Study Highlights Racial, Ethnic Disparities in Post-Breast Cancer Surgery Emergency Department Visits

Breast Cancer

Non-Hispanic Black women are approximately 40% more like to require a visit to the emergency department (ED) after breast cancer surgery, and Hispanic women are 11% more likely compared with non-Hispanic White women, according to results from a population-based study published in Breast Cancer Research and Treatment.^1,2

Results from the study showed that not only are rates of ED visits within 90 days of breast cancer surgery significantly higher for non-Hispanic Black and Hispanic patients (OR, 1.11; 95% CI, 1.04–1.18); P = .0016 and OR, 1.38; 95% CI, 1.27–1.50; P <.0001, respectively), but also that health insurance coverage from Medicare or Medicaid is associated with higher rates of ED visits vs commercial insurance for non-Hispanic White patients. This was also true for Hispanic and non-Hispanic Black patients, although to a lesser degree.

“It is well-documented that women of color consistently experience worse outcomes in breast cancer—for example, they tend to be diagnosed with later-stage cancer and experience longer delays in treatment—and we wanted to see if this disparity was reflected in emergency department visits following surgery as well,” lead study author Mary Falcone, PhD, a research scientist at USC Norris Comprehensive Cancer Center, said in a press release.

Racial and ethnic disparities in breast cancer care have been well-documented, with previous studies showing evidence that these disparities contribute to differences in treatment, later stages of diagnosis, access to care, and even tumor characteristics. Notably, non-Hispanic Black and Hispanic patients are at higher risk of experiencing delays in treatment, which can lead to poorer outcomes. They are also less likely to receive the care they require at National Cancer Institute (NCI)-designated cancer centers, which are associated with better survival outcomes.

Currently, surgery is a primary treatment for those with breast cancer, and 3% to 13% of patients will require a post-operative ED visit. Because ED visits have been used as an indicator of poor quality of and access to care for patients with cancer, and because non-Hispanic Black and Hispanic patients are at greater risk for post-operative complications, investigators sought to examine the racial and ethnic differences in ED visits after breast cancer surgery.

“We hypothesized that Hispanic and non-Hispanic Black women would be more likely to have at least 1 ED visit compared to NH White women. We further hypothesized that these disparities would be moderated by type of insurance coverage and hospital characteristics,” study authors wrote. “Understanding the factors that influence surgical outcomes such as emergency visits is necessary in order to identify patients at greater risk for adverse outcomes following breast cancer surgery and develop targeted interventions.”

To conduct this study, investigators analyzed data from the California Cancer Registry and California Office of Statewide Health Planning and Development (OSHPD). Records of women aged 18 years or older who were diagnosed with stage 0 to III breast cancer and received surgery from January 2005 to December 2013 were included on the study. Those with stage IV breast cancer were excluded, as surgery is not recommended for these patients.

Additionally, patients were excluded if records on their cancer stage, race, or ethnicity were unknown or unclear. Patient records were also excluded if they had been diagnosed with another type of cancer within 90 days of surgery, if a record of breast cancer surgery could not be located, or if a patient died within 1 day of surgery. Those with prior-military insurance were also excluded, as public insurance outside Medicare or Medicaid was not permitted on the study.

Patient records from OSHPD were examined from 2 months prior to diagnosis to 1 year after diagnosis to capture all breast cancer-related surgeries.

The primary outcome was breast-cancer related ED visits within 90 days of surgery.

Overall, data from 151,229 patients was included in the final analysis, 103,466 of whom had received lumpectomy, and 47,763 who received mastectomy. Moreover, among the patients included, 62.6% were non-Hispanic White, 17.2% were Hispanic, 13.4% were Asian/Pacific Islander, 6.3% were non-Hispanic Black, and 0.5% were American Indian/Alaskan Native.

Additional data showed that Hispanic (13.2%) and non-Hispanic Black (13.2%) patients had higher rates of diagnosis with stage III breast cancer compared with non-Hispanic White patients (9.5%). Moreover, non-Hispanic Black patients had the highest rates of treatment delays lasting longer than 60 days (21.0%) vs non-Hispanic White patients who had the lowest rates (12.2%). Non-Hispanic White patients also had the highest rates of lumpectomy (70.5%), and Asian/Pacific Islander patients had the highest rates of mastectomy (36.7%).

In terms of treatment type, Hispanic patients received chemotherapy at higher rates than the other groups (40.0%), and non-Hispanic White patients received radiation therapy at the highest rates (50.2%).

Hispanic patients had the highest rates of inpatient surgery (31.0%), and non-Hispanic White patients had the highest rates of outpatient surgery (73.7%). Additionally, Asian/Pacific Islander and American Indian/Alaskan Native patients were the most likely to receive treatment at a NCI-designated Comprehensive Cancer Center (8.7% each).

In terms of predictors of ED visits, additional data showed that Asian/Pacific Islander patients were significantly less likely to have an ED visit within 90 days of breast cancer surgery compared with other groups (aOR, 0.77; 95% CI, 0.71–0.84; P < .0001). Additionally, insurance with Medicare or Medicaid was associated with higher rates of ED visits compared with commercial insurance (aOR, 1.81; 95% CI, 1.69–1.95; P < .0001 and aOR, 1.36; 95% CI, 1.24–1.50; P <.0001, respectively). Moreover, receiving surgery at an NCI-designated Comprehensive Cancer Center was associated significantly lower rates of ED visits (aOR, 0.48; 95% CI, 0.42–0.54; P <.0001).

Additional data from a post hoc analysis also showed associated between race/ethnicity and insurance coverage, as well as the type of hospital a patient was treated on. For example, Hispanic, Asian/Pacific Islander, and non-Hispanic Black patients were more likely to require an ED visit if there were insured by Medicaid.

“Understanding and reducing inequities in access to cancer care is vital to reducing the significant ethnic and racial disparities in cancer mortality,” said senior study author Caryn Lerman, PhD, director of USC Norris and the H. Leslie and Elaine S. Hoffman Professor in Cancer Research. “Women should not have to seek emergency treatment for conditions that may be avoided with access to proper care.”

References

1. Falcone M, Liu L, Faria A, et al. Evidence for racial/ethnic disparities in emergency department visits following breast cancer surgery among women in California: a population‐based study. Breast Cancer Research and Treatment. 2021;187:831–841. doi:10.1007/s10549-021-06119-5
2. Racial and ethnic disparities discovered in post-operative breast cancer surgery outcomes. News release. Keck Medicine of USC. August 2, 2021. Accessed August 31, 2021. https://bit.ly/3mLP8b6