Less guideline-concordant care reported among Black breast cancer patients

Less guideline-concordant care reported among Black breast cancer patients | Image Credit: © steph photographies - © steph photographies - stock.adobe.com.

Non-Hispanic Black patients with early breast cancer experience increased risks of not receiving guideline-concordant care (GCC) and having less timely treatment initiation, according to a recent study published in JAMA Network Open.¹

Improvements in systemic treatment for breast cancer have led to significant decreases in breast cancer mortality over the past 4 decades, but significant disparities in survival across demographic groups remain. Significantly worse survival outcomes have been observed among older non-Hispanic Black patients diagnosed with breast cancer.²

There are likely multiple factors contributing to survival disparities across demographic groups, including disparities in the administration of guideline-concordant cancer care and therapy initiation timeliness.1 Older adults may also be underrepresented in cancer clinical trials, leading to a lack of knowledge about this population.

Investigators conducted a cohort study to evaluate disparities in GCC and timely treatment initiation among breast cancer patients. Data was obtained from the National Cancer Database, a nationwide oncology database including approximately 70% of newly diagnosed cancers in the United States.

Participants included female individuals aged 65 years or older with a diagnosis of stage 1 to 3 breast cancer identified as non-Hispanic Black or non-Hispanic White. Race was determined based on self-reported data in cancer registries. Patients with stage 0, stage 4, or M1 metastatic disease were excluded from the analysis.

GCC was reported as a binary outcome and included surgery, radiation therapy, and systemic treatment. Guidelines from the National Comprehensive Cancer Network were used to identify patients with GCC.

Receptor status, stage, nodal status, tumor stage, age, systemic therapy sequencing and choice, surgery, and receipt of radiation therapy were used to develop an algorithm for GCC. Investigators defined 13 core combinations with 43 possible pathways. Patients without treatment from any of these pathways were categorized as not receiving GCC.

Survival from time of diagnosis to time of death was measured through Kaplan-Meier survival analysis, with follow-up lasting from diagnosis to death. Rates of cancer-directed treatment initiation within 30 days, 60 days, and 90 days of diagnosis were compared between non-Hispanic White and non-Hispanic Black patients.

Covariates included age, clinical or pathologic stage at diagnosis, receptor status, year of diagnosis, and Charlson-Deyo comorbidity index. Patient demographics included insurance status, health care setting, and neighborhood-level educational attainment and income level.

There were 258,531 patients aged a mean 72.5 years included in the final analysis, 9.7% of whom were non-Hispanic Black and 90.3% were non-Hispanic White. A lack of guideline-concordant multimodality therapy retrieval was reported among 15.4% of participants. Of these patients, 11.4% were non-Hispanic Black and 88.6% were non-Hispanic White.

When evaluating care within racial groups, GCC was not given to 18.1% of non-Hispanic Black patients and 15.2% of non-Hispanic White patients. This indicated an increased risk of not receiving GCC among non-Hispanic Black patients, with an odds ratio (OR) of 1.24. This remained in the adjusted model, with an adjusted OR of 1.13.

Death at last contact was reported in 20.7% of non-Hispanic Black patients and 17.4% of non-Hispanic White patients during the median 63.4-month follow-up period. Non-Hispanic Black had a significantly increased risk of mortality, with a hazard ratio (HR) of 1.26.

This association was reduced when adjusting for time-dependent GCC. However, it remained significant with an adjusted HR of 1.05. GCC retrieval was linked to a 19% reduced risk in all-cause mortality, reducing the adjust HR to 0.81. The risk of mortality was also decreased by lower neighborhood-level educational attainment and median income.

The time to treatment initiation (TTI) was also increased among non-Hispanic Black patients. Rates of TTI were 35.1% within 30 days, 74.6% within 60 days, and 88.6% within 90 days for this population. In non-Hispanic White patients, these rates were 46.9%, 85.1%, and 93.5%, respectively.

These results indicated an increased risk of not receiving GCC among non-Hispanic black patients with breast cancer vs their non-Hispanic White counterparts. Investigators concluded “optimizing timely receipt of GCC may improve inferior survival outcomes among non-Hispanic Black older adults with breast cancer.”

References

1. Castillo BS, Boadi T, Han X, Shulman LN, Martei YM. Racial disparities in receipt of guideline-concordant care in older adults with early breast cancer. JAMA Netw Open. 2024;7(10):e2441056. doi:10.1001/jamanetworkopen.2024.41056
2. Yedjou CG, Sims JN, Miele L,et al. Health and racial disparity in breast cancer.Adv Exp Med Biol. 2019;1152:31-49. doi:10.1007/978-3-030-20301-6_3