Receipt of Guideline-Concordant Care Does Not Explain Breast Cancer Mortality Disparities by Race in Metropolitan Atlanta

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  • 1 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia;
  • | 2 Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah;
  • | 3 Winship Cancer Institute, Emory University, and
  • | 4 Emory University School of Medicine, Atlanta, Georgia; and
  • | 5 Department of Biostatistics and Bioinformatics, and
  • | 6 Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Background: Racial disparities in breast cancer mortality in the United States are well documented. Non-Hispanic Black (NHB) women are more likely to die of their disease than their non-Hispanic White (NHW) counterparts. The disparity is most pronounced among women diagnosed with prognostically favorable tumors, which may result in part from variations in their receipt of guideline care. In this study, we sought to estimate the effect of guideline-concordant care (GCC) on prognosis, and to evaluate whether receipt of GCC modified racial disparities in breast cancer mortality. Patients and Methods: Using the Georgia Cancer Registry, we identified 2,784 NHB and 4,262 NHW women diagnosed with a stage I–III first primary breast cancer in the metropolitan Atlanta area, Georgia, between 2010 and 2014. Women were included if they received surgery and information on their breast tumor characteristics was available; all others were excluded. Receipt of recommended therapies (chemotherapy, radiotherapy, endocrine therapy, and anti-HER2 therapy) as indicated was considered GCC. We used Cox proportional hazards models to estimate the impact of receiving GCC on breast cancer mortality overall and by race, with multivariable adjusted hazard ratios (HRs). Results: We found that NHB and NHW women were almost equally likely to receive GCC (65% vs 63%, respectively). Failure to receive GCC was associated with an increase in the hazard of breast cancer mortality (HR, 1.74; 95% CI, 1.37–2.20). However, racial disparities in breast cancer mortality persisted despite whether GCC was received (HRGCC: 2.17 [95% CI, 1.61–2.92]; HRnon-GCC: 1.81 [95% CI, 1.28–2.91] ). Conclusions: Although receipt of GCC is important for breast cancer outcomes, racial disparities in breast cancer mortality did not diminish with receipt of GCC; differences in mortality between Black and White patients persisted across the strata of GCC.

Submitted May 18, 2020; final revision received November 18, 2020; accepted for publication December 2, 2020. Published online August 16, 2021.

Author contributions: Study concept and design: Collin, McCullough. Methodology: Collin, Gogineni, Subhedar, Lipscomb, Torres, Lin, McCullough. Data analysis, curation, and interpretation: Collin, Yan, Jiang, Ward, Switchenko, Miller-Kleinhenz, McCullough. Funding acquisition: Ward, McCullough. Writing – first draft: Collin, McCullough. Writing - review and editing: All authors.

Disclosures: Dr. Gogineni has disclosed serving on an advisory board for Pfizer and Lilly, and receiving institutional research funding from Pfizer, Calithera, and Merck. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This work was supported in part by the Cancer Prevention and Control Research program and the Winship Research Informatics shared resources, a core supported by the Winship Cancer Institute of Emory University. Dr. Collin was supported by the NCI of the NIH under award number F31CA239566. The collection of cancer incidence data used in this study was supported by contract number HHSN261201800003I, task order number HHSN26100001 from the NCI, and cooperative agreement number 5NU58DP003875-04 from the CDC.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The findings and conclusions are those of the authors and do not necessarily represent the official position of their affiliations or the CDC.

Correspondence: Lauren E. McCullough, PhD, Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322. Email: lauren.mccullough@emory.edu

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