Exploring delay in treatment initiation among Black and white patients with breast cancer

Background: Black patients with breast cancer experience worse disease outcomes and higher mortality rates compared to white patients, and this may be driven by the disparity in delayed initiation of treatment. This study aimed to 1) measure the time elapsed from diagnosis to initiation of first and second breast cancer treatments, and to compare these durations by race, stage of diagnosis and treatment modality, 2) identify patient facilitators and barriers to initiating treatment, and 3) explore whether patient-provider communication influenced time to treatment initiation. Methods: This mixed-methods prospective study was conducted at Temple University Health System and had two components: 1) a chart review of Black and white women newly diagnosed with Stage I through III breast cancer, which collected dates of diagnosis, initiation of first treatment modality, and initiation of second treatment modality, and 2) a case-series of patients, drawn from the chart review, who were interviewed soon after initiating their first treatment after diagnosis. Interviews explored which factors influenced decision-making and time to treatment initiation and included administration of validated scales measuring patients’ cancer health literacy, information overload, trust in their physician, relational communication with their physician, and breast cancer self-efficacy. Themes that emerged from the interviews pertained to contextual details surrounding the diagnosis; the challenges (emotional and logistic), as well as the motivators or enablers of managing patients’ breast cancer diagnosis and treatment decision-making; and physicians’ approaches and behaviors that encouraged or discouraged confidence and trust and promoted or hindered patient decision-making. For the total sample, a one-way Multivariate Analysis of Variance (MANOVA) was conducted to simultaneously compare the time from diagnosis to first treatment initiation, as well as time from first treatment to second treatment initiation, between Black and white patients. A two-way MANOVA was conducted to compare the time elapsed between Black and white patients, controlling for stage of diagnosis. For the interview sample, qualitative analysis included a priori coding as well as inductive coding to identify prevalent themes. Summary statistics, chi-square tests and t-tests were conducted to measure associations between interview themes and patients’ race, stage of diagnosis, and first treatment modality. Results: The study’s sample consisted of a total of 236 patients from the chart review (hereafter referred to as the ‘total sample’). 76.3% of the sample was 50 years old or older (n=180), 69.1% were white (n=163). 49.6% had private insurance (n=117), 40.7% had Medicare (n=96), and 10.2% had Medicaid (n=24). 73.3% were diagnosed with Stage I disease (n=173), and 60.6% received a lumpectomy as their first treatment after diagnosis (n=143). The mean time from diagnosis to the date of first treatment initiation for the total sample was 46.3 days (SD = 25.5). The mean time elapsed among Black patients (M=51.18 days, SD=26.47) was significantly greater than the mean time among white patients (M=44.07 days, SD=24.8) (t(234)=1.99, p = 0.048). The mean times from first to second treatment initiation were nearly identical between Black (M=55.2 days, SD=23.0) and white patients (M=55.4 days, SD=21.2). Examining these two time intervals simultaneously, the one-way MANOVA showed no significant difference between Black and white patients (F(2, 156) = 2.58, p=0.079, eta-sq = 0.03). After excluding outliers, the two-way MANOVA showed significant difference in the main effects for stage (F(2, 139) = 3.32, p = 0.039, eta-sq = 0.05), but not the main effect for race (F(2, 139) = 2.37, p = 0.097, eta-sq = 0.03) or the interaction effect between race and stage (F(2, 139) = 0.55, p = 0.57, eta-sq = 0.0079). Of the patients identified in the total sample, 211 were eligible for the interview and invited to participate. 60 enrolled (hereafter referred to as the ‘interview sample’). 66.7% of the sample was 50 years old or older, 66.7% were white. 58.3% had private insurance, 26.7% had Medicare, and 10% had Medicaid. 71.7% were diagnosed with Stage I disease, and 51.7% received a lumpectomy as their first treatment after diagnosis. The interview sample had a significantly lower proportion of patients with Medicare (n=16, 26.7%) compared to those not interviewed (n=80, 45.5%) (X^2(1)=5.79, p=0.016). Besides the proportion with Medicare, the rest of the sociodemographic and disease characteristics, and treatments received, were not statistically significant between those interviewed (n=60) and those not interviewed (n=176). Qualitative coding of the interviews revealed the most prevalent barriers to treatment initiation pertained to emotions such as anxiety, feeling overwhelmed, and fear. Barriers that were more frequently reported among Black compared to white patients included insufficient information, fear of surgery, fear of dying, limited cancer health literacy and comorbidities. Facilitators more prevalent among Black compared to white patients include emotional support from relatives/friends, treatment information from external sources (e.g. internet, books), feeling comfortable with their physician, understanding their treatment plan, and faith and spiritual support. A higher proportion of Black patients noted: physician spending time with them, physician positivity, physician accessibility, and physician assurance that their diagnosis was not their fault. Throughout the interview sample, many patients were motivated to comply with medical advice to treat their cancer, however, few were provided guidance for when to start treatment. A prevalent barrier reported by the interview sample was feeling overwhelmed: however, patients described how a volume of information was reassuring rather than overwhelming as long as physicians did not rush patients and repeatedly prompted patients for questions. Overall, patients described how physicians’ assertiveness was reassuring as opposed to off-putting, if they listened to the patient, asked the patient about their priorities, and presented themselves as a team with the patient. Implications: This study had strengths, including the prospective design, in which data was collected as patients were in the midst of navigating their breast cancer treatment, as well as mixed methodologies, in which influences on patient decision-making could be triangulated. It also yielded a rich dataset of thick description of patient experiences. Another strength of the study is that it oversampled Black patients to create a diverse sample allowing us to compare Black and white patient experiences, knowledge, attitudes and preferences. Study limitations include a sample size that was insufficient to conduct complex inferential statistics, as well as by failing to interview patients who had delayed time to treatment initiation past the recruitment period, or who had not initiated any treatment. The study points to new directions for future research. The finding that there was a racial disparity in time elapsed from diagnosis to first treatment initiation, but no disparity in time elapsed from first to second treatment initiation, suggests that future studies should explore what interventions are likely to assist patients to initiate their first therapeutic visit at the point of diagnosis. Future research should examine whether informing patients of recommended treatment timelines influences their decision-making processes and behaviors. Interventions should be developed to address barriers that disproportionately affect Black patients, including surgical anxiety and gaps in cancer health literacy. The physician communication qualities and behaviors most frequently cited as beneficial in this study can inform the development of training interventions that equip physicians to conduct informative and supportive patient discussions.