Regional Disparities Observed in Uptake of Adjuvant Breast Cancer Therapy

A new study by researchers at the University of Virginia School of Medicine has uncovered notable disparities in uptake of adjuvant breast cancer therapies in the Appalachian region of the United States, a finding that suggests targeted intervention strategies may help to improve outcomes for this population of women.

"In our sample of elderly women with prescription insurance, we found evidence of suboptimal use of lifesaving hormonal therapy,” said Rajesh Balkrishnan. “We also found evidence that newer medications with adverse effects that need to be managed are poorly used, suggesting that patients are not educated enough about medication management issues.”

Balkrishnan, professor of public health sciences, University of Virginia School of Medicine, attributed this finding to a variety of complex factors, including poverty, geography, and the individual’s preventive health orientation.

For their study, researchers linked cancer registries to Medicare claims data for 428 women living in the Appalachian counties of four states: Kentucky, Ohio, North Carolina, and Pennsylvania. They found that 31 percent failed to follow through with their regimen of adjuvant hormone therapy.

“Almost a third of the prescriptions for adjuvant hormonal therapy were not filled, which is much, much higher compared with what we usually see in commercially insured populations,” said Balkrishnan in a statement.

“Usually it ranges from about 10 percent to 15 percent, so this is almost double that number. A third of the women going without adjuvant hormone therapy — that is a scary prospect.”

This study was one of the first of its kind to delve into disparities in breast cancer care within the Appalachian region where cancer is a leading cause of death, and access to healthcare can be a challenge because of socioeconomic deprivation and geographical barriers to care. “Women often have to drive many miles to get to the nearest tertiary cancer center or the pharmacy,” noted Balkrishnan.

Researchers also found that the women in their study were more likely to use tamoxifen than to try the newer aromatase inhibitors. A tendency in the region toward slower uptake of newer technologies may contribute to this missed opportunity for treatment, Balkrishnan explained.

“The other issue that comes to the forefront is that many of these medications have pretty severe adverse effects,” he continued. “There are high rates of discontinuance of the medication, because a lot of patients are not counseled properly on how to manage the side effects of these medications and how to take medications in conjunction with other aspects of their lifestyles and daily living.”

Balkrishnan offered some suggestions to address this unmet need. “Telemedicine and use of mobile technologies may be a way to get state-of-the-art oncology care to this population, which has distinct geographical and socioeconomic disparity. The use of patient navigators, such as social workers and community leaders, needs to be explored more. Greater awareness about preventive health is needed. Mobile health clinics are another option.

“What is happening in Appalachia is not isolated. It is a phenomenon affecting many far-flung, primarily rural residents who have significant difficulty accessing quality medical care for chronic life-threatening diseases that occur primarily at the end of life. We need to find innovative ways to get access to care to the populations who may need it the most, but who may be at a disadvantage in obtaining it.”

Tan X, Marshall VD, Anderson RT, et al. Adjuvant therapy use among Appalachian breast cancer survivors. Medicine (Baltimore). doi: 10.1097/MD.0000000000001071.