Is Treatment Quality Contributing to Disparities in Breast Cancer Mortality? A Closer Look is Needed

July 27, 2016|12:56 p.m.| Josh Berry

A clear health disparity exists in breast cancer mortality in the United States. CDC has found that black women are 40 percent more likely than white women to die of breast cancer once diagnosed, which represents 1,800 excess breast cancer deaths annually among black women. According to this same report, this mortality difference is severe and present in almost all states with sufficient data. Targeted action at the state level is needed to save lives and move towards equitable care to reduce breast cancer mortality.

Treatment quality and disparities in breast cancer mortality

There are many contributing causes to the observed disparity in breast cancer mortality. White women and black women differ in terms of breast cancer screening access, breast cancer stage at diagnosis, timely initiation of treatment after diagnosis, the incidence of invasive breast cancers, and many other factors. Data sources are readily available to state health departments that provide state, county, and local level epidemiologic data and allow states to assess whether disparities exist and whether they might contribute to disparities in breast cancer mortality. These data sources include CDC’s Behavioral Risk Factor Surveillance System (BRFSS) and other national surveys, the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) Program, individual state cancer registries, and NCI and CDC’s State Cancer Profiles.

In addition to these factors, it is possible that not all women with breast cancer receive the same quality of treatment across the board in U.S. clinics and hospitals. Therefore, we feel it is important also to consider treatment quality as a potential contributor to disparities in breast cancer mortality. Two questions then arise. First, how do we define quality treatment for breast cancer? Second, what resources are needed for states to be able to assess disparities that may exist in the quality of breast cancer treatment?

Defining and measuring treatment quality

There are two simple ways we can evaluate breast cancer treatment quality and the quality of treatment for other chronic conditions. First, states or localities can create standards for quality treatment in accordance with quality standards approved by a national organization of experts in the field. For example, the National Quality Forum (NQF), a national organization with expert representatives from throughout the healthcare sector, has endorsed a list of several quality measures for cancer, including 10 measures for breast cancer screening and treatment. Provider data can be analyzed with respect to these treatment recommendations to see if any sociodemographic groups are less likely to receive NQF-endorsed quality treatments than others. This allows for quality care to be measured at the patient level when such data is available. That is, either an individual has received breast cancer treatment that has been endorsed by the NQF, or they have not.

States or localities can also define quality treatment as treatment provided by accredited hospitals that are held accountable to certain standards of care. One such accreditation program is the American College of Surgeons’ Commission on Cancer (CoC), a voluntary accreditation program that includes approximately 30 percent of all hospitals in the United States. Facilities that pursue and receive CoC accreditation must meet a series of treatment quality standards in breast cancer and other cancers in an effort to improve patient outcomes. Some of the CoC’s quality measures have also been endorsed by the NQF. If members of different sociodemographic groups have different levels of access to CoC accredited facilities, that may be contributing to noted disparities in health outcomes, such as that which was discovered for black women with breast cancer.

The white paper Breast Cancer Statistics: The State of Breast Cancer in South Carolina published by the South Carolina Cancer Alliance, and an accompanying article published in the Southern Medical Journal, compared the prevalence of several breast cancer treatments administered by CoC accredited hospitals and South Carolina hospitals as a whole (for example, women with negative hormone receptor breast cancer who received chemotherapy within four months of diagnosis). They consistently found that CoC hospitals in South Carolina were more likely to provide women with high quality treatment. Researchers also found that white women were more likely to receive NQF-endorsed breast cancer treatment than black women in South Carolina. Thus the location of CoC-accredited hospitals within a state, and the demographic makeup of breast cancer patients who are able to receive care at CoC hospitals compared to unaccredited hospitals, can be an indicator of disparities in the quality of care.

Do disparities of treatment quality exist in your state?

Access by U.S. states and territories to appropriate data sources is critical to determine if disparities in treatment quality exist. Cancer registries, insurance claims and discharge records, electronic health records, and Cancer Program Practice Profile Reports (CP3R) from CoC accredited institutions can help a state assess treatment quality at the individual or institutional level, but access to these data sources may require connecting with stakeholders external to the public health agency. CP3R reports in particular are very strong sources of treatment quality data at CoC hospitals, as they include statistics pertaining to each quality measure at the hospital level and the census region level and the state level. However, these reports can only be obtained directly from a CoC accredited hospital (Note: state cancer registries do allow for the comparison of CoC hospitals as a group to non-CoC hospitals). Having relationships with these provider stakeholders is an essential step to understanding how treatment quality contributes to disparities in breast cancer mortality at the state level. Improved understanding of disparities in treatment quality and other factors can help states close disparities in breast cancer mortality and move towards a health system where everyone receives high quality, optimal treatment.

Josh Berry

Josh Berry, MPH, serves as an analyst of health promotion and disease prevention at ASTHO, where he supports projects relating to breast cancer, tobacco control, and hypertension.

Special thanks to Jan Eberth, PhD, from the University of South Carolina and Deborah Hurley, MSPH, from the South Carolina Central Cancer Registry for their contributions to this article.