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, with some patients still opting for a mastectomy, according to research from The University of Texas MD Anderson Cancer Center and presented recently at the 2014 Breast Cancer Symposium in San Francisco.
The study found the barriers that exist are socioeconomic, rather than medically-influenced. Meeghan Lautner, MD, formerly a Fellow at MD Anderson Cancer Center and now at The University of Texas San Antonio presented the group’s findings.1
Breast-conserving therapy for early-stage breast cancer includes surgery, followed by 6 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, said Isabelle Bedrosian, MD, 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,” said Dr. 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.”
National Cancer Database Used in Study
For the retrospective, population-based study, the MD Anderson team used the National Cancer Database, a nationwide outcomes registry of the American College of Surgeons, the American Cancer Society, and the Commission on Cancer that captures approximately 70% 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 breast-conserving therapy or a mastectomy.
Overall, the researchers found that breast-conserving therapy rates increased from 54% in 1998 to 59% in 2006, and stabilized since then. Adjusting for demographic and clinical characteristics, breast-conserving therapy use was more common in women aged 52 to 61 compared to younger or older patients, those with a higher education level and median income, those with private insurance, compared to those uninsured, and in those who were treated at an academic medical center vs a community medical center.
Geographically, breast-conserving therapy 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.
How Have Barriers Changed With Time?
An important question to then ask, said Dr. Bedrosian, was to compare barriers for women receiving breast-conserving therapy in 1998 to 2011 and understand how have those barriers changed. The researchers found that, overall, usage of breast-conserving therapy has dramatically increased across all demographic and clinical characteristics, however, significant disparities related to insurance, income, and distance to a treatment facility still exist.
Dr. Bedrosian was 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 noted 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, said Dr. Bedrosian.
“Now with health-care exchanges providing new insurance coverage options, will we rectify the disparity and overall increase breast-conserving therapy use? We will have wait to see,” she says.
Dr. Bedrosian hopes that health policymakers will take note of the findings and barriers related to women receiving breast-conserving therapy and make appropriate changes to democratize care. ■
Disclosure: The study was institutionally funded. Drs. Lautner and Bedrosian reported no potential conflicts of interest.
In addition to Drs. Bedrosian and Lautner, other MD Anderson authors on the study included Heather Y. Lin, PhD, and Yu Shen, PhD, both Biostatistics; Henry Kuerer, MD, PhD, and Gildy Babiera, MD, both Surgical Oncology; and Simona Flora Shaitelman, MD, Radiation Oncology. Catherine Parker, MD, formerly a Fellow at MD Anderson, also contributed to the findings.
