Racial/ethnic differences in patient experiences with health care in association with earlier stage at breast cancer diagnosis: findings from the SEER-CAHPS data

  • Albert J. FariasEmail author
  • Carol Y. Ochoa
  • Gabriela Toledo
  • Soo-In Bang
  • Ann S. Hamilton
  • Xianglin L. Du
Original Paper



Black women are more likely to be diagnosed with later stage breast cancer compared to white women due to biological or access to care factors. Therefore, our objective was to identify whether racial/ethnic differences in patient experiences with healthcare are associated with stage at diagnosis.


We used the SEER registry data linked with patient surveys from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) completed prior to the diagnosis date. We examined responses about various aspects of their care such as the ability to get needed care, and to get care quickly. We used multivariable linear regression to examine racial/ethnic differences in patient experiences, and a multivariable ordinal logistic regression to determine the association between patient experiences and earlier stage at diagnosis.


Of the 10,144 patients, 80.7% were non-Hispanic white, 7.6% black, 7.1% Hispanic, and 4.6% Asian. After controlling for potential confounders, black patients had significantly lower mean scores for getting care quickly (β =  − 2.78), getting needed care (β =  − 2.26), getting needed prescription drugs (β =  − 3.83), and lower ratings of their health care (β =  − 2.33) compared to white patients. More importantly, we found that black patients who reported a 1-unit increase in rating of their experiences with customer service (OR 1.04, 95% CI 1.01–1.06) and the ability to get care quickly (OR 1.03, 1.01–1.05) had higher odds of earlier stage breast cancer.


Racial/ethnic minorities reported poorer patient experiences with care preceding a diagnosis of breast cancer. Better ratings among black patients were associated with earlier stage at diagnosis.


Breast cancer Consumer Assessment of Healthcare and Providers (CAHPS) Health care disparities Patient experiences Cancer stage 



The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Centers for Medicare & Medicaid Services; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-CAHPS database.

Author contributions

AJF: Conceptualization, methodology, writing- original draft, review, and editing. CO: Conceptualization, writing- original draft, review, and editing. GT: Conceptualization, writing- original draft, review, and editing. SB: Formal analysis, methodology, writing- review and editing. ASH: Conceptualization, methodology, writing- review and editing. XLD: Conceptualization, methodology, writing- review and editing.


A.J.F was a postdoctoral fellow supported by a University of Texas Health Science Center at Houston School of Public Health Cancer Education and Career Development Program grant from the National Cancer Institute (Grant No. R25-CA57712). This study used the linked SEER-CAHPS database.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.


  1. 1.
    Ooi SL, Martinez ME, Li CI (2011) Disparities in breast cancer characteristics and outcomes by race/ethnicity. Breast Cancer Res Treat 127(3):729–738PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Banegas MP, Li CI (2012) Breast cancer characteristics and outcomes among Hispanic Black and Hispanic White women. Breast Cancer Res Treat 134(3):1297–1304PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Silber JH, Rosenbaum PR, Clark AS et al (2013) Characteristics associated with differences in survival among black and white women with breast cancer. JAMA 310(4):389–397PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Farias AJ, Du XL (2017) Racial differences in adjuvant endocrine therapy use and discontinuation in association with mortality among Medicare breast cancer patients by receptor status. Cancer Epidemiol Biomark Prev 26:1266–1275CrossRefGoogle Scholar
  5. 5.
    Tabar L, Yen MF, Vitak B, Chen HH, Smith RA, Duffy SW (2003) Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet 361(9367):1405–1410PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Du XL, Fang S, Meyer TE (2008) Impact of treatment and socioeconomic status on racial disparities in survival among older women with breast cancer. Am J Clin Oncol 31(2):125–132PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Hewitt M, Greenfield S, Stovall E (2005) From cancer patient to cancer survivor: lost in transition. The National Academies Press, Washington, DCGoogle Scholar
  8. 8.
    Taplin SH, Anhang Price R, Edwards HM et al (2012) (2012) Introduction: understanding and influencing multilevel factors across the cancer care continuum. J Natl Cancer Inst Monogr 44:2–10CrossRefGoogle Scholar
  9. 9.
    Niederhuber J (2011) Institute of Medicine (IOM) workshop. Oncologist 16(12):1665–1666PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Institute of Medicine (2013) Delivering high-quality cancer care: charting a new course for a system in crisis. The National Academies Press, Washington, DCGoogle Scholar
  11. 11.
    Rowland JH, Hewitt M, Ganz PA (2006) Cancer survivorship: a new challenge in delivering quality cancer care. J Clin Oncol 24(32):5101–5104PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Starfield B, Shi L (2004) The medical home, access to care, and insurance: a review of evidence. Pediatrics 113:1493–1498PubMedGoogle Scholar
  13. 13.
    Epstein RM, Street RL Jr. (2011) The values and value of patient-centered care. Ann Fam Med 9(2):100–103PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Davis K, Schoenbaum SC, Audet AM (2005) A 2020 vision of patient-centered primary care. J Gen Intern Med 20(10):953–957PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Hudon C, Fortin M, Haggerty JL, Lambert M, Poitras ME (2011) Measuring patients' perceptions of patient-centered care: a systematic review of tools for family medicine. Ann Fam Med 9(2):155–164PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Beal A, Hernandez S, Doty M (2009) Latino access to the patient-centered medical home. J Gen Intern Med 24:514–520PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Ferrer RL (2007) Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med 5(6):492–502PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Alexander JA, Bae D (2012) Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes. Health Serv Manag Res 25(2):51–59CrossRefGoogle Scholar
  19. 19.
    Reid RJ, Coleman K, Johnson EA et al (2010) The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff 29(5):835–843CrossRefGoogle Scholar
  20. 20.
    Reid RJ, Fishman PA, Yu O et al (2009) Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care 15(9):e71–87PubMedGoogle Scholar
  21. 21.
    Baicker K, Chandra A (2004) Medicare spending, the physician workforce, and beneficiaries' quality of care. Health Aff 23:W4–W184Google Scholar
  22. 22.
    Greenfield S, Nelson EC, Zubkoff M, et al (1992) Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA 267(12):1624–1630PubMedCrossRefGoogle Scholar
  23. 23.
    Smith LM, Anderson WL, Kenyon A et al (2015) Racial and Ethnic disparities in patients' experience with skilled home health care services. Med Care Res Rev 72(6):756–774PubMedCrossRefGoogle Scholar
  24. 24.
    Zhu J, Weingart SN, Ritter GA, Tompkins CP, Garnick DW (2015) Racial/Ethnic disparities in patient experience with communication in hospitals: real differences or measurement errors? Med Care 53(5):446–454PubMedCrossRefGoogle Scholar
  25. 25.
    Mollica MA, Enewold LR, Lines LM et al (2017) Examining colorectal cancer survivors' surveillance patterns and experiences of care: a SEER-CAHPS study. Cancer Causes Control 28(10):1133–1141PubMedCrossRefGoogle Scholar
  26. 26.
    Chawla N, Urato M, Ambs A et al (2015) Unveiling SEER-CAHPS(R): a new data resource for quality of care research. J Gen Intern Med 30(5):641–650PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    National Cancer Institute. Medicare CAHPS Data Documentation. Accessed October, 2019.
  28. 28.
    Dosch AR, Koru-Sengul T, Miao F, Tannenbaum SL, Byrne MM, Wright JL (2014) Racial and ethnic disparities in the diagnosis of breast cancer: changes in presenting stage in minority populations in Florida during 1981–2009. Breast Cancer Res Treat 148(2):379–387PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Balazy KE, Benitez CM, Gutkin PM, Jacobson CE, von Eyben R, Horst KC (2019) Association between primary language, a lack of mammographic screening, and later stage breast cancer presentation. Wiley, New YorkCrossRefGoogle Scholar
  30. 30.
    Price RA, Haviland AM, Hambarsoomian K et al (2015) Do experiences with medicare managed care vary according to the proportion of same-Race/Ethnicity/language individuals enrolled in one's contract? Health Serv Res 50(5):1649–1687PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Palmer NRA, Kent EE, Forsythe LP et al (2014) Racial and ethnic disparities in patient-provider communication, quality-of-care ratings, and patient activation among long-term cancer survivors. J Clin Oncol 32(36):4087–4094PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Paddison CAM, Elliott MN, Haviland AM et al (2012) Experiences of care among medicare beneficiaries with ESRD: medicare consumer assessment of healthcare providers and systems (CAHPS) survey results. Am J Kidney Dis 61(3):440–449PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Smith LM, Anderson WL, Kenyon A et al (2015) Racial and Ethnic disparities in patients’ experience with skilled home health care services. Med Care Res Rev 72(6):756–774PubMedCrossRefGoogle Scholar
  34. 34.
    Goldstein E, Elliott MN, Lehrman WG, Hambarsoomian K, Giordano LA (2010) Racial/Ethnic differences in patients’ perceptions of inpatient care using the HCAHPS survey. Med Care Res Rev 67(1):74–92PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Morales LS, Elliott MN, Weeck-Maldonado R, Spritzer KL, Hays RD (2001) Differences in CAHPS [R] adult survey reports and ratings by Race and Ethnicity: an analysis of the National CAHPS [R] Benchmarking Data 1.0.(National Consumer Assessment of Health Plans) (Statistical Data Included). Health Serv Res 36(3):595.Google Scholar
  36. 36.
    National Cancer Patient Experience Programme 2014 Survey (2014) Athena Information Solutions Pvt. Ltd.Google Scholar
  37. 37.
    Peterson EB, Ostroff JS, Duhamel KN et al (2016) Impact of provider-patient communication on cancer screening adherence: a systematic review. Prev Med 93:96–105PubMedPubMedCentralCrossRefGoogle Scholar
  38. 38.
    Smith B, Madak-Erdogan Z (2018) Urban neighborhood and residential factors associated with breast cancer in African American women: a systematic review. Hormones Cancer 9(2):71–81PubMedCrossRefGoogle Scholar
  39. 39.
    Campbell RT, Li X, Dolecek TA, Barrett RE, Weaver KE, Warnecke RB (2009) Economic, racial and ethnic disparities in breast cancer in the US: towards a more comprehensive model. Health Place 15(3):870–879CrossRefGoogle Scholar
  40. 40.
    MacKinnon JA, Duncan RC, Huang Y, Lee DJ, Fleming LE, Voti L, Rudolph M, Wilkinson JD (2007) Detecting an association between socioeconomic status and late stage breast cancer using spatial analysis and area-based measures. Cancer Epidemiol Prev Biomark 16(4):756–762CrossRefGoogle Scholar
  41. 41.
    Gerend MA, Pai M (2008) Social determinants of Black-White disparities in breast cancer mortality: a review. Cancer Epidemiol Prev Biomark 17(11):2913–2923CrossRefGoogle Scholar
  42. 42.
    Izadirad H, Zareban I (2015) The relationship of health literacy with health status, preventive behaviors and health services utilization in Baluchistan. Iran. Hamadan-Univ-Med-Sci 2(3):43–50Google Scholar
  43. 43.
    Wang F, McLafferty S, Escamilla V, Luo L (2008) Late-stage breast cancer diagnosis and health care access in Illinois. Prof Geogr 60(1):54–69PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Barry J, Breen N, Barrett M (2012) Significance of increasing poverty levels for determining late-stage breast cancer diagnosis in 1990 and 2000. J Urban Health 89(4):614–627PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Fowler BA (2014) Neighborhood-level influences on delays in diagnostic follow-up from mammography screening in African-American Women: a systematic review. J Women’s Health Care 3(151):1Google Scholar
  46. 46.
    Warnecke RB, Campbell RT, Vijayasiri G, Barrett RE, Rauscher GH (2019) Multilevel examination of health disparity: the role of policy implementation in neighborhood context, in patient resources, and in healthcare facilities on later stage of breast cancer diagnosis. Cancer Epidemiol Biomark Prev 28(1):59CrossRefGoogle Scholar
  47. 47.
    Jha AK, Orav EJ, Zheng J, Epstein AM (2008) Patients' perception of hospital care in the United States. N Engl J Med 359(18):1921–1931PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Preventive MedicineKeck School of Medicine of the University of Southern CaliforniaLos AngelesUSA
  2. 2.Gehr Family Center for Health System ScienceKeck School of Medicine of the University of Southern CaliforniaLos AngelesUSA
  3. 3.Department of Pharmaceutical and Health Economics, School of Pharmacy, Leonard Schaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesUSA
  4. 4.Department of Epidemiology, Human Genetics and Environmental Science, School of Public HealthUniversity of Texas Health Science Center At HoustonHoustonUSA
  5. 5.Department of Preventive MedicineKeck School of Medicine of the University of Southern CaliforniaLos AngelesUSA

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