Disparities persist in early stage breast cancer treatment

Despite its acceptance as standard of care for early stage breast cancer almost 25 years ago, barriers still exist that preclude patients from receiving breast conserving therapy (BCT), with some still opting for a mastectomy, according to research presented at the American Society of Clinical Oncology (ASCO) 2014 Breast Cancer Symposium in San Francisco, California. The study showed that those existing barriers are socio-economic and not medically influenced.

BCT for early stage breast cancer includes breast-conserving surgery, followed by 6 weeks of radiation. It has been the accepted standard of care for early stage breast cancer since 1990 when randomized, prospective clinical trials confirmed its efficacy. Yet, a number of patients still opt for a mastectomy. In hopes of ultimately democratizing care, it was important to look at surgical choices made by women and their association with disparities, explained Isabelle Bedrosian, MD, associate professor, Surgical Oncology at The University of Texas MD Anderson Cancer Center in Houston.

"What's particularly novel and most meaningful about our study is that we looked at how the landscape has changed over time," said senior author Bedrosian. "We hope this will help us understand where we are and are not making progress, as well as identify the barriers we need to overcome to create equity in the delivery of care for our patients."

For the retrospective, population-based study, the MD Anderson team used the National Cancer Database, a nation-wide outcomes registry that captures approximately 70% of newly diagnosed cases of cancer in the country. They identified 727,927 women with early stage breast cancer, all of whom received their diagnoses between 1998 and 2011 and had undergone either BCT or a mastectomy.

Overall, the researchers found that BCT rates increased from 54% in 1998 to 59% in 2006, and stabilized since then. Adjusting for demographic and clinical characteristics, BCT use was more common in some groups of women: age 52 to 61 years, compared with those younger or older; a higher education level and median income; private insurance, compared with those who are uninsured; and those treated at an academic medical center vs. a community medical center.

Geographically, BCT rates were higher in the Northeast than in the South, and in those women who lived within 17 miles of a treatment facility compared with those who lived further away.

An important question to then ask, said Bedrosian, was to compare barriers for women receiving BCT in 1998 to 2011, and understand how have those barriers changed. The researchers found that, overall, usage of BCT has dramatically increased across all demographic and clinical characteristics; however, significant disparities related to insurance, income, and distance to a treatment facility still exist.

Bedrosian is gratified to see that in the areas where physicians and the medical field can make a direct impact, such as geographic distribution and practice type, disparities have equalized over time. However, she notes that factors outside the influence of the medical field, such as insurance type, income, and education, still remain. Of great interest is the insurance disparity, said Bedrosian.

"Now with health care exchanges providing new insurance coverage options, will we rectify the disparity and overall increase BCT use? We will have wait to see," she said.

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