Disparities In Breast Cancer Treatment Research Articles

The Military Health System: Minimizing Disparities inBreast Cancer Treatment.

The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population. A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs. Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004). There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.

Reducing Racial Disparities in Breast Cancer Treatment

Racial disparities in breast cancer screening, treatment, and outcomes are well established. A recent multi-institutional paper showed a higher mean heart dose (MHD) in Black women and other minorities compared to White women who underwent left-sided breast or chest wall irradiation. We evaluated the MHD of women treated in our institution and investigated whether institution-wide measures can mitigate disparities. We identified 509 consecutively treated female patients from 2012 to 2021 who received left-sided breast or chest wall irradiation (with or without regional nodal irradiation). Medical records were queried to report cardiac dosimetry across various racial groups. Details regarding the use of active breathing control (ABC), breast size, internal mammary nodal irradiation, and whether the patient's treatment plan met the departmental boarding pass requirement and was prospectively presented at departmental peer review were noted. MHD were noted in absolute values and 2-Gy equivalent doses (EQD2). Kruskal-Wallis test was used to analyze differences in MHD between racial groups. Univariate and multivariable Cox regression analyses were performed to determine association of MHD with other factors. MHD was similar across racial groups; 1.38 Gy (1.12, 2.02) in Black women, 1.35 Gy (1.02, 1.97) in White women, and 1.39 Gy (1.07, 2.01) in others with an EQD2 of 0.71, 0.70 and 0.72 (P = 0.6). Rates of the use of hypofractionation, a cavity boost, regional nodal irradiation, internal mammary nodal irradiation, meeting departmental boarding pass requirement, and peer review of treatment plan before starting treatment were similar across all racial groups. The use of ABC was 83% in White women, 75% in Black women and 62% in other races (P = 0.005). The difference in ABC use was attributed to a higher rate of volumetric modulated arc therapy treatment in other races (33%). Median breast size was 1904 cc in Black women, 1504 cc in White women, and 1331 cc in other racial groups (P = 0.001). On univariate and multivariate analysis, MHD differed with IMN treatment, boost and use of ABC but remained similar across racial groups and varying breast size. Despite anatomical differences such as breast size, achieving similar cardiac dose is feasible across racial groups by uniformly utilizing ABC for left sided breast or chest wall irradiation, applying standardized boarding pass constraints and peer review of all cases. Further studies to identify factors that may lead to differences in the rates of cardiac morbidity among racial groups are warranted.

Reduced racial disparity in receipt of optimal locoregional treatment for women with early-stage breast cancer.

Racial disparities in breast cancer treatment contribute to Black women having the worst breast cancer survival rates in the U.S. We investigated whether differences in receipt of optimal locoregional treatment (OLT), defined as receipt of mastectomy, breast-conserving surgery, or no surgery when contraindicated, existed between Black and White women with early-stage breast cancer from 2008-2018. In this retrospective cohort study, data from the Surveillance, Epidemiology, and End Results (SEER) Program Incidence Database was utilized to identify tumor cases from Black and White women aged 20-64 years old with stage I-II breast cancer. Logistic regression analyses were used to evaluate the associations between race and receipt of OLT as well as potential effect modification by tumor characteristics, and year of diagnosis. Among 177,234 women diagnosed with early-stage breast tumors, disparities in OLT between Black and White women were present from 2008-2010 (2008: 82.1% Black vs. 85.7% White, p<0.001; 2009: 82.1% Black vs. 85.8% White, p<0.001; 2010: 82.2% Black vs. 87.2% White, p<0.001). This disparity was eliminated between 2010-2011 (86.3% Black vs. 87.5% White, p = 0.15), and did not reoccur during the remainder of the study period. From 2010-2011, more Black women received radiation therapy following breast-conserving surgery (43.4% to 48.9%; p = 0.001), which accounted for an overall increased receipt of OLT. Increased receipt of radiation therapy with breast-conserving surgery appeared to drive a substantial increase in OLT for Black women from 2010-2011 that lasted throughout the study period. Further research on the underlying mechanisms that reduced this disparity is warranted.

Early-stage breast cancer treatment disparities in the Midsouth: Has anything changed?

BackgroundWe sought to determine if racial disparities in treatment and survival persist among patients with breast cancer in the Midsouth. MethodsPatients with early-stage breast cancer were identified in the tumor registry of a large healthcare system in the Midsouth. Regression analyses were performed to determine how race was associated with receipt of treatment and mortality. ResultsAmong 4605 patients, 38.8% were Black. Black patients were less likely to undergo surgery (OR = 0.71; 95%CI 0.53–0.97) and receive hormone therapy (OR = 0.81; 95%CI 0.69–0.95) than White patients, but more likely to receive radiation (OR = 1.20; 95%CI 1.08–1.40) and chemotherapy (OR = 1.36; 95%CI 1.16–1.61). Among Black patients, the risk of mortality was lower among those who underwent partial (OR = 0.25; 95%CI 0.12–0.51) or total (OR = 0.35; 95%CI 0.16–0.76) mastectomy and among those who received hormone therapy (OR = 0.62; 95%CI 0.40–0.97). ConclusionThere remains room for improvement in providing treatments that optimize survival among this patient population.

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors.

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors. During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity. The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed. In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Breast cancer treatment disparities in patients with severe mental illness: A systematic review and meta-analysis.

The incidence and mortality rates of breast cancer in individuals with pre-existing severe mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, are higher than in the general population. Reduced screening is one factor but there is less information on possible barriers to subsequent treatment following diagnosis. We undertook a systematic review and meta-analysis on access to guideline-appropriate care following a diagnosis of breast cancer in people with SMI including the receipt of surgery, endocrine, chemo- or radiotherapy. We searched for full-text articles indexed by PubMed, EMBASE, PsycInfo and CINAHL that compared breast cancer treatment in those with and without pre-existing SMI. Study designs included population-based cohort or case-control studies. There were 13 studies included in the review, of which 4 contributed adjusted outcomes to the meta-analyses. People with SMI had a reduced likelihood of guideline-appropriate care (RR=0.83, 95% CI=0.77-0.90). Meta-analyses were not possible for the other outcomes but in adjusted results from a single study, people with SMI had longer wait-times to receiving guideline-appropriate care. The results for specific outcomes such as surgery, hormone, radio- or chemotherapy were mixed, possibly because results were largely unadjusted for age, comorbidities, or cancer stage. People with SMI receive less and/or delayed guideline-appropriate care for breast cancer than the general population. The reasons for this disparity warrant further investigation, as does the extent to which differences in treatment access or quality contribute to excess breast cancer mortality in people with SMI.

Abstract P6-08-14: Breast Cancer Treatment Choices and Results in Hispanic Women Without Funding for Radiation

Abstract Background: Although the survival rates for breast cancer have improved, there is still a disparity gap between Hispanic women and non-Hispanic women. Hispanic women in the US are vulnerable to cancer inequalities due to a plethora of barriers including disproportionate poverty, lack of health insurance, and citizenship status. A Surveillance, Epidemiology, and End Results analysis found that Hispanic women had lower rates of both early-stage breast cancer and receipts of radiation therapy (RT) after breast-conserving surgery than White women. For patients without private or government health insurance, charity and county indigent programs have variable levels of coverage, and some patients cannot access radiation services. The aim of this study is to identify disparities in breast cancer treatment for patients referred to the Travis County indigent cancer treatment program. Methods: We analyzed new referrals to the Ascension Seton Breast Clinic from April 2020 to January 2022. Demographics, disease stage, funding and treatments were extracted from medical records. We compared funding status at the time of referral vs time of surgery. We also analyzed the type of surgery elected and if RT was indicated and received. Results: We found that out of 242 referrals, 116 were diagnosed with a new malignancy. Of the 116, a total of 76 underwent breast surgery and RT was considered in 64 of these patients. 61% received RT. Of the remaining 25 patients, 16 patients elected simple mastectomies and 9 did not have funding to cover radiation (income was not low enough to qualify for RT benefit under the health district). Of the 9 women who did not have funding about 78% identified as Hispanic or Latino. 4 opted for simple mastectomies thus no longer needing RT, 3 received modified radical mastectomies without RT, 1 accessed charity funding for RT and 1 had lumpectomy without radiation and had recurrence of her breast cancer. Overall, the rate of breast conserving surgery was 43%. Discussion: The safety net system for patients in the US without access to private or government funding for healthcare is inherently limited. Costs of radiation treatment for cancer can be prohibitive for charity and indigent programs, but patients are forced to choose between mastectomy or risk a higher rate of recurrence. This data will be used to advocate for health district funding for this patient population. Citation Format: Maria De Los Leon-Camarena, Neha Reddy, Kimberly Ellison, Boone Goodgame. Breast Cancer Treatment Choices and Results in Hispanic Women Without Funding for Radiation [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-08-14.

Mitigating disparities in breast cancer treatment at an academic safety-net hospital.

Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital. We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status. 520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years. Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.

Adherence Disparities and Utilization Trends of Oncotype Dx Assay: A National Cancer Database Study

IntroductionOncotype Dx (ODX) is a genetic assay that analyzes tumor recurrence risk and provides chemotherapy recommendations for T1-T2 stage, hormone receptor-positive, human epidermal growth factor receptor-negative, and nodal-negative breast cancer patients. Despite its established validity, the utilization of this assay is suboptimal. The study aims to evaluate factors that are associated with adherence rate with the testing guidelines and examine changes in utilization trends. MethodsThis is a retrospective study, utilizing data from the National Cancer Database from 2010 to 2017. Patients who met the ODX testing guidelines were first evaluated for testing adherence. Secondly, all patients who underwent ODX testing were assessed to evaluate the trend in ODX utilization. ResultsA total of 429,648 patients met the criteria for ODX, and 43.4% of this population underwent testing. Advanced age, racial minorities, low-income status, well-differentiated tumor grade, uninsured status, and treatment at community cancer centers were associated with a decreased likelihood of receiving ODX in eligible patients. Additionally, a notable amount of testing was performed on patients who did not meet the ODX testing criteria. Among the 295,326 patients that underwent ODX testing, 16.6% of patients were node-positive and 1.8% had T3 or T4 stage tumors. ConclusionsA considerable number of patients who were eligible for ODX did not receive it, indicating potential barriers to care and disparities in breast cancer treatment. ODX usage has been expanded to broader patient populations, indicating more research is needed to validate the effectiveness of the assay in these patient groups.

Modifiable Barriers and Facilitators for Breast Cancer Care: A Thematic Analysis of Patient and Provider Perspectives

IntroductionWe sought to examine patient and provider perspectives regarding modifiable contributors to breast cancer treatment and to assess perceptual alignment between these two groups. MaterialsParticipants were women≥18 y with stage 0-IV breast cancer who received all oncologic care in a single health system and physicians and advanced practice providers who provided medical, radiation, or surgical oncology care for breast cancer. All completed ∼45-min semistructured interviews that were recorded and transcribed verbatim. A 5-stage approach to thematic analysis was conducted, with emergent themes and exemplar quotes placed into clinical, psychological, social/logistical, financial, and lifestyle categories using a multilevel conceptual framework. ResultsEighteen patients (9 Black, 9 White, and median age 60 y) and 10 providers (6 physicians and 4 advanced practice providers) were interviewed from May to November 2018. Both patients and providers perceived suboptimal communication, parking and transportation, and competing family-caregiving responsibilities as modifiable barriers to care. Treatment costs were cited by patients as barriers that were inadequately addressed even with referrals to financial counselors, but providers did not raise the issue of cost unless prompted by patients and did not feel prepared to discuss the topic when it arose. Providers cited obesity as a barrier to treatment, a view not shared by patients. ConclusionsSeveral modifiable factors were recognized by both patients and providers as either promoting or detracting from treatment receipt, but there was also significant incongruence and asymmetry. Alignment of provider and patient perceptions regarding contributors to guideline-concordant care receipt could mitigate disparities in breast cancer treatment and outcomes.

Health Disparities in Patients Seeking Physiological Surgical Treatment for Lymphedema.

Previous studies have demonstrated racial disparities in breast cancer treatment and secondary lymphedema. However, no studies have yet examined the effects of race and socioeconomic status on physiological surgical treatment for lymphedema. The authors aimed to evaluate whether disparities exist within patients seeking physiological surgical lymphedema treatment. A retrospective review was performed of patients presenting for physiological surgical treatment of lymphedema from 2013 to 2019. Data on demographics, medical history, socioeconomic factors, lymphedema, and treatments were collected. A total of 789 patients (712 women and 77 men) seeking physiological surgical treatment of lymphedema were selected. Their mean age was 54.4 ± 13.4 years. A total of 620 patients (78.5%) self-reported as White, 120 (15.2%) as Black, 17 (2.2%) as Asian, five (0.6%) as Hispanic, and eight (2.4%) as multiracial. A total of 566 patients (71.7%) met criteria for surgical candidacy. White race was associated with increased rates of surgical candidacy compared with Black race (46.6% versus 77.2%; P < 0.0001). Compared with White patients, Black patients presented with a longer symptom duration (11.07 versus 6.99 years; P < 0.001), had a higher body mass index (mean, 34.5 versus 28.1; P < 1 × 10 -10 ), had a higher International Society of Lymphology stage ( P < 0.05), and were less likely to have maximized medical treatment for lymphedema (30.8% versus 55.4%; P < 0.01). This study demonstrates racial disparities in patients seeking physiological surgical treatment for lymphedema. Black patients present later with more severe disease, receive less nonsurgical treatment before consultation, and are less likely to meet criteria for physiological surgery. Improved patient and provider education on lymphedema and appropriate diagnosis and nonsurgical treatment is of primary importance to address this disparity.

The Military Health System: Minimizing Disparities in Breast Cancer Treatment

The Military Health System: Minimizing Disparities in Breast Cancer Treatment

Factors Mediating Racial/Ethnic Disparities in Delayed Treatment of Breast Cancer.

BackgroundDespite improvements, disparities in breast cancer care have led to an inequitable distribution of treatment delays and worse outcomes among patients with breast cancer. This study aimed to quantify the contribution of mediators that may explain racial/ethnic disparities in breast cancer treatment delays.Patients and MethodsWe conducted a retrospective analysis of patients from the National Cancer Database with stage I–III breast cancer who underwent surgical resection. Mediation analyses estimated the extent to which racial/ethnic disparities in the distribution of patient characteristics account for racial/ethnic disparities in delayed treatment.ResultsOf the 1,349,715 patients with breast cancer included, 10%, 5%, and 4% were Black, Hispanic, and other non-white race/ethnicity, respectively. Multivariable models showed that patients in these racial/ethnic groups had 73%, 81%, and 24% increased odds of having a treatment delay relative to white patients. Mediation analyses suggested that 15%, 19%, and 15% of the treatment delays among Black, Hispanic, and other non-white race/ethnicity patients, respectively, are explained by disparities in education, comorbidities, insurance, and facility type. Therefore, if these mediators had been distributed equally among all races/ethnicities, a reduction of 15–19% in the delayed treatment disparities experienced by minority patients would have been observed. Academic facility type was the factor that could yield the largest reduction in time to treatment disparities, contributing to 8–13% of racial/ethnic disparities.ConclusionsPatients with breast cancer who identified as Black, Hispanic, and other non-white races/ethnicities are exposed to longer treatment delays relative to white patients. Efforts to equalize mediators could remove substantial portions of racial/ethnic disparities in delayed treatment.

Asian Ethnic Subgroup Disparities in Delays of Surgical Treatment for Breast Cancer.

BackgroundAs Asian American breast cancer incidence rises, it is necessary to investigate the origins of differential breast cancer outcomes among Asian ethnic subgroups. This study aimed to examine disparities in delays of breast cancer surgery among Asian ethnic subgroups.MethodsWe obtained California Cancer Registry data on female breast cancer diagnoses and treatment from 2012 to 2017. Our main independent variable was patient race and ethnicity, including 6 Asian ethnic subgroups. Dependent variables included time to surgical treatment for breast cancer and receipt of surgical treatment within 30 and 90 days of diagnosis. We conducted multivariable logistic regression to determine the odds of receiving surgery within 30 and 90 days of diagnosis and multivariable Cox proportional hazards regression to determine the risk of prolonged time to surgery.ResultsIn our cohort of 93 168 breast cancer patients, Hispanic (odds ratio [OR] = 0.86, 95% confidence interval [CI] = 0.82 to 0.89) and non-Hispanic Black (OR = 0.83, 95% CI = 0.78 to 0.88) patients were statistically significantly less likely than non-Hispanic White patients to receive surgery within 30 days of breast cancer diagnosis, whereas Asian Indian or Pakistani (OR = 1.23, 95% CI = 1.09 to 1.40) and Chinese (OR = 1.30, 95% CI = 1.20 to 1.40) patients were statistically significantly more likely to receive surgery within 30 days of diagnosis.ConclusionsThis large, population-based retrospective cohort study of female breast cancer patients is the first, to our knowledge, to demonstrate that time to surgical treatment is not equal for all Asians. Distinct differences among Asian ethnic subgroups suggest the necessity of further investigating breast cancer treatment patterns to fully understand and target disparities in breast cancer treatment.

Asian American ethnic subgroup disparities in time to surgical treatment for breast cancer in the California Cancer Registry.

101 Background: Health risks and outcomes among Asian American patients are not adequately understood when Asians are treated as a homogenous ethnic group. This work is the first to explore trends in time to surgical treatment for breast cancer amongst Asian American ethnic subgroups. Methods: We used data from the population-based California Cancer Registry to identify a cohort of females diagnosed with invasive breast cancer between 2012-2017 in California. Time to surgical treatment was defined as the time elapsed between definitive diagnosis of breast cancer and receipt of surgery. Covariates included individual patient sociodemographic, health history, and tumor characteristics. Multivariable logistic regression was used to determine the odds of receiving surgery within 30 and 90 days of breast cancer diagnosis and multivariable Cox proportional hazards regression was used to analyze the likelihood of shorter time to surgery. A Bonferroni corrected alpha level was used to account for multiple racial/ethnic group comparisons. Results: Of 106,441 breast cancer patients, 57% were non-Hispanic white (NHW), 21% were Hispanic, 14% were Asian (4% Filipino; 3% Chinese; 1% each of Asian Indian or Pakistani (AIP), Vietnamese, Japanese, and Korean; 3% other Asian), and 6% were non-Hispanic black (NHB). Compared to NHWs, Hispanics (OR = 0.86, 99.5% CI = 0.82-0.92) and NHBs (OR = 0.82, 99.5% CI = 0.76-0.90) were less likely to receive surgery within 30 days of breast cancer diagnosis, while Chinese (OR = 1.30, 99.5% CI = 1.17-1.45) and AIPs (OR = 1.24, 99.5% CI = 1.04-1.48) were more likely to receive surgery within 30 days. These trends persisted for Hispanic (OR = 0.87, 99.5% CI = 0.79-0.96), NHB (OR = 0.73, 99.5% CI = 0.63-0.85), and Chinese patients (OR = 1.33, 99.5% CI = 1.04-1.71) when analyzing the likelihood of receiving surgery within 90 days of diagnosis. Compared to NHWs, Hispanics (OR = 0.94, 99.5% CI = 0.92-0.97), NHBs (OR = 0.88, 99.5% CI = 0.85-0.91), and Vietnamese (OR = 0.90, 99.5% CI = 0.83-0.98) were less likely to experience shorter time to surgical treatment, while Chinese (OR = 1.15, 99.5% CI = 1.09-1.21) and AIPs (OR = 1.09, 99.5% CI = 1.01-1.18) were more likely to have shorter time to surgery. Conclusions: In this population-based study of the California Cancer Registry, trends in time to surgical treatment for breast cancer were not consistent for patients belonging to different Asian ethnic subgroups. While Chinese and AIP patients tended to receive surgery sooner than NHW patients, Vietnamese patients face a disparity in receiving timely surgical treatment relative to NHW patients. Further research is needed to fully understand and appropriately target disparities in breast cancer treatment for patients of different Asian American ethnic subgroups.

Residential Racial Segregation and Disparities in Breast Cancer Presentation, Treatment, and Survival.

To understand the role of racial residential segregation on Black-White disparities in breast cancer presentation, treatment, and outcomes. Racial disparities in breast cancer treatment and outcomes are well documented. Black individuals present at advanced stage, are less likely to receive appropriate surgical and adjuvant treatment, and have lower overall and stage-specific survival relative to White individuals. Using data from the Surveillance, Epidemiology, and End Results program, we performed a retrospective cohort study of Black and White patients diagnosed with invasive breast cancer from 2005 to 2015 within the 100 most populous participating counties. The racial index of dissimilarity was used as a validated measure of residential segregation. Multivariable regression was performed, predicting advanced stage at diagnosis (stage III/IV), surgery for localized disease (stage I/II), and overall stage-specific survival. After adjusting for age at diagnosis, estrogen/progesterone receptor status, and region, Black patients have a 49% greater risk (relative risk [RR] 1.49 95% confidence interval [CI] 1.27, 1.74) of presenting at advanced stage with increasing segregation, while there was no observed difference in Whites (RR 1.04, 95% CI 0.93, 1.16). Black patients were 3% less likely to undergo surgical resection for localized disease (RR 0.97, 95% CI 0.95, 0.99) with increasing segregation, while Whites saw no significant difference. Black patients had a 29% increased hazard of death (RR 1.29, 95% CI 1.04, 1.60) with increasing segregation; there was no significant difference among White patients. Our data suggest that residential racial segregation has a significant association with Black-White racial disparities in breast cancer. These findings illustrate the importance of addressing structural racism and residential segregation in efforts to reduce Black-White breast cancer disparities.

Protocol for Symptom Experience, Management, Outcomes, and Adherence in Women Receiving Breast Cancer Chemotherapy.

The 5-year survival for Black women with breast cancer in the United States is lower than White women for stage-matched disease. Our past and ongoing work and that of others suggest that symptom incidence, cancer-related distress, and ineffective communication contribute to racial disparity in dose reduction and early therapy termination. Although race is perhaps the most studied social determinant of health, it is clear that race alone does not account for all disparities. The aim of the study was to present a study protocol of Black and White women prescribed breast cancer chemotherapy. The aims are to (1) examine and compare chemotherapy received/prescribed over time and in total; (2a) examine and compare symptom incidence, distress, and management and clinical encounter, including patient-centeredness of care and management experience over time and (2b) correlate symptom incidence, distress, and management experience to Aim 1; and (3) explore the effects of social determinants of health, including age, income, education, zip code, and lifetime stress exposure, on Aims 1, 2a, and 2b. A longitudinal, repeated-measures (up to 18 time points), comparative, mixed-methods design is employed with 179 White and 179 Black women from 10 sites in Western Pennsylvania and Northeast Ohio over the course of chemotherapy and for 2 years following completion of therapy. The study began in January 2018, with estimated complete data collection by late 2023. This study is among the first to explore the mechanistic process for racial disparity in dosage and delay across the breast cancer chemotherapy course. It will be an important contribution to the explanatory model for breast cancer treatment disparity and may advance potential mitigation strategies for racial survival disparity.

Abstract B055: Translating research into practice: Early lessons from a pragmatic clinical trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

Abstract Racial and socioeconomic disparities in breast cancer mortality persist; in Boston, Black women and Medicaid patients are 2-3 times more likely to have delays in initiating cancer treatment compared to their white and privately insured counterparts. Evidence-based strategies for combating delays exist but are not systematically implemented. Our primary research question is: can systematically implement evidence-based coordination of care across the city of Boston to reduce delays for the most vulnerable women? Translating Research Into Practice (TRIP) addresses racial and socio-economic disparities using the principals of community engaged research. Four of the Massachusetts Clinical and Translational Science Institutes (CTSI) have collaborated with the Boston Breast Cancer Equity Coalition, the Boston Patient Navigation Network, and a Clinical Advisory Panel to systematically implement an evidence-based coordination of care intervention in six Boston hospitals. Key components of the intervention include: patient navigation, a shared regional registry to track women across institutions and facilitate navigator coordination, systematic screening for social barriers to care and referral to free or low-cost community resources. The multi-component implementation strategy includes ongoing stakeholder engagement, navigator performance review and feedback, training and support and navigator peer learning. A stepped-wedge hybrid type I (n=536 post implementation, n=564 historical controls) effectiveness-implementation study design was launched in June 2018, with 6 sites entering intervention phase by December 2019. Primary clinical outcomes are time to first treatment and receipt of guideline concordant care. Secondary implementation outcomes are acceptability, adoption, cost, fidelity, penetration, and sustainability. To date, we have 59 women on study in the intervention phase. We are reaching our target population: 39% of women are Black, 32% of Hispanic ethnicity, 47% are non-English speaking and 81% have Medicaid. Lessons learned with implementing a community-engaged, regional pragmatic trial include: 1) Patient Navigators are eager to collaborate in the care of their patients and to identify best practices; 2) Engaging all stakeholders, including hospital administrators, is necessary to implement health systems programs; 3) Workflow variation across each health system requires significant customization to adapt the evidence and tools; 4) Tension for change exists among all sites because of existing established care coordination programs; and 5) Lack of integration of EHRs within and across health systems makes use of new data platforms challenging. Regional, community-engaged, interdisciplinary collaborations are important to reduce population disparities than often transcend a single institution. TRIP outlines a coordinated model to address disparities in breast cancer care that could be translated to other regions and disease conditions. Citation Format: Amy LeClair, Stephenie Lemon, Jennifer Haas, Rachel Friedman, Howard Cabral, Karen Burns-White, Nicole Casanova, Karen Freund, Tracy Battaglia. Translating research into practice: Early lessons from a pragmatic clinical trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B055.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

BackgroundRacial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2–3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings. MethodsTranslating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost. ConclusionTRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

Correlates of Adjuvant Therapy Attitudes in African American Breast Cancer Patients

PurposeBlack breast cancer patients delay and underutilize adjuvant breast cancer therapies; yet, very few studies have specifically examined Black women's attitudes toward breast cancer therapy. This study observed the influence of self-reported interpersonal processes of care (e.g. self-efficacy) clinical and sociodemographic factors and sociocultural (e.g. religiosity), related to Black breast cancer patients' attitudes toward radiation and systemic therapies (chemotherapy and adjuvant endocrine therapy – “AET”). MethodsThis was a secondary analysis of data from the Narrowing Gaps in Adjuvant Therapy Study (2006–2011). The analysis included 210 Black women who were newly diagnosed with breast cancer. Bivariate and multiple regression analyses were performed between independent variables (e.g., demographics) and three outcome variables (chemotherapy, AET, and radiation therapy) to asses women's perceptions of therapy type. The lasso method was used to select variables correlated with therapy attitudes. ResultsMost women reported negative attitudes toward AET (56%) and radiation (54%); fewer negative attitudes were observed toward chemotherapy (47%). Higher education and greater perceived susceptibility of a recurrence were associated with more positive attitudes toward chemotherapy. Regarding radiation therapy, women with greater patient satisfaction were more likely to have more positive attitudes. ConclusionsOur study findings may aid in the development of behavioral interventions targeted to mitigate Black women breast cancer treatment disparities. We found modifiable factors (e.g. communication, satisfaction ratings) that support opportunities for clinicians to better address Black women's needs regarding adjuvant treatment options. The development of tailored interventions for newly diagnosed Black breast cancer patients on patient related factors in health care are warranted for Black women with lower educational levels.