Racial and Socioeconomic Disparities in Breast Cancer Diagnostic Work Up and Outcomes

项目摘要 美国少数族裔妇女、教育程度低、收入低、居住在农村和保险不足的人 与未患乳腺癌的女性相比，乳腺癌患者的疾病负担更重，生存率更低 特征，尽管最近在筛查途径和治疗方面有所改进。大多数努力是为了 缓解这些差距的重点是筛查乳房X光检查，但女性必须驾驭 怀疑癌症时的多个额外步骤，包括更多的成像、活组织检查和专科医生 磋商。每年，有1200万美国妇女进入这一诊断性护理连续体。收不到 及时的质量评估会导致延迟诊断，更具侵入性的手术，晚期癌症 确诊，以及更高的死亡率。与筛查相比，令人惊讶的是，人们对筛查期间的差异知之甚少 这段诊断期。据估计，高达30%的乳房X光检查发现异常的女性 未能获得适当或及时的后续行动，高达50%的种族/少数民族和社会经济状况 处于不利地位的妇女经历了这样的失败。更清楚地了解诊断过程中的差异 美国乳腺癌筛查和诊断的分散性阻碍了连续性， 护理方面的差异可能是由于个人、住宅和医疗保健提供因素的复杂组合造成的。 我们建议对诊断性乳房成像的差异进行美国迄今为止最大规模的观察性研究。 具体地说，我们的目标是1)确定较少获得和使用密钥的特定妇女亚群 诊断成像技术；2)确定可作为质量的诊断结果的差异 基于种族/族裔和社会经济地位的护理指标；以及3)查明 对不同人群的诊断评估。我们将使用多层次统计建模和中介 对可能影响不公平诊断护理的多因素交互作用进行分析。我们的队伍， 乳腺癌监测联盟，由国家乳腺癌流行病学专家组成， 生物统计学、卫生服务研究、医学和放射学。BCSC代表着最大的纵向 乳腺癌成像数据资源与长期结果相联系，代表了美国的一般情况。 按种族/民族分列的人口。我们系统地收集妇女、考试、住宿、实习、提供者和 七个区域登记和200多个个人诊所的肿瘤水平数据。收集到的数据 1300万次乳房成像检查，其中550万次是在传统差异中进行的 对于人口，我们的团队有能力进行拟议的分析。我们的研究将有助于转移乳房 癌症差异研究范式从关注筛查获得到评估整个诊断 这一集。通过确定新的护理质量指标和差异的“早期预警”指标，我们的结果将 告知旨在缩小地方差距的实践层面的干预措施和国家实践指南 以及旨在更公平地进行乳腺癌诊断评估的政策。

Project Summary U.S. women of minority race/ethnicity, lower education, lower income, rural residence, and the underinsured experience higher breast cancer disease burden and lower survival rates than women without these characteristics, despite recent improvements in screening access and treatments. The majority of efforts to mitigate these disparities have focused on screening mammography access, but women must navigate multiple additional steps when cancer is suspected, including more imaging, biopsies, and specialist consultations. Each year, >12 million U.S. women enter this diagnostic care continuum. Failure to receive timely, quality evaluation leads to delayed diagnosis, more invasive procedures, advanced cancer stage at diagnosis, and greater mortality. Compared to screening, surprisingly little is known about disparities during this diagnostic period. It is estimated that up to 30% of women with abnormalities detected by mammography fail to obtain appropriate or timely follow-up, and up to 50% of racial/ethnic minorities and socioeconomically disadvantaged women experience such failures. A clearer understanding of disparities along the diagnostic continuum is hindered by the decentralized nature of breast cancer screening and diagnosis in the U.S., with disparities in care likely due to a complex combination of individual, residential, and healthcare delivery factors. We propose to conduct the largest U.S. observational study of disparities in diagnostic breast imaging to date. Specifically, we aim to 1) identify specific subpopulations of women with lower access to and use of key diagnostic imaging technologies; 2) determine differences in diagnostic outcomes that can serve as quality of care indicators based on race/ethnicity and socioeconomic status; and 3) identify differences in timeliness of diagnostic evaluation among disparities populations. We will use multi-level statistical modeling and mediation analyses to account for multifactorial interactions that likely influence inequitable diagnostic care. Our team, the Breast Cancer Surveillance Consortium, consists of national experts in breast cancer epidemiology, biostatistics, health services research, medicine, and radiology. The BCSC represents the largest longitudinal breast cancer imaging data resource linked to long-term outcomes that is representative of the general U.S. population by race/ethnicity. We systematically collect woman-, exam-, residential-, practice-, provider- and tumor-level data across seven regional registries and more than 200 individual practices. With data collected for 13 million breast imaging exams, 5.5 million of which were performed among traditional disparities populations, our team is well-positioned to carry out the proposed analyses. Our study will help shift the breast cancer disparities research paradigm from focusing on screening access to evaluating the entire diagnostic episode. By identifying novel quality of care metrics and “early warning” indicators of disparities, our results will inform both practice-level interventions aimed at closing local disparities gaps and national practice guidelines and policies directed towards more equitable breast cancer diagnostic evaluation.