Health Care Delivery/Access

Barriers to quality cancer care persist

Every year, millions of men and women in the United States undergo cancer screening, 1.2 million develop cancer, and more than 550,000 die from it. Unfortunately, access to quality cancer care remains a problem, according to a recent review of research studies. The review was led by Jeanne S. Mandelblatt, M.D., M.P.H., of Georgetown University Medical Center, and supported in part by the Agency for Healthcare Research and Quality (HS08395).

Key patient barriers to cancer care include old age, minority race, and low socioeconomic class. Physicians who are not trained or are ill-prepared to communicate the complexities of cancer care to diverse patient populations pose additional barriers to care. Finally, constraints of the medical care system can impede delivery of care. It still is not clear whether the growth of managed care will constitute another barrier or be a facilitator to smooth access to care, according to Dr. Mandelblatt.

For the review, Dr. Mandelblatt and colleagues analyzed studies from 1980 to 1998 on access to cancer care, from initial screening, diagnosis, and staging to treatment, ongoing surveillance to detect recurrences, and end-of-life care. They used adapted behavioral models of care access, with patient-provider and provider-provider communication as key model components. The studies uncovered examples of barriers to care. For example, patients without private insurance received surgery for non-small-cell lung carcinoma less often than privately insured patients, and the rates of bone marrow transplantation for treatment of patients with leukemia or lymphoma were 34 to 50 percent lower for self-pay and Medicaid patients compared with privately insured patients.

Beyond insurance inequalities, economically and socially disadvantaged patients had as much as a 60 percent lower chance of survival for breast cancer compared with more advantaged patients. There was a similar pattern for patients with multiple myeloma, lung cancer, and prostate cancer. Minority patients were more apt to be diagnosed at advanced stages of the disease than whites, receive suboptimal cancer treatment, and have lower survival rates. Physician barriers ranged from screening biases and lack of culturally sensitive resources to time constraints and conflicting professional recommendations. Finally, medical system barriers ranged from financial disincentives to provide cancer care and inadequate tracking mechanisms to limited regional resources.

The authors conclude that additional research is needed to develop and test interventions to overcome remaining barriers. They also recommend that national and local data collection infrastructures be enhanced to measure changes in access and the impact of barriers on outcomes of care, including intermediate markers of cancer morbidity and mortality.

See "Equitable access to cancer services: A review of barriers to quality care," by Dr. Mandelblatt, K. Robin Yabroff, M.B.A., and Jon F. Kerner, Ph.D., in Cancer 86, pp. 2378-2390, 1999.

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