Abstract
Background
There are advantages to neoadjuvant chemotherapy in operable breast cancer, particularly for those with higher-risk cancers, but little is known about factors that are associated with the use of neoadjuvant chemotherapy outside of clinical trials. We examined whether use of neoadjuvant chemotherapy instead of adjuvant chemotherapy varies by nonclinical factors such as patient socioeconomic status or rural residence.
Methods
Women diagnosed with breast cancer in 2013–2014 at eight medical institutions were surveyed by mail regarding their experiences with breast cancer treatment, and this information was linked to hospital-based cancer registries. We examined the use of neoadjuvant chemotherapy among women with histologically confirmed invasive stage I–III breast cancer and used regression models to examine the association of socioeconomic status with chemotherapy timing. We also explored potential mechanisms for those differences.
Results
Over 29% of the chemotherapy sample overall received neoadjuvant chemotherapy. Neoadjuvant receipt was lower for those with income < $100,000 (AOR 0.56, 95% CI 0.2–0.9) even with adjustment for other demographics, stage, and biomarker status, and findings for education and a variable for both lowest education and income < $100,000 were similar. Rural/urban residence was not associated with neoadjuvant receipt. Differences by income in perceptions of the importance of neoadjuvant chemotherapy advantages and disadvantages did not appear to explain the differences in use by income.
Conclusions
In a multicenter sample of breast cancer patients, lower income was strongly associated with less receipt of neoadjuvant chemotherapy. Since patients with lower socioeconomic status are more likely to present with later-stage disease, this pattern has the potential to contribute to breast cancer outcome disparities.
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References
Killelea BK, Yang VQ, Wang S-Y et al (2015) Racial differences in the use and outcome of neoadjuvant chemotherapy for breast cancer: results from the national cancer data base. J Clin Oncol 33:4267–4276
Mougalian SS, Soulos PR, Killelea BK et al (2015) Use of neoadjuvant chemotherapy for patients with stage I to III breast cancer in the United States. Cancer 121:2544–2552
Gradishar WJ, Anderson BO, Balassanian R et al (2017) NCCN clinical practice guidelines in oncology: breast cancer version 3
Weeks JC, Uno H, Taback N et al (2014) Interinstitutional variation in management decisions for treatment of 4 common types of cancera multi-institutional cohort study interinstitutional variation in cancer management decisions. Ann Intern Med 161:20–30
Onitilo AA, Onesti JK, Single RM et al (2013) Utilization of neoadjuvant chemotherapy varies in the treatment of women with invasive breast cancer. PloS ONE 8:e84535
Spronk PER, van Bommel ACM, Siesling S, Wouters M, Vrancken Peeters M, Smorenburg CH (2017) Variation in use of neoadjuvant chemotherapy in patients with stage III breast cancer: results of the Dutch national breast cancer audit. Breast 36:34–38
Puig CA, Hoskin TL, Day CN, Habermann EB, Boughey JC (2017) National trends in the use of neoadjuvant chemotherapy for hormone receptor-negative breast cancer: a national cancer data base study. Ann Surg Oncol 24:1242–1250
Graham PJ, Brar MS, Foster T et al (2015) Neoadjuvant chemotherapy for breast cancer, is practice changing? A population-based review of current surgical trends. Ann Surg Oncol 22:3376–3382
Singh GK, Williams SD, Siahpush M, Mulhollen A. Socioeconomic (2011) Rural-urban, and racial inequalities in US cancer mortality: part I—all cancers and lung cancer and part II—colorectal, prostate, breast, and cervical cancers. J Cancer Epidemiol 2011:107497
Zdenkowski N, Butow P, Mann GB et al (2016) A survey of Australian and New Zealand clinical practice with neoadjuvant systemic therapy for breast cancer. Intern Med J 46:677–683
Yen TW, Sparapani RA, Guo C, Neuner JM, Laud PW, Nattinger AB (2010) Elderly breast cancer survivors accurately self-report key treatment information. J Am Geriatr Soc 58:410–412
Jagsi R, Hawley ST, Abrahamse P et al (2014) Impact of adjuvant chemotherapy on long-term employment of early-stage breast cancer survivors. Cancer 120:1854–1862
Degner LF, Kristjanson LJ, Bowman D et al (1997) INformation needs and decisional preferences in women with breast cancer. JAMA 277:1485–1492
Sulayman N, Spellman E, Graves KD et al (2012) Psychosocial and quality of life in women receiving the 21-gene recurrence score assay: the impact of decision style in women with intermediate RS. J Cancer Epidemiol 2012:728290
Ayanian JZ, Zaslavsky AM, Arora NK et al (2010) Patients’ experiences with care for lung cancer and colorectal cancer: findings from the cancer care outcomes research and surveillance consortium. J Clin Oncol 28:4154–4161
Ayanian JZ, Zaslavsky AM, Guadagnoli E et al (2005) Patients’ perceptions of quality of care for colorectal cancer by race, ethnicity, and language. J Clin Oncol 23:6576–6586
Halverson JL, Martinez-Donate AP, Palta M et al (2015) Health literacy and health-related quality of life among a population-based sample of cancer patients. J Health Commun 20:1320–1329
Chew LD, Bradley KA, Boyko EJ (2004) Brief questions to identify patients with inadequate health literacy. Fam Med 36:588–594
Berger AM, Buzalko RJ, Kupzyk KA, Gardner BJ, Djalilova DM, Otte JL (2017) Preferences and actual chemotherapy decision-making in the greater plains collaborative breast cancer study. Acta Oncol 56:1690–1697
Wu XC, Lund MJ, Kimmick GG et al (2012) Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers. J Clin Oncol 30:142–150
Nurgalieva ZZ, Franzini L, Morgan RO, Vernon SW, Liu CC, Du XL (2013) Impact of timing of adjuvant chemotherapy initiation and completion after surgery on racial disparities in survival among women with breast cancer. Med Oncol 30:419
Byers TE, Wolf HJ, Bauer KR 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 113:582–591
Livaudais JC, Franco R, Fei K, Bickell NA (2013) Breast cancer treatment decision-making: are we asking too much of patients? J Gen Intern Med 28:630–636
Polacek GNLJ, Ramos MC, Ferrer RL (2007) Breast cancer disparities and decision-making among U.S. women. Patient Educ Couns 65:158–165
Sparano JA, Gray RJ, Makower DF et al (2018) Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med 379:111–121
Sjostrom M, Chang SL, Fishbane N et al (2018) Comprehensive transcriptomic profiling to identify breast cancer patients that may be spared adjuvant systemic therapy. J Clin Oncol 36:suppl abstract 535
Matikas A, Foukakis T, Moebus V et al (2018) Dose tailoring of breast cancer adjuvant chemotherapy aiming at avoiding both over and undertreatment: results from the prospective PANTHER study. J Clin Oncol 36:suppl abstr 538
Siegel RL, Miller KD, Jemal A (2018) Cancer statistics. CA Cancer J Clin 2018 68:7–30
Acknowledgements
The authors would like to acknowledge the Share Thoughts on Breast Cancer patient advocates who helped develop the study question and questionnaire: Cheryl Jernigan, Jody Rock, and Laurel Hoeth; the study site coordinators and project managers who conducted the study mailings: Teresa Bosler, Michele Coady, Mack Dressler, Sarah Esmond, Bret Gardner, Brian Gryzlak, Julie McGregor, Deb Multerer, Char Napurski, Nick Rudzianski, Sabrina Uppal, Xiao Zhang, and Brittany Zschoche; investigators overseeing data collection: Ann Berger, PhD; Anne Blaes, MD; Elizabeth Chrischilles, PhD; Lindsay Cowell, PhD; Robert Greenlee, PhD, MPH; Barbara Haley, MD; Jennifer Klemp, PhD, MPH; Ingrid Lizarraga, MBBS; Joan Neuner, MD, MPH; Adedayo A. Onitilo, MD, PhD, MSCR, FACP; Amelie G. Ramirez, Ph.D., MPH; Priyanka Sharma, MD; Amy Trentham-Dietz, PhD; and Lee Gravatt Wilke, MD, FACS; the Greater Plains Collaborative informatics team who integrated tumor registry data and selected the study samples: Bhargav Adagarla, Daniel Connolly, Tamara McMahaon, Glenn Bushee, Supreet Kathpalia, Jim McClay, Enelda Mendonca, Tom MishSusan Morrison, Phillip Reeder, Nicholas Smith, Laurel Verhagen, and Kathy Williams.
Funding
The authors gratefully acknowledge funding by the National Institute on Minority Health and Health Disparities under Grant R01 MD010728 and from the PCORI research contract CDRN-1306-04631.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Iowa institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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Informed consent was obtained from all participants included in the study.
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Neuner, J.M., Kong, A., Blaes, A. et al. The association of socioeconomic status with receipt of neoadjuvant chemotherapy. Breast Cancer Res Treat 173, 179–188 (2019). https://doi.org/10.1007/s10549-018-4954-0
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DOI: https://doi.org/10.1007/s10549-018-4954-0