Disparities in breast cancer care delivery: solving a complex puzzle.
Disparities in breast cancer care delivery: solving a complex puzzle.
复制标题
乳腺癌护理服务的差异：解决一个复杂的难题。
DOI：
10.1007/s10549-012-2005-9
复制
发表时间：
2012
影响因子：
3.8
通讯作者：
Friese,ChristopherR
中科院分区：
文献类型：
--
作者：
Friese,ChristopherR
众所周知，在美国，乳腺癌护理服务参差不齐。临床医生和研究人员长期以来一直观察到，诊断为乳腺癌的女性的护理过程和结果存在差异，这可归因于可观察到的个体和社会特征[2-6]。研究人员报告了不同年龄、种族、民族、地理位置、教育程度和收入在筛查、诊断、治疗和死亡率方面的显著差异。重要的是要认识到文献中存在矛盾的发现，特别是关于种族/民族与化疗护理质量之间的关系。医学研究所（Institute of Medicine）的开创性报告《不平等待遇》（inequality Treatment）承认了这些差异，以及医疗服务提供方面的差异对国家健康状况的更广泛影响。该报告的作者指出，理解和补救现状都很复杂。纠正乳腺癌护理提供差异的一个持续挑战是对观察到的差异的原因了解有限。目前，我们有一个不确定的大小，范围和病因的问题。包括各种来源的三角数据的研究，如癌症登记、临床登记以及对患者和提供者的调查，将有助于理清当前的混乱，并刺激基于证据的质量改进和政策努力。在这种背景下，Lipscomb等人在本期《乳腺癌研究与治疗》上发表的论文是解决这一复杂难题的必要组成部分。这篇论文的一个关键贡献是，这些发现源于癌症登记数据和临床记录的独特结合。作者使用乔治亚州综合癌症登记处来确定乳腺癌病例，并提取了位于乔治亚州西南部相对农村的27个肿瘤学机构的868名妇女的治疗记录。这些相互关联的数据使我们能够理解，至少在一定程度上，几个个人特征如何影响高质量乳腺癌护理的变化。作者应该受到赞扬，因为他们通过敏感性分析和相互作用效应的检查，对潜在的混淆变量进行了详尽的关注。他们对这些问题的认真关注增加了对主要研究结果的信心。在多变量模型中，他们发现化疗开始没有种族差异。然而，居住在贫困地区的妇女开始化疗的可能性明显较低。这是一个值得进一步注意和讨论的重要发现。在研究中所有开始化疗的女性中，10%的人没有完成最初的计划，主要是由于毒性。在一个包括种族和婚姻状况、种族和合并症之间相互作用的多变量模型中，未婚黑人妇女比未婚白人妇女完成化疗的可能性更高。有合并症的未婚女性完成化疗的可能性低于无合并症的未婚女性。样本中已婚妇女化疗开始和完成的差异可以忽略不计。解释这些有趣发现的一种方法是通过社会支持的视角。婚姻状况可以作为更大的社会支持概念的代表，这可能影响治疗决定和结果。而社会支持则不然
Breast cancer care delivery is known to be uneven in the United States [1]. Clinicians and researchers have long observed differences in the process and outcomes of care for women diagnosed with breast cancer that can be attributed to observable individual and societal characteristics [2–6]. Researchers have reported noteworthy differences in screening, diagnosis, treatment, and mortality by age, race, ethnicity, geographic location, education, and income. It is important to recognize there are contradictory findings in the literature, specifically regarding the relationship between race/ethnicity and quality of chemotherapy care. The seminal Institute of Medicine report Unequal Treatment recognized these differences and the broader impact of disparities in health care delivery on the nation’s health [7]. The report’s authors noted the complexity in both understanding and remedying the current state. A persistent challenge to correcting disparities in breast cancer care delivery is the limited understanding of the reasons for the observed disparities [8]. Currently, we have a problem of uncertain size, scope, and etiology. Research studies that include triangulated data across sources, such as cancer registries, clinical registries, and surveys of patients and providers, will help disentangle current confusion and stimulate evidence-based quality improvement and policy efforts. In this context, the paper by Lipscomb et al. in this issue of Breast Cancer Research and Treatment is a necessary piece to solve this complex puzzle. A key contribution from this paper is that the findings stem from a unique combination of cancer registry data and clinical records. The authors used the Georgia Comprehensive Cancer registry to identify incident cases of breast cancer and abstracted records on 868 women treated in 27 oncology settings located in relatively rural Southwest Georgia. These linked data enable us to understand, at least in part, how several personal characteristics may influence variation in high-quality breast cancer care.The authors should be commended for their exhaustive attention to potentially confounding variables through sensitivity analyses and examination of interaction effects. Their careful attention to these issues increases the confidence in the principal study findings. In multivariable models, they found no differences in chemotherapy initiation by race. However, women who resided in impoverished areas were significantly less likely to initiate chemotherapy. This is an important finding that merits further attention and discussion. Of all the women in the study who initiated chemotherapy, 10% did not complete their originally intended plan, primarily due to toxicity. In a multivariable model that included interaction terms between race and marital status and race and comorbidity, unmarried black women had higher likelihood of chemotherapy completion compared with unmarried white women. Unmarried women with comorbid conditions were less likely to complete chemotherapy than unmarried women without comorbid conditions. Differences in chemotherapy initiation and completion were negligible for married women in the sample. One way to interpret these interesting findings is through the lens of social support. Marital status may serve as a proxy for the larger concept of social support, which may influence treatment decisions and outcomes. While social support was not