Low Socioeconomic Status at the Patient and Institutional Level Impact Achievement of Breast Cancer Quality Standards

BACKGROUND: The National Accreditation Program of Breast Centers (NAPBC) developed comprehensive, multidisciplinary standards to improve quality outcomes. We have previously shown that institutions treating larger proportions of breast cancer patients of low socioeconomic status (SES) achieve these benchmarks at lower rates. This study assesses whether a patient's SES interacts with an institution's SES mix in achieving the 2018 NAPBC standards.

METHODS: Using the National Cancer Database, low SES patients were defined by insurance status, income and educational attainment, and low SES institutions were defined as the decile containing the largest proportion of low SES patients. Cohorts were created for each measurable NAPBC standard: breast-conserving surgery, sentinel lymphadenectomy, adjuvant radiation, adjuvant chemotherapy, and adjuvant endocrine therapy. Adjusted odds of standard-compliant treatment (SCT) were analyzed.

RESULTS: We included 3,156,604 patients (23% being low SES) treated at 1180 non-low SES institutions and 283,155 patients (59% being low SES) treated at 131 low SES institutions. All subgroups reached the 50% threshold for breast-conserving surgery, with rates of SCT > 70% for all other standards. Both low SES institution and low SES patient status were independently associated with a lower probability of SCT for all standards (p < 0.001), except there was no association between institution type and receiving adjuvant radiation (p = 0.21).

CONCLUSIONS: Patient and institution SES impact the achievement of NAPBC standards; low SES patients received lower SCT regardless of institution SES. Further work to create strategies that address SES-related disparities are imperative to provide equitable care.