TABLE 2—

Reported Barriers to Care and Recommendations From Included Studies

Barriers and Recommendations	Description
Intrapersonal factors
Side effects	Side effects were noted as barriers to care.77,80,83 In particular body image and sexual concerns emerged as common barriers for women across all racial groups during a qualitative analysis.77 Fear of side effects was reported as a reason to not initiate ET among noninitiators (28.8%) and as a reason to discontinue (25%) among discontinuers. Also, some noninitiators (18.8%) chose not to initiate ET despite provider recommendations.80
Cost	Financial burden and job disruption emerged as barriers to care, with participants noting a need for affordable breast cancer care.77 However, in a survey, cost specific to ET was a barrier among only 5% of patients and insurance was a barrier among only 1% of patients.83 Another study reported a small number of women who discontinued ET reported lack of coverage by insurance as a reason for discontinuation (7.1%).80 A small proportion of noninitiators (5%) reported that ET was too expensive.80 However, a larger proportion of women noted cost as a reason for having discontinued ET (18.8%). Furthermore, < 1% of women were concerned about missing work.83
Education	Latina women felt that low education may be a barrier to care.77
Other	Patients infrequently listed inconvenience of use (< 1%) as a barrier to care.83 Some women reported disliking medication (23.2%), being unsure whether it was helping (22.3%), feeling as though they had taken ET long enough (17.9%) and wanting to move on from cancer (16.1%) as reasons for having discontinued ET early.
Interpersonal factors
Communication	Lack of a provider recommendation was the most commonly cited barrier across racial groups; however, Black women cited it most often.83 Language was noted as a barrier to communication and breast cancer care.77 “Doctor said I did not need” (33.8%), “doctor left it up to me” (21.3%), and “doctor never discussed” (7.5%) were reported as reasons for noninitiation among a group of noninitiators.80 Patients reported discontinuing ET early because a doctor told them to (25%).80
Social	Discouragement from family (< 1%) and discouragement from friends (< 1%) were given as barriers to care.83
Community factors: recommendations	Recommendations from focus groups in 1 study primarily target a community-level approach so that patients can receive culturally and linguistically appropriate care.77 Furthermore, educating the community and increasing cultural sensitivity were recommended to improve breast cancer care for a diverse patient population.77

Note. ET = endocrine therapy.