advanced stage at diagnosis, and aggressive subtypes.”²

The HT cohort presented differences in the distribution of treatment decline in race and ethnicity. Once potential confounders were controlled, American Indian/Alaska Native/other patients, Asian/Pacific Islander patients, and Black patients were less likely to decline HT compared with White patients. Higher odds of decline were associated with older age, being uninsured or having Medicaid coverage, and patients with late-stage disease.

Treatment refusals in the radiotherapy cohort were 5.5% for American Indian/Alaska Native/other, 5.2% for Asian/Pacific Islander patients, 6.2% for Black patients, 4.1% for Hispanic patients, and 6.2% for White patients. Following a multivariable analysis, Black patients had higher odds of declining radiotherapy while Hispanic patients had lower levels compared with White patients. Similarly to the previous groups, older patients, uninsured patients or those with Medicaid, and having a lower household income resulted in higher rates of treatment decline.

The surgery cohort included treatment refusals by 0.7% of American Indian/Alaska Native/other patients, 0.6% of Asian/Pacific Islander patients, 1.1% of Black patients, 0.4% of Hispanic patients, and 0.6% of White patients. After adjusting covariates, American Indian/Alaska Native/other, Asian/Pacific Islander, and Black patients had higher declination rates while Hispanic patients were less likely to decline surgery compared with White patients. Patients were more likely to decline treatment if they were older, were uninsured or had Medicaid coverage, had late-stage disease or lower tumor grade, had and a median household income of less than $40,227 $40,227 to $50,353 or $50,354 to $63,332.

All 4 treatment groups shower higher OS rates in patients who received longer follow-up time than patients who declined treatment. There were significant differences between OS across racial and ethnic groups. For instance, Black patients receiving chemotherapy, radiotherapy, or surgery had greater mortality risks than White patients receiving treatment. Even among patients who declined chemotherapy, Black patients were at higher mortality risk than White patients. White and Black patients who declined HT or radiotherapy had similar OS rates as well.

Regardless of the treatment decision, American Indian/Alaskan Native/other, Asian/Pacific Islander, and Hispanic patients who declined surgery had lower mortality risk vs White patients. Across all 4 cohorts, patients with breast cancer who were uninsured or public insured, had lower median household income, had higher Charlson Comorbidity Index scores, and had late-stage disease were independently associated with greater mortality risk when declining surgery.

The study was limited by underreporting due to unknown patient perceptions, lack of data on second opinions or treatment changes, unmeasured confounders, and limited generalizability. Additionally, associations between treatment decline and other health outcomes were not assessed.

A major gap exists in our understanding of treatment refusal for patients with breast cancer. While research consistently shows racial, ethnic, socioeconomic, and disease-related factors influence treatment decisions, national trends remain unclear. Additionally, the impact of treatment refusal on survival rates is not fully understood.

The Commonwealth Fund 2024 State Health Disparities Report found, “Many people of color contend with interpersonal racism and discrimination in health care settings and more often receive worse medical care than white patients.”³

It is vital that future investigations decipher the trends and patterns of treatment decline among populations of patients with breast cancer while addressing the racial and ethnic disparities rampant throughout health care systems.

References

1. Freeman JQ, Li JL, Fisher SG, et al. Declination of treatment, racial and ethnic disparity, and overall survival in US patients with breast cancer. JAMA Oncol. 2024;7(5):1-14. doi:10.1001/jamanetworkopen.2024.9449

2. Innovations in women’s health: bridging disparities in breast cancer. AMCP Learn. May 7, 2024. Accessed May 9, 2024. https://amcplearn.org/content/innovations-womens-health-bridging-disparities-breast-cancer#group-tabs-node-course-default4

3. Advancing racial equity in U.S. health care. The Commonwealth Fund. April 18, 2024. Accessed May 9, 2024. https://www.commonwealthfund.org/publications/fund-reports/2024/apr/advancing-racial-equity-us-health-care