Socioeconomic status and race could play a role in treatment decisions, according to new research.
Breast cancer is one of the most common cancers among women in the U.S. It’s also the most costly cancer to treat. Now, researchers at the NCI-designated Sidney Kimmel Cancer Center (SKCC) at Jefferson have shown that although the use of an effective and less expensive treatment is on the rise, some patients, specifically Black women and those without private insurance are offered the beneficial therapy less often. The findings pave the way for reducing healthcare costs and increasing patient satisfaction.
“We have identified patient populations at risk of not receiving a beneficial and more cost-effective therapy,” says Dr. Alliric Willis, a surgical oncologist and associate professor of surgery at Sidney Kimmel Medical College, who led the study along with his research team from SKCC and the College of Population Health at Thomas Jefferson University.
“This research really illustrates that not all patients are being treated equally,” says Dr. Willis, who published the results online September 12, 2020 in the International Journal of Radiation Oncology Biology Physics, also known as the Red Journal.
Standard breast-conserving cancer treatment involves surgery followed by radiation therapy, which helps to lower the risk of cancer recurring in the treated breast. Traditionally, patients receive 25 to 30 daily radiation treatments over five to six weeks. In recent years, however, doctors have begun using an alternative radiation treatment plan known as hypofractionated whole breast radiation (HR).
Patients should have access to all treatment options no matter their race, socioeconomic background or where they seek care.
— Dr. Alliric Willis
HR uses a higher radiation dose per treatment than the traditional regimen. The higher dose means patients require about half as many treatment sessions –15 to 16 treatments over three to four weeks – to achieve the same total dose. Compared with traditional radiation therapy, the approach is just as effective at reducing the risk of the cancer returning, more cost-effective and offers patients fewer side effects and better breast restoration outcomes following treatment.
“Despite the fact that both patients and practitioners say they prefer hypofractionated radiation because of its efficacy and better cosmetic outcomes, HR use in the U.S., while increasing, has lagged for particular groups,” Dr. Willis says.
To better understand who is at risk of missing out on the valuable therapy, Dr. Willis and colleagues turned to the National Cancer Database. The researchers examined data from nearly 260,000 early-stage breast cancer patients over 40 years old who were diagnosed between 2012 and 2016. All patients studied had received radiation treatment following breast conserving surgery. The researchers looked at demographics, tumor attributes and treatment facility characteristics between patients who received either HR or traditional radiation. These efforts are part of a larger group of SKCC research endeavors intended to understand and mitigate cancer disparities.
The investigation revealed that HR use increased over the four-year study period, from about a quarter of eligible patients in 2012 to more than two-thirds in 2016. Despite the upward trend, the analysis uncovered marked disparities among those who received HR therapy. Patients who identified as white were most likely to receive HR, whereas HR use was lowest for African Americans, for example.
“When we took all other factors into account, African American women were 15% less likely to be treated with HR than white women,” Dr. Willis says. “This demonstrates that even though treatment guidelines do not take race into account, race is a factor in breast cancer treatment.”
Socioeconomic status also affected those who received HR therapy. Patients with private insurance were more likely to receive HR than uninsured patients or those on Medicaid, according to the study. In addition, patients who lived in zip codes with the highest income levels were 25% more likely to undergo HR than patients from zip codes in the lowest income category.
Where patients sought care made a difference in their treatment, too. Treatment facilities associated with academic medical centers were twice as likely to use HR as community cancer or integrated network cancer facilities.
“This tells us that there is a need to actively communicate information to healthcare providers about the spectrum of treatment options across all facility types,” Dr. Willis says.
“These types of studies are critical for achieving equity in cancer care, and we are proud that the Sidney Kimmel Cancer Center’s Program in Cancer Risk and Control is focused on all aspects of improving cancer outcomes, including analysis of care delivery,” says Dr. Karen E. Knudsen, who directs the Sidney Kimmel Cancer Center. “Our core mission is to improve the lives of cancer patients and their families.”
Dr. Willis hopes that this research will shine light on treatment inconsistencies and motivate physicians to expand their treatment repertoire.
“Patients should have access to all treatment options no matter their race, socioeconomic background or where they seek care,” he says. “Hopefully, our research will help to address gaps in provider education and extend this favorable treatment to all patients.”