1. DiGiulio, Sarah

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One of the factors that may be behind some of the disparities between health outcomes for black women with breast cancer compared with those for white women with breast cancer may be delays in how long it takes from the point of diagnosis for women to start treatment and how long the treatment takes once started. That's according to research published in the journal Cancer (2019;125:3985-3992).

Katherine E. Reeder-... - Click to enlarge in new windowKatherine E. Reeder-Hayes, MD. Katherine E. Reeder-Hayes, MD

An analysis of 1,328 black women with breast cancer and 1,331 white women with breast cancer showed that the black women tended to start treatment for their cancers later than white women (even when receiving similar treatments), and similar therapies took longer to administer the full course to black women compared with white women. The black women were 1.73 times more likely to wait 60 days or longer from being diagnosed with breast cancer until they started treatment. The black women were also more likely to be in the highest quartile of treatment duration (when factors like other demographics, tumor type, and treatment type were controlled for).


And finally, the data found that women whose treatment took longer and those who had longer delays in starting treatment tended to have worse outcomes (though that trend was not statistically significant).


The data doesn't necessarily explain why on an individual level the delays are taking place, says the study's first author, Katherine E. Reeder-Hayes, MD, Assistant Professor of Medicine at University of North Carolina School of Medicine. "For instance, we don't know whether a woman chose to put off an appointment, whether the oncology providers serving her community don't have enough resources to see all patients quickly, or whether another health problem, lack of transportation, or lack of money to pay for care might have been the reason for the delay."


But the data do point to some significant realities that bear on racial disparities in cancer outcomes. Here's what Reeder-Hayes told Oncology Times about her group's work.


1 What are the key findings from your new research and how do they differ from what we already know about these kinds of disparities?

"We found that, after taking the characteristics of a person's cancer and the types of treatment they received into consideration, black women compared to white women were more likely to have lengthy waits between diagnosis and starting any cancer treatment, and also took longer to finish similar treatments. We know from other work that timely treatment-whether that is defined as getting started quickly or proceeding through treatment at the ideal pace-is connected to better cancer outcomes. So this is very concerning.


"This study is a type of disparities research that tries to understand what is different about the treatment experiences of one group of people (in this case, black women with breast cancer) that may explain worse cancer outcomes that have already been observed. This type of research is an important step along the way to actually intervening to improve disparity because a pattern of worse cancer survival can be observed without much understanding of why that pattern occurs, and it takes understanding the 'why' to design and test good interventions."


2 What types of interventions might eliminate these types of disparities in the way breast cancer treatment is delivered and, ultimately, outcomes?

"One intervention with a lot of potential is the use of oncology navigators. These individuals do not have to be medical providers, but should be familiar with the community they work in and the cancer care resources in that community-and they should have good teamwork with cancer care providers. The health system is very complex and fragmented. The idea of navigation is that the patients at highest risk of getting lost in that system, such as those with lower health literacy, less support from family or friends, less financial resources, or other barriers, would get extra help from a knowledgeable person to figure out their way through the system to the care they need.


"While we can't fix everything that's broken about the cancer care delivery system, I believe we can think creatively about ways to work with patients: Do I really need that next test before we begin treatment, or can we get it later? Did I ask my patient if she will be able to afford the medicines we just prescribed? Does my patient have the information needed to let me know quickly if they get sick during treatment?


"We can also think about how we allocate limited resources, like new patient appointments. Are we using a system that schedules the most urgent patients first, or just takes the next person in line, or accommodates a more privileged patient first? These simple practices all add up to more or less timely treatment, and our patients need us to be their advocates in this area."


3 So what's the next step to help make some of these changes happen?

"Many of the things that could make the health system more patient-friendly, like proactive telephone calls to check on symptoms or a navigator to intensively guide a patient, are fairly expensive and are not paid for by insurance companies. This makes it challenging to convince health systems to provide adequate numbers of staff in these areas. We hope that, as cancer care reimbursement begins to be better linked to quality metrics, systems will appreciate how these team members could improve their patients' outcomes.


"We are planning lots of exciting next steps, including reaching out to patients during some parts of breast cancer treatment using telephone counselors rather than requiring them to come in to clinic and creating maps of cancer care resources across the state that help us understand the gaps in what's available and how those gaps connect to the ultimate outcomes such as cancer survival."