The Role of Health Literacy in Breast Cancer Treatment and Outcomes

BACKGROUND: Breast cancer treatment is complex, incorporating multimodality and preference-sensitive treatments dependent on oncologic characteristics, patient understanding, and shared decision-making. Health literacy (HL) is a key determinant of health in chronic disease, yet its impact in breast cancer remains undefined. This study evaluated the association of HL with receipt of breast cancer care and oncologic outcomes. PATIENTS AND METHODS: We performed a retrospective cohort study of patients with breast cancer diagnosed from 2005 to 2022 at a tertiary care referral center. Surgical treatment was categorized as breast conservation therapy versus mastectomy, contralateral prophylactic mastectomy, and postmastectomy reconstruction. Multivariable logistic regression and Cox proportional hazard models were used to assess associations with treatment, overall survival, and recurrence-free survival. RESULTS: Among 3,579 patients with breast cancer, the mean SD Brief Health Literacy Screen (BHLS) score was 13.9 2.1 (range, 3-15). Patients with low HL tended to be older (median age, 64 vs 58 years), non-White (21.3% vs 14.3%), and less likely to have private insurance (27.6% vs 55.6%). Adjusted for patient characteristics, higher BHLS score was protective against presenting with later-stage disease (adjusted odds ratio aOR, 0.87; 95% CI, 0.85-0.91). Higher HL was also independently associated with an increased odds of undergoing prophylactic contralateral mastectomy (aOR, 1.07; 95% CI, 1.01-1.13) and reconstruction (aOR, 1.10; 95% CI, 1.03-1.16). There was no difference in receipt of breast conservation therapy versus mastectomy (aOR, 0.98; 95% CI, 0.94-1.02). Higher HL was associated with a decreased risk of all-cause mortality (adjusted hazard ratio aHR, 0.91; 95% CI, 0.89-0.94) and decreased risk of recurrence (aHR, 0.92; 95% CI, 0.87-0.97). CONCLUSIONS: HL is associated with stage at presentation, surgical treatment, and survival in breast cancer. These findings highlight the importance of HL in shared decision-making for breast cancer. Assessing and addressing HL in breast cancer care has the potential to contribute to early detection, treatment decisions, and survival outcomes.