The Impact of Social Determinants of Health on the Time Between Diagnostic Breast Imaging and Biopsy at a Safety Net Hospital.

Abstract

Although social determinants of health (SDH) are thought to be associated with health outcomes, there is limited literature on the direct impact of SDH on delays in breast cancer diagnosis via breast imaging. Identifying SDH associated with longer lapses (defined in this study as a time interval between two events) between imaging and biopsy is essential to early-stage detection of breast cancer, which has a significant impact on survival. Previous work demonstrated associations between both housing and food insecurity with longer lapses between diagnostic imaging and biopsy. We aim to expand upon this retrospective analysis with a longer study period, more participants, and improved data cleaning techniques to better understand how SDH may affect the lapse between imaging and biopsy. This retrospective study was institutional review board approved and HIPAA compliant. Informed consent was waived. Patients who underwent screening mammography between January 1, 2015, and January 1, 2020, were assessed for timing of recommended biopsy due to a BI-RADS category 4 or 5. SDH were assessed with the unique Tool for Health & Resilience in Vulnerable Environments screening questionnaire developed at Boston Medical Center. Associations between imaging and biopsy timing and eight explanatory SDH variables (food insecurity, housing insecurity, ability to pay for medications, transportation access, ability to pay for utilities, caretaking needs, employment, and desire for more education) were assessed with multivariate Cox proportional hazard modeling, as well as demographic data. There were 2,885 unique patients who underwent 3,142 unique diagnostic imaging studies and were included in the multivariate analysis. Of those 3,142 imaging studies, 196 (6.2%) had not yet been followed by the recommended biopsy by the end of the study period; 2,271 patients (78.7%) had SDH data in at least one domain; and the individual domains ranged from 962 patients (32.1%) with complete data for education to 2,175 patients (75.4%) with complete data for food insecurity. A positive screen for at least one SDH was associated with a longer lapse between diagnostic imaging and biopsy (P= .048). Furthermore, housing insecurity alone was nearly associated with longer lapses between diagnostic imaging and biopsy (P= .059). Those who desired more education were found to have shorter lapses between diagnostic imaging and biopsy (P= .037). Only a positive screen of the aggregate of all SDH (using a novel tool developed at our safety net hospital) was associated with a statistically significant lengthening of this lapse. Of the eight SDH screened, housing insecurity was the closest to association with longer lapses between diagnostic imaging and biopsy, whereas patients who desired more education were found to have statistically significant shorter lapses; however, this survey domain had the lowest completion rate. Identification of which SDH might affect the time from imaging to biopsy can potentially inform targeted programs to intervene. Government and health system interventions addressing SDH, notably housing insecurity, could allow for shorter time to breast cancer diagnosis and treatment.