Disparities in Breast Cancer Care Linked to Net Worth

Household net worth more important than income in gauging patient’s ability to afford treatment

Household net worth is a major and overlooked factor in adherence to hormonal therapy among breast cancer patients and partially explains racial disparities in quality of care. The findings suggest that physicians, health insurers, and policy makers need to pay more attention to this economic variable to ensure that breast cancer patients receive this potentially life-saving treatment. The study was published recently in the online issue of Journal of Clinical Oncology.

“We know that oral hormonal therapy can reduce the recurrence of hormone receptor–positive breast cancer by 50 percent. Yet up to 10 percent of patients discontinue therapy annually, and only about half finish the recommended five-year course of therapy. Thus, it’s imperative that we understand what is preventing women from taking their medications and what we can do to improve adherence,” said lead author Dawn Hershman, MD, MS, associate professor of medicine at the College of Physicians and Surgeons and associate professor of epidemiology at the Mailman School of Public Health, Columbia University Medical Center. Dr. Hershman is also leader of the Breast Cancer Program at the Herbert Irving Comprehensive Cancer Center at NewYork-Presbyterian/Columbia University Medical Center.

Several studies have shown that disparities in income contribute to disparities in health care among racial and ethnic groups, but no one had specifically analyzed the effect of household net worth on quality of care in breast cancer patients. To study this association, the CUMC team collected prescription and financial data on 2,473 women ages 50 and older with early-stage breast cancer who had been prescribed aromatase inhibitors (the most common type of hormone therapy) between 2007 and 2011. Net worth was divided into three categories: low ($250,000 or less), moderate ($250,000 to $750,000), and high ($750,000 or more).

The researchers found that financial factors, such as income and net worth, were directly associated with adherence to hormonal therapy. They also found that black race was associated with decreased adherence. However, when the researchers controlled for net worth, there was no racial difference in adherence in the moderate and high net worth groups.

“This suggests that income may be an inadequate assessment of financial resources,” said Dr. Hershman. “This is particularly true for the elderly, for whom net worth seems to be a more accurate measure of socioeconomic differences in use of health care services.”

The effect of low net worth on quality of care is likely to grow worse as more costly therapies are used to treat cancer. The average monthly cost of generic aromatase inhibitors is $150, while the average monthly cost of oral biologics ranges from $5,000 to $8,000.

Medication non-adherence is a major issue throughout the health care system, according to the researchers. One recent study estimated that the annual cost of non-adherence to all types of medication is $289 billion, or 13 percent of total U.S. health expenditures.

“It’s important that physicians ask patients whether they are able to pay for their medications,” said Dr. Hershman. “Many patients aren’t comfortable raising this issue and just discontinue therapy if they can’t afford it. By engaging patients in conversation, we may be able to come up with a solution, perhaps by finding less expensive alternatives or by asking pharmaceutical companies to assist patients with co-payments.”


Breast Cancer, CANCER



The paper is titled, “Household Net Worth, Racial Disparities, and Hormonal Therapy Adherence Among Women With Early-Stage Breast Cancer.” The other contributors are Jennifer Tsui, Jason D. Wright, Ellie J. Coromilas, Wei Yann Tsai, and Alfred I. Neugut (all at CUMC).

The authors declare no financial or other conflicts of interest.

The study was funded by grants from the American Cancer Society (RSGT-11-012-01-CPHPS), a fellowship from the National Cancer Institute (R25 CA094061), and the Breast Cancer Research Foundation.

The Herbert Irving Comprehensive Cancer Center (HICCC) of Columbia University and NewYork-Presbyterian Hospital is dedicated to the cure of cancer through innovative basic, clinical, and population-based research and outstanding patient care. HICCC researchers and physicians are dedicated to understanding the biology of cancer and to applying that knowledge to the design of cancer therapies and prevention strategies that reduce its incidence and progression and improve the quality of the lives of those affected by cancer. Initially funded by the National Cancer Institute (NCI) in 1972 and designated comprehensive in 1979, the HICCC is one of 41 NCI-designated comprehensive cancer centers in the United States, of which only three are in New York State. The designation recognizes the Center’s collaborative environment and expertise in harnessing translational research to bridge scientific discovery to clinical delivery, with the ultimate goal of successfully introducing novel diagnostic, therapeutic, and preventive approaches to cancer. For more information, visit www.hiccc.columbia.edu.

Columbia University Medical Center provides international leadership in basic, preclinical, and clinical research; medical and health sciences education; and patient care. The medical center trains future leaders and includes the dedicated work of many physicians, scientists, public health professionals, dentists, and nurses at the College of Physicians and Surgeons, the Mailman School of Public Health, the College of Dental Medicine, the School of Nursing, the biomedical departments of the Graduate School of Arts and Sciences, and allied research centers and institutions. Columbia University Medical Center is home to the largest medical research enterprise in New York City and State and one of the largest faculty medical practices in the Northeast. For more information, visit cumc.columbia.edu or columbiadoctors.org.