Individual- and Community-Level Determinants of Care Timeliness in the Carolina Breast Cancer Study

Introduction: Delays in breast cancer diagnosis and treatment can lead to worse survival and quality of life. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (pre-diagnosis, diagnosis, and treatment) and at multiple levels (patient, community, and health system). Methods: The Carolina Breast Cancer Study Phase 3 (CBCS3) is a population-based cohort (n=2998, 50% Black) with invasive breast cancer diagnoses (2008-2013). I used latent class analysis to group patients based on individual-level healthcare access factors (Aim 1) and to group North Carolina census tracts based on healthcare access factors (Aim 2). These latent classes were evaluated in association with 4 healthcare outcomes: delayed diagnosis (approximated with stage 3/4 at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment – by treatment modality), and receipt of OncotypeDx genomic testing. The community-level models were also evaluated in association with pre-diagnostic regular care and breast cancer screening. Associations were assessed with relative frequency differences (RFDs) with 95% confidence intervals (CIs). Results: Black patients had higher prevalence for each outcome. Patients with low SES and more barriers to care had greater frequency of delayed diagnosis (RFD = 5.5%, 2.4-8.5; RFD=6.7, 2.8-10.7, respectively) and prolonged treatment (RFD = 9.7%, 4.8-14.6; RFD = 7.3%, 2.4-12.2, respectively). Variable travel (short travel to diagnosis, long travel to surgery) was associated with delayed treatment (RFD = 10.7%, 2.7-18.8) compared to the short travel, high use referent group. Long travel to both diagnosis and surgery was associated with delayed treatment only among Black women. On a community-level, the low accessibility, low affordability group was associated with greater frequency of unfavorable outcomes, including under-screened (RFD= 18.6%, CI: 12.9, 24.3) and prolonged treatment (RFD=7.4%, CI: 1.9, 12.8), with similar magnitudes of effect for the high accessibility, low affordability group. Conclusions: Black patients face more frequent delays throughout the care continuum, likely stemming from different access barriers at key junctures. Improving equity in breast cancer will require addressing both individual- and community-level disparities in access.