Patient-reported causes of distress predict disparities in time to evaluation and time to treatment after breast cancer diagnosis

Abstract

Background: We examined whether the National Comprehensive Cancer Network distress thermometer (DT), a patient-reported outcome measure, could be used to identify levels and causes of distress associated with racial/ethnic disparities in time to care among patients with breast cancer.

Methods: We identified women aged ≥18 years with stage 0-IV breast cancer who were diagnosed in a single health system between January 2014 and July 2016. The baseline visit was defined as the first postdiagnosis, pretreatment clinical evaluation. Zero-inflated negative binomial (ZINB) regression (modeling non-zero DT scores and DT scores = 0) and logistic regression (modeling DT score ≥ 4, threshold for social services referral) were used to examine associations between baseline score (0 = none to 10 = extreme) and types of stressors (emotional, familial, practical, physical, spiritual) after adjustment for race/ethnicity and other characteristics. Linear regression with log transformation was used to identify predictors of time to evaluation and time to treatment.

Results: A total of 1029 women were included (median baseline DT score = 4). Emotional, physical, and practical stressors were associated with distress in both the ZINB and logistic models (all P < .05). Black patients (n = 258) were more likely to report no distress than Whites (n = 675; ZINB zero model odds ratio, 2.72; 95% CI, 1.68-4.40; P < .001) despite reporting a similar number of stressors (P = .07). Higher DT scores were associated with shorter time to evaluation and time to treatment while being Black and having physical or practical stressors were associated with delays in both (all P < .05).

Conclusions: Patient-reported stressors predicted delays in time to care, but patient-reported levels of distress did not, with Black patients having delayed time to care despite reporting low levels of distress. We describe anticipatory, culturally responsive strategies for using patient-reported outcomes to address observed disparities.

Keywords: breast cancer; distress; health disparities; modifiable risk factors; patient-reported outcomes; race/ethnicity.

Figure 1.

Flow diagram of patients newly diagnosed with breast cancer between January 2014 and July 2016. DT, distress thermometer; NCCN, National Comprehensive Cancer Network.

Figure 2.

Levels and causes of patient-reported distress among patients newly diagnosed with breast cancer between January 2014 and July 2016 (n = 1029). DT, distress thermometer; IQR, interquartile range; PI, Pacific Islander. *Statistically significant difference between racial/ethnic groups.

Figure 3.

Frequency of patient-reported stressors among patients newly diagnosed with breast cancer between January 2014 and July 2016 (n = 1029). (A) All patients. (B) Asian/PI patients. (C) Black patients. (D) Hispanic patients. (E) White patients. (F) Patients of other races/ethnicities. PI, Pacific Islander.

Figure 3.

Frequency of patient-reported stressors among patients newly diagnosed with breast cancer between January 2014 and July 2016 (n = 1029). (A) All patients. (B) Asian/PI patients. (C) Black patients. (D) Hispanic patients. (E) White patients. (F) Patients of other races/ethnicities. PI, Pacific Islander.

Figure 3.

Frequency of patient-reported stressors among patients newly diagnosed with breast cancer between January 2014 and July 2016 (n = 1029). (A) All patients. (B) Asian/PI patients. (C) Black patients. (D) Hispanic patients. (E) White patients. (F) Patients of other races/ethnicities. PI, Pacific Islander.