Unveiling inequities in palliative care and clinical trial participation among patients with metastatic breast cancer in the state of Florida.

Abstract

12120 Background: Persistent inequities in the care for patients with metastatic breast cancer (mBC) were recognized by ASCO and, in partnership with Pfizer, awarded our team a grant to understand and address them in people of color. Florida has a higher age-adjusted percentage of breast cancer in females and a higher mortality rate in those under the age of 65 compared to the United States. The racial disparity in mortality is further magnified among female patients with mBC. Therefore, we sought to characterize the prevalence and trends of palliative care utilization and clinical trial participation (CTP) among Floridians with mBC and quantify the associated factors. Methods: Using the OneFlorida+ Data Trust, a repository of patient-level electronic health records of ~17 million Floridians seen in public and private health care systems, including those enrolled in Medicaid, we obtained demographics of mBC patients, including sex, age, race, and ethnicity, insurance type, zip-code based socioeconomic status, Charlson comorbidity index (CCI) and rural/urban residence. CPT codes were obtained for palliative care services between the date of mBC diagnosis and death, including pain management, psychology, psychiatry, nutrition, and advanced care planning. Our analysis included the Cochran-Armitage trend test and bivariate analysis to correlate patient characteristics to palliative care receipt and CTP. Results: In Florida, 25,225 individuals (1.5% men and 98.5% women) were diagnosed with mBC between 2012 and 2021; 49.3% were under age 60. 19.5% of this cohort received palliative care at a median time of 10.1 months (IQR 2.1 – 27.1) from the initial diagnosis of mBC. The median survival was 13.6 months (IQR 3.4 – 31.6). On multivariable analysis, significant variables (p < 0.001) associated with increased palliative care utilization were Non-Hispanic Black, self-pay/uninsured and Medicaid insured, and a CCI of 5+. Only 3% of the study cohort had advanced care planning. There was a declining trend in CTP among patients with mBC, from 13.9% in 2012 to 7.9% in 2021. Among those participating in clinical trials, 80.2% did not receive palliative care. Variables associated with higher CTP (p < 0.001) were younger age (18-49), Asian and Hispanic race/ethnicity, the highest quartile of median household income and education level, private insurance, metropolitan residence, and CCI of 0. Further, there was a trend towards more prolonged survival among those enrolled in clinical trials. Conclusions: This robust statewide assessment highlights that less than 20% of patients with mBC receive palliative care, and its receipt is exclusive of CTP. We identified significant racial and socioeconomic disparities in CTP. Educational interventions with palliative care trained navigators, partnerships with providers on palliative care benefits, and state policy support are needed.