Racial Inequities in Guideline-Adherent Breast Cancer Care and Timely Treatment

Older non-Hispanic Black adults with early-stage breast cancer are less likely to receive timely treatment and guideline-concordant care, increasing their risk of death compared with non-Hispanic White women. | Image Credit: Andrii - stock.adobe.com

Older adults with stage I to III breast cancer who identified as non-Hispanic Black have increased odds of not receiving guideline-concordant care or timely treatment compared with patients who are non-Hispanic White, according to a study published in JAMA Network Open.¹

Since 1989, breast cancer occurrence and trends have decreased by 44%, according to the American Cancer Society.² This decline, according to the authors, “is partly attributable to improved systemic treatment for early-stage breast cancer.” However, disparities remain in breast cancer survival among different demographic groups following a diagnosis, especially individuals who identify as non-Hispanic and Black.¹

Between 2015 and 2019, non-Hispanic Black women were just as likely to receive a breast cancer diagnosis but had a 40% higher chance of mortality compared with non-Hispanic White women.³ Differences in survival rates among various groups may be linked to disparities in the receipt of guideline-concordant cancer care and timely initiation of therapy.¹

Patients with breast cancer were enrolled in a retrospective cohort analysis from the National Cancer Database (NCDB) from July 2022 to June 2023. Data included a nationwide oncology outcomes database that captured about 70% of all newly diagnosed cancers within the US.

There were 258,531 eligible patients (9.7%, non-Hispanic Black; 90.3% non-Hispanic White) with an average age of 72.5 years, 15.4% of whom did not receive guideline-concordant multimodality therapy. Overall, 18.1% of non-Hispanic Black patients did not receive guideline-concordant care compared with 15.2% of non-Hispanic White individuals.

Non-Hispanic Black patients were associated with greater odds of nonreceipt of guideline-concordant care after clinical and demographic variables were adjusted for the model (adjusted OR, 1.13; 95% CI, 1.08-1.17; P < .001). Individuals of non-Hispanic Black race were associated with a 26.1% increased risk of all-cause mortality in the univariate analysis. After adjusting for guideline-concordant care and clinical/sociodemographic factors, overall mortality risk decreased to 4.7% (adjusted HR, 1.05; 95% CI, 1.01-1.08; P = .006).

Patients 75 years or older with stage III disease, who had a higher Charlson-Deyo comorbidity index score, were associated with the largest magnitude for all-cause mortality not mediated by guideline-concordant care.

The time to treatment initiation for non-Hispanic White patients was 46.9% within 30 days, 85.1% within 60 days, and 93.5% within 90 days compared with 35.1% within 30 days, 74.6% within 60 days, and 88.6% within 90 days for non-Hispanic Black patients.

The bivariate analysis found increased associations of treatment initiation between non-Hispanic White patients and non-Hispanic Black patients within 30 (OR, 1.65; 95% CI, 1.6-1.69), 60 (OR, 2.11; 95% CI, 2.04-2.18), and 90 (OR, 2.39; 95% CI, 2.27-2.51) days of breast cancer diagnosis.

The study relied on NCDB data, which potentially underrepresents certain populations and therefore limited the scope of the present analysis. Additionally, the lack of granularity on systemic therapies and novel diagnostic tests and the exclusion of death as a competing risk and cancer-specific mortality introduced potential biases. The inability of the model to account for frailty and performance status further limited its insights into treatment decisions for this population.

“Optimizing timely receipt of [guideline-concordant care] may improve inferior survival outcomes among non-Hispanic Black older adults with breast cancer,” the authors concluded.

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. New ACS report: breast cancer mortality continues three decade decline overall, but steeper increases in incidence for women <50 & Asian American, Pacific Islanders of all ages. Press release. American Cancer Society. October 1, 2024. Accessed November 18, 2024. https://pressroom.cancer.org/breastcancerfactsandfigures2024

3. Cancer and African Americans. Office of Minority Health. September 21, 2023. Accessed November 18, 2024. https://minorityhealth.hhs.gov/cancer-and-african-americans