When designing a health care system, one rule of thumb is: “Quality, access, and cost—pick two.”
Universal access to the best possible care is expensive, but if costs are cut, then quality or access has to suffer. The human impact of this equation is illustrated by three recent studies that document disparities in access to high-quality care among poor and minority women with breast cancer.
A retrospective study has found that in adolescent and young women (ages 15 to 39) with breast cancer, delays in initiating treatment significantly reduce survival, and the impact is most pronounced in African-American women, women on public insurance, and the uninsured.1
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The researchers used the California Cancer Registry database to retrospectively examine the records of 8,860 young women treated for breast cancer over a 10-year period. The study investigators found that 5-year survival was significantly lower in subjects who delayed the initiation of treatment for at least 6 weeks, than in those who began treatment less than 2 weeks from diagnosis (80% vs. 90%).
Treatment delay, defined as longer than 6 weeks, occurred in 15% of Hispanic women, 15% of African-American women, and 8% of non-Hispanic white women. Women with public or no insurance were far more likely than women with private insurance to delay treatment longer than 6 weeks (18% vs. 10%).
These disparities in access to care were closely related to survival outcomes: 5-year survival was 73% among African-American women, 78% among Hispanic women, 85% among non-Hispanic white women, and 86% among Asian women. Five-year survival was also lower among women with public or no insurance and among women with low socioeconomic status.
Another retrospective breast cancer study, conducted at a single health system in Ohio with data from 1,539 cases, found that women on Medicaid had significantly larger tumors at diagnosis than women on private insurance, suggesting that they had less access to care.2 Patients on Medicaid were more likely than privately insured patients to receive mastectomy rather than breast-conserving treatment overall, and more likely to receive mastectomy for large tumors.
Oddly, among women with smaller tumors, those with private insurance were more likely than those with Medicaid to receive mastectomy. The authors speculate that this choice might be driven by surgeons, who are compensated more for performing a mastectomy than for breast-conserving surgery, or by patient preference.
Improving the physician-patient relationship and increasing awareness of sociocultural factors may be important steps in reducing disparities in access to cancer care, according to the results of a survey of 359 women with breast cancer. In this study, African-American women who reported good communication with their oncologist were 3 times more likely to initiate chemotherapy than African-American women who reported poor communication.
By contrast, good communication with the oncologist was associated with a lower rate of initiating chemotherapy among white women. African-American women were more likely than white women to initiate chemotherapy, but among the group who did start chemotherapy, African-American women experienced a longer delay (72 vs. 55 days).
Multivariate analysis, however, showed that this delay was primarily attributable to relationship status (single vs. married) and high degrees of religiosity. This study may point to differing needs among African-American and white women for communication with providers and differing cultural influences in the decision to undergo chemotherapy.
Clearly, the quality of and access to care for women with breast cancer are influenced by racial and socioeconomic factors; however, these trends are not always predictable.. Decisions regarding what treatment to receive, and when, are complex and do not lend themselves to easy analysis along racial lines.
References
1. Smith EC, Ziogas A, Anton-Culver H. Delay in surgical treatment and survival after breast cancer diagnosis in young women by race/ethnicity. JAMA Surg. Published online April 24, 2013. doi:10.1001/jamasurg.2013.1680.
2. Adepoju L, Wanjiku S, Brown M, et al. Effect of insurance payer status on the surgical treatment of early stage breast cancer. Data analysis from a single health system. JAMA Surg. Published online April 24, 2013. doi:10.1001/jamasurg.2013.61.
3. Sheppard VB, Isaacs C, Luta G, et al. Narrowing racial gaps in breast cancer chemotherapy initiation: the role of the patient-provider relationship. Breast Cancer Res Treat. 2013;139:207-216.
