Quality of breast cancer care in the US territories: Insights from the Medicare program

Background: Recent findings suggest quality gaps exist between Medicare beneficiaries hospitalized in the US mainland versus US territories; it is unknown whether these gaps extend to breast cancer care.

Methods: We identified a national sample of female Medicare fee-for-service beneficiaries ages 66-74, of all disease stages who received breast cancer surgery in 2008 through 2010. We compared breast cancer care quality among residents of the US territories (Puerto Rico, Guam, US Virgin Islands, American Samoa, and the Northern Mariana Islands) to the continental US states (hereafter mainland). We defined quality as receipt and timeliness of recommended care including: receipt of a diagnostic needle biopsy and adjuvant radiation therapy (RT) among women who had breast conserving surgery (BCS); and timeliness of care (time from diagnostic needle biopsy to breast surgery; and from BCS to adjuvant RT). We used logistic regression to examine the relationship between territory status and each quality measure adjusting for patient demographic and clinical factors.

Results: Among 109,858 women there were 267 territory; and 109,591 mainland residents. Territory residents did not differ significantly from mainland residents in receipt of a diagnostic needle biopsy (76% vs. 80%; adjusted OR=1.16 [95% CI: 0.86-1.55]). However, they were less likely to receive surgical treatment for breast cancer within 1 month after needle biopsy compared to mainland residents (45% vs. 62%; adjusted OR=0.60 [95% CI: 0.45-0.81]). This difference was no longer significant at 3 months after needle biopsy (90% vs. 95%; adjusted OR=0.88 [95% CI: 0.54-1.44]). Among women treated with BCS, there was no significant difference in receipt of adjuvant RT among territory compared to mainland residents (62% vs. 80%; adjusted OR=0.65 [95% CI: 0.40-1.04]). However, territory residents were less likely to receive adjuvant RT within 12 weeks after BCS compared to mainland residents (40% vs. 67%; adjusted OR=0.49 [95% CI: 0.29-0.83]). Other factors independently associated with non-receipt of and delays in recommended care included non-white race and presence of comorbid conditions.

Conclusion: As a group, US territory residents receive recommended breast cancer care similar to that among mainland residents; however they experience greater delays in care. Further research is needed to identify barriers to timely cancer care within the territories.