Race, geography, and risk of breast cancer treatment delays: A population-based study 2004-2015.

BACKGROUND: Treatment delays affect breast cancer survival and constitute poor-quality care. Black patients experience more treatment delay, but the relationship of geography to these disparities is poorly understood. METHODS: We studied a population-based, retrospective, observational cohort of patients with breast cancer in North Carolina between 2004 and 2017 from the Cancer Information and Population Health Resource, which links cancer registry and sociodemographic data to multipayer insurance claims. We included patients >18 years with Stage I-III breast cancer who received surgery or chemotherapy as their first treatment. Delay was defined as >60 days from diagnosis to first treatment. Counties were aggregated into nine Area Health Education Center regions. Race was dichotomized as Black versus non-Black. RESULTS: Among 32,626 patients, 6190 (19.0%) were Black. Black patients were more likely to experience treatment delay >60 days (15.0% of Black vs. 8.0% of non-Black). Using race-stratified modified Poisson regression, age-adjusted relative risk of delay in the highest risk region was approximately twice that in the lowest risk region among Black (relative risk, 2.1; 95% CI, 1.6-2.6) and non-Black patients (relative risk, 1.9; 95% CI, 1.5-2.3). Adjustment for clinical and sociodemographic features only slightly attenuated interregion differences. The magnitude of the racial gap in treatment delay varied by region, from 0.0% to 9.4%. CONCLUSIONS: Geographic region was significantly associated with risk of treatment delays for both Black and non-Black patients. The magnitude of racial disparities in treatment delay varied markedly between regions. Future studies should consider both high-risk geographic regions and high-risk patient groups for intervention to prevent delays.

Seeking Racial Equity in Hematology and Oncology: a Fellow-Led Educational Series to Promote Reflection and Action.

The USA is experiencing a reckoning with racial injustice and graduate medical education programs are seeking ways to address this important topic in training. Fellows in hematology/oncology at the University of North Carolina recognized this important gap and adapted a curriculum for medical residents on racial equity to a subspecialty audience. Aims were (1) to improve knowledge and awareness about implicit bias and systemic racism and (2) introduce methods to address racial inequities. We used lived experiences and collated materials from scientific literature and lay media to illustrate key points. The course explored the effects of implicit bias on individual, clinical, and health system levels, anchored in Kahneman's two-system theory. Videos, journal articles, and group discussion were employed to appeal to many learning styles. A post-curriculum survey assessed perceptions of racial inequality in medicine and the series' effects using a Likert scale. Twenty-nine participants completed the survey (12 fellows), 71% reported improved awareness of racial inequities, and 61% reported improved comfort level in addressing racial inequities. All participants recognized at least "some" racial inequity in medicine, and over 75% of participants indicated interest in further sessions. Formulation of an educational curriculum by fellows and delivered in a division-wide setting was feasible and well received by participants, filling a key educational gap. We encourage other institutions to take similar steps to highlight issues of systemic racism and move our field in the right direction.

USPSTF Colorectal Cancer Screening Recommendation and Uptake for Individuals Aged 45 to 49 Years.

Importance: In May 2021, the US Preventive Services Task Force (USPSTF) issued a grade B recommendation encouraging colorectal cancer (CRC) screening among average-risk individuals aged 45 to 49 years. The patterns of screening uptake and possible socioeconomic disparities in screening in this age group remain unknown. Objective: To evaluate changes in CRC screening uptake among average-risk individuals aged 45 to 49 years after the USPSTF recommendation was issued in 2021. Design, Setting, and Participants: This retrospective cohort study used deidentified claims data from commercially insured Blue Cross Blue Shield beneficiaries aged 45 to 49 years across the US between January 1, 2017, and December 31, 2022. Exposure: Publication of the May 2021 USPSTF CRC screening recommendation for adults aged 45 to 49 years. Main Outcomes and Measures: Absolute and relative changes in screening uptake were compared between a 20-month period preceding (May 1, 2018, to December 31, 2019) and a 20-month period following (May 1, 2021, to December, 31, 2022) the USPSTF recommendation. Interrupted time-series analysis and autoregressive integrated moving average models were used to evaluate changes in screening rates, adjusting for temporal autocorrelation and seasonality. Results: In this cohort study of 10 221 114 distinct beneficiaries aged 45 to 49 years (mean [SD] age, 47.04 [1.41] years; 51.04% female), bimonthly mean (SD) numbers of average-risk beneficiaries were 3 213 935 (31 508) and 2 923 327 (105 716) in the prerecommendation and postrecommendation periods, respectively. Mean (SD) screening uptake increased from 0.50% (0.02%) to 1.51% (0.59%) between the 2 periods (P < .001), representing an absolute change of 1.01 percentage points (95% CI, 0.62-1.40 percentage points) but no significant relative change (202.51%; 95% CI, -30.59% to 436.87%). Compared with average-risk beneficiaries residing in areas with the lowest socioeconomic status (SES), those residing in areas with the highest SES experienced the largest absolute change in screening (1.25 [95% CI, 0.77-1.74] percentage points vs 0.75 [95% CI, 0.47-1.02] percentage points), but relative changes were not significant (214.01% [95% CI, -30.91% to 461.15%] vs 167.73% [95% CI, -16.30% to 352.62%]). After the recommendation was issued, the screening uptake rate also increased fastest among average-risk beneficiaries residing in the areas with highest SES (0.24 [95% CI, 0.23-0.25] percentage points every 2 months) and metropolitan areas (0.20 [95% CI, 0.19-0.21] percentage points every 2 months). Conclusions and Relevance: This study found that among privately insured beneficiaries aged 45 to 49 years, CRC screening uptake increased after the USPSTF recommendation, with potential disparities based on SES and locality.