Introduction
ASTHO’s
evidence-based Breast
Cancer Learning Community Change Package, informed by an extensive journal
literature review and the action plan proposals of learning community public
health agencies, systematically lists different strategies that can be
implemented based on a state’s identified disparities. Strategies are organized
into two categories along the cancer care continuum – follow-up between
diagnosis and treatment, and treatment quality.
Additional references to assess the implications of other interventions
can be explored within the following resources:
ASTHO conducted a literature review to explore the answers to questions to help guide data analysis decisions and to inform the selection of intervention and avoid unintended consequences.
To what extent do geographic disparities exist in breast cancer screening?
Although mammography rates have become more or less equal among black and white women, screening rates vary greatly by geographic location.1 Consistently, low adherence to mammography screening guidelines were observed in areas of New Mexico, Wyoming, Mississippi, Oklahoma, and Indiana. However, increases in adherence
were observed in southern Appalachia including northern Alabama and Georgia.2 One study identified an increased need for screening adherence and access in the southern Black Belt region (Virginia, North Carolina, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana, Texas, Arkansas, and Tennessee).3
Mammography use varied geographically, and the magnitude of geographic disparities differed by race and age. Additionally, findings showed variation between states on county level screening rates.4 The majority
of states exhibit the standard disparities reported national statistics, whereas others show no disparities at all and some studies even find reverse disparities in states such as Michigan and New Jersey.5 Non-white women showed the lowest levels of screening compared with all other groups. Women aged 40 to 49 also had lower screening rates when compared with other age groups.4
What populations underutilize breast cancer screening?
Although screening rates have been increasing, racial/ethnic minorities in the United States are underutilizing preventive health services.6 Racial/ethnic minorities and those with low socioeconomic status report low screening rates, with the lowest mammogram rates reported among uninsured women.6, 7 Underutilization of breast cancer screening services is an ongoing issue, particularly for
African American women. Compared to non-Hispanic white women, black women are less likely to be screened for breast cancer.8 In addition, a recent study found that 34 percent of African American women received insufficient breast cancer screening prior to their diagnosis.9
Hispanic women screen less frequently than black and white women.10 The most significant barriers reported by previous studies include language barriers, not having a usual source of care, and lack of health insurance.10 These racial disparities in mammogram utilization prominently exist among women aged 40 to 65 years old, and women aged 65 and older.10
1. https://www.ncbi.nlm.nih.gov/pubmed/28033538
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5181819/
3. http://onlinelibrary.wiley.com/doi/10.1002/cncr.10933/full
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2774639/
5. http://eds.a.ebscohost.com.proxygw.wrlc.org/eds/pdfviewer/pdfviewer?sid=73ea8453-ee93-46ae-b83a-bc1fca4f2545%40sessionmgr4010&vid=2&hid=4210
6. https://www.ncbi.nlm.nih.gov/pubmed/15009798
7. https://www.sciencedirect.com/science/article/abs/pii/S1353829210000870
8. http://www.sciencedirect.com/science/article/pii/S1353829210000870
9. https://www.ncbi.nlm.nih.gov/pubmed/16618951
10. http://www.jacr.org/article/S1546-1440(16)30722-0/fulltext
ASTHO
conducted a literature review to explore the answers to questions to help guide
data analysis decisions and to inform the selection of intervention and avoid
unintended consequences.
What is the association between primary care provider availability and
breast cancer screening or late-stage diagnosis rates?
There is a strong association between primary care provider availability
and breast cancer screening and late stage diagnosis rates.1 One
study in Illinois found an inverse relationship between access to primary care
and late stage diagnosis risk.2 Data
suggests that with increasing visits to the physician, breast cancer outcomes
are improved and late-stage diagnoses are reduced.1 Additionally,
research has indicated that poorer geographic access to primary care is linked
to late diagnosis.3 Accessible
and available primary medical care is an important factor in achieving better
outcomes for patients with a diagnosis of breast cancer.
Does geographic access to mammography affect breast cancer screening
or late-stage diagnosis rates?
A systematic review found mixed results for the relationship between
geographic access to mammography and breast cancer screening utilization.4 When
examining the impact of mammography capacity on screening uptake, one study
compared seven states and determined that women in counties with inadequate capacity
were more likely to have longer wait times for screening and were less likely
to have a mammogram.5,6 One
study analyzed the effect of density and often found a positive correlation between
percent of women screened and the number of mammography facilities per 10,000
women at the state level.7
Cancer stage at diagnosis has a substantial impact on treatment received,
recovery, and survival. In a cross-sectional retrospective study examining the
impact of spatial access to healthcare services on late detection of female
breast cancer diagnosis in Missouri, it was revealed that geographical
differences exist between metro and suburban/rural areas in terms of access,
distance traveled to the nearest healthcare facility, and stage at breast
cancer diagnosis. The findings from this study support the hypothesis that
women living in areas with limited access to mammography facilities are more
likely to be diagnosed with late-stage breast cancer.8 Similarly,
a study which took place in metropolitan Detroit suggests that living in areas
with poorer mammography access can significantly increase the risk of late
diagnosis of breast cancer.3 In
contrast, Henry et al. (2013)
did not find a significant relationship between late stage diagnosis of breast
cancer and geographic access to mammography in a large 10-state study.
Additionally, one Mississippi study showed no statistically significant connection between
breast cancer outcomes and the availability or access to mammography
facilities.9
The majority of analyses using distance and travel time measures found no
statistically significant results between geographic access and mammography use
or late-stage at diagnosis, whereas the majority of results from capacity and
density found statistically significant associations.4 Distance
and travel time alone may not be sufficient measures of geographic access to
care. Having more standardized and granular representations of geographic
access to care will improve the ability to make valid inferences about these
relationships.4,10
Does geographic access to breast cancer treatment (surgery, radiation
therapy or chemotherapy) affect adherence to breast cancer treatment or quality
of care received?
While travel time to screening mammography has been broadly
characterized, distance or travel time to breast cancer treatment has been less
well studied. In a study investigating the association between the influence of
travel time to the nearest radiology facility and breast cancer treatment found
that travel time appears to influence the type of primary therapy received
among women with breast cancer in that women with travel times greater than 30
minutes were more likely to have a mastectomy compared to women with travel
times less than 10 minutes.11 These
findings suggest that without adequate access to radiology facilities, women
are likely to prefer services such as mastectomies, which would be considered
low frequency services.11
A
cohort study examining the relationship between distance and breast cancer
treatment received found a significant decrease in the likelihood of undergoing
breast-conserving surgery among women living greater than 15 miles from a
hospital with radiotherapy facilities.12 Among
women who underwent breast-conserving surgery, a lower probability of
undergoing radiotherapy was observed specifically to those who live greater
than 40 miles from a hospital with radiotherapy facilities.12 Because
radiotherapy is recommended for women who undergo breast-conserving study as
primary therapy, Nattinger et al. (2001)
cited the lower use of radiotherapy among breast-conserving surgery patients
living greater than 40 miles from a hospital with a radiotherapy facility as a
cause for concern in the issue of appropriateness of care. Additionally,
patients who live far from a reference care center are less likely to be
referred to specialized surgeons that may practice farther away, and receive
less assistance with overall disease management.13 Due
to limitations in studies performed, such as the potential accuracy and wide
variability in measures, it is difficult to draw conclusions regarding the
effect of geographic access to treatment on quality of care.4
1. http://www.annfammed.org/content/10/5/401.full
2. https://www.tandfonline.com/doi/full/10.1080/00330120701724087?scroll=top&needAccess=true&
3. https://www.ncbi.nlm.nih.gov/pubmed/20630792
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933961/
5. https://www.ncbi.nlm.nih.gov/pubmed/22037904
6. https://www.ncbi.nlm.nih.gov/pubmed/20195174
7. https://www.ncbi.nlm.nih.gov/pubmed/15772962
8. https://www.ncbi.nlm.nih.gov/pubmed/26223824
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959918/
10. https://www.ncbi.nlm.nih.gov/pubmed/22952626
11. https://www.ncbi.nlm.nih.gov/pubmed/21553117
12. https://academic.oup.com/jnci/article/93/17/1344/2519497
13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475100/
ASTHO conducted a literature review to explore the answers to questions to help guide data analysis decisions and to inform the selection of intervention and avoid unintended consequences.
To what extent do geographic disparities exist in breast cancer treatment?
One study in Georgia found that patients who live in small rural areas have increased chances of receiving surgery and decreased chance of receiving radiotherapy as well as decreased mortality risk.1 Furthermore, geographic variation of treatment has a significant impact on treatment type, treatment intensity and cost of care.2,3
There is also geographic variation in the magnitude of racial disparities in breast cancer treatment across the United States.3 For instance, black patients in areas of the northeastern and southern United States show the lowest rates of radiation therapy.4 Poor spatial accessibility to health care services, especially for women who rely on public transportation, prevent optimal treatment for women with breast cancer.5
What populations receive less than optimal breast cancer treatment?
Generally, minority populations receive poorer quality breast cancer treatment than white women. Racial disparities in breast cancer treatment were evident in several studies despite adjusting for insurance and socioeconomic status.6 There are clear racial differences between treatment and outcomes. African American women diagnosed with breast cancer have overall lower incidences than white women, but experience higher mortality rates, possibly due to a delay in diagnosis and treatment which can negatively impact patient outcomes.7 Multiple studies found that black and Hispanic women fail to receive definitive local therapy, chemotherapy and radiotherapy for curable breast cancers as often as White women.8,9,10,11 Additionally, studies show mixed
results for whether black women are more likely to receive mastectomies compared to white women.12,13,14 Conversely, one study in Alabama
found that there was no difference in quality of care received by Medicare beneficiaries based on race, but a significant difference was observed based on socioeconomic status.15
The literature has shown mixed results regarding the relationship between timely breast cancer treatment and survival.16,17,18,19,20,21 Risk factors for treatment delay include older age, the nature of the breast
symptom, patients’ negative attitudes towards their general practitioner, and fears about cancer treatment.22 African American women experience more diagnosis and treatment delays when compared to women of other racial/ethnic subgroups.23,24,25,26,27 Relative to white women, black women are four to five times more likely to experience treatment delays longer than 60 days, and are significantly less likely to receive cancer-directed surgery, radiation therapy after lumpectomy, and hormonal therapy for hormone receptor-positive tumors, after controlling for tumor characteristics.8 Madubata and colleagues (2016) found that black women had higher odds of radiation delay than their white counterparts.13
1. https://www.ncbi.nlm.nih.gov/pubmed/23909950
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4164811/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596448/
4. https://www.ncbi.nlm.nih.gov/pubmed/20014181
5. https://www.ncbi.nlm.nih.gov/pubmed/23726213
6. https://www.ncbi.nlm.nih.gov/pubmed/20939011
7, https://www.ncbi.nlm.nih.gov/pubmed/23386565
8. http://theoncologist.alphamedpress.org/content/18/9/986.full
9. https://www.ncbi.nlm.nih.gov/pubmed/22066691
10. https://www.ncbi.nlm.nih.gov/pubmed/25135847
11. https://www.ncbi.nlm.nih.gov/pubmed/20939011
12. https://www.ncbi.nlm.nih.gov/pubmed/26231096
13. https://www.ncbi.nlm.nih.gov/pubmed/27771840
14. https://www.ncbi.nlm.nih.gov/pubmed/26047763
15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991993
16. https://www.ncbi.nlm.nih.gov/pubmed/24987898
17. https://www.ncbi.nlm.nih.gov/pubmed/23292872
18. https://www.ncbi.nlm.nih.gov/pubmed/23615681
19. https://www.ncbi.nlm.nih.gov/pubmed/23292484
20. https://www.ncbi.nlm.nih.gov/pubmed/16823507
21. https://www.ncbi.nlm.nih.gov/pubmed/17015884
22. https://www.ncbi.nlm.nih.gov/pubmed/15992567
23. https://www.ncbi.nlm.nih.gov/pubmed/17101943
24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3596448/
25. https://www.ncbi.nlm.nih.gov/pubmed/25650628
26. https://www.ncbi.nlm.nih.gov/pubmed/21170814
27. https://www.ncbi.nlm.nih.gov/pubmed/25057404