Investigating Disparities in Early Breast Cancer Care

Announcer:
You’re listening to Breaking Boundaries in Breast Cancer on ReachMD, sponsored by Lilly. Here’s your host, Dr. Charles Turck.

Dr. Turck:
Breast cancer mortality rates have decreased by 40 percent from 1989 to 2017, which is a true testament to the advanced therapeutic options that have become available over the years. But unfortunately, not all women have benefited from these improvements. That’s why today we’ll be investigating this troubling pattern and what’s being done to help eliminate the disparity. This is Breaking Boundaries in Breast Cancer on ReachMD. I’m Dr. Charles Turck, and joining me to discuss treatment differences and disparities among early breast cancer patients is Dr. Mariana Chavez MacGregor, Associate Professor at the University of Texas MD Anderson Cancer Center. She also recently spoke about this topic at the 2020 San Antonio Breast Cancer Symposium. Dr. Chavez MacGregor, welcome to the program.

Dr. Chavez MacGregor:
Thank you. Pleasure to be here.

Dr. Turck:
Now, Dr. Chavez MacGregor, there’s no denying that there’s been a decline in breast cancer mortality rates in recent years, but would you share with our audience why that’s not the full story?

Dr. Chavez MacGregor:
Of course. As you mentioned, over the last decades, the outcomes of breast cancer patients have improved. We, today, have better treatment, have a more organized multi-disciplinary approach to the treatment of breast cancer. As you know, breast cancer is the most common cancer in women, and therefore it’s an important health care problem. Now what we have seen, and this has been consistently reported, is that these benefits and our new treatments are not equally distributed, meaning the benefits in survival are not equally benefitting all the population. We know, very clearly, that when we compare whites with other racial and ethnic minorities, particularly black patients have higher risk of dying of breast cancer, and made them comparable in terms of age, stage, and breast cancer subtype. So, as you said, the breast cancer mortality rates are declining, but they’re not declining the same for all.

Dr. Turck:
Are there certain groups of women who are at higher risk of breast cancer and who are less likely to receive prompt treatment?

Dr. Chavez MacGregor:
There are women that are at higher risk of breast cancer, based on risk factors, family history or some genetic factors. However, I think the challenge is not only identifying these high-risk individuals, but also how we just make sure that women with breast cancer in the general population receive promptly treatment, and of course, before treatment, diagnosis. We know that women, again, belonging to racial and ethnic minorities, particularly blacks and Hispanics, are less likely to participate in screening campaigns. They are less likely to undergo regular checkups, and they’re more likely to present with more advanced stages. It is clearly demonstrated through epidemiological data that blacks are more likely to have highly proliferative tumors that are more aggressive. However, we don’t think that black patients present with more advanced stages just because they have more aggressive tumors. There is also a component of not getting diagnosed timely. And in some of these same groups are the ones that we have seen that are more likely to delay initiation of treatment, not only surgery, but also chemotherapy. Some of the work that I have done has helped identify, together with the valuable work from other groups, that women belonging to low socioeconomical strata, lower educational levels, and those of black or Hispanic background are more likely to have delays in diagnosis and also more likely, after diagnosis, to have a delay in treatment initiation, which also will have an impact in outcomes.

Dr. Turck:
And within these groups specifically looking at patients who are diagnosed with early breast cancer, what barriers prevent them from receiving a timely diagnosis and treatment?

Dr. Chavez MacGregor:
I really think this is a very complex question to answer. Clearly, the factors associated with timely diagnosis and treatment are multi-factorial. There are important social determinants of health that play an important role, and we should understand these social determinants of health as all those factors that determine where we live, where we work, where we play, right? Everything that surrounds the life of the individual, and you could think that women with transportation issues are not going to be likely to go to their appointments, or those that live in unsafe neighborhoods may not be able to go out for a walk and be more fit, or have more likely higher odds of being obese, etcetera. So there are all those factors that will, for sure, play an important role. There are, of course, factors related to the health care system that can make us delay the diagnosis and the initiation of treatment  related, of course, to lack of insurance, but also the complexities of navigating a very complicated at times, health care system, or going from one doctor to referral to the other. There are factors related to the patient’s own comorbidities, so women that maybe has poorly controlled diabetes, or some cardiac disease that needs to be optimized before her going into surgery or chemotherapy can, you know, delay diagnosis and treatment. And of course, there is the patient itself. I have had patients that have, you know, received two – three – four second opinions, trying to, you know, make the best decisions for themselves, but that as a personal choice can also cause delays. So I think it’s very hard to pinpoint at one cause of treatment delays, but clearly the sociodemographic factors associated with poverty to raise, to insurance access are determinant. And my group and a number of other groups are really trying to understand better why are women delaying the initiation of cancer treatment. I think this is a population that it’s easier to intervene on, right? Because these are women that will already have a diagnosis on. Some of them already are going to surgery. These patients that already having a diagnosis and being part of the health care system, how we can accelerate or avoid the delays. What my group, and several other groups, have been doing is try to really focus on the delay in initiation of treatment after breast cancer diagnosis, since it’s a group of patients that it’s more easy to identify, and really try to work with more vulnerable populations, with higher risk groups, to intervene, right? Try to pilot different interventions that can help us move these patients faster through the cancer treatment journey. But I cannot emphasize enough the importance of addressing this important topic from a multi-dimensional perspective, because  we do need to provide easier and better access to all patients, so everybody can be benefitted the same way from our new therapies.

Dr. Turck:
And just as a quick follow-up to that, Dr. Chavez MacGregor, what are some of the consequences of these barriers and delays for early breast cancer patients?

Dr. Chavez MacGregor:
Thank you for asking that. I think some of the consequences relate to, of course, different experience throughout the cancer journey. Women that get delays can have a worse experience compared to those that have a more smooth transition from one treatment to the other. But ultimately, what we have seen is that treatment delays are associated with worse outcomes. Consistently, we have seen that delays from the initial diagnosis to surgery — every 30-day delay is associated with small, but they can add on, worsening in overall survival. The work that I have done has clearly demonstrated that a time, from surgery to the first dose of chemotherapy, greater than 90 days is associated with worse breast cancer specific survival, and overall survival. So we are affecting the outcomes of our patients. And going back to your first question — to what degree this can help us understand some of those disparities in terms of mortality that we talked at the beginning — I think it’s clearly a piece of the puzzle. I cannot say that treatment delays are the only reason why certain populations are not benefiting equally from our treatments, but I do believe that it’s a piece to this very complex  situation, that clearly affects the lives of the individual, in the case our patients, but also their families, communities and the society as a whole.

Dr. Turck:
For those just tuning in, you’re listening to Breaking Boundaries in Breast Cancer on ReachMD. I’m Dr. Charles Turck, and today I’m speaking with Dr. Mariana Chavez MacGregor, about the health care disparities experienced by patients with early breast cancer. Now Dr. Chavez MacGregor, based on our discussion, we know that these disparities can have severe consequences on our patients with early breast cancer, but how might recent policy changes such as the Medicaid expansion  help combat these disparities.

Dr. Chavez MacGregor:
When we think about disparities, as might not surprise the audience, of course access to care is very important. And as recently as the Affordable Care Act was instituted, Medicaid expansion was selected by different states, what we have seen is that providing access to health care can improve, or at least decrease the gap between, certain racial and ethnic groups, particularly white and blacks. Me and my group, we have done some work evaluating the impact of Medicaid expansion, and determining the rate of treatment delays, pre-Medicaid expansion and post-Medicaid expansion, doing some complex difference and difference analysis to try to see if the gap between blacks and whites was decreased. And what we have seen is that actually this access to care, it’s decreasing the gap. So I think policy can help us. Again, I don’t think it’s gonna be a single-sided solution. We need to tackle this problem from a multidimensional perspective, but without a doubt, if through health policy we can improve the access to health care, patients are gonna be able to receive the treatments  hopefully in a more timely manner, and ultimately improve their outcomes.

Dr. Turck:
And looking ahead, Dr. Chavez MacGregor, what would you like to see changed or modified, and what are the necessary steps to help us better combat these disparities seen in early breast cancer?

Dr. Chavez MacGregor:
What I would like to see, of course, is all our breast cancer patients being cured for the disease. And as we improve those treatments, I would like to see that every single woman has access to the best therapies and can benefit the same way from our treatment and our multidisciplinary management. So that’s what I would like to see. Of course, we need to keep moving our field forward with our treatments and recognize that this disparity exists. I think having this conversation, it’s a step in the right direction. We need to start working individually with our own biases. There’s clear descriptions that decisions have implicit bias that can affect treatment. We need to work in our centers, in our institutions to make sure that we reach everybody in the community. We clearly, as related to your last question, need to support policy changes that are gonna give improved access to everybody. We do have to tackle this involving community leaders, because we need to implement strategies that are gonna be well-received by communities that may have issues trusting physicians or trusting the health care systems, since they have been historically been discriminated.

Dr. Turck:
Well, as we come to the end of today’s program, I think it’s become clear that while we’ve made great strides in certain areas of breast cancer care, there’s still more work to be done. And I want to thank my guest, Dr. Mariana Chavez MacGregor, for joining me to discuss how we can better combat the disparities seen among patients with early breast cancer. Dr. Chavez MacGregor, it was great having you on the program.

Dr. Chavez MacGregor:
Thank you so much for the invitation. It was my pleasure.

Announcer:
You’ve been listening to Breaking Boundaries in Breast Cancer sponsored by Lilly. To revisit any part of this discussion and to access other episodes of this series, visit reach-m-d-dot-com, where you can Be Part of the Knowledge. Thanks for listening.