Breast Cancer Detection, Breast Cancer Detection, Treatment, and Survival in Treatment, and Survival in

Medicare and Medicaid Medicare and Medicaid Insured PatientsInsured Patients

Cathy J. Bradley, Ph.D.Cathy J. Bradley, Ph.D.Professor of Health AdministrationProfessor of Health AdministrationCo-leader, Cancer Prevention and Co-leader, Cancer Prevention and

Control, Massey Cancer CenterControl, Massey Cancer Center

DisparitiesDisparities25 Years Ago25 Years Ago

Trends in racial differences in breast cancer mortality Trends in racial differences in breast cancer mortality began in 1982began in 1982

Detection, treatment, & mortalityDetection, treatment, & mortality Mammography useMammography use Sentinel lymph node biopsySentinel lymph node biopsy Radiation following BCSRadiation following BCS Surveillance following diagnosis & treatmentSurveillance following diagnosis & treatment

GroupsGroups Racial/ethnic minoritiesRacial/ethnic minorities Low socioeconomic statusLow socioeconomic status Age, comorbid conditionsAge, comorbid conditions

• Appropriateness of careAppropriateness of care UninsuredUninsured Medicaid insuredMedicaid insured

Calendar vs. birth cohort trendsCalendar vs. birth cohort trends

Calendar trends reflect effects of new Calendar trends reflect effects of new medical interventionsmedical interventions

Birth cohort trends reflect alterations in risk Birth cohort trends reflect alterations in risk factorsfactors

Setting the stage: Calendar Period Setting the stage: Calendar Period Trends in Breast Cancer MortalityTrends in Breast Cancer Mortality

Source: J Clin Onc 23;7836-7841, 2005.

Birth cohort trends in breast cancer Birth cohort trends in breast cancer mortalitymortality

Source: J Clin Onc 23;7836-7841, 2005.

Trends in breast cancer mortalityTrends in breast cancer mortality

Indicates that the majority of the difference Indicates that the majority of the difference is due to gaps in use of best treatment is due to gaps in use of best treatment practices. practices.

What happened?What happened?

1980s1980s Mammography use became widespreadMammography use became widespread

1990s1990s Adjuvant care (radiation, chemotherapy) Adjuvant care (radiation, chemotherapy)

became standard of carebecame standard of care 19991999

Sentinel lymph node biopsy to devise Sentinel lymph node biopsy to devise treatment plantreatment plan

Disparate groupsDisparate groups

Racial/ethnic minoritiesRacial/ethnic minorities UninsuredUninsured Publicly insuredPublicly insured Other Other

Uncertain of benefits of detection and treatmentUncertain of benefits of detection and treatment

Complex relationship because racial/ethnic Complex relationship because racial/ethnic minorities are more likely to be uninsured or minorities are more likely to be uninsured or publicly insured.publicly insured.

African American womenAfrican American women

Literature agreesLiterature agrees Later stage at diagnosisLater stage at diagnosis Less likely to receive surgery and adjuvant careLess likely to receive surgery and adjuvant care Less likely to have SLNBLess likely to have SLNB

ControversyControversy Equal treatment, controlling for stage, no survival Equal treatment, controlling for stage, no survival

differences (Bradley et al., 2002; Du et al., 2008). differences (Bradley et al., 2002; Du et al., 2008). Some researchers find that survival disadvantages Some researchers find that survival disadvantages

persist for African American women even after persist for African American women even after controlling for SES.controlling for SES.

Elderly dually eligible womenElderly dually eligible women(Low-income, publicly insured)(Low-income, publicly insured)

More likely to be diagnosed at later stageMore likely to be diagnosed at later stage Nearly 3x more likely to be diagnosed at a later stage Nearly 3x more likely to be diagnosed at a later stage

(Bradley et al., 2007).(Bradley et al., 2007).

Less likely to receive treatment – surgery, Less likely to receive treatment – surgery, chemotherapy, radiation – within 6 months chemotherapy, radiation – within 6 months following diagnosis relative to women on following diagnosis relative to women on Medicare.Medicare.

Longer time from diagnosis to treatmentLonger time from diagnosis to treatment Shorter survival period (Bradley et al., 2002)Shorter survival period (Bradley et al., 2002)

UninsuredUninsured

Disparities across all outcomesDisparities across all outcomes StageStage TreatmentTreatment MortalityMortality

DisparitiesDisparitiesNOWNOW

No decrease in racial disparities in treatment No decrease in racial disparities in treatment from 1992 to 2002 (Gross et al., 2008). from 1992 to 2002 (Gross et al., 2008).

Dually eligible women are less likely to be Dually eligible women are less likely to be treated than Medicare only women.treated than Medicare only women.

Wealthy women are more likely to have a Wealthy women are more likely to have a mammogram, even when their life expectancy is mammogram, even when their life expectancy is short (Williams et al., 2008).short (Williams et al., 2008).

Regardless of outcome or controls for patient Regardless of outcome or controls for patient characteristics, differences between insured and characteristics, differences between insured and uninsured persist.uninsured persist.

ImplicationsImplications

Small amount of gap can be closed by better Small amount of gap can be closed by better defining when screening & treatment is defining when screening & treatment is beneficial (efficiency).beneficial (efficiency).

Provide better insurance coverage may close Provide better insurance coverage may close the gap further.the gap further.

However, disparities in publicly insured still However, disparities in publicly insured still persist.persist. Patient educationPatient education Physician/patient communicationPhysician/patient communication Shift to a preventive modelShift to a preventive model

ChallengesChallenges

Provision of technology and treatment Provision of technology and treatment advancements to low-income and advancements to low-income and racial/ethnic minorities. racial/ethnic minorities.

Absence of health insurance.Absence of health insurance. Assessing when treatment can benefit Assessing when treatment can benefit

somewhat high risk patients (older, somewhat high risk patients (older, patients with comorbid conditions).patients with comorbid conditions).