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Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study

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Abstract

Purpose

To examine racial–ethnic variation in adherence to established quality metrics (NCCN guidelines and ASCO quality metrics) for breast cancer, accounting for individual-, facility-, and area-level factors.

Methods

Data from women diagnosed with invasive breast cancer at 66+ years of age from 2000 to 2017 were examined using SEER-Medicare. Associations between race and ethnicity and guideline-concordant diagnostics, locoregional treatment, systemic therapy, documented stage, and oncologist encounters were estimated using multilevel logistic regression models to account for clustering within facilities or counties.

Results

Black and American Indian/Alaska Native (AIAN) women had consistently lower odds of guideline-recommended care than non-Hispanic White (NHW) women (Diagnostic workup: ORBlack 0.83 (0.79–0.88), ORAIAN 0.66 (0.54–0.81); known stage: ORBlack 0.87 (0.80–0.94), ORAIAN 0.63 (0.47–0.85); seeing an oncologist: ORBlack 0.75 (0.71–0.79), ORAIAN 0.60 (0.47–0.72); locoregional treatment: ORBlack 0.80 (0.76–0.84), ORAIAN 0.84 (0.68–1.02); systemic therapies: ORBlack 0.90 (0.83–0.98), ORAIAN 0.66 (0.48–0.91)). Commission on Cancer accreditation and facility volume were significantly associated with higher odds of guideline-concordant diagnostics, stage, oncologist visits, and systemic therapy. Black residential segregation was associated with significantly lower odds of guideline-concordant locoregional treatment and systemic therapy. Rurality and area SES were associated with significantly lower odds of guideline-concordant diagnostics and oncologist visits.

Conclusions

This is the first study to examine guideline-concordance across the continuum of breast cancer care from diagnosis to treatment initiation. Disparities were present from the diagnostic phase and persisted throughout the clinical course. Facility and area characteristics may facilitate or pose barriers to guideline-adherent treatment and warrant future investigation as mediators of racial–ethnic disparities in breast cancer care.

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Data availability

The SEER-Medicare datasets used to conduct this research are available to researchers upon approval of the research protocol by NCI and SEER. Instructions for obtaining these data are available at https://healthcaredelivery.cancer.gov/seermedicare/obtain/. Linkage with the AMA Physician Masterfile was performed by NCI/SEER contractors. All publically available data sources used in this study are cited in Online Resource 1.

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Acknowledgments

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 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. The Healthcare Delivery Research Program and National Cancer Institute created the Social Determinants of Health Data Set used in this work. This data set and documentation were created by Information Management Services, Inc. under US Government contracts HHSN261201500003B/75N91020F00001 to facilitate research activities of the NCI-funded Population-based Research to Optimize the Screening Process (PROSPR) consortium. PROSPR grantees, funded under US Government grants U24CA221936, UM1CA221939, UM1CA221940, and UM1CA222035, provided documentation for segregation indices and guidance regarding their creation. 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 103885; 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

This work was supported by the National Cancer Institute (P30 CA086862, R50 CA243692). This work was supported by a Research Stimulus Award from the Geographic Management of Cancer Health Disparities Program Region 4 (awarded to E. L. Herbach).

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Authors and Affiliations

  1. Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA

    Emma L. Herbach, Ryan M. Carnahan, Sarah H. Nash & Mary Charlton

  2. Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA

    Emma L. Herbach

  3. Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA

    Michaela Curran

  4. Department of Health Policy and Management, School of Global Public Health, University of North Carolina at Chapel Hill, Gillings, Chapel Hill, NC, USA

    Mya L. Roberson

  5. University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA

    Bradley D. McDowell

  6. Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA

    Kai Wang

  7. Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA

    Ingrid Lizarraga

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  1. Emma L. Herbach
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Contributions

Study conception and design were developed by ELH, MC, RMC, KW, IL, SHN, and MC. Material preparation, data collection and analysis were performed by ELH. The first draft of the manuscript was written by ELH with support from SHN and MC. Coding and analysis support was provided by BDM. Interpretation of results was supported by MLR. All authors reviewed and edited previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Emma L. Herbach.

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This project was approved by the University of Iowa Institutional Review Board. Informed consent was not required for the conduct of this research.

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Herbach, E.L., Curran, M., Roberson, M.L. et al. Guideline-concordant breast cancer care by patient race and ethnicity accounting for individual-, facility- and area-level characteristics: a SEER-Medicare study. Cancer Causes Control (2024). https://doi.org/10.1007/s10552-024-01859-3

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