Geographical Disparities and Factors Associated With the Decision to Decline Chemotherapy in Breast Cancer

Abstract

PURPOSE: Social determinants of health have been linked to treatment-related disparities in breast cancer. We analyzed data from a large national registry to explore factors related to accepting or declining recommended chemotherapy and whether patients' decisions vary geographically across the United States. METHODS: We used the National Cancer Database to study treatment decision making in patients with advanced breast cancer (American Joint Committee on Cancer clinical stage III-IV) between 2004 and 2017. We focused the analysis on patients who were recommended chemotherapy by their physicians but who declined this treatment. Multivariate logistic regression analysis was performed. RESULTS: A total of N = 215,284 patients with stage III and IV breast cancers were included. Patients in the New England region were more likely to refuse chemotherapy compared with the rest, with patients in the East South Central regions (AL, KY, MS, and TN) and West South Central (AR, LA, OK, and TX) noted to be least likely to refuse chemotherapy. Factors related to a higher rate of refusal by patients included older age > 70 years; hormone receptor–positive tumors; and having higher comorbidity. Patients identified as Hispanic, those who are privately insured, and patients at academic institutions were less likely to decline chemotherapy. CONCLUSION: This analysis identified a significant difference in rates of refusal of recommended chemotherapy by geographical location, insurance status, and treatment facility after adjusting for known social determinants of health. Further understanding of the factors affecting treatment decisions would be important to improve the efficacy of care delivery in patients with cancer and reduce reversible causes of disparity.

Factors Associated with the Decision to Decline Chemotherapy in Metastatic Non-Small Cell Lung Cancer

“…Additionally, the highest refusal rates were found in the New England region, followed by the Pacific region and the West North Central region of the US. A previous NCDB-based study on stage III and stage IV patients with breast cancer also reported comparable findings, with the New England region having the highest likelihood of patient refusal of recommended chemotherapy [ 13 ]. While the NCDB does not document the specific causes for refusal, several reasons could be behind these observations.…”

“…Factors that lead patients to select or refuse treatments are complex and varied [ 8 , 9 ]. Beyond the physicians’ recommendation, patients’ selection of therapy may be influenced by health literacy and understanding [ 10 ], financial toxicity [ 11 ], and other sociodemographic and cultural factors [ 12 , 13 ]. Additionally, fear of unpleasant side effects from cancer treatment could be one of the most motivating factors to find alternative treatment methods.…”

Declination of Treatment, Racial and Ethnic Disparity, and Overall Survival in US Patients With Breast Cancer

“…For BC, several analyses have reported similar sociodemographic and clinical factors associated with treatment declination in this patient population. 7,10,[18][19][20][21][22] However, these studies focused on either chemotherapy or surgery only or the associations of treatment decisions with mortality, and most of them did not evaluate the pattern and long-term trends associated with treatment declination among patients with BC. Although a few studies have assessed racial and ethnic disparities in declination of surgery or chemotherapy, they largely focused on Black and Hispanic patients, and, to a lesser extent, Asian patients, 10,18,19,21 and 2 analyses included only White women.…”

“…7,10,[18][19][20][21][22] However, these studies focused on either chemotherapy or surgery only or the associations of treatment decisions with mortality, and most of them did not evaluate the pattern and long-term trends associated with treatment declination among patients with BC. Although a few studies have assessed racial and ethnic disparities in declination of surgery or chemotherapy, they largely focused on Black and Hispanic patients, and, to a lesser extent, Asian patients, 10,18,19,21 and 2 analyses included only White women. 4,7 There remain gaps in the literature regarding national trends in declination of treatment recommendations, racial and ethnic disparities, sociodemographic and clinicopathologic characteristics associated with treatment declination, and the implication of treatment declination for overall survival (OS) among patients with BC.…”

“…that among patients with stage III to IV BC or hormone receptor-positive and ERBB2negative BC and high-risk scores on multigene assays, Black patients had a 9.0% to 20.0% greater likelihood of declining chemotherapy, while Hispanic patients were 18.0% less likely to do so, compared with White patients 18,19. However, these studies did not compare American Indian, Alaska Native, or other patients or Asian or Pacific Islander patients with White patients; whereas, we found that American Indian, Alaska Native, or other patients and Asian or Pacific Islander patients were 13.0% and 21.0% more likely to decline chemotherapy and were 29.0% and 47.0% more likely to decline surgery, respectively.…”