Examining the Associations Among Treatment Declination, Racial and Ethnic Inequities, and Breast Cancer Survival

Minoritized racial and ethnic populations, including American Indian and Alaska Native, Asian and Pacific Islander, Black, and Hispanic communities, endure complex and persistent inequities in breast cancer outcomes. Socioeconomic factors, limited health care access, cultural and linguistic barriers, along with environmental factors, all contribute to disparities in breast cancer prevention, screening, treatment, and survivorship. Although disparities in breast cancer treatment have been well documented,¹ the associations among race and ethnicity, declining recommended primary treatment (including surgery, radiation, chemotherapy and hormone therapy), and disparity in survival outcomes have been relatively understudied. In the field of pharmacoepidemiology, declining to initiate treatment as recommended by a health care practitioner is referred to as primary nonadherence² Most observational studies of adherence to recommended cancer treatments are limited by their focus on patients who initiate therapy and the outcome of whether patients continue the treatment as directed or discontinue prematurely (ie, secondary nonadherence). The gap in knowledge on primary nonadherence to breast cancer treatment leaves health care practitioners and policymakers with more questions than answers as they attempt to explain why patients from historically marginalized groups, such as racial and ethnic minority groups, are less likely to initiate guideline concordant cancer care.