Racial Disparities in Breast Cancer Treatment Refusal

Age, public insurance status, lack of insurance, comorbidities, nonmetastatic illness, lower tumor grade, and being older are associated with racial and ethnic disparities in the reduction in breast cancer therapy—that is, treatment refusal. These elements highlight the significance of focused health equity initiatives that prioritize OS through treatment benefits, as well as enhanced communication techniques, collaborative decision-making, and inequality reduction.

A recent study has connected the drop in breast cancer therapy to racial and ethnic differences concerning age, income, and insurance. Better survival was seen in patients who got all therapies, underscoring the necessity of initiatives to increase access and lessen inequities.

A cross-sectional analysis was carried out retrospectively between 2004 and 2020 utilizing data from the National Cancer Database (NCDB).1. Chemotherapy, hormone therapy (HT), radiation therapy, and surgery were the four treatment modalities evaluated in the study. Patients receiving hormone therapy (HT) had stage I to IV hormone receptor-positive disease, patients receiving chemotherapy had stage I to IV disease, and patients receiving radiation and surgery had stage I to III disease.

The study’s main goal was to look at patterns and variables related to decreases in the four treatment modalities. Their secondary goal was to evaluate the overall survival (OS) of breast cancer patients based on their race, ethnicity, and choice of treatment.

Patient characteristics included age at diagnosis, sex assigned at birth, type of health insurance (uninsured, private, Medicaid, Medicare, and other government or unknown), residence in a rural or urban area, facility type, cancer stage group, histology, molecular subtype, tumor grade, and year of initial diagnosis in addition to race and ethnicity. Survival was monitored until the patient’s last follow-up date or until death (from any cause).

With an average age of 61.6 years, 2,837,446 patients were enrolled in the study overall; 99.1% of participants were female. The majority of patients (78%), Black (11.2%), Hispanic (5.6%), Asian/Pacific Islander (3.5%), American Indian/Alaskan Native/other participants (1.7%), and White (78%) were the next most common ethnic groups. Of the patients who were enrolled, 49.9% had managed care or private insurance, while 39.3% had Medicare and 6.3% had Medicaid. 74% of the population had a disease that was hormone receptor-positive but ERBB2-negative, and the majority of patients (55.6%) had stage I disease.

We looked closely at the trends shown and the prevalence of treatment decline. Chemotherapy was the most commonly refused treatment (9.6%), then radiation (6.1%), HT (5%), and surgery (0.6%). There were discernible trends in the number of patients who rejected all available treatments (0.4%) and those who rejected one to three (9.8%). Eighty-nine percent of the patients got every recommended treatment. Chemotherapy decreased over time, but patterns of decline in radiation, surgery, and HT were found for the years 2004 to 2020 over the data collection period.

Furthermore, correlations were seen between racial/ethnic discrepancies and chemotherapy refusal. Compared to American Indian/Alaska Native/other (8.7%), Asian or Pacific Islander (8.8%), Black (8.1%), and Hispanic (5.7%) patients, more White patients (10.3%) declined chemotherapy. Following covariate adjustments, patients who identified as Black, Asian/Pacific Islander, American Indian/Alaska Native, or other were more likely to decline chemotherapy than patients who identified as White. On the other hand, Hispanic patients were less likely to decline chemotherapy than White patients. The likelihood that a patient would refuse therapy increased with age.

“Innovations in Women’s Health: Bridging Disparities in Breast Cancer,” “There are known racial disparities in breast cancer. When comparing to non-Hispanic White women, we do see that there’s a higher incidence of breast cancer within that non-Hispanic White population. When compared to non-Hispanic White patients, the non-Hispanic Black patients have an earlier onset of disease, often more aggressive disease or advanced stage at diagnosis, and aggressive subtypes.”

In the radiation cohort, patients who identified as American Indian, Alaska Native, or other, 5.2% of patients from Asia or the Pacific Islands, 6.2% of Black patients, 4.1% of Hispanic patients, and 6.2% of White patients declined treatment. After a multivariate analysis, compared to White patients, Black patients had higher probabilities while Hispanic patients had lower levels of radiation refusal. Like the other groups, treatment decline rates were greater for older patients, Medicaid-eligible patients, uninsured patients, and those with lower family incomes.

Treatment refusals were reported by 0.7% of patients who identified as American Indian, Alaska Native, or other, 0.6% of patients who were Asian or Pacific Islander, 1.1% of Black patients, 0.4% of Hispanic patients, and 0.6% of White patients in the surgery cohort. Following the adjustment of variables, patients who identified as Asian/Pacific Islander, Black, American Indian/Alaska Native/other, and/or Hispanic had lower rates of surgical decrease than White patients. Individuals who were older, uninsured or covered by Medicaid, had a lower tumor grade or late-stage cancer, and had a median household income of less than $40,227 ($40,227 to $50,353 or $50,354 to $63,332) were more likely to refuse treatment.

Treatment refusals were reported by 0.7% of patients who identified as American Indian, Alaska Native, or other, 0.6% of patients who were Asian or Pacific Islander, 1.1% of Black patients, 0.4% of Hispanic patients, and 0.6% of White patients in the surgery cohort. Following the adjustment of variables, patients who identified as Asian/Pacific Islander, Black, American Indian/Alaska Native/other, and/or Hispanic had lower rates of surgical decrease than White patients. Individuals who were older, uninsured or covered by Medicaid, had a lower tumor grade or late-stage cancer, and had a median household income of less than $40,227 ($40,227 to $50,353 or $50,354 to $63,332) were more likely to refuse treatment.

The study’s limitations were underreporting because of unmeasured confounders, low generalizability, and a lack of data on second views or therapy modifications. Furthermore, no evaluation was done on the relationships between treatment deterioration and other health outcomes.

“Many people of color contend with interpersonal racism and discrimination in health care settings and more often receive worse medical care than white patients,” according to the Commonwealth Fund 2024 State Health Disparities.

Future research must address the pervasive racial and ethnic inequities in healthcare systems while analyzing the trends and patterns of treatment reduction among populations of breast cancer patients.

For more information: Declination of Treatment, Racial and Ethnic Disparity, and Overall Survival in US Patients With Breast Cancer, Jama Network, doi:10.1001/jamanetworkopen.2024.9449