Abstract
Background:
Palliative care improves cancer patients' quality of life. Limited research has investigated racial/ethnic disparities in palliative care utilization and its associated survival among metastatic breast cancer (MBC) patients.
Objectives:
To examine racial/ethnic palliative care use disparities and assess racial/ethnic overall survival differences in MBC patients stratified by palliative care use.
Design:
A retrospective study of MBC patients from the 2004–2020 National Cancer Database.
Measurements:
Palliative care was defined as noncurative cancer treatment, including surgery, radiotherapy, systemic therapy, and/or pain management; utilization was coded “yes/no.” Racial/ethnic groups included Asian, American Indian or Alaska Native (AIAN), Black, Hawaiian or Other Pacific Islander (HPI), Hispanic, and White. Logistic regression was performed to assess palliative care use disparities. Overall survival was modeled using Cox regression.
Results:
Of 148,931 patients, the mean age was 62 years; 99% were female; 73% identified as White, 17% as Black, 6% as Hispanic, 3% as Asian, 0.3% as AIAN, and 0.3% as HPI; 42% and 39% had Medicare and private insurance, respectively. Overall, 21% used palliative care, with an increasing utilization rate from 2004 to 2020 (3.6% increase per year, p-trend <0.001). Black (adjusted odds ratio [aOR] = 0.89; 95% confidence interval [CI]: 0.84 to 0.94), Asian (aOR = 0.76; 95% CI: 0.68 to 0.86), and Hispanic (aOR = 0.68; 95% CI: 0.62 to 0.74) patients had a lower likelihood of palliative care utilization than White patients. Among palliative care users, compared with White patients, Black (adjusted hazard ratio [aHR] = 1.14, 95% CI: 1.07 to 1.21) patients had a greater mortality risk, while Asian (aHR = 0.83, 95% CI: 0.71 to 0.97) and Hispanic (aHR = 0.77, 95% CI: 0.69 to 0.87) patients had a lower mortality risk.
Conclusions:
Palliative care utilization among MBC patients significantly increased but remained suboptimal. Racial/ethnic minority patients were less likely to use palliative care, and Black patients had worse survival, than White patients, suggesting the need for improving palliative care access and ameliorating disparities in MBC patients.
Keywords: metastatic breast cancer, NCDB, overall survival, palliative care, racial/ethnic disparities
Introduction
Breast cancer is the most commonly diagnosed malignancy and the second leading cause of cancer-related death among women in the United States.1,2 In 2020, the age-adjusted incidence rate of metastatic breast cancer (MBC) was 7.3 per 100,0003 and an estimated 168,292 women were living with MBC.4 MBC diagnosis and treatment can take a heavy toll on patients' physical, psychological, and financial health.5–7 Palliative care is a type of specialized care that helps mitigate these health issues and challenges faced by patients with serious illnesses, including MBC, while addressing the practical, psychosocial, and/or spiritual needs of the patients and their family members.8,9 The goals of palliative care are to manage cancer symptoms and side effects of cancer treatment, reduce the severity of suffering, and improve the quality of life of the patients.8,9 Patients with MBC experience more disease burdens and require a stronger support system and thereby are particularly in need of and benefit largely from palliative care and other supportive services across the cancer care continuum.
Early palliative care interventions have been shown to significantly ameliorate advanced cancer patients' physical and depressive symptoms and quality of life.10–13 Studies also have suggested a positive impact of palliative care on overall survival among patients with stage IIIB–IV lung cancer or other cancers, including MBC.10,14,15 The American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) have established guidelines recommending timely palliative care provision across the oncology care continuum for cancer patients of all stages and their caregivers.8,16,17
Despite current ASCO and NCCN recommendations of early palliative care integration with standard oncology care and its benefits, palliative care remains underutilized among patients with metastatic diseases in the United States. For example, a study found that only 5%, 12%, and 12% of patients with stage III–IV ovarian, cervical, and uterine cancers had used palliative care, respectively.18 Among metastatic liver cancer patients, approximately one in six reported having received palliative care.19 Another analysis revealed a 33% prevalence of palliative care utilization in stage-IV colorectal cancer patients.20
As for the MBC patient population, there is a paucity of data on palliative care utilization, its national trend, racial/ethnic disparities, and survival differences. Among MBC patients >65 years of age, 16% used palliative care, with a significantly increased trend from 2006 to 2017.21 A retrospective analysis of hospitalized MBC patients demonstrated a 19% prevalence of, and a significant increasing trend in, palliative care utilization.22 A recent study reported that approximately one in 5 MBC patients had received palliative care but did not evaluate trends in its utilization.23 Similarly, another two studies found 16% and 17% of palliative care use prevalence among breast cancer patients, respectively; neither the trend nor racial/ethnic disparities were assessed.24,25
Racial/ethnic disparities in palliative care utilization and access inequities are major concerns for MBC patients. However, previous research on racial/ethnic palliative care use disparities in this patient population is inconsistent and focused largely on Black patients and, to a lesser degree, Hispanic patients.21,22,24 Furthermore, none of these studies has examined racial/ethnic survival differences by palliative care use.18,21–25
Current knowledge gaps exist regarding trends and racial/ethnic disparities in palliative care utilization and survival differences among MBC patients. A better understanding of these disparities can help cancer programs tailor their palliative care interventions and delivery and offer optimal care support to this patient population. To fill these critical gaps in the literature and inform palliative care practice in breast oncology, we undertook this study aiming to estimate palliative care use prevalence and trend, assess racial/ethnic disparities in palliative care utilization, and examine overall survival differences across racial/ethnic groups stratified by use of palliative care in MBC patients from a U.S. national oncology database.
Materials and Methods
Study design and population
This was a retrospective study of MBC patients from the 2004–2020 National Cancer Database (NCDB). The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. It is a large clinical oncology registry that represents more than 1500 Commission on Cancer-accredited hospitals and captures ∼70% of new cancer diagnoses in the United States each year.26–28 Participants were eligible if they were ≥18 years of age at diagnosis, had stage IV disease, and had available information on palliative care use. In compliance with NCDB Data Use Agreement, we suppressed reporting of cell counts <10 to protect patients' confidentiality. This study was exempt from the University of Chicago Institutional Review Board review because the NCDB contains deidentified patient-level data.
Measures
Palliative care utilization was a primary outcome variable. As per the NCDB, palliative care was defined as noncurative cancer treatment, including surgery, radiotherapy, systemic therapy, other pain management, or any combination of these therapies, performed to control pain and alleviate symptoms or treatment side effects. Palliative care was categorized based on the type of therapy documented: surgery, radiotherapy, systemic therapy, pain management, and any combination, and was dichotomized as “any vs. no” for regression analyses.
Overall survival, another outcome measure, was defined as all-cause mortality or censored at the time of death from all causes or at the time of last known patient contact. According to the NCDB, mortality information was not available for MBC patients who were diagnosed in 2020 due to the limited time of patient follow-up; therefore, these patients were excluded from survival analysis. Median survival time (in months) and two-, three-, and five-year survival rates by race/ethnicity and palliative care use were calculated.
Racial/ethnic groups included Asian, American Indian or Alaska Native (AIAN), Black, Hawaiian or Other Pacific Islander (HPI), Hispanic, and White. Other sociodemographic and clinicopathologic factors were age at diagnosis, year of initial cancer diagnosis, sex, type of health insurance (uninsured, private or managed care, Medicaid, Medicare), median household income quartile (<$40,227, $40,227–50,353, $50,354–63,332, ≥$63,333), rural/urban area (metro, urban, rural), type of facility, Charlson–Deyo comorbidity index, histologic type, molecular subtype, and tumor grade.
Statistical analyses
We used summary statistics to describe the characteristics of the patient cohort. Means and standard deviations or medians and interquartile ranges were calculated for continuous variables, and racial/ethnic group variations were compared using analysis of variance or Kruskal–Wallis tests. For categorical data, frequencies and percentages were tabulated and then compared using Pearson's χ2 tests. We examined the trends in palliative care utilization from 2004 to 2020, overall and by race/ethnicity, using a generalized linear model with a binomial distribution and log link.
To evaluate racial/ethnic disparities in palliative care utilization, we performed logistic regression, controlling for sociodemographic and clinicopathologic characteristics. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CIs) were computed. Using the Kaplan–Meier method, we determined the median survival time and two-, three-, and five-year survival rates with 95% CIs. Survival functions were compared using the log-rank test. To assess racial/ethnic differences in overall survival, we fit multivariable Cox proportional hazards regression models stratified by palliative care use. Adjusted hazard ratio (aHR) and 95% CIs were calculated. All statistical tests were two-sided at a 0.05 significance level. All analyses were conducted using Stata 17 (StataCorp, College Station, TX).
Results
Patient characteristics
A total of 148,931 MBC patients were analyzed, with the vast majority being female (98.6%). The mean age of the cohort was 62 years (standard deviation = 14). Most patients (74%) identified as White, 17% as Black, 6% as Hispanic, 3% as Asian, 0.3% as AIAN, and 0.3% as HPI. A higher proportion of the patients (42%) had Medicare, 39% were privately insured, and 12% were on Medicaid. Sixty-two percent had ductal histology. The median follow-up time for the cohort was 24 months (interquartile range: 8–48) (Table 1). Compared with White patients, racial/ethnic minority patients were diagnosed with MBC at a younger age and were more likely to be on Medicaid or without insurance coverage, be at a lower median household income quartile, and have grade 3 tumors (Table 2).
Table 1.
Overall Demographic and Clinical Characteristics of Patients With Metastatic Breast Cancer
| Characteristic | Total (N = 148,931), n (%) |
|---|---|
| Age at diagnosis (years), mean (SD) | 62 (14) |
| Age group (years) | |
| <45 | 16,461 (11) |
| 45–65 | 70,969 (48) |
| >65 | 61,501 (41) |
| Race/Ethnicity | |
| White | 107,768 (74) |
| Black | 25,152 (17) |
| Asian | 4121 (3) |
| American Indian or Alaska Native | 453 (0.3) |
| Hawaiian or Other Pacific Islander | 394 (0.3) |
| Hispanic | 8803 (6) |
| Sex | |
| Male | 2094 (1) |
| Female | 146,837 (99) |
| Type of health insurance | |
| Uninsured | 7381 (5) |
| Private or managed care | 57,534 (39) |
| Medicaid | 17,477 (12) |
| Medicare | 61,959 (42) |
| Other government or unknown | 4580 (3) |
| Median household income quartilea | |
| <$40,227 | 27,025 (20) |
| $40,227–$50,353 | 28,688 (22) |
| $50,354–$63,332 | 30,419 (23) |
| ≥$63,333 | 46,253 (35) |
| Rural/urban areab | |
| Metro | 125,700 (87) |
| Urban | 16,988 (12) |
| Rural | 2283 (2) |
| Charlson–Deyo comorbidity score | |
| 0 | 119,510 (80) |
| 1 | 19,913 (13) |
| ≥2 | 9508 (6) |
| Histologic type | |
| Ductal | 92,009 (62) |
| Lobular | 15,516 (10) |
| Ductal and lobular | 5052 (3) |
| Other | 36,354 (24) |
| Molecular subtype | |
| HR+/HER2− | 59,199 (62) |
| HR+/HER2+ | 15,097 (16) |
| HR−/HER2+ | 8123 (9) |
| TNBC | 13,608 (14) |
| Tumor grade | |
| 1 | 8807 (8) |
| 2 | 46,496 (43) |
| 3 | 54,046 (49) |
| Type of cancer program | |
| Community | 11,529 (8) |
| Comprehensive community | 55,114 (39) |
| Academic or research | 44,804 (32) |
| Integrated network | 28,323 (20) |
| Median follow-up time (months), median (IQR) | 24 (8–48) |
Based on the 2016 American Community Survey data, spanning years 2012–2016 and adjusted for 2016 inflation.
Measured by matching the state and county FIPS code of the patient recorded at the time of diagnosis against 2013 files published by the United States Department of Agriculture Economic Research Service.
HER2, human epidermal growth factor receptor 2; HR, hormone receptor; IQR, interquartile range; SD, standard deviation; TNBC, triple-negative breast cancer.
Table 2.
Demographic and Clinical Characteristics of Patients With Metastatic Breast Cancer by Race/Ethnicity
| Characteristic | White (n = 107,768), n (%) | Black (n = 25,152), n (%) | Asian (n = 4121), n (%) | American Indian or Alaska native (n = 453), n (%) | Hawaiian or Other Pacific Islander (n = 394), n (%) | Hispanic (n = 8803), n (%) | p a |
|---|---|---|---|---|---|---|---|
| Age at diagnosis (years), mean (SD) | 64 (14) | 59 (14) | 58 (14) | 59 (14) | 57 (14) | 57 (15) | <0.001 |
| Age group (years) | |||||||
| <45 | 9583 (9) | 3800 (15) | 741 (18) | 77 (17) | 72 (18) | 1883 (21) | <0.001 |
| 45–65 | 49,463 (46) | 13,270 (53) | 2190 (53) | 224 (49) | 216 (55) | 4516 (51) | |
| >65 | 48,722 (45) | 8082 (32) | 1190 (29) | 152 (34) | 106 (27) | 2404 (27) | |
| Sex | |||||||
| Male | 1525 (1) | 391 (2) | 43 (1) | <10 (<1) | <10 (<2) | 91 (1) | 0.003 |
| Female | 106,243 (99) | 24,761 (98) | 4078 (99) | >440 (>99) | >380 (>98) | 8712 (99) | |
| Type of health insurance | |||||||
| Uninsured | 3763 (4) | 1913 (8) | 282 (7) | 17 (4) | 27 (7) | 1232 (14) | <0.001 |
| Private or managed care | 42,996 (40) | 8560 (34) | 1898 (46) | 119 (26) | 148 (38) | 2871 (33) | |
| Medicaid | 9073 (8) | 4983 (20) | 751 (18) | 103 (23) | 105 (27) | 2147 (24) | |
| Medicare | 49,061 (46) | 8754 (35) | 1002 (24) | 152 (34) | 100 (25) | 2164 (25) | |
| Other government | 2875 (3) | 942 (4) | 188 (5) | 62 (14) | 14 (4) | 389 (4) | |
| Median household income quartileb | |||||||
| <$40,227 | 13,854 (15) | 10,095 (45) | 299 (8) | 156 (41) | 32 (10) | 2288 (29) | <0.001 |
| $40,227–$50,353 | 21,105 (22) | 4798 (21) | 483 (13) | 79 (21) | 56 (17) | 1792 (23) | |
| $50,354–$63,332 | 23,560 (25) | 3514 (16) | 851 (23) | 75 (20) | 92 (28) | 1840 (23) | |
| ≥$63,333 | 37,120 (39) | 3970 (18) | 2102 (56) | 73 (19) | 155 (46) | 1988 (25) | |
| Rural/urban areac | |||||||
| Metro | 88,202 (84) | 22,685 (92) | 3920 (97) | 260 (60) | 359 (92) | 8287 (96) | <0.001 |
| Urban | 14,501 (14) | 1707 (7) | 97 (2) | 143 (33) | <35 (<9) | 356 (4) | |
| Rural | 1986 (2) | 208 (1) | 15 (0.4) | 32 (7) | <10 (<1) | 23 (0.3) | |
| Charlson–Deyo comorbidity score | |||||||
| 0 | 86,849 (81) | 19,288 (77) | 3554 (86) | 337 (74) | 308 (78) | 7271 (83) | <0.001 |
| 1 | 14,135 (13) | 3858 (15) | 404 (10) | 71 (16) | 57 (15) | 1135 (13) | |
| ≥2 | 6784 (6) | 2006 (8) | 163 (4) | 45 (10) | 29 (7) | 397 (5) | |
| Histologic type | |||||||
| Ductal | 65,415 (61) | 16,137 (64) | 2868 (70) | 299 (66) | 265 (67) | 5648 (64) | <0.001 |
| Lobular | 12,172 (11) | 1988 (8) | 276 (7) | 40 (9) | <25 (<7) | 782 (9) | |
| Ductal and lobular | 3874 (4) | 652 (3) | 121 (3) | 19 (4) | <10 (<2) | 301 (3) | |
| Other | 26,307 (24) | 6375 (25) | 856 (21) | 95 (21) | 98 (25) | 2072 (24) | |
| Molecular subtype | |||||||
| HR+/HER2− | 43,921 (64) | 8826 (54) | 1747 (58) | 226 (68) | 189 (66) | 3431 (57) | <0.001 |
| HR+/HER2+ | 10,666 (16) | 2529 (15) | 550 (18) | 50 (15) | 48 (17) | 1024 (17) | |
| HR−/HER2+ | 5400 (8) | 1516 (9) | 378 (13) | 22 (7) | 25 (9) | 646 (11) | |
| TNBC | 8535 (13) | 3596 (22) | 341 (11) | 36 (11) | 25 (9) | 877 (15) | |
| Tumor grade | |||||||
| 1 | 7006 (9) | 1031 (5) | 185 (6) | 31 (9) | 19 (7) | 435 (7) | <0.001 |
| 2 | 34,823 (45) | 6834 (36) | 1312 (41) | 142 (40) | 115 (40) | 2647 (40) | |
| 3 | 36,408 (47) | 11,261 (59) | 1678 (53) | 183 (51) | 155 (54) | 3479 (53) | |
| Type of cancer program | |||||||
| Community | 9196 (9) | 1321 (6) | 281 (8) | 51 (123) | 40 (11) | 528 (7) | <0.001 |
| Comprehensive community | 43,220 (42) | 7512 (33) | 1218 (33) | 185 (46) | 107 (30) | 2289 (30) | |
| Academic or research | 28,875 (28) | 9662 (42) | 1570 (42) | 116 (29) | 132 (37) | 3533 (46) | |
| Integrated network | 21,271 (21) | 4494 (20) | 646 (17) | 55 (14) | 80 (22) | 1328 (17) | |
| Median follow-up time (months), median (IQR) | 25 (8–50) | 19 (6–39) | 30 (12–54) | 24 (7–47) | 24 (7–45) | 27 (11–52) | <0.001 |
p Values were calculated using ANOVA or Kruskal–Wallis tests for continuous data and Pearson's χ2 tests for categorical data.
Based on the 2016 American Community Survey data, spanning years 2012–2016 and adjusted for 2016 inflation.
Measured by matching the state and county FIPS code of the patient recorded at the time of diagnosis against 2013 files published by the United States Department of Agriculture Economic Research Service.
ANOVA, analysis of variance.
Palliative care use trends and racial/ethnic disparities
Overall, 21% of the MBC patients used palliative care, of whom 37% and 36% received radiotherapy and systemic therapy, respectively (Table 3). Palliative care utilization increased significantly, from 15% in 2004 to 28% in 2020 (p for trend <0.001) (Fig. 1), with a 3.6% (95% CI: 3.4% to 3.9%) increase per year (Table 3). Significant differences were observed between patients who received palliative care and those who did not (Supplementary Table S1). The distributions for specific types of palliative care from 2004 to 2020 showed that systemic therapy and any combination of therapies became more common in recent years (Supplementary Table S2).
Table 3.
Prevalence of Palliative Care Use and Type for Patients With Metastatic Breast Cancer Overall and by Race/Ethnicity
| White | Black | Asian | American Indian or Alaska native | Hawaiian or Other Pacific Islander | Hispanic | All | |
|---|---|---|---|---|---|---|---|
| Palliative care use, n (%) | |||||||
| No | 84,396 (79) | 20,044 (80) | 3388 (82) | 352 (78) | 320 (81) | 7343 (84) | 117,621 (79) |
| Yes | 23,015 (21) | 5004 (20) | 722 (18) | 101 (22) | 74 (19) | 1397 (16) | 30,772 (21) |
| p a | <0.001 | ||||||
| Percent increase in palliative care use per year, 2004–2020b, % (95% CI) | 3.6 (3.3 to 3.8) | 3.7 (3.2 to 4.3) | 5.8 (4.1 to 7.6) | 2.5 (−1.4 to 6.5) | 1.3 (−3.3 to 6.1) | 5.4 (4.2 to 6.6) | 3.6 (3.4 to 3.9) |
| p | <0.001 | <0.001 | <0.001 | 0.213 | 0.590 | <0.001 | <0.001 |
| Type of palliative care,c n (%) | |||||||
| Surgery | 814 (3) | 164 (3) | 34 (5) | <10 (<6) | <10 (<7) | 47 (3) | 1089 (3) |
| Radiation therapy | 8504 (37) | 1774 (36) | 234 (32) | 34 (34) | 21 (28) | 539 (39) | 11,269 (37) |
| Systemic therapy | 8236 (36) | 1975 (40) | 258 (36) | 31 (31) | 24 (32) | 495 (35) | 11,180 (36) |
| Pain management | 1112 (5) | 239 (5) | 34 (5) | <10 (<7) | <10 (<11) | 60 (4) | 1485 (5) |
| Any combination of therapies | 3405 (15) | 615 (12) | 129 (18) | 19 (19) | 15 (20) | 211 (15) | 4453 (15) |
| Type not specified | 944 (4) | 237 (5) | 33 (5) | <10 (<6) | <10 (<2) | 45 (3) | 1296 (4) |
| p a | <0.001 | ||||||
p Values were calculated using Pearson's χ2 tests for categorical data.
Percent (95% CI) increase in palliative care use per year were calculated using the generalized linear model with the binomial distribution and log link.
According to the National Cancer Database, palliative care, including surgery, radiation therapy, systemic therapy, and/or pain management therapy, is performed to control pain and/or relieve symptoms, with no attempt to diagnose, stage, or treat the primary tumor.
CI, confidence interval.
FIG. 1.
Percentages of and trends in palliative care use among patients with metastatic breast cancer by race/ethnicity.
By race/ethnicity, 22% of AIAN patients used palliative care, 21% of White, 20% of Black, 19% of HPI, 18% of Asian, and 16% of Hispanic patients (Table 3). Significantly increased trends were observed among White (16% in 2004 to 28% in 2020, p for trend <0.001), Black (13% in 2004 to 27% in 2020, p for trend <0.001), Asian (13% in 2004 to 23% in 2020, p for trend <0.001), and Hispanic (11% in 2004 to 23% in 2020, p for trend <0.001) patients, but not for AIAN and HPI patients, possibly due to small sample size (Fig. 1).
In the adjusted model (model 3), Black (aOR = 0.89, 95% CI: 0.84 to 0.94), Asian (aOR = 0.76; 95% CI: 0.68 to 0.86), and Hispanic (aOR = 0.68, 95% CI: 0.62 to 0.74) MBC patients had lower odds of having received palliative care than White patients. Compared with White patients, HPI patients had lower odds (aOR = 0.71, 95% CI: 0.47 to 1.05), whereas AIAN patients had similar odds (aOR = 1.11, 95% CI: 0.80 to 1.53) of having received palliative care; and differences in the last two comparisons were not statistically significant (Table 4).
Table 4.
Racial/Ethnic Disparities in Palliative Care Use Among Patients With Metastatic Breast Cancer
| Characteristic | Model 1 |
Model 2 |
Model 3 |
|---|---|---|---|
| aOR (95% CI) | aOR (95% CI) | aOR (95% CI) | |
| Race/Ethnicity | |||
| White | 1.0 (Reference) | 1.0 (Reference) | 1.0 (Reference) |
| Black | 0.91 (0.88 to 0.94)*** | 0.88 (0.84 to 0.91)*** | 0.89 (0.84 to 0.94)*** |
| Asian | 0.74 (0.68 to 0.81)*** | 0.74 (0.67 to 0.81)*** | 0.76 (0.68 to 0.86)*** |
| American Indian or Alaska Native | 0.99 (0.80 to 1.24) | 1.00 (0.77 to 1.29) | 1.11 (0.80 to 1.53) |
| Hawaiian or Other Pacific Islander | 0.80 (0.62 to 1.04) | 0.83 (0.63 to 1.11) | 0.71 (0.47 to 1.05) |
| Hispanic | 0.67 (0.64 to 0.72)*** | 0.65 (0.61 to 0.70)*** | 0.68 (0.62 to 0.74)*** |
| Year of initial diagnosis (per one-year increase) | 1.05 (1.04 to 1.05)*** | 1.05 (1.04 to 1.05)*** | 1.05 (1.04 to 1.06)*** |
| Age at diagnosis (per 10-year increase) | 0.96 (0.95 to 0.98)*** | 0.98 (0.96 to 0.999)* | |
| Sex | |||
| Male | 1.0 (Reference) | 1.0 (Reference) | |
| Female | 0.99 (0.88 to 1.11) | 1.01 (0.86 to 1.19) | |
| Type of health insurance | |||
| Uninsured | 1.21 (1.13 to 1.29)*** | 1.28 (1.17 to 1.41)*** | |
| Private or managed care | 1.0 (Reference) | 1.0 (Reference) | |
| Medicaid | 1.12 (1.06 to 1.17)*** | 1.15 (1.08 to 1.23)*** | |
| Medicare | 1.04 (0.99 to 1.08) | 1.02 (0.97 to 1.08) | |
| Other government or unknown | 0.79 (0.72 to 0.87)*** | 0.88 (0.76 to 1.02) | |
| Median household income quartilea | |||
| <$40,227 | 1.02 (0.97 to 1.06) | 1.05 (0.99 to 1.11) | |
| $40,227–$50,353 | 1.06 (1.02 to 1.10)** | 1.08 (1.02 to 1.14)** | |
| $50,354–$63,332 | 1.04 (1.00 to 1.08) | 1.09 (1.04 to 1.15)** | |
| ≥$63,333 | 1.0 (Reference) | 1.0 (Reference) | |
| Rural/urban areab | |||
| Metro | 1.0 (Reference) | 1.0 (Reference) | |
| Urban | 1.20 (1.15 to 1.26)*** | 1.15 (1.08 to 1.22)*** | |
| Rural | 1.02 (0.91 to 1.14) | 1.02 (0.87 to 1.19) | |
| Charlson–Deyo comorbidity score | |||
| 0 | 1.0 (Reference) | 1.0 (Reference) | |
| 1 | 1.11 (1.06 to 1.16)*** | 1.11 (1.05 to 1.18)*** | |
| ≥2 | 1.18 (1.12 to 1.25)*** | 1.25 (1.15 to 1.35)*** | |
| Type of cancer program | |||
| Community | 1.0 (Reference) | 1.0 (Reference) | |
| Comprehensive community | 1.14 (1.08 to 1.20)*** | 1.06 (0.98 to 1.15) | |
| Academic or research | 1.16 (1.10 to 1.23)*** | 1.08 (1.00 to 1.17) | |
| Integrated network | 1.33 (1.26 to 1.42)*** | 1.27 (1.17 to 1.38)*** | |
| Histologic type | |||
| Ductal | 1.0 (Reference) | ||
| Lobular | 0.93 (0.87 to 0.99)* | ||
| Ductal and lobular | 0.95 (0.86 to 1.06) | ||
| Other | 0.94 (0.88 to 0.99)* | ||
| Molecular subtype | |||
| HR+/HER2− | 1.03 (0.97 to 1.09) | ||
| HR+/HER2+ | 0.95 (0.89 to 1.03) | ||
| HR−/HER2+ | 0.84 (0.77 to 0.92)*** | ||
| TNBC | 1.0 (Reference) | ||
| Tumor grade | |||
| 1 | 1.07 (0.99 tot 1.16) | ||
| 2 | 1.05 (1.00 to 1.09)* | ||
| 3 | 1.0 (Reference) | ||
Based on the 2016 American Community Survey data, spanning years 2012–2016 and adjusted for 2016 inflation.
Measured by matching the state and county FIPS code of the patient recorded at the time of diagnosis against 2013 files published by the United States Department of Agriculture Economic Research Service.
p < 0.05; **p < 0.01; ***p < 0.001.
aOR, adjusted odds ratio.
Additionally, patients who were uninsured (aOR = 1.28, 95% CI: 1.17 to 1.41) or on Medicaid (aOR = 1.15, 95% CI: 1.08 to 1.23) had increased odds of having received palliative care than those privately insured. Patients earning between $40,227–$50,353 (aOR = 1.08, 95% CI: 1.02 to 1.14) or between $50,354–$63,332 (aOR = 1.09, 95% CI: 1.04 to 1.15) were slightly more likely than those earning ≥$63,333 to have used palliative care. Patients with a comorbidity index of 1 (aOR = 1.11, 95% CI: 1.05 to 1.18) or ≥2 (aOR = 1.25, 95% CI: 1.15 to 1.35) had a greater odds of palliative care utilization than those with 0 comorbidity index (Table 4).
Racial/ethnic overall survival differences
Kaplan–Meier curves stratified by race/ethnicity and palliative care utilization are presented in Figure 2. Among patients who received palliative care, AIAN patients (18 months, 95% CI: 10 to 29) and Black patients (19 months, 95% CI: 17 to 19) had the lowest median survival than White (26 months, 95% CI: 25 to 26), Hispanic (31 months, 95% CI: 28 to 34), HPI (32 months, 95% CI: 24 to 45), and Asian (33 months, 95% CI: 31 to 38) patients (p < 0.001) (Table 5). Furthermore, Black patients had the lowest two-year (42%, 95% CI: 41% to 44%), three-year (30%, 95% CI: 29% to 31%), and five-year (16%, 95% CI: 15% to 17%) survival rates; a similar pattern was found in patients who did not use palliative care (Supplementary Table S3).
FIG. 2.
Kaplan–Meier curves of overall survival for patients with metastatic breast by race/ethnicity and palliative care use. AIAN, American Indian or Alaska Native; HPI, Hawaiian or Other Pacific Islander.
Table 5.
Racial/Ethnic Differences in Overall Survival Among Patients With Metastatic Breast Cancer by Palliative Care Use
| Race/ethnicity | No. of subjects | No. of events | Median survival time in monthsa (95% CI) | p b | Crude hazard ratio (95% CI) | Model 1 aHRc (95% CI) | Model 2 aHRd (95% CI) | |
|---|---|---|---|---|---|---|---|---|
| Among patients who did not use palliative care | White | 78,979 | 56,137 | 32 (32 to 32) | <0.001 | 1.0 (Reference) | 1.0 (Reference) | 1.0 (Reference) |
| Black | 18,675 | 13,872 | 23 (23 to 24) | 1.22 (1.20 to 1.24)*** | 1.23 (1.20 to 1.27)*** | 1.13 (1.09 to 1.17)*** | ||
| Asian | 3081 | 1695 | 47 (44 to 49) | 0.71 (0.68 to 0.75)*** | 0.78 (0.73 to 0.84)*** | 0.76 (0.70 to 0.82)*** | ||
| American Indian or Alaska Native | 311 | 215 | 34 (27 to 43) | 1.00 (0.87 to 1.14) | 0.97 (0.80 to 1.18) | 0.86 (0.69 to 1.09) | ||
| Hawaiian or Other Pacific Islander | 281 | 175 | 32 (26 to 39) | 0.96 (0.83 to 1.11) | 1.26 (1.02 to 1.55)*** | 1.20 (0.94 to 1.54) | ||
| Hispanic | 6724 | 3977 | 40 (38 to 41) | 0.80 (0.77 to 0.82)*** | 0.90 (0.86 to 0.95)*** | 0.80 (0.76 to 0.85)*** | ||
| Among patients who used palliative care | White | 20,929 | 15,817 | 26 (25 to 26) | <0.001 | 1.0 (Reference) | 1.0 (Reference) | 1.0 (Reference) |
| Black | 4504 | 3591 | 19 (17 to 19) | 1.25 (1.20 to 1.29)*** | 1.23 (1.17 to 1.30)*** | 1.14 (1.07 to 1.21)*** | ||
| Asian | 632 | 376 | 33 (31 to 38) | 0.76 (0.69 to 0.84)*** | 0.82 (0.71 to 0.94)** | 0.83 (0.71 to 0.97)* | ||
| American Indian or Alaska Native | 93 | 69 | 18 (10 to 29) | 1.05 (0.83 to 1.34) | 1.09 (0.80 to 1.47) | 1.02 (0.72 to 1.43) | ||
| Hawaiian or Other Pacific Islander | 62 | 41 | 32 (24 to 45) | 0.82 (0.60 to 1.11) | 1.08 (0.68 to 1.72) | 1.06 (0.61 to 1.82) | ||
| Hispanic | 1212 | 760 | 31 (28 to 34) | 0.78 (0.73 to 0.84)*** | 0.85 (0.77 to 0.94)** | 0.77 (0.69 to 0.87)*** |
Median overall survival time in months and 95% CIs were estimated using the Kaplan–Meier method.
p Values were calculated using the log-rank test.
Adjusted for age, Charlson–Deyo comorbidity score, histologic type, molecular subtype, and tumor grade.
Adjusted for age, sex, type of insurance, rural/urban area, median household income quartile, Charlson–Deyo comorbidity score, type of cancer program, histologic type, molecular subtype, and tumor grade.
p < 0.05; **p < 0.01; ***p < 0.001.
aHR, adjusted hazard ratio.
On multivariable Cox regression analysis (model 2), Black patients who received palliative care had a greater risk of dying (aHR = 1.14, 95% CI: 1.07 to 1.21), whereas Asian (aHR = 0.83, 95% CI: 0.71 to 0.97) or Hispanic (aHR = 0.77, 95% CI: 0.69 to 0.87) patients had a lower risk of dying than White patients who received palliative care. Mortality risks were not statistically significant between HPI (aHR = 1.06, 95% CI: 0.61 to 1.82) or AIAN (aHR = 1.02, 95% CI: 0.72 to 1.43) patients and White patients who received palliative care. We observed similar results in MBC patients who did not use palliative care (Table 5). Overall, patients who received palliative care had a higher mortality risk than those who did not (aHR = 1.31, 95% CI: 1.27 to 1.34) (Supplementary Table S4).
Discussion
To our knowledge, the current study is the largest to examine palliative care use trends, racial/ethnic disparities, and overall survival differences among MBC patients from a U.S. national oncology registry. Despite ASCO and NCCN's call for early palliative care intervention8,16,17 and an increasing pattern of palliative care utilization in our study, palliative care utilization among MBC patients remained low. Racial/ethnic disparities exist in palliative care use in MBC patients. Asian, Black, or Hispanic patients were less likely than their White counterparts to have received palliative care. Furthermore, we observed a significant survival difference by race/ethnicity. Specifically, compared with White patients, Black patients had a greater mortality risk, while Asian and Hispanic patients had a lower risk of mortality. Taken together, these findings suggest suboptimal palliative care utilization and clear racial/ethnic disparities among MBC patients, which underscore the importance of promoting the benefits of palliative care and addressing these disparities to improve this patient population's quality of life.
In this study, one in five MBC patients received palliative care, which aligns with prior studies on palliative care use among patients with MBC21–25 or other metastatic diseases.18,19 Moreover, palliative care usage significantly increased from 2004 to 2020. The overall increase could be due to the increased knowledge, awareness, and acceptance of palliative care among cancer patients and their providers, as well as increased availability of palliative care at clinics. ASCO and NCCN's call for early palliative care integration into oncology care may also play a role. Our finding is congruent with previous studies of hospitalized MBC patients or those aged >65 years.21,22 However, these studies did not describe the trends in palliative care utilization across racial/ethnic groups, whereas we illustrated significantly increased patterns for White, Black, Asian, or Hispanic patients. Although palliative care utilization for AIAN and HPI patients did not increase significantly over time due to limited sample size, the data did suggest an upward trend for these racial groups. Further investigation is worth determining what facilitators have led to the growing palliative care utilization in this patient population and whether they differ across racial/ethnic groups.
Additionally, our analysis revealed that lack of health insurance or Medicaid coverage, lower median household income quartiles, and higher comorbidity index scores were associated with greater likelihoods of palliative care utilization. These associations indicate that patients with low socioeconomic status may have higher palliative care needs. Notwithstanding palliative care utilization significantly increased for MBC patients overall and by race/ethnicity, it remained suboptimal as the majority (>77%) had not received palliative care. Given the documented benefits of and growing demand for palliative care, it is essential to identify the unmet needs of this patient population and evaluate how oncology programs can improve the delivery of palliative and other supportive care in clinical settings.
Our results showed that racial/ethnic minority patients with MBC had a lower likelihood of palliative care utilization than their White counterparts. These findings have some similarities and notable contrasts to prior research.21,22,24 We found that Black patients were less likely to receive palliative care than White patients, consistent with Kim et al.'s study results.22 However, they did not observe a statistical difference in palliative care use between White and other racial/ethnic minority patients.22 The null findings are probably due to the small sample size, which was probably underpowered to detect the racial/ethnic differences in palliative care utilization. Furthermore, the patient cohort was inpatient-based from the National Inpatient Sample database,22 whereas our study included MBC patients in both inpatient and outpatient settings. Giap et al.'s analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data found no statistical differences in palliative care use across racial/ethnic groups.21 Unlike our study, their sample was limited to only patients >65 years of age.
The nonsignificant racial/ethnic differences demonstrated the potential homogeneity of palliative care usage in this older population.21 Nonetheless, our findings of palliative care utilization disparities among racial/ethnic minority patients could have implications for targeted care delivery in breast oncology.
Although we controlled for key sociodemographic and clinicopathologic characteristics in our analysis, reasons for MBC patients not using palliative care services remained unknown, as they were not collected as per NCDB. There are many explanations for not receiving palliative care and they may differ between racial/ethnic minority and White patients. For example, lack of knowledge and awareness of palliative, hospice, and end-of-life care were more prevalent in Black or Hispanic than in White patients diagnosed with chronic conditions, including cancer.29,30 Racial/ethnic disparities in health care access and utilization have been well documented. In our cohort, compared with White patients, racial/ethnic minority patients were more likely to be uninsured or on Medicaid, and Black, Hispanic, or HPI patients tended to live in communities with a median household income of <$40,227. These socioeconomic/health care access factors may have influenced minority patients' receipt of palliative care services. Physician preferences and cultural beliefs could also affect the racial/ethnic disparities observed in this study. Thus, more research is needed to explore barriers and intersectional factors contributing to racial/ethnic palliative care use disparities in MBC patients.
Furthermore, our study is the first to date to assess racial/ethnic differences in overall survival among MBC patients stratified by palliative care use. Previous studies have documented improved overall survival for patients with metastatic lung cancer who received early palliative care compared with those with delayed palliative care or standard care alone.10,14 A study of patients with mixed cancer diagnoses (including breast cancer) reported a significantly higher one-year survival rate in those who received early palliative care consultations than in those who were delayed.15 However, these studies focused on different metastatic cancer patient populations other than MBC and did not assess racial/ethnic survival differences.
Our study noted that compared with patients who did not receive palliative care, those who did had lower survival rates overall and by race/ethnicity. Importantly, we found that among patients who received palliative care, compared with White patients, Black patients had a 14% greater hazard of death, whereas Asian and Hispanic patients had a 17% and 23% lower hazard of death, respectively, after controlling for sociodemographic and clinicopathologic factors. Similar results were observed among patients who did not use palliative care. These findings are consistent with existing literature on racial/ethnic survival differences in the U.S. breast cancer population,1,2 and highlight that racial/ethnic disparities persist in the MBC patients, regardless of palliative care use. Additionally, our study found a higher mortality risk among patients who received palliative care than among those who did not. This finding may be related to the timing and duration of palliative care, as studies found that early use of palliative care may be associated with improved overall survival.10,14 However, the timing of and duration of palliative care use were not recorded in the NCDB, so it is worthwhile to collect and analyze the data for MBC patients in future research. Another possible reason for this finding is that patients receiving palliative care may have more advanced comorbidities and lower performance status than those without, but these differences have not been fully adjusted for.
Limitations
Several limitations of this study must be considered. First, it is important to point out that the NCDB's definition of palliative care did not cover a comprehensive list of palliative and other supportive services. Therefore, more detailed aspects of palliative care should be considered in future studies. Second, due to the nature of the registry, underreporting and misclassifications are likely and thus, prospective cohort studies are needed to accurately capture palliative care use in MBC patients and confirm our results. Third, we adjusted for key sociodemographic and clinicopathologic characteristics in our regression models, and observed no dramatic changes in the estimates for racial/ethnic disparities in palliative care utilization. However, there remain unmeasured factors, such as cancer symptoms and treatment side effects that could potentially affect the racial/ethnic disparities observed in this study. Fourth, the timing or duration of palliative care use was not collected by the registry, which probably would impact the differential survival rates across racial/ethnic groups. Hence, investigators should take into account these factors in future research.
Lastly, it should be noted that the patient cohort may not be representative of MBC patients receiving care and services at small community hospitals. However, as per the NCDB, ∼80% of new breast cancer cases were captured nationally.28 The estimated proportion of palliative care use by facility type was similar. Moreover, the findings of palliative care use prevalence and trends from the NCDB were consistent with prior studies using SEER and National Inpatient Sample data. Therefore, our findings may represent the true palliative care use prevalence in the United States.
Conclusion
In this large, racially/ethnically diverse cohort of MBC patients, there were significantly increased trends in palliative care utilization from 2004 to 2020 overall and within each racial/ethnic group. However, it remained suboptimal. Racial/ethnic minority groups were associated with a lower likelihood of receiving palliative care services. Furthermore, Black patients had worse overall survival, while Asian and HPI patients had better survival, than their White counterparts. All in all, our findings suggest the need for improving the utilization of and access to palliative care and ameliorating these racial/ethnic disparities among MBC patients. Breast cancer programs should promote the benefits of palliative care, tailor their palliative care interventions and care delivery, and ensure equal and equitable access to palliative care and other supportive services to achieve the best outcome for this patient population.
Data Availability Statement
Data for this study were obtained from the NCDB, which can be requested directly by submitting an application and a concept proposal to the American College of Surgeons through https://www.facs.org/quality-programs/cancer-programs/national-cancer-database
Supplementary Material
Acknowledgments
The data used in the study are derived from a deidentified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator. Parts of the data were presented at the 16th American Association for Cancer Research (AACR) Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved, Orlando, FL, September 29 to October 2, 2023. (doi: 10.1158/1538-7755.DISP23-B011)
Authors' Contributions
J.Q.F.: conceptualization, study design, data analysis, creating and formatting tables/figures, and drafting the initial article. O.J.O.: conceptualization, study design, and administrative support. F.Z.: conceptualization, study design, and administrative support. D.H.: conceptualization, study design, administrative support, and overall supervision. All authors contributed to interpretations of the findings, writing, review, editing of the article, and approval of the final article and submission.
Funding Information
This study is supported in part by the Breast Cancer Research Foundation (BCRF-22-071), the National Cancer Institute (P20CA233307), the Susan G. Komen Breast Cancer Foundation (TREND21675016), and the National Institute on Aging under grant award T32 AG000243. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes/National Institute on Aging.
Author Disclosure Statement
The authors declared no potential financial or nonfinancial conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data for this study were obtained from the NCDB, which can be requested directly by submitting an application and a concept proposal to the American College of Surgeons through https://www.facs.org/quality-programs/cancer-programs/national-cancer-database