Underuse of Breast Cancer Adjuvant Treatment: Patient Knowledge, Beliefs, and Medical Mistrust

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States
Journal of Clinical Oncology (Impact Factor: 17.88). 09/2009; 27(31):5160-7. DOI: 10.1200/JCO.2009.22.9773
Source: PubMed

ABSTRACT Little is known about why women with breast cancer who have surgery do not receive proven effective postsurgical adjuvant treatments.
We surveyed 258 women who recently underwent surgical treatment at six New York City hospitals for early-stage breast cancer about their care, knowledge, and beliefs about breast cancer and its treatment. As per national guidelines, all women should have received adjuvant treatment. Adjuvant treatment data were obtained from inpatient and outpatient charts. Factor analysis was used to create scales scored to 100 of treatment beliefs and knowledge, medical mistrust, and physician communication about treatment. Bivariate and multivariate analyses assessed differences between treated and untreated women.
Compared with treated women, untreated women were less likely to know that adjuvant therapies increase survival (on a 100-point scale; 66 v 75; P < .0001), had greater mistrust (64 v 53; P = .001), and had less self-efficacy (92 v 97; P < .05); physician communication about treatment did not affect patient knowledge of treatment benefits (r = 0.8; P = .21). Multivariate analysis found that untreated women were more likely to be 70 years or older (adjusted relative risk [aRR], 1.11; 95% CI, 1.00 to 1.13), to have comorbidities (aRR, 1.10; 95% CI, 1.04 to 1.12), and to express mistrust in the medical delivery system (aRR, 1.003; 95% CI, 1.00 to 1.007), even though they were more likely to believe adjuvant treatments were beneficial (aRR, 0.99; 95% CI, 0.98 to 0.99; model c, 0.84; P < or = .0001).
Patient knowledge and beliefs about treatment and medical mistrust are mutable factors associated with underuse of effective adjuvant therapies. Physicians may improve cancer care by ensuring that discussions about adjuvant therapy include a clear presentation of the benefits, not just the risks of treatment, and by addressing patient trust in and concerns about the medical system.

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    ABSTRACT: Rationale: Minority patients with lung cancer are less likely to receive stage-appropriate treatment. Along with access to care and provider factors, cultural factors such as patients' lung cancer beliefs, fatalism, and medical mistrust, may help explain this disparity. Objectives: To determine cultural factors associated with disparities in lung cancer treatment. Methods: Patients with newly-diagnosed lung cancer were recruited from four medical centers in New York City from 2008 to 2011. Participants were surveyed about their beliefs regarding lung cancer, fatalism, and medical mistrust using validated tools. Rates of stage-appropriate treatment were compared among blacks, Hispanics and non-minority patients. Multiple regression analyses and structural equation modeling were used to assess if cultural factors are associated with or mediate disparities in care. Measurements and Main Results: Of the 352 lung cancer patients in the study, 21% were black and 20% were Hispanic. Blacks were less likely to receive stage-appropriate treatment (odds ratio [OR]: 0.50, 95% confidence interval [CI]: 0.27-0.93) compared with whites, even after adjusting for age, gender, marital status, insurance, income, comorbidities and performance status. No differences in treatment rates were observed among Hispanics (OR: 1.05, 95% CI: 0.53-2.07). Structural equation modeling showed that cultural factors (negative surgical beliefs, fatalism and medical mistrust) partially mediated the relationship between black race and lower rates of stage-appropriate treatment (total effect -0.43, indirect effect = -0.13, 30% of total effect explained by cultural factors). Conclusions: Negative surgical beliefs, fatalism, and mistrust are more prevalent among minorities and appear to explain almost a third of the observed disparities in lung cancer treatment among black patients. Interventions targeting cultural factors may help reduce undertreatment of minorities.
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