Review
Breast cancer disparities and decision-making among U.S. women

https://doi.org/10.1016/j.pec.2006.06.003Get rights and content

Abstract

Objective

The impact of breast cancer is immense for all women, but the literature reveals an even greater impact on women of color and among socially and economically disadvantaged populations. Persistent differences in incidence and outcome are undoubtedly due to multiple factors, but one element in poor outcome may be treatment choice. Those treatments shown to be related to best outcomes are less likely to be chosen by certain groups of women. The effects of economic and cultural factors on breast cancer treatment choice have not been thoroughly explored; these factors must be understood if health care professionals are to intervene effectively to address disparities and improve breast cancer outcomes for all women.

Methods

A review of the breast cancer literature was conducted in order to: (1) describe breast cancer disparities in the United States; (2) delineate factors that might contribute to those disparities; (3) assess possible mitigating factors for predominant causes; (4) begin to decide how health care interventions might allay the factors that contribute to disparities in breast cancer incidence and mortality.

Results

Breast cancer incidence and outcome disparities in the United States are due to multiple interacting factors. These include information about treatment, different types of treatment, the emotional context of decision-making, and patient preference for level of involvement. Treatment decision-making is complex.

Conclusion

Health literacy and level of decision-making involvement, both embedded in social and economic reality, are key components in breast cancer treatment decision-making and may contribute to breast cancer disparities in the United States. Current models of shared decision-making may not be generalizable to all breast cancer patients.

Practice implications

Optimal breast cancer outcomes for all women depend on culturally and ethnically appropriate professional support.

Introduction

With widely available screening for early detection and definitive therapy with tested agents, breast cancer need not be a universally lethal diagnosis. Yet breast cancer levies a high cost for women, particularly those in the ethnically and economic diverse populations least likely to be health literate. Not only can screening measures be underused and ineffective in these communities, but socioeconomic, racial, and ethnic disparities persist in the use of the best evidence-based treatments (with the best outcomes) for diagnosed breast cancer [1], [2], [3], [4], [5].

Treatment decisions are complex for those fortunate women and families who have access to care, have health care coverage, and who possess adequate knowledge and skill in navigating the health care delivery system. For women who struggle with any of these factors, the task is even more troublesome. It is appreciated that treatment decisions are complex and linked to patient outcomes, but the interactive decision-making process between the patient, family, and health care team has not been studied in depth among those populations likely to have the poorest outcomes. Moreover, the role of treatment decision-making in contributing to breast cancer disparities is poorly understood. This paper serves to explore disparities in treatment and decision-making in U.S. women, specifically women of color, women who are disadvantaged, and minority women.

Section snippets

Methods

In the context of a larger project, searches were conducted on major health care databases (including MEDLINE, PubMed, OVID, and CINAHL), to identify articles concerning breast cancer (including incidence, treatment, and outcomes) in all populations of women. English language articles concerning breast cancer published in refereed medical, nursing, health education, epidemiology, and public health journals were included in the initial review. Reference lists were then used to pull past articles

Findings

The findings from this search resulted in several themes. These are described in detail below and include breast cancer disparities in the United States across ethnic and socioeconomic groups; treatment disparities; decision-making about treatment, level of involvement in the decision-making process; and the complexity of decision-making.

Discussion

Emerging patterns of complex interactions between health status, health care access and delivery, and decision-making create a maze of possibilities in which women tend to preserve their own identities and preferences, independent of the health care authority hierarchy. The health care system is not easy to use for anyone, and the fewer resources a women and her family have, the less manageable the system will be for extended periods of intervention. One would wonder if mistrust in the medical

References (84)

  • M.A. Gilligan et al.

    Persistent differences in sociodemographic determinants of breast conserving treatment despite overall increased adoption

    Med Care

    (2002)
  • Center to Reduce Cancer Health Disparities Website, available at http://www.crchd.nci.nih.gov/, accessed February 10,...
  • A. Jemal et al.

    Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival

    Cancer

    (2004)
  • J. Jacobellis et al.

    Mammography screening and differences in stage of disease by race/ethnicity

    Am J Public Health

    (2002)
  • C.I. Li et al.

    Differences in breast cancer stage, treatment, and survival by race and ethnicity

    Arch Intern Med

    (2003)
  • N.U. Ahmed et al.

    Empowering factors in mammography: insights from the stoires of underserved women

    J Ambulatory Care Manage

    (2004)
  • E.J. Bailey et al.

    Using cultural beliefs and patterns to improve mammography utilization among African-American Women: the witness project

    J Natl Med Assoc

    (2000)
  • K.C. Chu et al.

    Racial disparities in breast carcinoma survival rates: separating factors that affect diagnosis from factors that affect treatment

    Cancer

    (2003)
  • Z. Huang et al.

    Waist circumference, waist:hip ratio, and risk of breast cancer in the Nurses’ Health Study

    Am J Epidemiol

    (1999)
  • J.Z. Ayanian et al.

    The relation between health insurance coverage and clinical outcomes among women with breast cancer

    New Engl J Med

    (1993)
  • M.T. Bassett et al.

    Social class and Black–White differences in breast cancer survival

    Am J Public Health

    (1986)
  • J.S. Mandelblatt et al.

    Determinants of late-stage diagnosis of breast and cervical cancer: the impact of age, race, social class, and hospital type

    Am J Public Health

    (1991)
  • L.S. McGinnis et al.

    National Cancer Data Base survey of breast cancer management for patients from low income zip codes

    Cancer

    (2000)
  • V.L. Staradub et al.

    Factors that influence surgical choices among women with breast carcinoma

    Cancer

    (2002)
  • R.G. Roetzheim et al.

    Effects of health insurance and race on breast carcinoma treatments and outcomes

    Cancer

    (2000)
  • M. Adams-Cameron et al.

    Trends in incidence and treatment for ductal carcinoma in situ in Hispanic, American Indian, and non-Hispanic White women in New Mexico

    Cancer

    (1999)
  • D. Lazovich et al.

    Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma

    Cancer

    (1999)
  • A.B. Nattinger et al.

    Geographic variation in the use of breast-conserving treatment for breast cancer

    New Engl J Med

    (1992)
  • B.B. Tarbox et al.

    Are modified radical mastectomies done for T1 breast cancers because of surgeon's advice or patient's choice?

    Am J Surg

    (1992)
  • K.S. Elward et al.

    Variation in the use of breast-conserving therapy for Medicare beneficiaries in Virginia: clinical, geographic, and hospital characteristics

    Clin Perform Qual Health Care

    (1998)
  • G. Maskarinec et al.

    The use of breast conserving surgery: linking insurance claims with tumor registry data

    BMC Cancer

    (2002)
  • K.L. Mcvea et al.

    Low-income women with early-stage breast cancer: physician and patient decision-making styles

    Psycho-Oncology

    (2001)
  • S. Saha et al.

    Physician–patient relationships and racial disparities in the quality of health care

    Am J Public Health

    (2003)
  • R.A. Silliman et al.

    The impact of age, marital status, and physician–patient interactions on the care of older women with breast carcinoma

    Cancer

    (1997)
  • S. Benedict et al.

    Factors influencing choice between mastectomy and lumpectomy for women in the Carolinas

    J Surg Oncol

    (2001)
  • J.S. Mandelblatt et al.

    Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences

    Cancer

    (2000)
  • A.B. Nattinger et al.

    Effect of Nancy Reagan's mastectomy on choice of surgery for breast cancer

    J Am Med

    (1998)
  • M. Blichert-Toft et al.

    A Danish randomized trial comparing breast-preserving therapy with mastectomy in mammary carcinoma

    Acta Oncol

    (1988)
  • B. Fisher et al.

    Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer

    New Engl J Med

    (1985)
  • U. Veronesi et al.

    Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast

    New Engl J Med

    (1981)
  • N.I.o.H.C.D. Panel

    Treatment of early-stage breast cancer

    Natl I Health Consensus Dev Conf Statement

    (1990)
  • B. Fisher et al.

    Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer

    New Engl J Med

    (2002)
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