Socio-economic barriers preclude patients from receiving breast conserving therapy

Overall rates improve, yet researchers identify socio-economic barriers that preclude women from receiving breast-conserving therapy

Despite its acceptance as standard of care for early stage breast cancer almost 25 years ago, barriers still exist that preclude patients from receiving breast conserving therapy (BCT), with some still opting for a mastectomy, according to research from The University of Texas MD Anderson Cancer Center.

The study, to be presented at the 2014 Breast Cancer Symposium, finds that those barriers that still exist are socio-economic, rather than medically-influenced. Meeghan Lautner, M.D., formerly a fellow at MD Anderson, now at The University of Texas San Antonio, will present the findings.

BCT for early stage breast cancer includes breast conserving surgery, followed by six weeks of radiation. It has been the accepted standard of care for early stage breast cancer since 1990 when randomized, prospective clinical trials confirmed its efficacy -- leading to the National Institute of Health issuing a consensus statement. Yet, a number of patients still opt for a mastectomy. In hopes of ultimately democratizing care, it was important to look at surgical choices made by women and their association with disparities, explains Isabelle Bedrosian, M.D., associate professor, Surgical Oncology at MD Anderson.

"What's particularly novel and most meaningful about our study is that we looked at how the landscape has changed over time," says Bedrosian, the study's senior author. "We hope this will help us understand where we are and are not making progress, as well as identify the barriers we need to overcome to create equity in the delivery of care for our patients."

For the retrospective, population-based study, the MD Anderson team used the National Cancer Database, a nation-wide outcomes registry of the American College of Surgeons, the American Cancer Society and the Commission on Cancer that captures approximately 70 percent of newly-diagnosed cases of cancer in the country. They identified 727,927 women with early-stage breast cancer, all of whom were diagnosed between 1998 and 2011 and had undergone either BCT or a mastectomy.

Overall, the researchers found that BCT rates increased from 54 percent in 1998 to 59 percent in 2006, and stabilized since then. Adjusting for demographic and clinical characteristics, BCT use was more common in women: age 52-61 compared to younger or older patients; with a higher education level and median income; with private insurance, compared to those uninsured; and who were treated at an academic medical center versus a community medical center.

Geographically, BCT rates were higher in the Northeast than in the South, and in those women who lived within 17 miles of a treatment facility compared to those who lived further away.

An important question to then ask, says Bedrosian, was to compare barriers for women receiving BCT in 1998 to 2011 -- and understand how have those barriers changed. The researchers found that, overall, usage of BCT has dramatically increased across all demographic and clinical characteristics, however, significant disparities related to insurance, income and distance to a treatment facility still exist.

Bedrosian is gratified to see that in the areas where physicians and the medical field can make a direct impact -- such as geographic distribution and practice type -- disparities have equalized over time. However, she notes that factors outside the influence of the medical field, such as insurance type, income and education, still remain. Of great interest is the insurance disparity, says Bedrosian.

"Now with healthcare exchanges providing new insurance coverage options, will we rectify the disparity and overall increase BCT use? We will have wait to see," she says.

Bedrosian hopes that health policy makers will take note of the findings and barriers related to women receiving BCT and make appropriate changes to democratize care.