Abstract C35: Racial disparities in barriers to follow-up care among breast cancer survivors
Authors: Palmer Nynikka , Weaver Kathryn , Hauser Sally , Talton Jennifer , Case L. Douglas , Lawrence Julia , Dezern Kimberly , Geiger Ann 
Published: May 2015

Abstract
Purpose: After completing primary treatment for breast cancer, regular follow-up care is recommended to monitor for recurrence and second primary cancers, and to manage late and long-term effects of cancer and its treatment, comorbidities, and psychosocial issue. Lack of follow-up care may be particularly concerning for African American women, who have higher breast cancer mortality despite lower incidence rates compared to White women. Reasons why survivors may not receive follow-up care are poorly understood; therefore we describe breast cancer survivors' perceived barriers to follow-up care, including differences between African American and White women, and examine factors associated with perceived barriers to care.
Methods: We conducted a mailed cross-sectional survey of women identified from an institutional cancer registry and treated for non-metastatic breast cancer 6 to 24 months post-treatment. Survivors were asked whether each of 14 potential barriers presented a big problem, somewhat of a problem or no problem in receiving follow-up care. The list of barriers was adapted from an earlier survey of follow-up care among cancer survivors. We created two dichotomous measures: any barrier to care (any barrier rated as “somewhat of a problem” or “a big problem,” vs. all 14 barriers reported as “no problem”) and cost-related barriers to care (any of three cost-related barriers rated as “somewhat of a problem” or “big problem versus all three barriers reported as “no problem). We used logistic regression analysis to explore associations between barriers (any barrier and cost-related barriers) and race, adjusting for age at diagnosis, current residence, marital status, education, employment, health insurance coverage, and time since diagnosis.
Results: Thirty-one African American and 160 White survivors made up our analytic sample. The mean age at diagnosis was 58.5 (SD=11.4), all had surgery, 37% received chemotherapy, 51% received radiation therapy, and 53% received hormone therapy. Sixty-two percent of survivors reported at least one barrier to follow-up care. African American survivors were more likely to identify the following barriers to care compared to White survivors: out of pocket medical costs (52% vs. 28%), cannot afford other associated costs (45% vs. 21%), feeling anxious or worried (52% vs. 29%), and lack of transportation to doctor (16% vs. 4%). Compared to African American survivors, White survivors were more likely to report distance to travel to see doctor as a barrier (3% vs. 19%). Overall, African American survivors were more likely to report at least one barrier (81% vs. 58%) and at least one cost-related barrier (59% vs. 33%). In models adjusting for sociodemographic and clinical characteristics, African Americans were more likely to report any barrier (OR=3.3, 95% CI=1.1-10.1). For cost-related barriers, race was not significant after adjusting for other factors (OR=2.5, 95% CI=0.9-6.6); however, having public health insurance coverage (OR=4.8, 95% CI=1.1-20.4) and no insurance (OR=31.0, 95% CI=2.7-360.5) remained significant predictors compared to having both public and private health insurance.
Conclusions: A majority of breast cancer survivors report barriers to follow-up care, most commonly anxiety or worry or financial concerns. African American breast cancer survivors were more likely to report any barrier to care, even after adjustment for sociodemographic and clinical factors. Different interventions are likely needed to help survivors overcome barriers to care. Enhancing insurance coverage or addressing out of pocket costs may reduce financial barriers, but psychosocial care aimed at reducing fear of cancer recurrence may reduce barriers associated with anxiety or fear.
Citation Format: Nynikka Palmer, Kathryn Weaver, Sally Hauser, Jennifer Talton, L. Douglas Case, Julia Lawrence, Kimberly Dezern, Ann Geiger. Racial disparities in barriers to follow-up care among breast cancer survivors. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C35. doi:10.1158/1538-7755.DISP13-C35