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, with some still opting for a mastectomy, according to research from the University of Texas MD Anderson Cancer Center.
The study, presented last week at the 2014 Breast Cancer Symposium, finds that those barriers that still exist are socioeconomic, rather than medically-influenced. Dr. Meeghan Lautner, M.D., formerly a fellow at MD Anderson, now at The University of Texas San Antonio, presented the findings.
Breast conserving therapy (BCT) for early stage breast cancer includes breast conserving surgery, sometimes called partial (or segmental) mastectomy, followed by six 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 — prompting the National Institutes of Health to issue a consensus statement on its use. Since then, the evidence supporting the effectiveness of BCT has become even stronger, and in a 2005 review article, researchers synthesized the evidence from six randomized clinical trials and showed that recurrence and survival rates are equivalent for BCT and mastectomy.
Breast Conserving Surgery
Despite the effectiveness of BCT, a number of patients still opt for mastectomy, a far more invasive procedure with the potential for long-term complications. In hopes of ultimately eliminating inequities in care, it is important to look at surgical choices made by women and their association with disparities, explains Dr. Isabelle Bedrosian, M.D., associate professor, Surgical Oncology at MD Anderson.
“What’s particularly novel and most meaningful about our study is that we looked at how the landscape has changed over time,” says Dr. Bedrosian, the study’s senior author. “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.”
Socioeconomic, insurance-related barriers contribute to disparities in care
For the retrospective, population-based study, the MD Anderson team used the National Cancer Database, a nationwide outcomes registry of the American College of Surgeons, the American Cancer Society, and the Commission on Cancer that captures approximately 70 percent of newly-diagnosed cases of cancer in the country. They identified 727,927 women with early-stage breast cancer, all of whom were diagnosed between 1998 and 2011 and had undergone either BCT or a mastectomy.
Overall, the researchers found that BCT rates increased from 54 percent in 1998 to 59 percent in 2006, and stabilized since then. Adjusting for demographic and clinical characteristics, women with the following characteristics were more likely to undergo BCT:
- Between the ages of 52-61 (compared to younger or older patients);
- Higher education level and median income
- Privately insured (compared to the uninsured and publicly insured)
- Treated at an academic medical center (versus 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 to those who lived further away.
However, the researchers still weren’t sure why certain women were less likely to receive BCT and, most importantly, why inequities in care are so persistent. To better understand these issues, the team looked at patterns and changes in barriers for women receiving BCT between the years of 1998 and 2011. The researchers found that although usage of BCT has dramatically increased across all demographic and clinical characteristics, significant disparities related to insurance, income and distance to a treatment facility still exist.
On a positive note, Dr. Bedrosian points out that 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, says Dr. Bedrosian. She is hopeful that the recent implementation of the Affordable Care Act will reduce disparities stemming from lack of insurance coverage, but adds that it’s too early to know for sure yet. “Now with healthcare exchanges providing new insurance coverage options, will we rectify the disparity and overall increase BCT use? We will have wait to see,” she says.
Dr. Bedrosian hopes that health policy makers will take note of the findings and barriers related to women receiving BCT and make appropriate changes to reduce inequities in breast cancer care and survival.
Other concerning disparities in breast cancer treatment have been documented in previous research. For instance, African American women who undergo breast-conserving surgery are significantly less likely than their white counterparts to receive the recommended subsequent radiation therapy. And in a groundbreaking study published in 2002, researchers found evidence of racial disparities throughout the continuum of cancer care, including “receipt of definitive primary therapy, conservative therapy, and adjuvant therapy.” What’s more, these treatment disparities had an adverse impact on the health outcomes of racial/ethnic minorities, leading to more frequent recurrence, shorter disease-free survival, and higher mortality.