Underuse of Radiation in Younger Women With Breast Cancer
Background Evidence-based literature has confirmed the effectiveness of radiation therapy (RT) after breast-conserving surgery (BCS), especially for young women. However, women with young children may be less likely to be compliant. This study explores factors associated with noncompliance of RT among insured young patients.
Method Using the MarketScan Database, we identified the study cohort as women aged 20 to 64 years who had a BCS between January 1, 2004, and December 31, 2009, and had continuous enrollment 12 months before and after the date of BCS. Patients who had any radiation claims within a year of BCS were considered compliant. Adjusted odds of compliance were estimated from logistic regressions for the full sample and age-stratified subgroups. Sensitivity analyses were performed to evaluate the robustness of study findings. All statistical tests were two-sided.
Results Eighteen thousand one hundred twenty of 21 008 (86.25%) nonmetastatic BCS patients received RT. Among patients aged 20 to 64 years, those with children aged 7 to 12 years, those with children aged 13 to 17 years, and those with no children or children aged 18 years or older were more likely to receive RT than patients with at least one child aged less than 7 years (7–12 years: odds ratio (OR) = 1.32, 95% confidence interval (CI) = 1.05 to 1.66, P = .02; 13–17 years: OR = 1.41, 95% CI = 1.13 to 1.75, P = .002; no children or ≥18 years: OR = 1.38, 95% CI = 1.13 to 1.68, P = .001). Stratified analyses showed that the above association was primarily driven by women in the youngest age group (aged 20–50). Other important factors included breast cancer quality of care measures, enrollment in health maintenance organizations or capitated preferred provider organizations, travelled to a Census division outside their residence for BCS, and whether patients were primary holders of the insurance policy.
Conclusions Competing demands from child care can constitute a barrier to complete guideline-concordant breast cancer therapy. Younger patients may be confronted by unique challenges that warrant more attention in future research.
Clinical benefits of radiation therapy (RT) after breast-conserving surgery (BCS) for women with early-stage breast cancer are well documented in the literature. Many professional associations now consider RT after BCS to be an important quality of care indicator for breast cancer. Several population-based studies have investigated the compliance rates of RT and the associated factors. The majority of these studies focused on an elderly population and used either Medicare claims or the Surveillance, Epidemiology and End Results (SEER)–Medicare data. However, recent estimates reported that approximately 60% of breast cancer patients diagnosed between 2005 and 2009 were aged less than 65 years, yet the pattern of RT after BCS among young women remained underexplored.
Understanding the pattern of RT after BCS among young patients and factors associated with noncompliance has important clinical and economic implications. Today it is well accepted that breast cancers diagnosed at younger ages differ from those diagnosed at older ages; younger women tend to have more aggressive tumors that are associated with higher risks of local and distant recurrence. A meta-analysis reported that RT after BCS increased survival and reduced local recurrence, especially among young patients. Thus, young breast cancer patients who underwent BCS are expected to benefit more from RT. From an economic perspective, many women aged less than 65 years are active participants in the workforce; therefore, their absence from the labor market because of morbidity associated with cancer symptoms and treatment or premature death from cancer will lead to substantial productivity loss. Indeed, the estimated costs of productivity loss because of breast cancer were $10.9 billion in 2010.
The few studies that included young breast cancer patients used cancer registry data, such as SEER or the National Cancer Database, to determine the pattern of RT after BCS. Although the rate of RT may be underestimated in these studies because validation studies have raised the concern of underascertainment for RT identified from registry data, an interesting pattern was observed in the two studies that focused exclusively on young breast cancer patients. Both reported a lower rate of RT after BCS among patients at a younger age. One study found that the rate of RT was 81% for women aged 50 to 55 years and was 75% for those aged 35 years or younger; the other reported the rate to be 69%, 73%, and 80% for women in the age ranges of 35 years or younger, 36 to 40 years, and 61 to 64, respectively.
The purpose of our study was twofold. First, we used claims and enrollment data from employer-sponsored insurance plans to explore factors associated with the use of RT after BCS among young patients with breast cancer. Second, we tested a hypothesis that the lower rate of RT observed among younger women may be associated with competing demand of their time in providing child care. Specifically, we investigated whether younger women with young children were less likely to undergo RT after BCS compared to women at similar ages without young children.
Abstract and Introduction
Abstract
Background Evidence-based literature has confirmed the effectiveness of radiation therapy (RT) after breast-conserving surgery (BCS), especially for young women. However, women with young children may be less likely to be compliant. This study explores factors associated with noncompliance of RT among insured young patients.
Method Using the MarketScan Database, we identified the study cohort as women aged 20 to 64 years who had a BCS between January 1, 2004, and December 31, 2009, and had continuous enrollment 12 months before and after the date of BCS. Patients who had any radiation claims within a year of BCS were considered compliant. Adjusted odds of compliance were estimated from logistic regressions for the full sample and age-stratified subgroups. Sensitivity analyses were performed to evaluate the robustness of study findings. All statistical tests were two-sided.
Results Eighteen thousand one hundred twenty of 21 008 (86.25%) nonmetastatic BCS patients received RT. Among patients aged 20 to 64 years, those with children aged 7 to 12 years, those with children aged 13 to 17 years, and those with no children or children aged 18 years or older were more likely to receive RT than patients with at least one child aged less than 7 years (7–12 years: odds ratio (OR) = 1.32, 95% confidence interval (CI) = 1.05 to 1.66, P = .02; 13–17 years: OR = 1.41, 95% CI = 1.13 to 1.75, P = .002; no children or ≥18 years: OR = 1.38, 95% CI = 1.13 to 1.68, P = .001). Stratified analyses showed that the above association was primarily driven by women in the youngest age group (aged 20–50). Other important factors included breast cancer quality of care measures, enrollment in health maintenance organizations or capitated preferred provider organizations, travelled to a Census division outside their residence for BCS, and whether patients were primary holders of the insurance policy.
Conclusions Competing demands from child care can constitute a barrier to complete guideline-concordant breast cancer therapy. Younger patients may be confronted by unique challenges that warrant more attention in future research.
Introduction
Clinical benefits of radiation therapy (RT) after breast-conserving surgery (BCS) for women with early-stage breast cancer are well documented in the literature. Many professional associations now consider RT after BCS to be an important quality of care indicator for breast cancer. Several population-based studies have investigated the compliance rates of RT and the associated factors. The majority of these studies focused on an elderly population and used either Medicare claims or the Surveillance, Epidemiology and End Results (SEER)–Medicare data. However, recent estimates reported that approximately 60% of breast cancer patients diagnosed between 2005 and 2009 were aged less than 65 years, yet the pattern of RT after BCS among young women remained underexplored.
Understanding the pattern of RT after BCS among young patients and factors associated with noncompliance has important clinical and economic implications. Today it is well accepted that breast cancers diagnosed at younger ages differ from those diagnosed at older ages; younger women tend to have more aggressive tumors that are associated with higher risks of local and distant recurrence. A meta-analysis reported that RT after BCS increased survival and reduced local recurrence, especially among young patients. Thus, young breast cancer patients who underwent BCS are expected to benefit more from RT. From an economic perspective, many women aged less than 65 years are active participants in the workforce; therefore, their absence from the labor market because of morbidity associated with cancer symptoms and treatment or premature death from cancer will lead to substantial productivity loss. Indeed, the estimated costs of productivity loss because of breast cancer were $10.9 billion in 2010.
The few studies that included young breast cancer patients used cancer registry data, such as SEER or the National Cancer Database, to determine the pattern of RT after BCS. Although the rate of RT may be underestimated in these studies because validation studies have raised the concern of underascertainment for RT identified from registry data, an interesting pattern was observed in the two studies that focused exclusively on young breast cancer patients. Both reported a lower rate of RT after BCS among patients at a younger age. One study found that the rate of RT was 81% for women aged 50 to 55 years and was 75% for those aged 35 years or younger; the other reported the rate to be 69%, 73%, and 80% for women in the age ranges of 35 years or younger, 36 to 40 years, and 61 to 64, respectively.
The purpose of our study was twofold. First, we used claims and enrollment data from employer-sponsored insurance plans to explore factors associated with the use of RT after BCS among young patients with breast cancer. Second, we tested a hypothesis that the lower rate of RT observed among younger women may be associated with competing demand of their time in providing child care. Specifically, we investigated whether younger women with young children were less likely to undergo RT after BCS compared to women at similar ages without young children.