Dunn Matthew R, Niu Hongqian, Li Didong, Emerson Marc A, Thompson Caroline A, Nichols Hazel B, Roberson Mya L, Wheeler Stephanie B, Hyslop Terry, Elston Lafata Jennifer, Troester Melissa A
Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina.
Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.
Cancer Epidemiol Biomarkers Prev. 2025 Jul 1;34(7):1199-1209. doi: 10.1158/1055-9965.EPI-25-0011.
Geographic disparities in breast cancer outcomes exist. Few studies have examined community- and health system-level factors associated with care timeliness, an important measure of care quality.
The Carolina Breast Cancer Study is a population-based cohort of 2,998 women with invasive breast cancer (2008-2013). Using latent class modeling, patients' census tracts of residence were characterized by healthcare accessibility and affordability. Centers for Medicare and Medicaid Services ratings were used to classify hospitals as low- or high-quality. Six timeliness outcomes were assessed: (i) lacking prediagnostic regular care, (ii) being underscreened, (iii) late-stage diagnosis, (iv) delayed treatment initiation, (v) prolonged treatment duration, and (vi) lacking receipt of Oncotype DX genomic testing. Associations of geographic accessibility, healthcare affordability, and hospital-level quality with care timeliness were evaluated with relative frequency differences (RFD) and 95% confidence intervals (CI).
Compared with "high-accessibility, high-affordability" census tracts, patients residing in "low-accessibility, low-affordability" areas were more likely to be underscreened (RFD = 18.7%, CI, 13.0, 24.3), have late-stage diagnosis (RFD = 6.2%, CI, 2.4, 10.1), and experience prolonged treatment (RFD = 6.9%, CI, 1.4, 12.3). "High-accessibility, low-affordability" areas had the highest frequency of treatment delay (RFD = 9.3%, CI, 3.9, 14.7). Initial surgery at a high-quality facility was associated with less delayed treatment (RFD = -3.9%, CI, -7.5, -0.4) and prolonged treatment (RFD = -5.9%, CI, -9.9, -1.9).
Community- and health system-level factors were associated with timely breast cancer care.
Policy efforts to improve access in communities should consider multiple dimensions of access, including geospatial accessibility and affordability.
乳腺癌治疗结果存在地区差异。很少有研究考察与医疗及时性相关的社区和卫生系统层面的因素，而医疗及时性是衡量医疗质量的一项重要指标。
卡罗来纳乳腺癌研究是一项基于人群的队列研究，纳入了2998例浸润性乳腺癌女性患者（2008 - 2013年）。采用潜在类别模型，根据医疗可及性和可负担性对患者的居住普查区进行特征描述。利用医疗保险和医疗补助服务中心的评级将医院分为低质量或高质量。评估了六个及时性结果：（i）缺乏诊断前的常规护理，（ii）筛查不足，（iii）晚期诊断，（iv）治疗开始延迟，（v）治疗持续时间延长，以及（vi）未接受Oncotype DX基因检测。采用相对频率差异（RFD）和95%置信区间（CI）评估地理可及性、医疗可负担性和医院层面质量与医疗及时性之间的关联。
与“高可及性、高可负担性”普查区相比，居住在“低可及性、低可负担性”地区的患者更有可能筛查不足（RFD = 18.7%，CI，13.0，24.3）、晚期诊断（RFD = 6.2%，CI，2.4，10.1）以及经历治疗持续时间延长（RFD = 6.9%，CI，1.4，12.3）。“高可及性、低可负担性”地区治疗延迟的频率最高（RFD = 9.3%，CI，3.9，14.7）。在高质量机构进行初次手术与较少的治疗延迟（RFD = -3.9%，CI，-7.5，-0.4）和治疗持续时间延长（RFD = -5.9%，CI，-9.9，-1.9）相关。
社区和卫生系统层面的因素与乳腺癌的及时治疗相关。
改善社区医疗可及性的政策措施应考虑可及性的多个维度，包括地理空间可及性和可负担性。
