Journal of the National Cancer Institute Advance Access originally published online on November 25, 2008
JNCI Journal of the National Cancer Institute 2008 100(23):1661-1663; doi:10.1093/jnci/djn412
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© The Author 2008. Published by Oxford University Press.
EDITORIALS |
Reducing Disparities in Breast Cancer Care—A Daunting but Essential Responsibility
Affiliations of authors: Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA (RAF, EPW); Susan G. Komen for the Cure, Dallas, TX (EPW)
Correspondence to: Eric P. Winer, MD, Department of Medical Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115 (e-mail: ewiner{at}partners.org).
Disparities in breast cancer care and outcomes by race and ethnicity are well documented. For example, black women have a lower incidence of breast cancer than their white counterparts but have a higher overall mortality (1). The inferior outcomes observed among black women are multifactorial in origin and can be attributed to many factors including more advanced stage at diagnosis (2,3), a lower proportion of hormone receptor–positive tumors (4), differences in comorbidity (5), provider variability (6), and a range of socioeconomic and cultural factors (7–10). Unraveling the complex relationship between race and socioeconomic status (SES) is difficult. Research has often focused on census data and population-based registries with variable inclusion of education, income, and insurance status into the analyses (11–13). Even when studies have controlled for SES, race appears to influence the likelihood that a patient will receive standard adjuvant treatment (11–13).
Because breast cancer care requires that a patient see several physicians and receive a series of treatments, the failure to transition from one step to the next can result in suboptimal care. It is well documented that women from underserved populations are less likely to receive radiation therapy (14,15), chemotherapy (16), and hormonal therapy (16) than their white counterparts. It is also known that adjuvant treatment improves disease-free and overall survival, and by extrapolation, failure to receive effective therapy would lead to inferior outcomes (17,18). However, the extent to which inadequate treatment leads to less favorable survival outcomes in underserved women is not fully understood. Some studies report equal breast cancer–specific outcomes by race when all patients receive similar care (19,20), but others have observed differences in overall survival despite administration of homogeneous treatments in a controlled setting (21–23). Indeed, the etiologic factors that account for the inferior outcomes of breast cancer in racial minorities may include complex societal forces and biologic influences (4). Although efforts to ensure equal access to care remain critical, specific interventions aimed to improve the quality of breast cancer care for vulnerable patients have been relatively slow to take hold.
In this issue of the Journal, Bickell et al. (24) have attempted to promote optimal care by implementing a provider-based intervention. A tracking registry in six New York City hospitals used an electronic database within surgical practices to document follow-up appointments with medical oncologists for a group of 300 women with stage I–II breast cancer. If a medical oncology appointment passed without attendance, the surgical practice was contacted by a research assistant to encourage patient follow-through. The researchers did not assess whether the surgical practices actually followed up with patients after the reminder calls. The intervention was implemented in 2006, and rates of medical oncology consultations and receipt of clinically indicated adjuvant treatments were compared with a retrospective cohort of 639 patients treated during 1999–2000.
In comparison to historical controls, Bickell et al. (24) have observed improved rates of medical and radiation oncology consultations and more appropriate use of adjuvant therapies for women in the intervention group. Among black and Hispanic women, statistically significant increases in completed oncology consultations as well as increases in use of radiotherapy, chemotherapy, and endocrine therapy were observed. Indeed, after adjustment for age, comorbidity, stage, and insurance status during the intervention period, patients identified as black or Hispanic were equally likely to have an oncology consultation as their white or Asian counterparts (odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.5 to 1.8). They were also equally likely to receive adjuvant treatment (OR = 1.1, 95% CI = 0.7 to 7.7).
Although the findings (24) are encouraging, the study has several limitations, most of which are unavoidable in a nonrandomized design that relies on the use of historical controls. It is possible that other practice improvements accounted for the differences seen over time. Without detailed information about the follow-through on the part of the surgical practices, it is difficult to know if the intervention actually affected surgical practice or patients’ behavior. Furthermore, physicians’ and patients’ behavior may have been influenced by the knowledge that they were participating in a study, independent of the actual intervention. Of concern, the intervention was not provided to more than 40% of potentially eligible patients due to inability of research staff to make telephone contact or because of patients’ refusal to participate. As a result, women at highest risk for suboptimal care may have been excluded.
Although Bickell et al. (24) acknowledge that navigator programs were in place in four of six hospitals before and after the intervention, they do not comment on whether their navigation services expanded over the study period or if these programs could have partially accounted for improved rates of medical oncology consultations. For the past decade, navigator programs designed to assist underserved patients have been broadly implemented to assist patients with the coordination of appropriate care and to avoid delays in treatment. Trained and experienced patient navigators can address multiple patient, provider, and institutional barriers to care (25). Multiple programs funded by the National Cancer Institute's Patient Navigation Research Program (26) have been in place since 2005 and have been augmented by locally funded navigator services. Although navigation is widely used and is viewed favorably (27), limited data are available about the efficacy, impact, and cost-effectiveness of patient navigator programs.
In a study reported by Battaglia et al., a pre–post intervention study of navigator services was conducted at a major academic medical center in Boston and at its community affiliates to assess receipt of "timely follow-up" among healthy women who had been identified to have breast abnormalities. The authors reported timely follow-up for 64% of patients in the preintervention group vs 78% in the postintervention group (P < .001) (28). Other efforts to assess navigator programs have been conducted in screening populations and have demonstrated improved follow-up rates (29–31) and shorter times to diagnostic resolution of mammographic abnormalities (32). However, these studies have not consistently randomized patients and have been mostly examined in individuals without a known diagnosis of cancer.
Although the study by Bickell et al. (24) offers an innovative provider-based approach to increase the proportion of patients who are seen for consultation, their research should be viewed as preliminary. If a simple tracking system can help eliminate disparities, some might argue that similar programs should be broadly implemented even if definitive evidence is lacking. We believe that the work described by Bickell et al., albeit promising, needs to be replicated using a prospective, randomized design. The intervention appears to be a low-cost solution, but it relies heavily on busy providers to follow up with patients. If the financial burden associated with the physician and staff time is included, the expense will increase substantially. More importantly, there is an opportunity cost associated with almost any intervention. If the tracking registry is ultimately not as effective as the initial study would suggest, it may divert resources away from other efforts. Disparities in cancer care represent one of the most important challenges facing the oncological community, and although we need to act quickly, we cannot rush to implement approaches that have not been thoroughly evaluated through rigorous investigation.
Additional research is urgently needed. Of the 40 000 deaths from breast cancer each year, we know that a substantial number could be prevented if all women had the same access to care and actually received the same care as a prototypic white, middle-aged, married woman living in a city who has been well educated, has social support, and does not lack health insurance. As cancer treatment becomes more complex, more costly, and more effective, the potential for disparities will only increase. Now is the time to conduct the research that will allow us to eliminate these disparities in the years ahead. Failure to do so will limit our ability to take full advantage of the progress that is occurring in basic, translational, and clinical research. Addressing these disparities will require not only clarification of the contributions of SES, insurance status, and race but also a more complete understanding of patient preferences, provider practice patterns, and the cultural and structural barriers that limit breast cancer care. The task is daunting, but it is a challenge we simply must address.
NOTES
The authors take full responsibility for the writing of this editorial and report no conflicts of interest. The authors acknowledge Ann H. Partridge, MD, MPH, for her thoughtful review of the article.
REFERENCES
1. Ries L, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2005 (2008) Bethesda, MD: National Cancer Institute. http://seer.cancer.gov/csr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER Web site.
2. Aziz H, Hussain F, Sohn C, et al. Early onset of breast carcinoma in African American women with poor prognostic factors. Am J Clin Oncol (1999) 22(5):436–440.[CrossRef][Web of Science][Medline]
3. McBride R, Hershman D, Tsai WY, Jacobson JS, Grann V, Neugut AI. Within-stage racial differences in tumor size and number of positive lymph nodes in women with breast cancer. Cancer (2007) 110(6):1201–1208.[CrossRef][Web of Science][Medline]
4. Carey LA, Perou CM, Livasy CA, et al. Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA (2006) 295(21):2492–2502.
5. Satariano WA, Ragland DR. The effect of comorbidity on 3-year survival of women with primary breast cancer. Ann Intern Med (1994) 120(2):104–110.
6. Bickell NA, LePar F, Wang JJ, Leventhal H. Lost opportunities: physicians’ reasons and disparities in breast cancer treatment. J Clin Oncol (2007) 25(18):2516–2521.
7. Griggs JJ, Culakova E, Sorbero ME, et al. Social and racial differences in selection of breast cancer adjuvant chemotherapy regimens. J Clin Oncol (2007) 25(18):2522–2527.
8. Halpern MT, Bian J, Ward EM, Schrag NM, Chen AY. Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer (2007) 110(2):403–411.[CrossRef][Web of Science][Medline]
9. Harlan LC, Greene AL, Clegg LX, Mooney M, Stevens JL, Brown ML. Insurance status and the use of guideline therapy in the treatment of selected cancers. J Clin Oncol (2005) 23(36):9079–9088.
10. Naik AM, Joseph K, Harris M, Davis C, Shapiro R, Hiotis KL. Indigent breast cancer patients among all racial and ethnic groups present with more advanced disease compared with nationally reported data. Am J Surg (2003) 186(4):400–403.[CrossRef][Web of Science][Medline]
11. Curtis E, Quale C, Haggstrom D, Smith-Bindman R. Racial and ethnic differences in breast cancer survival: how much is explained by screening, tumor severity, biology, treatment, comorbidities, and demographics? Cancer (2008) 112(1):171–180.[CrossRef][Web of Science][Medline]
12. Haggstrom DA, Quale C, Smith-Bindman R. Differences in the quality of breast cancer care among vulnerable populations. Cancer (2005) 104(11):2347–2358.[CrossRef][Web of Science][Medline]
13. Shavers VL, Harlan LC, Stevens JL. Racial/ethnic variation in clinical presentation, treatment, and survival among breast cancer patients under age 35. Cancer (2003) 97(1):134–147.[CrossRef][Web of Science][Medline]
14. Smith GL, Shih YT, Xu Y, et al. Racial disparities in treatment for early invasive breast cancer: a national Medicare study of radiotherapy after conservative surgery. In: Grunberg SM, ed. Breast Cancer Symposium. Washington, DC. American Society for Clinical Oncology; September 57, 2008: Abstract 91.
15. Freedman R, He Y, Winer E, Keating N. Racial disparity trends in definitive primary therapy of early-stage breast cancer. Presented at 2008 ASCO Annual Meeting. J Clin Oncol (2008) 26(suppl). Abstract 535.
16. Bickell NA, Wang JJ, Oluwole S, et al. Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol (2006) 24(9):1357–1362.
17. Early Breast Cancer Trialists' Collaborative Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet (2005) 365(9472):1687–1717.[CrossRef][Web of Science][Medline]
18. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet (2005) 366(9503):2087–2106.[Web of Science][Medline]
19. Dawood S, Broglio K, Shu-Wan Kau S, et al. Triple receptor-negative breast cancer: The effect of race on response to primary systemic treatment and survival outcomes. In: Breast Cancer Symposium. Washington, DC. Grunberg SM, ed.
20. Roach M 3rd, Cirrincione C, Budman D, et al. Race and survival from breast cancer: based on Cancer and Leukemia Group B trial 8541. Cancer J Sci Am (1997) 3(2):107–112.[Web of Science][Medline]
21. Albain K, Unger J, Hutchins L, et al. Outcome of African Americans on Southwest Oncology Group breast cancer adjuvant therapy trials. In: 26th San Antonio Breast Cancer Symposium. San Antonio, TX. Lippman ME, ed. December 36, 2003: Kluwer Academic Publishing.
22. Dignam JJ. Efficacy of systemic adjuvant therapy for breast cancer in African-American and Caucasian women. J Natl Cancer Inst Monogr (2001) (30):36–43.
23. Polite BN, Cirrincione C, Fleming GF, et al. Racial differences in clinical outcomes from metastatic breast cancer: a pooled analysis of CALGB 9342 and 9840—Cancer and Leukemia Group B. J Clin Oncol (2008) 26(16):2659–2665.
24. Bickell NA, Shastri K, Fei K, et al. A tracking and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst (2008) (23):100–1723, 1717.
25. Dohan D, Schrag D. Using navigators to improve care of underserved patients: current practices and approaches. Cancer (2005) 104(4):848–855.[CrossRef][Web of Science][Medline]
26. National Cancer Institute (NCI) and Center to Reduce Health Care Disparities. Patient Navigation Resarch Program. http//crchd.cancer.gov/pnp/pnrp-index.html. Accessed September 8, 2008.
27. Smedley BD, Stith AY, Nelson AR, eds. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. In: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Appendix C: Federal-Level and Other Initiatives to Address Racial and Ethnic Disparities in Healthcare (384–391) (2003) Washington, DC. National Academies Press.
28. Battaglia TA, Roloff K, Posner MA, Freund KM. Improving follow-up to abnormal breast cancer screening in an urban population. A patient navigation intervention. Cancer (2007) 109(suppl_2):359–367.[CrossRef][Web of Science][Medline]
29. Psooy BJ, Schreuer D, Borgaonkar J, Caines JS. Patient navigation: improving timeliness in the diagnosis of breast abnormalities. Can Assoc Radiol J (2004) 55(3):145–150.[Web of Science][Medline]
30. Dignan MB, Burhansstipanov L, Hariton J, et al. A comparison of two Native American Navigator formats: face-to-face and telephone. Cancer Control (2005) 12(suppl 2):28–33.[Medline]
31. Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract (1995) 3(1):19–30.[Medline]
32. Ferrante JM, Chen PH, Kim S. The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial. J Urban Health (2008) 85(1):114–124.[CrossRef][Web of Science][Medline]
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