Association between socioeconomic factors and outcomes in breast cancer.

Abstract

Persistent socioeconomic disparities are evident in the delivery of health care. Despite previous research into health disparities, the extent of the effect of economic inequalities in the management of breast cancer is not well understood. The purpose of our study is to perform a national assessment of the impact of economic factors on key aspects of breast cancer management. This is a retrospective study using data from the National Cancer Database. The population consisted of female patients with primary breast cancer diagnosed between 2011 and 2015. Patients were categorized based on household income and insurance status. Outcomes investigated were stage at diagnosis, rate of breast conservation therapy, use of immediate reconstruction following mastectomy, and administration of systemic therapy for stage 3 and 4 disease. Multivariable logistic regression analyses were performed to determine significant associations between economic factors and clinical outcomes. Survival analysis was performed to evaluate the influence of income and insurance on survival. In total, 666487 women were evaluated. Multivariable regression analyses revealed that patients with lower income (OR, 1.23) and no insurance (OR, 1.64) were more often diagnosed with later stage disease. Patients with lower income (OR, 1.08) and no insurance (OR, 1.05) had a higher likelihood of undergoing mastectomy instead of breast conserving therapy. Patients with lower income (OR, 0.51) and no insurance (OR, 0.27) were less likely to receive immediate breast reconstruction. Administration of systemic therapy was less frequent in patients with lower income (OR, 0.90) and no insurance (OR, 0.52). A survival benefit was demonstrated in patients with high income and insurance. Our findings demonstrate prevailing disparities in the delivery of care among patients with limited economic resources, which pertains to some of the most important aspects of breast cancer care. The full etiology of the observed disparities is complex and multifactorial, and a better understanding of these issues offers the potential to close the existing gap in quality of care.