Single, Older Women Less Likely to Receive Guideline- Recommended Treatment for Breast Cancer in Rural Georgia

Neil Canavan

June 2013, Vol 4, No 5 - Economics of Cancer Care

New Orleans, LA—Researchers looking at whether guideline-directed adjuvant treatments for breast cancer were actually being administered in rural areas of the United States found that only 41% of the patients in this study received all of the suggested treatment modalities for breast cancer. Being single and advancing in age were negative predictors for receiving guideline-based care.

“Identifying and addressing modifiable factors that lead to nonguideline concordant treatment may reduce disparities in treatment and improve cancer outcomes,” stated Gery P. Guy Jr, PhD, MPH, and colleagues, Emory University, Rollins School of Public Health, GA. Dr Guy presented the results of this study at the 2013 International Society for Pharma­co­economics and Outcomes Research annual conference.

Dr Guy and his team reviewed the medical records of 845 women with breast cancer who were treated at cancer centers in southwest Georgia, a relatively unstudied population.

The guideline-recommended treatment modalities reviewed included:

  • Adjuvant chemotherapy
  • Adjuvant radiation therapy
  • Adjuvant hormonal therapy
  • All 3 adjuvant treatments jointly.

The study population was largely (70%) white, roughly 50% of the women were married, 70% had private insurance, 50% were below the poverty level, and most of them lived in a rural area. The vast majority of the patients were diagnosed with early-stage (I-II) breast cancer, 66% had undergone a mastectomy, and 76% were hormone receptor–positive.

Disparities in Care
Results showed that although only 41% of the patients were managed with all 3 treatment modalities in accordance with current guidelines, the use of a specific treatment varied considerably:

  • Chemotherapy was used as recommended 63% of the time
  • Adjuvant radiation was used as recommended 81% of the time
  • Hormonal therapy was used 78% of the time.

Patients with higher socioeconomic status were 3 times more likely to receive all guideline-concordant adjuvant treatments for breast cancer, and patients with Medicaid insurance were 4 times as likely to receive the appropriate adjuvant chemotherapy compared with uninsured patients.
The likelihood of being guideline concordant for adjuvant chemotherapy and adjuvant radiation therapy decreased by 50% for women who were unmarried; increasing age was also a negative predictor of appropriate care.

The investigators noted that they were unable to control for patient or physician attitudes and preferences that may have impacted care; some patients do not want to be aggressively treated, and some oncologists are wary of guidelines. They also did not look at the level of education for this patient cohort.

A number of recent studies have shown that not adhering to consensus guidelines is associated with increased rates of cancer recurrence (and subsequent mortality). Identifying modifiable reasons why guideline-recommended adjuvant treatments are unused and embracing the drivers for enhanced compliance with treatment guidelines may reduce treatment disparities and improve outcomes, the investigators suggest.