The association of socioeconomic status with receipt of neoadjuvant chemotherapy
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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.
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.
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.
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.
KeywordsBreast cancer Disparities Neoadjuvant chemotherapy Socioeconomic status
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.
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.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Research involving human participants
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.
Informed consent was obtained from all participants included in the study.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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