Incidence of surgical procedure refusal has amplified by just about 50% among the Black and Hispanic ladies with perhaps curable, nonmetastatic breast most cancers above the past decade, in accordance to conclusions from an evaluation of Surveillance, Epidemiology, and Stop Outcomes (SEER) System information.
The fee of refusal amplified from .6% in 2005 to .9% in 2015. The review population involved 56,450 Hispanic girls and 57,537 non-Hispanic Black females who had been offered surgical procedures for breast most cancers from 2005 to 2015. Among these who refused surgical treatment, 29.7% (n = 237) ended up recognized as Hispanic and 70.3% (n = 562) recognized as Black.
“Thank goodness, it was not a substantial populace,” lead writer Bridget Oppong, MD, an associate professor in the Division of Surgical Oncology and a breast surgical oncologist at The Ohio Point out College Medical Faculty in Columbus, claimed in an job interview with OncLive®. “But the astonishing point is that it is an growing inhabitants. It was about 50 percent a per cent at the beginning of the examine period, or 2005. Now it’s approaching 1% as we get into 2015. It’s a phenomenon that’s increasing, and, exclusively, it’s escalating among the non-Hispanic black girls.”
Black women of all ages have been far more most likely to refuse surgical treatment in 2005 (.8%) and in 2015 (1.2%). Throughout the examine time period, 9.18% of this populace died of triggers that were being secondary to cancer. Only 4.4% of refusers gained radiation and 12.1% acquired chemotherapy.
Between Hispanic females, surgical refusal enhanced from .3% to .6%, and 9.65% of these individuals died of triggers secondary to most cancers. A complete 2.9% of these patients received radiation and 12.2% obtained chemotherapy.
Surgical procedure refusal was drastically affiliated with an increased possibility for demise in equally Black and Hispanic women of all ages (P <.0001).
Oppong was inspired to investigate the rate of refusal based on observations from her own practice. She noted that more patients were presenting with advanced disease and refusing treatment or who came to her after initially refusing treatment. At that point, the patient’s disease had advanced, limiting the available treatment options.
Although cost of surgery may have been a concern, most of the women who refused surgery were insured.
Those who refused surgery were more likely to be aged 81 years or older and less likely to be 41 years of age or younger (P <.001). For all patients, Oppong said fear and denial are the main drivers of refusal. “This is the population that, for a variety of reasons…just cannot accept that they need to have surgery,” she said.
“Then you have the subset who, yes, they’ve gotten a mammogram, they’ve gotten the workup, but, again, they want to control the narrative, and will only accept the treatments that they feel comfortable accepting. A lot of people are wary of medications and wary of what we call research-backed or evidence-based treatments. They’re more comfortable trying things that are quote/unquote, natural.”
The endemic mistrust Black Americans hold toward the medical establishment is long standing and well documented.2 Oppong and her colleagues found different motivators for refusal based on age. Older women, she said, often want to avoid invasive treatment. Or the patient decides she doesn’t have a lot of years left any way and puts a different valuation on life.
Younger women, she said, are more likely to have researched their disease online and found alternative treatments. They want to avoid the health care system in general.
“These women only will come in when they see things are advancing, or things are uncomfortable—if they have drainage, if they have a wound,” Oppong said. “But again, just that mistrust makes it really difficult for them to even see me and to learn about the pathology, learn about how things are going to go.”
Oppong acknowledges that a certain amount of trepidation about traditional medicine makes sense—these treatments have side effects that can be serious and painful. Therefore, she spends a great deal of time walking patients through the process of surgery, going so far as explaining how the incisions will look.
“I offer for them to meet a peer or [a previous patient],” she said. “Usually, we try to do a race concordance, and…they’re willing to go over what the experience has been like, what the scar is, and that sometimes helps—it gives them time.”
Patients may not know about how surgery and chemotherapy have improved over time. Oppong said patients are often survived at how noninvasive breast cancer surgery can be and how cosmetic outcomes can be better than expected, even for patients who undergo mastectomy.
Sometimes, she has to take a more direct approach.
“‘You will die from this,’” she tells them. “I’m very blunt with them. And I think the message does permeate, but it takes time.”
As a younger physician, Oppong was more likely to discharge these patients. She has learned that she can reach many of them with education and by consistently reinforcing the message that treatment is necessary. She will work with family members, primary physicians, and even religious leaders if it will help a patient overcome her reluctance.
“I do get a lot of women to change their minds and go ahead with surgery,” Oppong said. “But sometimes when they do agree, it’s already too late, [the disease is] already too far gone, it’s already spread. Those are the unfortunate cases. That’s what I’m always stressed about trying to prevent, because I don’t want them to move to that area where the disease is no longer curable.”
- Relation T, Ndumele A, Bhattacharyya O, et al. Refusal among Black and Hispanic women with non-metastatic breast cancer. Ann Surg Oncol. 202229(11):6634-6643. doi:10.1245/s10434-022-11832-6
- Sullivan LS. Trust, risk, and race in American medicine. Hastings Cent Rep. 202050(1):18-26. doi:10.1002/hast.1080