title: Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers.
abstract: OBJECTIVE
  For breast cancer, guidelines direct the delivery of adjuvant systemic therapy on the basis of lymph node status, histology, tumor size, grade, and hormonal receptor status. We explored how race/ethnicity, insurance, census tract-level poverty and education, and hospital Commission on Cancer (CoC) status were associated with the receipt of guideline-concordant adjuvant systemic therapy.
  
  
  METHODS
  Locoregional breast cancers diagnosed in 2004 (n = 6,734) were from the National Program of Cancer Registries-funded seven-state Patterns of Care study of the Centers for Disease Control and Prevention. Predictors of guideline-concordant (receiving/not receiving) adjuvant systemic therapy, according to National Comprehensive Cancer Network Guidelines, were explored by logistic regression.
  
  
  RESULTS
  Overall, 35% of women received nonguideline chemotherapy, 12% received nonguideline regimens, and 20% received nonguideline hormonal therapy. Significant predictors of nonguideline chemotherapy included Medicaid insurance (odds ratio [OR], 0.66; 95% CI, 0.50 to 0.86), high-poverty areas (OR, 0.77; 95% CI, 0.62 to 0.96), and treatment at non-CoC hospitals (OR, 0.69; 95% CI, 0.56 to 0.85), with adjustment for age, registry, and clinical variables. Predictors of nonguideline regimens among chemotherapy recipients included lack of insurance (OR, 0.47; 95% CI, 0.25 to 0.92), high-poverty areas (OR, 0.71; 95% CI, 0.51 to 0.97), and low-education areas (OR, 0.65; 95% CI, 0.48 to 0.89) after adjustment. Living in high-poverty areas (OR, 0.78; 95% CI, 0.64 to 0.96) and treatment at non-CoC hospitals (OR, 0.68; 95% CI, 0.55 to 0.83) predicted nonguideline hormonal therapy after adjustment. ORs for poverty, education, and insurance were attenuated in the full models.
  
  
  CONCLUSIONS
  Sociodemographic and hospital factors are associated with guideline-concordant use of systemic therapy for breast cancer. The identification of modifiable factors that lead to nonguideline treatment may reduce disparities in breast cancer survival.
authors.affiliation: Louisiana State University Health Sciences Center, 1615 Poydras St, Suite 1400, New Orleans, LA 70112, USA. xwu@lsuhsc.edu
authors.forename: Xiao-Cheng
authors.initials: XC
authors.lastname: Wu
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Lund
authors.forename: Gretchen G
authors.initials: GG
authors.lastname: Kimmick
authors.forename: Lisa C
authors.initials: LC
authors.lastname: Richardson
authors.forename: Susan A
authors.initials: SA
authors.lastname: Sabatino
authors.forename: Vivien W
authors.initials: VW
authors.lastname: Chen
authors.forename: Steven T
authors.initials: ST
authors.lastname: Fleming
authors.forename: Cyllene R
authors.initials: CR
authors.lastname: Morris
authors.forename: Bin
authors.initials: B
authors.lastname: Huang
authors.forename: Amy
authors.initials: A
authors.lastname: Trentham-Dietz
authors.forename: Joseph
authors.initials: J
authors.lastname: Lipscomb
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000191:economics / Q000208:ethnology; D017024:Chemotherapy, Adjuvant / Q000592:standards; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006761:Hospitals / Q000592:standards; D006801:Humans; D007348:Insurance, Health; D008875:Middle Aged; D012923:Social Class; D014481:United States; D055815:Young Adult