A latent class assessment of healthcare access factors and disparities in breast cancer care timeliness

• Published in: PLoS medicine 2024-12, Vol.21 (12), p.e1004500
• Main Authors: Dunn, Matthew R, Li, Didong, Emerson, Marc A, Thompson, Caroline A, Nichols, Hazel B, Van Alsten, Sarah C, Roberson, Mya L, Wheeler, Stephanie B, Carey, Lisa A, Hyslop, Terry, Elston Lafata, Jennifer, Troester, Melissa A
• Format: Article
• Language: English
• Subjects: Adult; Aged; Black or African American; Breast Neoplasms - diagnosis; Breast Neoplasms - ethnology; Breast Neoplasms - genetics; Breast Neoplasms - therapy; Delayed Diagnosis - statistics & numerical data; Female; Health Services Accessibility; Healthcare Disparities; Humans; Latent Class Analysis; Medicine and Health Sciences; Middle Aged; Research and Analysis Methods; Social Sciences; Time Factors; Time-to-Treatment - statistics & numerical data; White
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1004500

Delays in breast cancer diagnosis and treatment lead to worse survival and quality of life. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (diagnosis, treatment initiation, treatment duration, and genomic testing). The Carolina Breast Cancer Study (CBCS) Phase 3 is a population-based, case-only cohort (n = 2,998, 50% black) of patients with invasive breast cancer diagnoses (2008 to 2013). We used latent class analysis (LCA) to group participants based on patterns of factors within 3 separate domains: socioeconomic status ("SES"), "care barriers," and "care use." These classes were evaluated in association with delayed diagnosis (approximated with stages III-IV at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment-by treatment modality), and receipt of OncotypeDx genomic testing (evaluated among patients with early stage, ER+ (estrogen receptor-positive), HER2- (human epidermal growth factor receptor 2-negative) disease). Associations were evaluated using adjusted linear-risk regression to estimate relative frequency differences (RFDs) with 95% confidence intervals (CIs). Delayed diagnosis models were adjusted for age; delayed and prolonged treatment models were adjusted for age and tumor size, stage, and grade at diagnosis; and OncotypeDx models were adjusted for age and tumor size and grade. Overall, 18% of CBCS participants had late stage/delayed diagnosis, 35% had delayed treatment initiation, 48% had prolonged treatment duration, and 62% were not OncotypeDx tested. Black women had higher prevalence for each outcome. We identified 3 latent classes for SES ("high SES," "moderate SES," and "low SES"), 2 classes for care barriers ("few barriers," "more barriers"), and 5 classes for care use ("short travel/high preventive care," "short travel/low preventive care," "medium travel," "variable travel," and "long travel") in which travel is defined by estimated road driving time. Low SES and more barriers to care were associated with greater frequency of delayed diagnosis (RFDadj = 5.5%, 95% CI [2.4, 8.5]; RFDadj = 6.7%, 95% CI [2.8,10.7], respectively) and prolonged treatment (RFDadj = 9.7%, 95% CI [4.8 to 14.6]; RFDadj = 7.3%, 95% CI [2.4 to 12.2], respectively). Variable travel (short travel to diagnosis but long travel to surgery) was associated with d