Factors affecting timely breast cancer treatment among black women in a high-risk urban community: a qualitative study

Evaluating the impact of the National Health Insurance Fund oncology benefits package and a healthcare workers' strike on time to cancer treatment initiation in Nairobi County, Kenya: An interrupted time series analysis

INTRODUCTION

In April 2015, Kenya introduced the National Health Insurance Oncology Benefits Package and its complementary reforms (oncology insurance scheme) to alleviate financial hardship among its members upon a cancer diagnosis. In this study, we hypothesised that the time it took to start treatment would have an impact on health outcomes: the longer patients waited the worse their outcomes would be. We did not have outcomes in the data but we could compute time to treatment initiation (TTI). While assessing the impact of the oncology insurance scheme on TTI, we encountered a substantial sudden increase in average TTI in June 2018 which we needed to explore.

METHODS

We conducted our analysis using R, a statistical computing software, for interrupted time series analysis (ITSA) on Nairobi Cancer Registry data to assess the impact of the introduction of the oncology insurance scheme on TTI in days among Nairobi County residents diagnosed with cancer. We calculated the monthly median TTI, resulting in 120 data points (one for each of the 120 months of the observation period - January 1st 2010 to December 31st 2019). Since the oncology insurance scheme was available to the entire Kenyan population, a suitable control group was unavailable. To address this, we used auto regressive integrated moving average (ARIMA) modelling to forecast an expected trend, allowing us to estimate both sudden and gradual changes during April 2015 and June 2018 (intervention months).

RESULTS

After cleaning the data, 7584 (35%) cases of the original 21,464 were left for analysis. Females were more than males at 57.8%. Approximately 65% of the cases with known stage at diagnosis were in stages III and IV. No statistically significant impact was associated with the introduction of oncology insurance scheme; an additional 9.06 days (95% CI: -8.7 to 26.8) and a gradual change of 0.88 days per month (95% CI: -0.11 to 1.88). However, a statistically significant sudden increase in monthly median TTI in June 2018 of 34.6 days (95% CI 15.4 to 53.8) and the gradual change of -1.6 days (95% CI -3.5 to 0.4) per month which was not statistically significant, were associated with a healthcare workers' strike. We could not accurately analyse case trends from these data because the registry had not completed collating data for the later years (2015-2019).

CONCLUSIONS

These results suggest that the oncology insurance scheme may not have reduced average TTI for the cancer patients as we had hypothesized. However, a healthcare workers' strike (based on corroboration with findings from the 2018 Kenya Household Health Expenditure and Utilization Survey), increased the average TTI among these patients. Data science techniques and ITSAs using cancer registry data is a cost-effective method to answer important population-level research questions in resource-limited settings.

Racial and Ethnic Disparities in Receipt of ERBB2-Targeted Therapy for Breast Cancer, 2010-2020

Importance

Among older women (aged ≥50 years) with ERBB2 (formerly HER2 or HER2/neu)-positive breast cancer, research has shown racial and ethnic disparities in access to ERBB2-targeted therapies, with Black women receiving treatment at lower rates than their White counterparts.

Objective

To examine racial and ethnic disparities in receipt of ERBB2-targeted therapies and changes in receipt over time.

Design, Setting, and Participants

This retrospective cohort study used Surveillance, Epidemiology, and End Results-Medicare linked data from January 1, 2010, to December 31, 2020. Beneficiaries who were diagnosed with ERBB2-positive breast cancer between 2010 and 2019, were aged 66 years or older at diagnosis, were continuously enrolled in Medicare Parts A and B in the 12 months before and after diagnosis, and had localized or regional stage disease at diagnosis were included. Data were analyzed from February through September 2024.

Exposure

Race and ethnicity defined as non-Hispanic Black or African American, Hispanic, or non-Hispanic White.

Main Outcome and Measures

The primary outcome was receipt of ERBB2-targeted therapies in the 12 months after diagnosis of ERBB2-positive breast cancer. Modified Poisson regression was used to evaluate the probability of receiving ERBB2-targeted therapy by race and ethnicity.

Results

Among 12 765 beneficiaries with ERBB2-positive breast cancer (median [IQR] age, 74 [69-80] years; 99.2% female), 8.1% were of Black, 6.9% Hispanic, and 85.0% White race and ethnicity, and 54.2% received ERBB2-targeted therapy. The overall proportion who received ERBB2-targeted therapies increased from 41.3% in 2010-2011 to 64.3% in 2018-2019. Compared with White patients, Black patients had a lower likelihood of receiving ERBB2-targeted therapies in 2010-2011 (adjusted risk ratio [ARR], 0.81; 95% confidence limit [CL], 0.68-0.97), as did Hispanic patients (ARR, 0.75; 95% CL, 0.62-0.92). Racial and ethnic disparities in receipt of ERBB2-targeted therapies narrowed over time, with no significant differences observed across racial and ethnic groups in 2018-2019 for Black patients (ARR, 0.97; 95% CL, 0.87-1.08) and Hispanic patients (ARR, 1.05; 95% CL, 0.95-1.16).

Conclusions and Relevance

These findings suggest a narrowing of racial and ethnic disparities in receipt of ERBB2-targeted therapies over time among older Medicare beneficiaries with ERBB2-positive breast cancer. Future research is needed to understand the practices that contributed to the narrowing of racial and ethnic disparities and to develop implementation strategies to effectively improve the quality and equity of breast cancer care.

Treatment Decision-Making in West African Women With Breast Cancer: A Critical Ethnography

OBJECTIVES

This study aimed to understand and characterize how culture affected behavior and decision-making about treatment and care in West African women with breast cancer living in the United Kingdom.

METHODS

A critical ethnographic design was used with a sample consisting of 32 West African women, 27 supporters, and 18 health care professionals. Data were collected through 263 hours of participant observation and 98 informal and 10 formal interviews in a London cancer unit. Study materials and approach were informed by patient and public involvement group recommendations. Data were analyzed using an adapted Carspecken critical ethnographic approach.

RESULTS

Three main themes were developed from the data: cultural knowledge, beliefs, and values; otherness; and cultural curiosity. West African women described a range of meanings and beliefs about their breast cancer diagnoses and treatments. They felt "Other" from, and were seen as "Other" by, their communities and health care teams. The clinical team exhibited varying levels of cultural curiosity, which evolved over time.

CONCLUSION

Cultural beliefs concerning cancer and its treatment were so strong that they led to some women refusing, delaying, or interrupting treatment. Nurses must seek to understand and value the perspectives and beliefs of people from unfamiliar cultures and consider how services might be made more flexible to meet their specific needs.

IMPLICATIONS FOR NURSING PRACTICE

By being culturally curious and gaining understanding about how a woman's culture affects decisions about treatment and care, health care professionals began to understand that patients are more able to accept optimum treatment if adjustments are made to the service.

A Rising Tide Raises All Ships: Was the Effect of Medicaid Expansion on Cancer Outcomes Similar Across Subgroups of Patients With Cancer on Medicaid?

Introduction

The authors determined whether certain subgroups of patients with cancer on Ohio Medicaid benefited from the program's expansion to a greater/lesser extent. Study outcomes included stage at diagnosis for screening-amenable cancers (breast [n=1,707 and 2,976], cervical [n=309 and 655], and colorectal [n=927 and 2,009] cancer, before and after expansion, respectively) and time to treatment initiation.

Methods

Using linked data from the 2011-2017 Ohio cancer registry and Medicaid, the authors conducted a robust Poisson regression analysis for stage at diagnosis and Cox regression analysis for time to treatment initiation to obtain the adjusted risk for earlier stage at diagnosis before to after expansion or hazard of shorter time to treatment initiation for each demographic or clinical subgroup after compared with before pre-Medicaid expansion. The authors subsequently calculated the ratio of risk (or hazard) ratios.

Results

The effect of Medicaid expansion on outcomes was mostly similar across subgroups of patients with cancer on Medicaid. However, those who were non-Hispanic Black or of other race had a lower probability of being diagnosed with early-stage breast cancer (ratio of risk ratio=0.85 [95% CI=0.74, 0.98] and ratio of risk ratio=0.72 [95% CI=0.55, 0.95], respectively) than non-Hispanic White women.

Conclusions

These findings point to differences that should be investigated to ensure that the benefits of Medicaid expansion are realized equitably.

Association Between Social Determinants of Health and Cancer Treatment Delay in an Urban Population

PURPOSE

Delays in oncologic time to treatment initiation (TTI) independently and adversely affect disease-specific mortality. Social Determinants of Health (SDoH) are increasingly recognized as significant contributors to patients' disease management and health outcomes. Our academic center has validated a 10-item SDoH screener, and we elucidated which specific needs may be predictive of delayed TTI.

METHODS

This is a retrospective cohort study at an urban academic center of patients with a SDoH screening and diagnosis of breast, colorectal, endocrine/neuroendocrine, GI, genitourinary, gynecologic, head and neck, hematologic, hepatobiliary, lung, or pancreatic cancer from 2018 to 2022. Variables of interest included household income, tumor stage, and emergency department (ED) or inpatient admission 30 days before diagnosis. Factors associated with delayed TTI ≥45 days were assessed using multivariable logistic regression.

RESULTS

Among 2,328 patients (mean [standard deviation] age, 64.0 (12.8) years; 66.6% female), having >1 unmet social need was associated with delayed TTI (odds ratio [OR], 1.68; 95% CI, 1.54 to 1.82). The disparities most associated with delay were legal help, transportation, housing stability, and needing to provide care for others. Those with ED (OR, 0.49; 95% CI, 0.44 to 0.54) or inpatient (OR, 0.54; 95% CI, 0.50 to 0.58) admission 30 days before diagnosis were less likely to experience delay.

CONCLUSION

Delays in oncologic TTI ≥45 days are independently associated with unmet social needs. ED or inpatient admissions before diagnosis increase care coordination, leading to improved TTI. Although limitations included the retrospective nature of the study and self-reporting bias, these findings more precisely identify targets for intervention that may more effectively decrease delay. Patients with SDoH barriers are at higher risk of treatment delay and could especially benefit from legal, transportation, caregiver, and housing assistance.

Navigating the cancer care continuum: A comparative study of Black and White breast cancer patients

Despite improvements in early detection and therapeutic interventions, the mortality rate for Black breast cancer patients is still significantly higher than that of White breast cancer patients. This study seeks to understand differences in the patient experience that lead to this disparity. Semi-structured interviews were conducted to understand the breast cancer treatment process and patient experiences. This study collected health services and timeline data from medical records. Based on these two data sources, the patient's journey in breast cancer treatment was mapped and a thematic analysis was conducted to identify challenges and barriers in the process. The cancer care continuum consists of four stages-diagnosis, surgery, chemotherapy/radiation, and follow-up care. The themes contributing to patient experiences and challenges were identified and compared in each stage for both Black and White patients. Both Black and White participants faced challenges related to financial constraints, treatment changes, lack of autonomy, and insufficient emotional support. However, Black participants additionally faced significant barriers in terms of cultural concordance, effective patient-provider communication, and delay in diagnosis. This study highlights the importance of incorporating effective provider-patient communication, navigation, and emotional support, especially for Black breast cancer patients throughout the cancer care continuum to address healthcare disparities.

Young Black Women's Breast Cancer Knowledge and Beliefs: A Sequential Explanatory Mixed Methods Study

INTRODUCTION

Black women under the age of 50 have a 111% higher breast cancer mortality rate than their White counterparts. The breast cancer mortality disparities among young Black women may be due in part to the fact that they are more likely to be diagnosed with late-stage, invasive breast cancer tumors. Psychosocial factors, such as lack of perceived risk for breast cancer, lack of awareness of breast cancer risk factors, and ambiguity about breast cancer screening guidelines are areas that are under investigated among young Black women. The purpose of this study was to identify young Black women's cancer beliefs and level of breast cancer risk knowledge.

METHODS

A sequential explanatory mixed methods study was conducted using quantitative data from the Health Information Trends Survey 6 (HINTS 6) (n = 25) and qualitative data from interviews with young Black female college students (n = 13). The results of the quantitative data analysis were used to guide the development of the qualitative interview guide. Data regarding participants' cancer beliefs, cancer risk factor knowledge, perceived cancer risk, and ambiguity about cancer screening behaviors were analyzed.

RESULTS

The findings indicated young Black women have low perceived risk of developing cancer. Most participants were not aware of cancer recommendations that were targeted towards women under the age of 40. In addition, knowledge about lifestyle behavior risk factors for breast cancer was relatively low.

CONCLUSION

Our findings underscore the importance of developing, disseminating, and implementing breast cancer education interventions that are targeted towards young Black women.

The intersection of travel burdens and financial hardship in cancer care: a scoping review

BACKGROUND

In addition to greater delays in cancer screening and greater financial hardship, rural-dwelling cancer patients experience greater costs associated with accessing cancer care, including higher cumulative travel costs. This study aimed to identify and synthesize peer-reviewed research on the cumulative and overlapping costs associated with care access and utilization.

METHODS

A scoping review was conducted to identify relevant studies published after 1995 by searching 5 electronic databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and Healthcare Administration. Eligibility was determined using the PEO (Population, Exposure, and Outcomes) method, with clearly defined populations (cancer patients), exposures (financial hardship, toxicity, or distress; travel-related burdens), and outcomes (treatment access, treatment outcomes, health-related quality of life, and survival/mortality). Study characteristics, methods, and findings were extracted and summarized.

RESULTS

Database searches yielded 6439 results, of which 3366 were unique citations. Of those, 141 were eligible for full-text review, and 98 studies at the intersection of cancer-related travel burdens and financial hardship were included. Five themes emerged as we extracted from the full texts of the included articles: 1) Cancer treatment choices, 2) Receipt of guideline-concordant care, 3) Cancer treatment outcomes, 4) Health-related quality of life, and 5) Propensity to participate in clinical trials.

CONCLUSIONS

This scoping review identifies and summarizes available research at the intersection of cancer care-related travel burdens and financial hardship. This review will inform the development of future interventions aimed at reducing the negative effects of cancer-care related costs on patient outcomes and quality of life.

Minorities Face Delays to Pancreatic Cancer Treatment Regardless of Diagnosis Setting

INTRODUCTION

Our analysis was designed to characterize the demographics and disparities between the diagnosis of pancreas cancer during emergency presentation (EP) and the outpatient setting (OP) and to see the impact of our institutions pancreatic multidisciplinary clinic (PMDC) on these disparities.

METHODS

Institutional review board-approved retrospective review of our institutional cancer registry and PMDC databases identified patients diagnosed/treated for pancreatic ductal adenocarcinoma between 2014 and 2022. Chi-square tests were used for categorical variables, and one-way ANOVA with a Bonferroni correction was used for continuous variables. Statistical significance was set at p < 0.05.

RESULTS

A total of 286 patients met inclusion criteria. Eighty-nine patients (31.1%) were underrepresented minorities (URM). Fifty-seven (64.0%) URMs presented during an EP versus 100 (50.8%) non-URMs (p = 0.037). Forty-one (46.1%) URMs were reviewed at PMDC versus 71 (36.0%) non-URMs (p = 0.10). No differences in clinical and pathologic stage between the cohorts (p = 0.28) were present. URMs took 22 days longer on average to receive treatment (66.5 days vs. 44.8 days, p = 0.003) in the EP cohort and 18 days longer in OP cohort (58.0 days vs. 40.5 days, p < 0.001) compared with non-URMs. Pancreatic Multidisciplinary Clinic enrollment in EP cohort eliminated the difference in time to treatment between cohorts (48.3 days vs. 37.0 days; p = 0.151).

RESULTS

Underrepresented minorities were more likely to be diagnosed via EP and showed delayed times to treatment compared with non-URM counterparts. Our PMDC alleviated some of these observed disparities. Future studies are required to elucidate the specific factors that resulted in these findings and to identify solutions.

Racial disparities in breast cancer risk factors and risk management

Racial disparities in breast cancer outcomes are well described across the spectrum of screening, diagnosis, treatment, and survivorship. Breast cancer mortality is markedly elevated for Non-Hispanic Black women compared with other racial and ethnic groups, with multifactorial causes. Here, we aim to reduce this burden by identifying disparities in breast cancer risk factors, risk assessment, and risk management before breast cancer is diagnosed. We describe a reproductive profile and modifiable risk factors specific to the development of triple-negative breast cancer. We also propose that screening strategies should be both risk- and race-based, given the prevalence of early-onset triple-negative breast cancer in young Black women. We emphasize the importance of early risk assessment and identification of patients at hereditary and familial risk and discuss indications for a high-risk referral. We discuss the subtleties following genetic testing and highlight "uncertain" genetic testing results and risk estimation challenges in women who test negative. We trace aspects of the obesity epidemic in the Black community to infant feeding patterns and emphasize healthy eating and activity. Finally, we discuss building an environment of trust to foster adherence to recommendations, follow-up care, and participation in clinical trials. Addressing relevant social determinants of health; educating patients and clinicians on factors impacting disparities in outcomes; and encouraging participation in targeted, culturally sensitive research are essential to best serve all communities.

Negotiating cancer alone: A qualitative study exploring care experiences of racially and ethnically diverse women diagnosed with breast cancer during COVID-19

COVID-19 has critically impacted cancer care services including reduced screenings, diagnoses, and surgeries; particularly among Black and Latina/x women who already suffer worse outcomes. This qualitative study explored the care experiences of a diverse sample of breast cancer survivors (N = 21; 7 Black, 4 Hispanic, 10 White) undergoing treatment during the pandemic via online semi-structured interviews. Grounded theory analysis yielded the core category "negotiating cancer alone," that included: (1) psychological distress, negotiating the cancer trajectory in isolation; (2) provider/healthcare system diagnostic and treatment delays; (3) heightened anxiety about treatment delays causing cancer progression; (4) supportive care limitations; and (5) disparate experiences of cancer care disruptions. Black and Latina/x women described greater delays in care, financial challenges, treatment complications, and insurance limitations than White women. The study identifies cancer patients' pandemic-related psychological, healthcare system, and health equity challenges and suggests recommendations to support their increased psychological needs during oncologic care disruptions.

Neighborhood social vulnerability and disparities in time to kidney cancer surgical treatment and survival in Arizona

BACKGROUND

Hispanics and American Indians (AI) have high kidney cancer incidence and mortality rates in Arizona. This study assessed: (1) whether racial and ethnic minority patients and patients from neighborhoods with high social vulnerability index (SVI) experience a longer time to surgery after clinical diagnosis, and (2) whether time to surgery, race and ethnicity, and SVI are associated with upstaging to pT3/pT4, disease-free survival (DFS), and overall survival (OS).

METHODS

Arizona Cancer Registry (2009-2018) kidney and renal pelvis cases (n = 4592) were analyzed using logistic regression models to assess longer time to surgery and upstaging. Cox-regression hazard models were used to test DFS and OS.

RESULTS

Hispanic and AI patients with T1 tumors had a longer time to surgery than non-Hispanic White patients (median time of 56, 55, and 45 days, respectively). Living in neighborhoods with high (≥75) overall SVI increased odds of a longer time to surgery for cT1a (OR 1.54, 95% CI: 1.02-2.31) and cT2 (OR 2.32, 95% CI: 1.13-4.73). Race and ethnicity were not associated with time to surgery. Among cT1a patients, a longer time to surgery increased odds of upstaging to pT3/pT4 (OR 1.95, 95% CI: 0.99-3.84). A longer time to surgery was associated with PFS (HR 1.52, 95% CI: 1.17-1.99) and OS (HR 1.63, 95% CI: 1.26-2.11). Among patients with cT2 tumor, living in high SVI neighborhoods was associated with worse OS (HR 1.66, 95% CI: 1.07-2.57).

CONCLUSIONS

High social vulnerability was associated with increased time to surgery and poor survival after surgery.

Understanding Disparities in Receipt of Complex Gastrointestinal Cancer Surgery at a Small Geographic Scale

OBJECTIVE

To define neighborhood-level disparities in the receipt of complex cancer surgery.

BACKGROUND

Little is known about the geographic variation of receipt of surgery among patients with complex gastrointestinal (GI) cancers, especially at a small geographic scale.

METHODS

This study included individuals diagnosed with 5 invasive, nonmetastatic, complex GI cancers (esophagus, stomach, pancreas, bile ducts, liver) from the Ohio Cancer Incidence Surveillance System during 2009 and 2018. To preserve patient privacy, we combined US census tracts into the smallest geographic areas that included a minimum number of surgery cases (n=11) using the Max-p-regions method and called these new areas "MaxTracts." Age-adjusted surgery rates were calculated for MaxTracts, and the Hot Spot analysis identified clusters of high and low surgery rates. US Census and CDC PLACES were used to compare neighborhood characteristics between the high- and low-surgery clusters.

RESULTS

This study included 33,091 individuals with complex GI cancers located in 1006 MaxTracts throughout Ohio. The proportion in each MaxTract receiving surgery ranged from 20.7% to 92.3% with a median (interquartile range) of 48.9% (42.4-56.3). Low-surgery clusters were mostly in urban cores and the Appalachian region, whereas high-surgery clusters were mostly in suburbs. Low-surgery clusters differed from high-surgery clusters in several ways, including higher rates of poverty (23% vs. 12%), fewer married households (40% vs. 50%), and more tobacco use (25% vs. 19%; all P <0.01).

CONCLUSIONS

This improved understanding of neighborhood-level variation in receipt of potentially curative surgery will guide future outreach and community-based interventions to reduce treatment disparities. Similar methods can be used to target other treatment phases and other cancers.

Penicillin Allergy Evaluation and Health Equity: A Call to Action

Allergists have been at the forefront of addressing the burden of unverified penicillin allergy labels. Coordinated national efforts with infectious diseases, antimicrobial stewardship experts, and pharmacy societies to advocate for formal evaluation of patient-reported penicillin allergy have resulted in improvements in delabeling efforts. Given the poorer health outcomes associated with the penicillin allergy label and the potential health benefits that can be gained with delabeling, improving access to penicillin allergy evaluation is of the utmost importance. Health disparities are widely recognized to impact all aspects of health care, and multilevel interventions at the patient, clinician, and systems level are required to ensure equitable care delivery. Structural racism underpins many social determinants of health and is a key driver of racial and ethnic health disparities. In this Rostrum, we use a conceptual framework from the 2015 National Academy of Medicine report Improving Diagnosis in Health Care to explore how inequities are related to the evaluation of penicillin allergy. We use the National Institute on Minority Health and Health Disparities Strategies to Advance Health Disparities to elucidate areas of important study. Building upon existing efforts to address disparities in Allergy/Immunology, we highlight the urgent importance of understanding and eliminating health disparities in penicillin allergy evaluation and delabeling.