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Socioeconomic status and breast cancer treatment

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Abstract

Purpose

Evidence suggests substantial disparities in breast cancer survival by socioeconomic status (SES). We examine the extent to which receipt of newer, less invasive, or more effective treatments—a plausible source of disparities in survival—varies by SES among elderly women with early-stage breast cancer.

Methods

Multivariate regression analyses applied to 11,368 women (age 66–90 years) identified from SEER-Medicare as having invasive breast cancer diagnosed in 2006–2009. Socioeconomic status was defined based on Medicaid enrollment and level of poverty of the census tract of residence. All analyses controlled for demographic, clinical health status, spatial, and healthcare system characteristics.

Results

Poor and near-poor women were less likely than high SES women to receive sentinel lymph node biopsy and radiation after breast-conserving surgery (BCS). Poor women were also less likely than near-poor or high SES women to receive any axillary surgery and adjuvant chemotherapy. There were no significant differences in use of aromatase inhibitors (AI) between poor and high SES women. However, near-poor women who initiated hormonal therapy were more likely to rely exclusively on tamoxifen, and less likely to use the more expensive but more effective AI when compared to both poor and high SES women.

Conclusions

Our results indicate that SES disparities in the receipt of treatments for incident breast cancer are both pervasive and substantial. These disparities remained despite women’s geographic area of residence and extent of disease, suggesting important gaps in access to effective breast cancer care.

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References

  1. Singh GK, Miller BA, Hankey BF, Edwards BK (2003) Area socioeconomic variations in US cancer incidence, mortality, stage, treatment, and survival, 1975–1999

  2. Gordon NH, Crowe JP, Brumberg DJ, Berger NA (1992) Socioeconomic factors and race in breast cancer recurrence and survival. Am J Epidemiol 135(6):609–618

    Article  CAS  PubMed  Google Scholar 

  3. Gorey KM, Luginaah IN, Holowaty EJ, Fung KY, Hamm C (2009) Breast cancer survival in ontario and california, 1998–2006: socioeconomic inequity remains much greater in the United States. Ann Epidemiol 19(2):121–124. doi:10.1016/j.annepidem.2008.10.010

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sprague BL, Trentham-Dietz A, Gangnon RE et al (2011) Socioeconomic status and survival after an invasive breast cancer diagnosis. Cancer 117(7):1542–1551. doi:10.1002/cncr.25589

    Article  PubMed  Google Scholar 

  5. Harper S, Lynch J, Meersman SC, Breen N, Davis WW, Reichman MC (2009) Trends in area-socioeconomic and race-ethnic disparities in breast cancer incidence, stage at diagnosis, screening, mortality, and survival among women ages 50 years and over (1987–2005). Cancer Epidemiol Biomark Prev 18(1):121–131. doi:10.1158/1055-9965.EPI-08-0679

    Article  Google Scholar 

  6. Byers T, Wolf H, Bauer K et al (2008) The impact of socioeconomic status on survival after cancer in the United States: findings from the National Program of Cancer Registries Patterns of Care Study. Cancer 113(3):582–591. doi:10.1002/cncr.23567

    Article  PubMed  Google Scholar 

  7. Yu XQ (2009) Socioeconomic disparities in breast cancer survival: relation to stage at diagnosis, treatment and race. BMC Cancer. 9:364. doi:10.1186/1471-2407-9-364

    Article  PubMed  PubMed Central  Google Scholar 

  8. Kish J, Yu M, Percy-Laurry A, Altekruse S (2014) Racial and ethnic disparities in cancer survival by neighborhood socioeconomic status in surveillance, epidemiology, and end results (SEER) Registries. J Natl Cancer Inst Monogr 2014(49):236–243. doi:10.1093/jncimonographs/lgu020

    Article  PubMed  PubMed Central  Google Scholar 

  9. Feinglass J, Rydzewski N, Yang A (2015) The socioeconomic gradient in all-cause mortality for women with breast cancer: findings from the 1998 to 2006 National Cancer Data Base with follow-up through 2011. Ann Epidemiol 25(8):549–555. doi:10.1016/j.annepidem.2015.02.006

    Article  PubMed  Google Scholar 

  10. Bassett Krieger (1986) Social class and black-white differences in breast cancer survival. Am J Public Health 76(12):1400–1403

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Singh GK, Williams S, Siahpush M (2012) Socioeconomic, rural-urban, and racial inequalities in US cancer mortality: Part I—All cancers and lung cancer and Part II—Colorectal, prostate, breast, and cervical

  12. Gilligan M, Kneusel R, Hoffmann R, Greer A, Nattinger A (2002) Persistent differences in sociodemographic determinants of breast conserving treatment despite overall increased adoption. Med Care 40(3):181–189. doi:10.1097/00005650-200203000-00002

    Article  PubMed  Google Scholar 

  13. Alderman A, Bynum J, Sutherland J, Birkmeyer N, Collins ED, Birkmeyer J (2011) Surgical treatment of breast cancer among the elderly in the United States. Cancer 117(4):698–704. doi:10.1002/cncr.25617

    Article  PubMed  Google Scholar 

  14. Smith GL, Xu Y, Shih Y-CTC et al (2009) Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States. J Am Coll Surg 209(4):425–433.e2. doi:10.1016/j.jamcollsurg.2009.06.363

    Article  PubMed  Google Scholar 

  15. Michalski T, Nattinger A (1997) The influence of black race and socioeconomic status on the use of breast-conserving surgery for medicare beneficiaries. Cancer 79(2):314–319. doi:10.1002/(SICI)1097-0142(19970115)79:2<314:AID-CNCR14>3.0.CO;2-3

    Article  CAS  PubMed  Google Scholar 

  16. Mandelblatt J, Kerner J, Hadley J et al (2002) Variations in breast carcinoma treatment in older medicare beneficiaries. Cancer 95(7):1401–1414. doi:10.1002/cncr.10825

    Article  PubMed  Google Scholar 

  17. U.S. Census Bureau (2014) American Community Survey 2005–2009

  18. Winer EP, Hudis C, Burstein HJ et al (2005) American Society of Clinical Oncology technology assessment on the use of aromatase inhibitors as adjuvant therapy for postmenopausal women with hormone receptor-positive breast cancer: status report 2004. J Clin Oncol 23(3):619–629. doi:10.1200/JCO.2005.09.121

    Article  CAS  PubMed  Google Scholar 

  19. Klabunde CN, Legler JM, Warren JL, Baldwin LM (2007) A refined comorbidity measurement algorithm for claims-based studies of breast, prostate, colorectal, and lung cancer patients. Ann Epidemiol 17(8):584–590

    Article  PubMed  Google Scholar 

  20. Bouchardy C, Rapiti E, Fioretta G et al (2003) Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol 21(19):3580–3587. doi:10.1200/JCO.2003.02.046

    Article  PubMed  Google Scholar 

  21. Howell A, Cuzick J, Baum M et al (2005) Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years’ adjuvant treatment for breast cancer. Lancet 365(9453):60–62. doi:10.1016/S0140-6736(04)17666-6

    Article  CAS  PubMed  Google Scholar 

  22. Thürlimann B, Keshaviah A, Coates AS et al (2005) A comparison of letrozole and tamoxifen in postmenopausal women with early breast cancer. N Engl J Med 353(26):2747–2757. doi:10.1056/NEJMoa052258

    Article  PubMed  Google Scholar 

  23. Wang X, Du X (2015) Socio-demographic and geographic variations in the utilization of hormone therapy in older women with breast cancer after Medicare Part-D coverage. Med Oncol (Northwood, London, England) 32(5):154. doi:10.1007/s12032-015-0599-6

    Article  Google Scholar 

  24. Dookeran K, Silva A, Warnecke R, Rauscher G (2015) Race/ethnicity and disparities in mastectomy practice in the Breast Cancer Care in Chicago study. Ann Surg Oncol 22(1):66–74. doi:10.1245/s10434-014-3945-6

    Article  PubMed  Google Scholar 

  25. White A, Richardson L, Krontiras H, Pisu M (2014) Socioeconomic disparities in breast cancer treatment among older women. J Women’s Health 23(4):335–341. doi:10.1089/jwh.2013.4460

    Article  Google Scholar 

  26. Nguyen B, Alawadi Z, Roife D, Kao L, Ko T, Wray C (2016) Do socioeconomic factors and race determine the likelihood of breast-conserving surgery? Clin Breast Cancer. 16(4):e93–e97. doi:10.1016/j.clbc.2016.05.008

    Article  PubMed  Google Scholar 

  27. Guy GP, Lipscomb J, Gillespie TW, Goodman M, Richardson LC, Ward KC (2015) Variations in guideline-concordant breast cancer adjuvant therapy in rural georgia. Health Serv Res 50(4):1088–1108. doi:10.1111/1475-6773.12269

    Article  PubMed  Google Scholar 

  28. Gomez S, Press D, Lichtensztajn D et al (2012) Patient, hospital, and neighborhood factors associated with treatment of early-stage breast cancer among Asian American women in California. Cancer Epidemiol Biomark Prev 21(5):821–834. doi:10.1158/1055-9965.EPI-11-1143

    Article  Google Scholar 

  29. Olaya W, Wong J, Morgan J, Roy-Chowdhury S, Lum S (2009) Disparities in the surgical management of women with stage I breast cancer. Am Surg 75(10):869–872

    PubMed  Google Scholar 

  30. Olaya W, Wong J, Morgan J et al (2010) Factors associated with variance in compliance with a sentinel lymph node dissection quality measure in early-stage breast cancer. Ann Surg Oncol 17(3):297–302. doi:10.1245/s10434-010-1248-0

    Article  PubMed  Google Scholar 

  31. Bradley C, Given C, Roberts C (2002) Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer I. 94(7):490–496. doi:10.1093/jnci/94.7.490

    Article  Google Scholar 

  32. McGinnis LS, Menck HR, Eyre HJ, Bland KI (2000) National Cancer Data Base survey of breast cancer management for patients from low income zip codes. Cancer. doi:10.1002/(SICI)1097-0142(20000215)88:4<933:AID-CNCR25>3.0.CO;2-I

    Google Scholar 

  33. Montgomery M, Pope GC, Greenwald L, Kautter J (2010) Medicare advantage plan availability, premiums and benefits, and beneficiary enrollment in 2007.

  34. Turner N, Zafarana E, Becheri D, Mottino G, Biganzoli L (2013) Breast cancer in the elderly: which lessons have we learned? Future Oncol. 9(12):1871–1881. doi:10.2217/fon.13.140

    Article  CAS  PubMed  Google Scholar 

  35. Partridge Ann H et al (2016) Subtype-dependent relationship between young age at diagnosis and breast cancer survival. J Clin Oncol 34(27):3308–3314

    Article  PubMed  Google Scholar 

  36. Bhargava A, Du X (2009) Racial and socioeconomic disparities in adjuvant chemotherapy for older women with lymph node-positive, operable breast cancer. Cancer 115(13):2999–3008. doi:10.1002/cncr.24363

    Article  PubMed  Google Scholar 

  37. Chen A, Halpern M, Schrag N, Stewart A, Leitch M, Ward E (2008) Disparities and trends in sentinel lymph node biopsy among early-stage breast cancer patients (1998–2005). J Natl Cancer Inst 100(7):462–474. doi:10.1093/jnci/djn057

    Article  PubMed  Google Scholar 

  38. Reeder-Hayes K, Bainbridge J, Meyer A (2011) Race and age disparities in receipt of sentinel lymph node biopsy for early-stage breast cancer. Breast Cancer Res Treat. doi:10.1007/s10549-011-1398-1

    PubMed  PubMed Central  Google Scholar 

  39. Neuner JM., et al. (2015) The introduction of generic aromatase inhibitors and treatment adherence among Medicare D enrollees. J Natl Cancer Inst 107(8): djv130.39

  40. Riley, Gerald F., et al. (2011) Endocrine therapy use among elderly hormone receptor-positive breast cancer patients enrolled in Medicare Part D. Medicare Medicaid Res Rev 1(4)

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Acknowledgements

The collection of cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code section 103,885; the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement # U58DP003862-01 awarded to the California Department of Public Health. The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred. The authors acknowledge the efforts of the National Cancer Institute; 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

Funding

The authors gratefully acknowledge funding by NCI under Grant R01-CA 170945 and the American Cancer Society (RSG-13-070-01-CPHPS).

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Authors and Affiliations

  1. Department of Medicine and Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Suite H3100, Milwaukee, WI, 53226, USA

    Marie S. Dreyer, Ann B. Nattinger, Emily L. McGinley & Liliana E. Pezzin

Authors
  1. Marie S. Dreyer
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  2. Ann B. Nattinger
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  3. Emily L. McGinley
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  4. Liliana E. Pezzin
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Contributions

MSD and LEP are jointly responsible for the planning, conduct, and reporting of results; ELM conducted the statistical analyses; ABN provided clinical insights into variable construction and interpretation of results. As senior author, LEP is responsible for the overall content of the manuscript.

Corresponding author

Correspondence to Liliana E. Pezzin.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study has received ethical approval by the Medical College of Wisconsin/Froedtert Hospital Institutional Review Board #5 as it satisfies requirements of 45 CFR 46.111.

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Dreyer, M.S., Nattinger, A.B., McGinley, E.L. et al. Socioeconomic status and breast cancer treatment. Breast Cancer Res Treat 167, 1–8 (2018). https://doi.org/10.1007/s10549-017-4490-3

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