Disparities in Breast Cancer Treatment and Survival for Women with Disabilities

7 November 2006 | Volume 145 Issue 9 | Pages 637-645

Background: Breast-conserving surgery combined with axillary lymph node dissection and radiotherapy or mastectomy are definitive treatments for women with early-stage breast cancer. Little is known about breast cancer treatment for women with disabilities.

Objective: To compare initial treatment for early-stage breast cancer between women with and without disabilities and to examine the association of treatment differences and survival.

Design: Retrospective cohort study.

Setting: 11 Surveillance, Epidemiology, and End Results (SEER) Program tumor registries.

Participants: 100 311 women who received a diagnosis of stage I to IIIA breast cancer at 21 to 64 years of age from 1988 to 1999. Women who qualified for Social Security Disability Insurance (SSDI) and Medicare at breast cancer diagnosis were considered disabled.

Measurements: Receipt of breast-conserving surgery versus mastectomy. For women who had breast-conserving surgery (n = 49 166), the authors examined receipt of radiotherapy and axillary lymph node dissection. Survival was measured from diagnosis until death or until 31 December 2001.

Results: Women with SSDI and Medicare coverage had lower rates of breast-conserving surgery than other women (43.2% vs. 49.2%; adjusted relative risk, 0.80 [95% CI, 0.76 to 0.84]). Among women who had breast-conserving surgery, women with SSDI and Medicare coverage were less likely than other women to receive radiotherapy (adjusted relative risk, 0.83 [CI, 0.77 to 0.90]) and axillary lymph node dissection (adjusted relative risk, 0.81 [CI, 0.74 to 0.90]). Women with SSDI and Medicare coverage had lower survival rates than those of other women in all-cause mortality (adjusted hazard ratio, 2.02 [CI, 1.88 to 2.16]) and breast cancer–specific mortality (adjusted hazard ratio, 1.31 [CI, 1.18 to 1.45]). Results were similar after adjustment for treatment differences.

Limitations: Findings are limited to women who qualified for SSDI and Medicare. No data on adjuvant chemotherapy and hormonal therapy were available, and details about the underlying disability were lacking.

Conclusions: Women with disabilities had higher breast cancer mortality rates and were less likely to undergo standard therapy after breast-conserving surgery than other women. Differences in treatment did not explain the differences in breast cancer mortality rates.

Editors' Notes Context We know little about breast cancer treatment for women with disabilities. Contribution This large study of 100 311 women younger than 65 years of age with stage I to stage IIIA breast cancer found that women with disabilities had lower rates of breast-conserving surgery and higher all-cause and breast cancer–specific mortality rates than other women. Among those who had breast-conserving surgery, women with disabilities were less likely to receive radiotherapy and axillary lymph node dissection. Cautions Disability was defined as meeting the qualifications for Social Security Disability Insurance and Medicare. Details about types and severity of disability and comorbid medical conditions were not available. —The Editors

 

Author and Article Information

From Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, and H. Lee Moffitt Cancer Center & Research Institute, University of South Florida, Tampa, Florida.

Disclaimer: Although this study used the linked SEER–Medicare database, the interpretation and reporting of these data are solely the authors' responsibility.

Acknowledgments: The authors acknowledge the efforts of several groups responsible for the creation and dissemination of the linked SEER–Medicare database, including the Applied Research Program, National Cancer Institute; the Office of Research, Development and Information, Centers for Medicare & Medicaid Services; Information Management Services, Inc.; and the SEER Program tumor registries. The authors thank Roger B. Davis, ScD, for his statistical assistance.

Grant Support: By the National Cancer Institute (RO1 CA100029).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Ellen P. McCarthy, PhD, MPH, Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon Street, Suite 220, Brookline, MA 02444; e-mail, emccarth{at}bidmc.harvard.edu.

Current Author Addresses: Dr. McCarthy: Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon Street, Suite 220, Brookline, MA 02444.

Drs. Ngo, Li, Drews, and Iezzoni: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.

Dr. Roetzheim: University of South Florida, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612.

Dr. Chirikos: H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612.

Author Contributions: Conception and design: E.P. McCarthy, R.G. Roetzheim, L.I. Iezzoni.

Analysis and interpretation of the data: E.P. McCarthy, L.H. Ngo, R.G. Roetzheim, T.N. Chirikos, D. Li, R.E. Drews, L.I. Iezzoni.

Drafting of the article: E.P. McCarthy, L.I. Iezzoni.

Critical revision of the article for important intellectual content: E.P. McCarthy, R.G. Roetzheim, T.N. Chirikos, R.E. Drews, L.I. Iezzoni.

Final approval of the article: E.P. McCarthy, L.H. Ngo, R.G. Roetzheim, T.N. Chirikos, D. Li, R.E. Drews, L.I. Iezzoni.

Provision of study materials or patients: L.I. Iezzoni.

Statistical expertise: E.P. McCarthy, L.H. Ngo, T.N. Chirikos, D. Li, L.I. Iezzoni.

Obtaining of funding: E.P. McCarthy, L.I. Iezzoni.

Administrative, technical, or logistic support: L.H. Ngo, D. Li, R.E. Drews.

Collection and assembly of data: E.P. McCarthy, D. Li.