Associations of social determinants of health with avoidance of information, treatment receipt, and physician mistrust for women with breast cancer.
Authors: Kantor Olga , Lederman Ruth , Ko Naomi , Gagnon Haley , Fikre Tsion , Gundersen Daniel A. , Revette Anna C. , Odai-Afotey Ashley , Hershman Dawn L. , Crew Katherine D. , Keating Nancy Lynn , Freedman Rachel A. 
Published: June 2024

1507

Background: Social determinants of health (SDoH) are key factors contributing to breast cancer disparities but are difficult to measure. We surveyed a diverse population of women with breast cancer to identify SDoH and demographic measures associated with avoiding information, treatment receipt, and physician mistrust. Methods: During 2018-2020, we interviewed 297 women (60% White, 25% Black, 15% Hispanic) with a history of breast cancer treated at three academic institutions. We used multivariable regression to assess the associations of SDoH, demographics, and related factors (social support, discrimination in daily life and within healthcare, education, financial strain, faith, age, birth country, race and ethnicity, marital status) with three outcomes: (1) avoiding information about cancer, (2) lack of initiation of recommended treatments, and (3) physician mistrust. For each model, we included factors statistically significant (p<0.05) in unadjusted analyses. Results: Overall, 79 participants (26.6%) reported avoiding information about cancer. Age <40, discrimination (treated with less courtesy or as if dishonest), and financial strain (worry about medical bills, uninsured status) were all significantly associated with avoiding information (p<0.05 for all). In multivariable analyses, discrimination in daily life (OR 3.37, 95% CI 1.40-8.10 for being treated as if dishonest) and age (OR 3.36 for age <40 compared to >60) were associated with avoiding information. Twenty-two participants (7.4%) reported not initiating at least one recommended treatment. Discrimination in daily life and in healthcare were both significantly associated with treatment receipt, as was financial strain (all p<0.01). In multivariable analyses, discrimination (OR 3.51, 95% CI 1.05-11.76 for being treated as if dishonest) and worrying about medical bills (OR 3.53, 95% CI 1.40-8.93) were associated with lack of treatment initiation. Twelve participants (4.0%) reported not trusting physician’s judgements about medical care. Discrimination in daily life and in health care and insurance status were significantly associated with physician mistrust (both p<0.05). Multivariable analysis found that discrimination in both daily life and in health care (OR 5.95, 95% CI 1.40-25.3 for being treated with less courtesy in daily life, and OR 12.79, 95% CI 2.49-65.6 for reporting being treated as dishonest in health care setting) were associated with mistrust. Race and ethnicity were not significantly associated with any of the outcome measures in unadjusted or adjusted analyses (all p>0.05). Conclusions: SDoH measures and not race were associated with lack of engagement and trust within the health care system, with experiences of discrimination and financial strain associated with avoiding information, not initiating treatments, and physician mistrust.