Racial/ethnic Differences in Treatment Delay

in a Multi-ethnic Sample of Women with Breast Cancer

Mahasin S. Mujahid, PhDRWJ Health and Society Scholar

Harvard University School of Public Health

AcknowledgementsSarah T. Hawley, PhD

Nancy K. Janz, PhDJennifer J. Griggs, PhD

Ann Hamilton, PhDJohn Graff, PhD

Steven J. Katz, MDUniversity of Michigan

Los Angeles and Detroit Metropolitan Area SEER RegistriesUniversity of Southern California and Wayne State University

Funded by the National Cancer Institute (R01CA109696; R01 CA088370)

Background• There are persistent racial/ethnic differences in

breast cancer survival in the US

• Differences have been attributed to:•Tumor biology and pathogenesis•Socioeconomic characteristics•Co-morbidities•Access to and quality of medical care

•Breast cancer screening•Timely receipt of appropriate treatment

Background (2)

• Treatment delay is an important area of study• Longer delays associated with worse

survival rates

• Few studies have examined racial/ethnic differences in treatment delay• population-based multi-ethnic studies• underlying factors contributing to

differences

Research Aims

1. To describe the prevalence of treatment delay in in a population-based sample

2. To examine racial/ethnic differences in treatment delay

3. To determine the sociodemographic, clinical/treatment, and access barriers that may account for racial/ethnic differences in treatment delay

Study Population• Population-based sample (8/05-2/07)

• Detroit and Los Angeles Metropolitan areas• Rapid case ascertainment (9 months post diagnosis)

• Accrued and Eligible Sample (N=3133)• 20-79 years of age• Stage 0-III disease• Able to complete self-administered questionnaire• African American and Latina women were over-

sampled

• Final Sample (N=2268); 72% response rate

Study VariablesStudy Outcome (Treatment Delay)Time between diagnosis and first surgical

procedure• <1month• 1-3 months moderate delay• >3 months significant delay

Key Covariate (Race/ethnicity)• White (non-Latina)• African American (non-Latina)• Latina

Additional VariablesSociodemographic Factors• Age at diagnosis

• Married/partner

• Education

• Income

• Employed

• Insurance

Clinical /Treatment Factors

• Number of co-morbidities

• Cancer stage

• Chemotherapy

• Breast reconstruction at time of surgery

Additional Variables (2)Access BarriersDifficulty (yes/no):

1. Finding a doctor

2. Scheduling surgical procedure

1. Getting to doctors’ office

2. Financial cost (office visits, treatments)

Statistical Analyses

• Multinomial Logistic Regression Models• Three level dependent variable

•< 1 month •1-3 months•> 3 months

Point estimates adjusted by weights to account for differential selection by race/ethnicity and non-response

Significant Delay

Patient Characteristics

N=2195*

Weighted %

Age Mean =58 years

Race/ethnicityLatinaAfrican AmericanWhite

562585994

171568

Education≤ H.S diplomaH.S diploma> H.S diploma

401461

1292

132067

*Restricted to women who had a surgical procedure

Prevalence of Treatment Delay

43

7

50

0

10

20

30

40

50

60

<1 month 1-3 months >3 months

pe

rce

nt

Prevalence of Treatment Delay

by Race/ethnicity

40

5

43

48

9

39

51

10

54

0

10

20

30

40

50

60

< 1month 1-3 months >3 months

White African American Latina

p<0.001

perc

ent

Sociodemographic Factors by Race/ethnicity

6

18

42

2

63

1513

34

42

6

38

19

48

41

47

18

61

11

0

10

20

30

40

50

60

70

< 45 years < H.S <$30,000 unemployed uninusured married

White African American Latina

all p’s <0.001

perc

ent

Clinical/Treatment Factors by Race/ethnicity

10

54

12

42

12

52

9

28

13

45

8

29

0

10

20

30

40

50

60

2+ comorbidities stage III chemotherapy reconstruction

White African American Latina

all p’s <0.05

perc

ent

Access Barriers by Race/ethnicity

1211

24

4

12

7

17

8

16

9

14

6

0

5

10

15

20

25

30

finding doctor getting to office schedulingsurgery

financial cost

White African American Latina

all p’s <0.05

perc

ent

Adjusted Odds of Treatment Delay (>3mo vs. < 1mo) by

Race/Ethnicity

2.1

1.7

2.6

2.1

1

10

unadjusted adjusted unadjusted adjusted

Latina vs. White African American vs. White

Model adjusts for sociodemographic, clinical/treatment, and access barriers

od

ds

rati

os

• Sociodemographic • Married*

• Clinical/Treatment • More co-morbidities• Higher cancer stage*• Chemotherapy• Breast reconstruction*

• Access Barriers • Scheduling surgical procedure*

Other Significant Correlates of Treatment Delay (> 3months*)

Conclusion

• Overall few women experienced significant treatment delay

• However, we found racial/ethnic differences in delay that are concerning

• These differences were partially explained by social, clinical/treatment, and access barriers

Implications• Providers should be aware of the potential for

treatment delay among race/ethnic minorities, and work to assist patients with navigating the health care system

• Further efforts are needed to ensure support for treatment decision making

• Ensuring information is culturally appropriate and available in different languages may improve the timely use of cancer treatment services

Thank you!!!