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Supportive care medications, palliative services underused by black women with breast cancer
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Non-Hispanic black women with stage IV breast cancer used nonopioid supportive medications and hospice care at a lower rate than white women, according to study results.
Although supportive medicine receipt did not appear to attenuate end-of-life disparities, black women were more likely to die while hospitalized and to be admitted to an ED in their last month of life, results showed.
Devon K. Check
“Although we did not find evidence of a relationship between supportive medications use and end-of-life care, disparities in supportive medication use are concerning as they could point to inadequate symptom management and reduced quality of life,” Devon K. Check, PhD, research fellow at the University of North Carolina Gillings School of Global Public Health, told HemOnc Today. “Studies have found that early introduction of palliative or supportive care is tied to higher rates of hospice use and less intensive end-of-life care, both of which are markers of high-quality end-of-life care.”
Prior research has suggested that black women with cancer are less likely to access supportive medicine and palliative services than white counterparts.
Check and colleagues sought to examine racial disparities in the early use of medication for common cancer symptoms — such as depression, insomnia and anxiety — as well as their effects on end-of-life care among women who died of stage IV breast cancer.
The researchers accessed the SEER–Medicare linked database and identified 883 women (non-Hispanic white, n = 752; non-Hispanic black, n = 131) who died of breast cancer between 2007 and 2012. They collected data on the use of opioid pain medications and nonopioid psychotropics — including antidepressants, anxiolytics and sleep aids — in the 90 days directly following diagnosis.
Regression models assessed the relationship between race, supportive medicine use and end-of-life care, including hospice use, ICU admission, number of hospitalizations or ED visits in the last month of life, and death during hospitalization.
All women had similar patterns of disease-directed therapy, although black women had a higher comorbidity burden (P = .03). Fewer black women were married or partnered at the time of diagnosis (8% vs. 27% of white women; P < .001), and a greater proportion of black women resided in areas of lower socioeconomic status (P < .001).
White women used nonopioid psychotropic drugs at a significantly higher rate in the months preceding a breast cancer diagnosis (23% vs. 13% of black women; P = .02).
Use of opioid medication did not significantly differ by race. However, black women had a 44% decreased risk for nonopioid psychotropic drugs use compared with white women (adjusted risk ratio [aRR] = 0.56; 95% CI, 0.39-0.8).
Racial disparities extended into end-of-life care, with black women being 14% less likely to access hospice care (aRR = 0.86; 95% CI, 0.74-0.99).
Black women also had a 30% increased risk for an ICU admission or more than one ED visit or hospitalization in the last 30 days of life (aRR = 1.3; 95% CI, 1.02-1.65), and were 60% more likely to have an in-hospital death (aRR = 1.6; 95% CI, 1.22-2.09)
Adjusted models did not show a significant association by racial subgroup between the use of nonopioid medications and hospice use, hospital death, or health care utilization in the last month of life.
The researchers acknowledged study limitations, including their inclusion of data only from women using fee-for-service Medicare and Medicare Part D coverage. They further noted that other forms of supportive care — such as counseling and decision-making support — are often undercoded, and that they could not account for patient preferences in supportive care choice.
“To our knowledge, ours is the first study to demonstrate disparities in the use of supportive care medications,” Check said. “It is important for patients and providers to communicate about supportive care needs and preferences — like the management of symptoms of anxiety, depression, insomnia and pain — to alleviate patient distress and suffering. In order to determine whether disparities in medication utilization indicate disparities in quality, future research should include data on patients’ supportive care need and preferences surrounding medication use.” – by Cameron Kelsall
For more information:
Devon K. Check, PhD, can be reached at dkcheck@unc.edu.
Disclosure: The researchers report no relevant financial disclosures.
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