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Structural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients

  • Epidemiology
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Abstract

Observed racial/ethnic disparities in the process and outcomes of breast cancer care may be explained, in part, by structural/organizational characteristics of health care systems. We examined the role of surgical facility characteristics and distance to care in explaining racial/ethnic variation in timing of initiation of guideline-recommended radiation therapy (RT) after breast conserving surgery (BCS). We used Surveillance Epidemiology and End Results-Medicare data to identify women ages 65 and older diagnosed with stages I–III breast cancer and treated with BCS in 1994–2002. We used stepwise multivariate logistic regression to examine the interactive effects of race/ethnicity and facility profit status, teaching status, size, and institutional affiliations, and distance to nearest RT on timing of RT initiation, controlling for known covariates. Among 38,574 eligible women who received BCS, 39% received RT within 2 months, 52% received RT within 6 months, and 57% received RT within 12 months post-diagnosis, with significant variation by race/ethnicity. In multivariate models, women attending smaller surgical facilities and those with on-site radiation had higher odds of RT at each time interval, and women attending governmental facilities had lower odds of RT at each time interval (P < 0.05). Increasing distance between patients’ residence and nearest RT provider was associated with lower overall odds of RT, particularly among Hispanic women (P < 0.05). In fully adjusted models including race-by-distance interaction terms, racial/ethnic disparities disappeared in RT initiation within 6 and 12 months. Racial/ethnic disparities in timing of RT for breast cancer can be partially explained by structural/organizational health system characteristics. Identifying modifiable system-level factors associated with quality cancer care may help us target policy interventions that can reduce disparities in outcomes.

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Acknowledgments

This study was supported by the lead author’s National Research Service Award (NRSA) Predoctoral Traineeship from the Agency for Healthcare Research and Quality (AHRQ) sponsored by the Cecil G. Sheps Center for Health Services Research, UNC at Chapel Hill, Grant No. 5-T-32 HS000032-20 and Mentored Clinical Scientists Comparative Effectiveness Research Development Award (K12), National Institutes of Health, Grant No. 1-K-12 HS019468-01, and a pilot grant, Grant No. 2KR50906 (PI: Wheeler) from the North Carolina Translational and Clinical Sciences (NC TraCS) Institute, Clinical and Translational Science Award (CTSA) Number UL1RR025747 from the National Center for Research Resources, National Institutes of Health. We would like to acknowledge Jane Darter and John Bainbridge for their helpful programming assistance. This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

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The authors declare they have no conflict of interest.

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Authors and Affiliations

  1. Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, 135 Dauer Drive, CB 7411, Chapel Hill, NC, 27599-7411, USA

    Stephanie B. Wheeler, William R. Carpenter, Morris Weinberger & Andrea K. Biddle

  2. Division of Medical Oncology, Department of Medicine, Duke University, Durham, NC, USA

    Jeffrey Peppercorn

  3. Public Health Leadership Program, University of North Carolina, Chapel Hill, NC, USA

    Anna P. Schenck

  4. Department of Veterans Affairs, Center of Excellence in Health Services Research in Primary Care, Durham, NC, USA

    Morris Weinberger

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  1. Stephanie B. Wheeler
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Correspondence to Stephanie B. Wheeler.

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Wheeler, S.B., Carpenter, W.R., Peppercorn, J. et al. Structural/organizational characteristics of health services partly explain racial variation in timeliness of radiation therapy among elderly breast cancer patients. Breast Cancer Res Treat 133, 333–345 (2012). https://doi.org/10.1007/s10549-012-1955-2

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