Disparities complicate many aspects of breast cancer care for American Indian and Alaska Native (AI/AN) women. Although the incidence of breast cancer is lower among AI/AN women than among non-Hispanic White (NHW) women, AI/AN women undergo screening less frequently, are more likely to be diagnosed at later stages, experience higher rates of breast cancer–specific mortality, and endorse poorer quality of life in survivorship relative to NHW women.1–8 In addition, AI/AN women with early-stage breast cancer undergo mastectomy, rather than breast-conserving therapy (BCT), more frequently than do similarly staged NHW patients.7,9 A recent study demonstrated that for early-stage breast cancer, 41% of AI/AN women underwent mastectomy, whereas only 34% of NHW women underwent mastectomy.9 Multiple factors, including accessibility of radiation therapy (RT), geographic barriers, and chronic medical conditions may contribute to the use of mastectomy over BCT in AI/AN women.9 However, the disproportionate use of mastectomy in AI/AN women compared with NHW women suggests opportunities for improvements in surgical breast cancer care for these patients.
Postmastectomy breast reconstruction (PMR) is associated with improved quality of life in breast cancer survivorship among NHW women.10–15 Annual rates of PMR among NHW women with breast cancer are increasing, which likely reflects widespread adoption of PMR as a critical element of breast cancer care following the passage of the Women’s Health and Cancer Rights Act of 1998.16–18 Despite this, rates of PMR among minority patients have not kept pace with rates of PMR among NHW patients.19–22 In a study of the Surveillance, Epidemiology, and End Results database from 1998 to 2014, Sergesketter et al. found that NHW patients underwent PMR at a rate of 23.3%, relative to 19.1% for non-Hispanic Black patients and 18.7% for Hispanic patients.17 In a 2020 study using Surveillance, Epidemiology, and End Results data, rates of PMR among AI/AN women were even lower, at 17% for AI women and 9% for AN women.7
Factors associated with low PMR rates among non-Hispanic Black and Hispanic patients are described in detail,19–22 yet factors associated with low PMR rates among AI/AN women are poorly described. Although conclusions from studies of PMR in underserved minority populations may be extrapolated to AI/AN women, AI/AN women occupy a unique historical and cultural position, and are best served by dedicated investigation.23,24
In view of the historical marginalization of AI/AN women and the known disparities in PMR use between NHW and minority women, we sought to describe current national trends in receipt of PMR among AI/AN women and describe factors associated with receipt of PMR among AI/AN women. We hypothesized that PMR use would be lower among AI/AN women than among NHW women, and that factors such as comorbid illness and stage of disease would be associated with low PMR use among AI/AN women.
PATIENTS AND METHODS
We performed a retrospective cohort study using the National Cancer Database (NCDB) from 2004 to 2017. The NCDB is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospital participating in the CoC NCDB are the source of the deidentified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The NCDB contains over 30 million records of individual cancer cases collected by more than 1500 CoC-approved facilities across the United States. The NCDB is estimated to capture approximately 70% of all newly diagnosed cases of cancer in the United States.25 The University of Minnesota’s institutional review board has deemed analysis of the NCDB dataset exempt from review.
Inclusion criteria were female AI/AN and NHW patients, aged 18 to 64 years, who underwent mastectomy for stage 0 to III unilateral primary breast cancer diagnosed between 2004 and 2017. Ductal carcinoma (code 8500), and lobular carcinoma (codes 8520 and 8522) constituted over 90% of invasive histologies included. Patients who underwent BCT and were Hispanic, non-Hispanic Black, Asian, or listed unknown/other for race were excluded. Patients aged 65 years and older were excluded to minimize confounding, because of age being colinear with Medicare insurance coverage. Patient selection is illustrated in Figure 1.
;)
Fig. 1.: Flow diagram of cohort selection. Patient-specific variables investigated were age at diagnosis, year of diagnosis, Charlson Comorbidity Index (0 to 3), type of residence (rural or urban), distance to treating facility, type of treating facility (academic or community), educational attainment level in the patient’s zip code of residence, and patient’s insurance carrier (private, government, not insured/ unknown). Educational attainment level is described as a percentage of residents in the patient’s zip code without a high school degree; higher level of educational attainment corresponds to a lower percentage of residents without high school degree.
Disease-specific variables were tumor size (<2 cm, 2 to 5 cm, >5 cm, unknown), lymph node status (positive, negative, unknown), tumor grade (1 to 3), and estrogen receptor status. Receptor status was classified as estrogen receptor (ER)-positive (ER+), negative (ER−), or indeterminate (ER status unknown or missing). Human epidermal growth factor receptor 2 status was not included, because this data item is not well populated in the NCDB before the year 2010.
Treatment variables were type of mastectomy (unilateral [UM] or contralateral prophylactic [CPM]), receipt of PMR, and receipt of RT. Postmastectomy RT was categorized as “received” or “not received.” CPM was defined as any surgical code that included the term “with removal of uninvolved contralateral breast.” Types of PMR included tissue-based (autologous), implant-based, combined tissue- and implant-based, and not otherwise specified. Surgical codes are available in the Appendix. (See Appendix, Supplemental Digital Content 1, which shows surgical codes used [from Adamo M, Dickie L, Ruhl J. SEER Program Coding and Staging Manual 2015. Bethesda, MD: National Cancer Institute; 2015], https://links.lww.com/PRS/G751.) Because the NCBD includes only treatment received as part the patient’s planned first course of therapy, all PMRs were considered immediate or early delayed (part of the first course of treatment). This has been described in other studies of PMR using the NCDB.21,26
Categorical variables were described using the chi-square method; continuous variables were described using the Mann-Whitney U test. PMR rate annually and over the study period was compared between cohorts using the Cochran-Armitage test for trend. To control for confounding, factors associated with PMR were analyzed using multivariable logistical regression. A stepwise regression was used to identify variables for inclusion in our models. All variables except type of PMR and distance to treating facility were included in all models. Model fit was verified using the area under the receiver operating characteristic curve and is described with each respective model. Patients with missing data were included in the analysis. Missing data points are indicated as “unknown” and are analyzed as a separate variable in all models. All statistical tests were two-sided, with a significance level of P ≤ 0.05. All statistical analyses were performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC).
RESULTS
Study Cohort
During the study period, 414,036 NHW women (99.5%) and 1980 AI/AN women (0.5%) aged 18 to 64 were diagnosed with stage 0 to III breast cancer and underwent mastectomy (Table 1). AI/AN and NHW women were diagnosed at similar median age (51 and 52 years, respectively; P = 0.25). A greater proportion of patients were diagnosed with breast cancer in more recent years among both AI/AN and NHW groups. Relative to NHW women, AI/AN women more frequently had larger tumors, positive lymph nodes, and a higher rate of ER− disease. AI/AN women tended to have more comorbidities, receive treatment at community facilities, reside in areas with lower educational attainment, and have nonprivate insurance.
Table 1. -
Characteristics of Women Who Underwent Mastectomy for Stage 0 to III Breast Cancer, by Race
a
|
NHW (%) |
AI/AN (%) |
P
|
| No. |
414,036 (99.52) |
1980 (0.48) |
|
| Median age at diagnosis, yr |
52 |
51 |
0.25 |
| Year of diagnosis |
|
|
<0.001 |
| 2004 |
21,735 (5) |
67 (3) |
| 2005 |
21,854 (5) |
90 (5) |
| 2006 |
23,439 (6) |
98 (5) |
| 2007 |
25,201 (6) |
102 (5) |
| 2008 |
27,407 (7) |
122 (6) |
| 2009 |
29,952 (7) |
145 (7) |
| 2010 |
30,835 (7) |
131 (7) |
| 2011 |
32,110 (8) |
151 (8) |
| 2012 |
33,722 (8) |
156 (8) |
| 2013 |
35,579 (9) |
162 (8) |
| 2014 |
34,897 (8) |
202 (1) |
| 2015 |
33,685 (8) |
190 (10) |
| 2016 |
32,562 (8) |
180 (9) |
| 2017 |
31,058 (8) |
184 (9) |
| Tumor size |
|
|
<0.001 |
| <2 cm |
173,085 (42) |
708 (36) |
| 2–5 cm |
157,856 (38) |
897 (45) |
| >5 cm |
47,048 (11) |
241 (12) |
| Unknown |
36,047 (9) |
134 (7) |
| Lymph node status |
|
|
0.002 |
| Negative |
242,428 (59) |
1069 (54) |
| Positive |
149,709 (36) |
787 (40) |
| Unknown |
21,899 (5) |
124 (6) |
| Tumor grade |
|
|
<0.001 |
| 1 |
193,067 (47) |
923 (47) |
| 2 |
146,524 (35) |
762 (38) |
| 3 |
74,445 (18) |
295 (15) |
| ER status |
|
|
0.002 |
| Positive |
308,736 (75) |
1438 (73) |
| Negative |
86,317 (21) |
469 (24) |
| Indeterminate |
18,983 (5) |
73 (4) |
| Charlson Comorbidity Index |
|
|
<0.001 |
| 0 |
366,183 (88) |
1588 (80) |
| 1 |
39,937 (10) |
310 (16) |
| 2 |
6195 (2) |
55 (3) |
| 3 |
1721 (0.4) |
27 (1) |
| Residence type |
|
|
<0.001 |
| Urban |
395,320 (95) |
1748 (88) |
| Rural |
6596 (2) |
171 (9) |
| Unknown |
12,120 (3) |
61 (3) |
| Facility type |
|
|
<0.001 |
| Academic |
114,802 (28) |
413 (21) |
| Community |
299,234 (72) |
1567 (79) |
| No high school degree |
|
|
<0.001 |
| ≥17.6% |
49,871 (12) |
506 (26) |
| 10.9–17.5% |
84,623 (20) |
476 (24) |
| 6.3–10.8% |
111,530 (27) |
431 (22) |
| <6.3% |
124,755 (30) |
286 (14) |
| Unknown |
43,257 (10) |
281 (14) |
| Insurance coverage |
|
|
<0.001 |
| Private |
329,360 (80) |
1021 (52) |
| Government |
71,181 (17) |
850 (43) |
| Not insured/unknown |
13,495 (3) |
109 (6) |
| Type of mastectomy |
|
|
<0.001 |
| Unilateral |
252,750 (61) |
1374 (69) |
| Contralateral prophylactic |
161,286 (39) |
606 (31) |
| Received radiation therapy |
|
|
0.01 |
| No |
293,450 (71) |
1368 (69) |
| Yes |
115,824 (28) |
599 (30) |
| Unknown |
4762 (1) |
13 (1) |
| Underwent reconstruction |
|
|
<0.001 |
| No |
214,409 (52) |
1361 (69) |
| Yes |
199,627 (48) |
619 (31) |
| Type of reconstruction |
|
|
0.24 |
| Tissue |
57,002 (29) |
173 (28) |
| Implant |
73,347 (37) |
245 (40) |
| Combined (tissue and implant) |
21,860 (11) |
54 (9) |
| Unknown |
47,418 (24) |
147 (24) |
aNational Cancer Database, n = 416,016.
AI/AN women underwent UM more frequently than NHW women (69% versus 61%; P ≤ 0.001) and received RT more frequently than NHW women (30% versus 28%; P = 0.01). AI/AN women underwent PMR less frequently than NHW women (31% versus 48%; P ≤ 0.001). Tissue-based PMR and combined tissue- and implant-based PMR were used at similar rates between cohorts. Further details of PMR type according to race are described in Table 1.
Trends in Postmastectomy Reconstruction
Over the 13-year study period, annual rates of PMR increased, from 13% to 47% for AI/AN women and from 29% to 62% for NHW women, but remained persistently lower for AI/AN women (P ≤ 0.001) (Fig. 2).
Fig. 2.: Annual rates of postmastectomy reconstruction among AI/AN and NHW women with stage 0 to III breast cancer from the National Cancer Database (2004 to 2017) (n = 416,016; P < 0.001). PMR, postmastectomy reconstruction.
Factors Associated with Postmastectomy Reconstruction
On multivariable analysis (Fig. 3), AI/AN race was independently associated with lower odds of undergoing PMR. Other factors significantly associated with decreased odds of PMR included older age at diagnosis, more remote year of diagnosis, advanced disease (larger tumor size, positive or unknown lymph nodes, ER− status), and presence of comorbidities. Patients who underwent UM or received RT had lower odds of undergoing PMR. Additional variables associated with decreased odds of PMR included treatment at a community facility, rural residence, nonprivate insurance, and lower educational attainment in the patient’s zip code of residence (Fig. 3).
Fig. 3.: Multivariable analysis, factors associated with postmastectomy reconstruction in AI/AN and NHW women with stage 0 to III breast cancer (National Cancer Database, 2004 to 2017; n = 416,016). Model fit with area under the receiver operating characteristic curve: 0.75. (From Adamo M, Dickie L, Ruhl J. SEER Program Coding and Staging Manual 2015. Bethesda, MD: National Cancer Institute; 2015.)
Use of Postmastectomy Reconstruction among AI/AN Women
Among AI/AN women, a minority underwent PMR (31%) (Table 2). Those who underwent PMR were younger at diagnosis (median age, 48 years versus 53 years; P < 0.001), tended to be diagnosed in more recent years, had less advanced disease (fewer tumors >5 cm, more negative lymph nodes), and had fewer comorbidities than AI/AN women who did not undergo PMR. AI/AN women who underwent PMR more frequently underwent CPM (49% versus 22%; P < 0.001) and less frequently received RT (28% versus 34%; P < 0.001). In addition, AI/AN women who underwent PMR more frequently hailed from urban areas or areas with higher educational attainment and more frequently had private insurance than those who did not undergo PMR (Table 2).
Table 2. -
Characteristics of AI/AN Women with Stage 0 to III Breast Cancer, by Reconstruction Status
a
| Characteristic |
No Reconstruction (%) |
Reconstruction (%) |
P
|
| No. |
1361 (69) |
619 (31) |
|
| Median age at diagnosis, yr |
53 |
48 |
<0.001 |
| Year of diagnosis |
|
|
<0.001 |
| 2004 |
59 (4) |
8 (1) |
| 2005 |
75 (6) |
15 (2) |
| 2006 |
85 (6) |
13 (2) |
| 2007 |
77 (6) |
25 (4) |
| 2008 |
93 (7) |
29 (5) |
| 2009 |
107 (8) |
38 (6) |
| 2010 |
95 (7) |
36 (6) |
| 2011 |
116 (9) |
35 (6) |
| 2012 |
94 (7) |
62 (10) |
| 2013 |
113 (8) |
49 (8) |
| 2014 |
132 (10) |
70 (11) |
| 2015 |
116 (9) |
74 (12) |
| 2016 |
99 (7) |
81 (13) |
| 2017 |
100 (7) |
84 (14) |
| Tumor size |
|
|
0.01 |
| <2 cm |
433 (32) |
275 (44) |
| 2–5 cm |
651 (48) |
246 (40) |
| >5 cm |
195 (14) |
46 (7) |
| Unknown |
82 (6) |
52 (8) |
| Lymph node status |
|
|
<0.001 |
| Negative |
682 (50) |
387 (63) |
| Positive |
600 (44) |
187 (30) |
| Unknown |
79 (6) |
45 (7) |
| Tumor grade |
|
|
0.2 |
| 1 |
624 (46) |
299 (48) |
| 2 |
544 (40) |
218 (35) |
| 3 |
193 (14) |
102 (16) |
| ER status |
|
|
0.004 |
| Positive |
961 (71) |
477 (77) |
| Negative |
348 (26) |
121 (20) |
| Indeterminate |
52 (4) |
21 (3) |
| Type of mastectomy |
|
|
<0.001 |
| Unilateral |
1057 (78) |
317 (51) |
| Contralateral prophylactic |
304 (22) |
302 (49) |
| Received radiation therapy |
|
|
<0.001 |
| No |
889 (65) |
479 (72) |
| Yes |
462 (34) |
137 (28) |
| Unknown |
10 (1) |
3 (0) |
| Charlson Comorbidity Index |
|
|
<0.001 |
| 0 |
1,062 (78) |
526 (85) |
| 1 |
234 (17) |
76 (12) |
| 2 |
44 (3) |
11 (2) |
| 3 |
21 (2) |
6 (1) |
| Residence type |
|
|
0.01 |
| Urban |
1189 (87) |
559 (90) |
| Rural |
134 (10) |
37 (6) |
| Unknown |
38 (3) |
23 (4) |
| Facility type |
|
|
0.48 |
| Academic |
278 (20) |
135 (22) |
| Community |
1083 (80) |
484 (78) |
| No high school degree |
|
|
<0.001 |
| ≥17.6% |
403 (30) |
103 (17) |
| 10.9–17.5% |
362 (27) |
114 (18) |
| 6.3–10.8% |
276 (20) |
155 (25) |
| <6.3% |
150 (11) |
136 (22) |
| Unknown |
170 (12) |
111 (18) |
| Insurance coverage |
|
|
<0.001 |
| Private |
583 (43) |
438 (71) |
| Government |
684 (50) |
166 (27) |
| Uninsured/unknown |
94 (7) |
15 (2) |
| Median distance to treating facility, miles |
|
|
<0.01 |
| Urban |
16 |
12 |
| Rural |
82 |
73 |
aNational Cancer Database, n = 1980.
Multivariable analysis of factors associated with receipt of PMR for AI/AN women is described in Table 3. Decreased odds of PMR were independently associated with multiple factors, including older age, more remote year of diagnosis, advanced disease (tumor size >5 cm, positive lymph nodes, ER− status), UM, receipt of RT, nonprivate insurance, and decreased level of educational attainment in the patient’s zip code (Table 3). Treatment at a community facility, patient residence, and the presence of comorbidities were not associated with decreased likelihood of PMR (Table 3).
Table 3. -
Multivariable Analysis, Odds of Undergoing Postmastectomy Reconstruction among AI/AN Women with Stage 0 to III Breast Cancer
a,
b
| Characteristic |
OR |
95% CI |
| Age at diagnosis |
0.95 |
0.94–0.96 |
| Year of diagnosis |
1.14 |
1.10–1.17 |
| Tumor size |
|
|
| <2 cm |
Ref |
|
| 2–5 cm |
0.81 |
0.63–1.05 |
| >5 cm |
0.51 |
0.34–0.77 |
| Unknown |
1.24 |
0.79–1.94 |
| Lymph node status |
|
|
| Negative |
Ref |
|
| Positive |
0.69 |
0.53–0.91 |
| Unknown |
1.25 |
0.79–1.96 |
| Tumor grade |
|
|
| 1 |
Ref |
|
| 2 |
1.33 |
0.94–1.88 |
| 3 |
1.13 |
0.79–1.62 |
| ER status |
|
|
| Positive |
Ref |
|
| Negative |
0.68 |
0.52–0.90 |
| Indeterminate |
1.23 |
0.66–2.31 |
| Mastectomy type |
|
|
| Unilateral |
Ref |
|
| Contralateral prophylactic |
2.21 |
1.76–2.78 |
| Received radiation therapy |
|
|
| No |
Ref |
|
| Yes |
0.64 |
0.47–0.87 |
| Unknown |
0.77 |
0.16–3.76 |
| Charlson Comorbidity Index |
|
|
| 0 |
Ref |
|
| 1 |
0.83 |
0.60–1.14 |
| 2 |
0.87 |
0.42–1.79 |
| 3 |
0.81 |
0.31–2.13 |
| Residence type |
|
|
| Urban |
Ref |
|
| Rural |
0.88 |
0.57–1.34 |
| Unknown |
1.13 |
0.59–2.14 |
| Facility type |
|
|
| Academic |
Ref |
|
| Community |
0.82 |
0.62–1.07 |
| No high school degree |
|
|
| ≥17.6% |
Ref |
|
| 10.9–17.5% |
1.05 |
0.75–1.47 |
| 6.3–10.8% |
1.59 |
1.14–2.21 |
| <6.3% |
2.55 |
1.78–3.66 |
| Unknown |
1.53 |
1.06–2.21 |
| Insurance coverage |
|
|
| Private |
Ref |
|
| Government |
0.41 |
0.33–0.52 |
| Uninsured/unknown |
0.23 |
0.12–0.42 |
Ref, reference.
aFrom the National Cancer Database, n = 1980.
bModel fit with area under the receiver operating characteristic curve, 0.79.
DISCUSSION
This hospital-based, retrospective cohort study is the first to detail factors associated with use of PMR in the AI/AN population. PMR use was significantly lower among AI/AN women than among NHW women. Over the study period, PMR rates for both populations increased but remained persistently lower among AI/AN women than among NHW women. After controlling for patient, tumor, and treatment characteristics, AI/AN race was independently associated with decreased odds of PMR. Within the AI/AN population, older age, advanced disease, more remote year of diagnosis, lower level of educational attainment, and nonprivate insurance were associated with decreased odds of undergoing PMR.
There is no optimal proportion of patients who should have PMR. The decision is personal and deeply influenced by cultural, social, historical, and medical factors, with some women preferring to “go flat.”27 The factors influencing the decision to pursue PMR may result in variable PMR use across demographic groups, because rates of PMR largely seem to match demand.28,29 However, multiple studies have suggested that lower rates of PMR in minority populations—Black, Hispanic, Asian, and Pacific Islander—are also related to socioeconomic disparities.19–22,28,29 Factors associated with lower PMR use in these populations include nonprivate insurance,19 scarcity of accessible facilities and reconstructive surgeons,20 lower educational attainment and income,21,29 more advanced stage of disease at diagnosis,20,30 and patient distrust of the medical system.31 Although disparities in PMR use for these patient populations have been detailed, little is known about factors associated with low rates of PMR among AI/AN women, who experience unique barriers to care.
The AI/AN population has higher rates of chronic health conditions—obesity, type 2 diabetes, heart disease, and tobacco use—and higher rates of disease-specific mortality than NHW women.32,33 They also have high rates of chronic health conditions compared with other minority patients.34 In addition to these underlying health conditions, AI/AN women experience diagnosis of breast cancer at more advanced stages of disease than NHW women and have higher breast cancer–specific mortality than NHW women.30,35 Complicating the health care environment in which AI/AN women receive medical care is chronic underfunding of the Indian Health Service (IHS),24,36 implicit bias against AI/AN women,37 and fraught relationships between physicians and AI/AN patients.38–40
The IHS was established in 1955 to fulfill the United States’ “trust responsibility” to AI/AN people in accordance with the Snyder Act of 1921.24,41 This affirmed that, in exchange for native lands and peaceful coexistence, the United States would provide AI/AN people with health care on lands set aside for them as reserves.41 Today, the IHS is a federally administered program that provides medical care to 2.7 million AI/AN people through approximately 600 hospitals, clinics, and facilities located on or near reservations.42 Since its inception, the IHS has been funded at a low level relative to other federally administered health care programs, including the Veterans’ Administration, Medicaid, and federal prisons.36,43 These budgetary constraints impact all aspects of IHS functioning, from facility maintenance to disease prevention.44 Working within these limitations, the IHS has endeavored to increase the matriculation of AI/AN people into health professions by means of the Indian Health Professions Program. In addition, communities in the “lower 48” are working to implement the Community Health Aid Program in underserved areas.44 This program originated in Alaska in the 1960s in response to rural health care needs and has been successful in preventive care and triage in remote communities.45
Despite these efforts to improve care through the IHS, breast cancer screening at IHS centers remains an area of concern. AI/AN women who receive care at IHS facilities have significantly lower rates of breast cancer screening than NHW women, with a 37% 3-year prevalence of screening mammography among women aged 45 years and older.46 Nevertheless, compared with AI/AN women who are not eligible for IHS services, IHS-eligible AI/AN women have higher rates of breast cancer screening and are less likely to be diagnosed with advanced stage breast cancer.40,47
Among patients who hail from rural environments, as AI/AN patients disproportionately do,48 there is significant nihilism regarding cancer prevention and treatment.49 In a study of rural AI women in Vermont, Canales et al. found that women who identified as more traditional in their cultural practices had significantly lower rates of breast cancer screening and were more likely to see a traditional healer than those who were “less traditional.”50 Idoate et al., surveying cancer attitudes among a Great Plains urban Indian population, described a general understanding that cancer is a taboo subject and an almost universally fatal “disease of the White man.”51 These beliefs, and the financial, geographic, and educational barriers experienced by many AI/AN people, may manifest in the disparities seen throughout breast cancer care for AI/AN women: low rates of screening mammography, lower rates of BCT, higher rates of mastectomy, and poorer breast cancer–specific outcomes.3,4,6,9 Concurrent with these prevailing sentiments toward cancer prevention and treatment, data suggests that AI/AN women appear to desire PMR.7,19–22 However, little is known about AI/AN access to, or perspectives on PMR. Those studies that have focused on disparities in breast cancer treatment in the AI/AN population have considered PMR among a host of other disparities, without specific attention to factors associated with low rates of PMR for AI/AN women.
We provide the first exposition of factors associated with PMR use among AI/AN women. Relative to NHW women, AI/AN women who underwent mastectomy for stage 0 to III breast cancer had more advanced disease, more comorbidities, and were more frequently from rural areas and areas with lower educational attainment. Factors associated with lower rates of PMR for AI/AN women reiterate the barriers to care that these women face, while suggesting opportunities to break down those barriers. For instance, interventions to improve screening mammography rates could result in earlier detection, allowing women to pursue PMR if they desire. In addition, ongoing optimization of chronic disease and healthy living could minimize the impact of comorbidities, increasing the likelihood a woman would be a good candidate for PMR. Finally, accessible educational materials could facilitate informed decision-making and enhance patient agency in choosing PMR.
Our study is not without limitations. Selection bias inherent in the NCDB data set may result in a falsely elevated rate of PMR above the national level in both cohorts. As with all databases, missing data because of incomplete documentation or incomplete coding is a limitation. We chose to include patients with unknown variables in our analysis because they represent real-world data. Regarding the decision for PMR, the NCDB does not report patient or physician preferences, or the granular details of comorbidities that might impact PMR use (eg, obesity, tobacco use, diabetes, and others).25,52 There is also a risk of underestimating the number of AI/AN women in the NCDB, given that AI/AN women have been misclassified as other races in registries.53 Because delayed PMR is not captured by our data, it is possible that AI/AN women who underwent delayed PMR, either related to RT, comorbidities, or delayed decision for PMR, are not identified in our study. This limits any conclusions that can be drawn regarding RT use and delayed PMR in this patient population. The small sample size of some AI/AN subsets in our study, such as AI/AN women with unknown RT status, could limit the applicability of conclusions drawn from those subsets.54 Despite these limitations, our findings illuminate previously unreported elements of cancer care for AI/AN women who are historically marginalized and little studied.
CONCLUSIONS
In recent years, rates of PMR for AI/AN women have increased, although they continue to lag behind rates for NHW women. Multidisciplinary efforts to improve care delivery to AI/AN women may continue to minimize disparities through earlier diagnosis and treatment. Simultaneously, qualitative research into AI/AN perspectives on breast cancer care could improve shared decision-making between physicians and AI/AN patients, empowering AI/AN women to choose PMR if they so desire.
DISCLOSURE
The authors have no conflicts of interest to declare.
ACKNOWLEDGMENTS
This work was funded by the Pilot Program Grant through the Office of Diversity, Equity, and Inclusion in the Department of Surgery at the University of Minnesota. The authors thank Eric H. Jensen, MD.
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