Disparities in Breast Cancer Treatment and Outcomes: Biological, Social, and Health System Determinants and Opportunities for Research

Abstract

Racial disparities in breast cancer mortality have been widely documented for several decades and persist despite advances in receipt of mammography across racial groups. This persistence leads to questions about the roles of biological, social, and health system determinants of poor outcomes. Cancer outcomes are a function not only of innate biological factors but also of modifiable characteristics of individual behavior and decision making as well as characteristics of patient-health system interaction and the health system itself. Attempts to explain persistent racial disparities have mostly been limited to discussion of differences in insurance coverage, socioeconomic status, tumor stage at diagnosis, comorbidity, and molecular subtype of the tumor. This article summarizes existing literature exploring reasons for racial disparities in breast cancer mortality, with an emphasis on treatment disparities and opportunities for future research. Because breast cancer care requires a high degree of multidisciplinary team collaboration, ensuring that guideline recommended treatment (such as endocrine therapy for hormone receptor positive patients) is received by all racial/ethnic groups is critical and requires coordination across multiple providers and health care settings. Recognition that variation in cancer care quality may be correlated with race (and socioeconomic and health system factors) may assist policy makers in identifying strategies to more equally distribute clinical expertise and health infrastructure across multiple user populations. The Oncologist 2013;18:986 -993 Implications for Practice: Disparities in breast cancer outcomes result not only from racially specific tumor differences, but also modifiable social and health system determinants, such as poor access to care and health education, lack of financial resources, problematic patient-provider interactions, and structural barriers within the health system itself. Breast cancer care requires a high degree of multidisciplinary team collaboration; therefore, ensuring that care is delivered in a coordinated, continuous, culturally and socioeconomically sensitive fashion is critical to ensuring equitable receipt of guideline recommended treatments, which in turn, will help improve outcomes across racial groups. Understanding how biological, social, and health system factors act in concert to influence outcomes may help clinicians, researchers, and policy makers to identify more innovative strategies to address breast cancer disparities going forward.

What Health Care Providers Know and How They Communicate Breast Cancer Risk to Patients

“…While many providers are aware of mortality disparities in breast cancer that can be linked to these subtypes, future efforts to educate HCPs should build upon this awareness by presenting new research that links these disparities to incidence of specific breast cancer subtypes. 31,32 Recent data suggests that beyond querying patients about family history of breast cancer, asking patients about the pathologic characteristics of their family member's breast cancer can help improve genetic risk assessment. 33 Efforts to provide information to HCPs are important in disseminating prevention strategies for BBC.…”

A Spatial and Temporal Analysis of the Socioeconomic Factors Associated with Breast Cancer in Illinois Using Geographically Weighted Generalized Linear Regression

“…Often, cultural, social, economic, and biological factors interplay together in shaping the risk of breast cancer (Wheeler et al 2013). Studies have suggested that the effect of racial disparities is not comparable to the effect of socioeconomic disparities in explaining the risk of breast cancer (Baquet and Commiskey 2000).…”

Lung Cancer Treatment Disparities in China: A Question in Need of an Answer

“…The U.S. Department of Health and Human Services made it clear that elimination of health disparities was a national priority [7]. If cancer patients receive less-than-standard treatment, differences in outcomes are likely to result [8]. Reducing these disparities is a critical next step for China.…”