Association of Nativity Status With Quality of Breast Cancer Care for Hispanic Women and Non-Hispanic White Women in the United States

For minority communities, an individual’s nativity status (native-born or foreign-born) offers a new lens with which to examine intracommunity disparities but has received little attention. Most research has focused on comparing minority individuals with white individuals; for example, clinical outcomes for Hispanic patients with breast cancer are poor compared with white patients, despite lower incidence.^1,2 The goal of this study was to examine the effect of nativity status on clinical outcomes among Hispanic patients with breast cancer. We hypothesized that foreign-born Hispanic individuals would have less access to diagnostic services and present at a later stage, and those who presented with more advanced cancer would receive poorer-quality care with less radiation therapy than patients born in the United States, regardless of race/ethnicity.

The Surveillance, Epidemiology, and End Results (SEER) database was analyzed from 1988 to 2009 and was linked with county-level data from the Area Health Resources File. Our study population consisted of US-born Hispanic patients, foreign-born Hispanic patients, and US-born non-Hispanic white patients diagnosed with breast cancer without prior breast cancer diagnoses (n = 296 055). Foreign-born non-Hispanic white patients treated in the United States controlled for the effect of immigration. Our primary outcome, evaluating access, was presentation with advanced stage (SEER stage 2 [regional extension] or 4 [distant metastasis]) vs early stage (SEER stage 1 [localized]) breast cancer. A subset of patients with advanced-stage disease who received breast-conserving surgery was selected to evaluate the effect of nativity status on receiving radiation vs no radiation (n = 29 665). Odds ratios (ORs) for select outcomes were calculated by logistic regression, adjusting for age at diagnosis and marital status, and county-level factors (average family size, public health, and general practitioner availability within county). This study was exempt from institutional review board review because the research involved the use of publicly available existing data recorded in such a manner that patients could not be identified directly or through identifiers linked to the patients. Patient consent was not required because the data came from a publicly available databases curated by federal and state government agencies and did not include patient-identifying information in their data collection.

Both US-born Hispanic patients and foreign-born Hispanic patients were more likely to be diagnosed at advanced stage (OR, 1.18; 95% CI, 1.13-1.23 and OR, 1.26; 95% CI, 1.22-1.31, respectively) relative to US-born non-Hispanic white patients. Foreign-born Hispanic patients also had greater odds of presenting with advanced-stage breast cancer compared with foreign-born non-Hispanic white patients (Figure). Evaluating receipt of radiation for advanced patients undergoing breast-conserving surgery, foreign-born Hispanic patients had 20% lower odds of receiving radiation therapy (OR, 0.80; 95% CI, 0.73-0.88) relative to US-born non-Hispanic white patients. Similarly, US-born Hispanic patients had 15% lower odds of receiving any form of radiation (OR, 0.85; 95% CI, 0.75-0.96) compared with US-born non-Hispanic white patients. Foreign-born non-Hispanic white patients had 26% greater odds of receiving radiation compared with US-born non-Hispanic white patients (OR, 1.26; 95% CI, 1.04-1.53). Foreign-born Hispanic patients had significantly lower odds of receiving radiation compared with foreign-born non-Hispanic white patients.

Immigration status was associated with quality of breast cancer care, but this effect was only seen in foreign-born Hispanic patients and not in foreign-born non-Hispanic white patients. Foreign-born Hispanic patients also presented with more advanced breast cancer. Difficulty navigating health systems and poor cultural dexterity among health care professionals may also influence timing of presentation and adherence to treatment.³ Hispanic immigrants make up 48.8% of the US foreign labor force.⁴ We hope that through this study, there will be increasing awareness of the effect of nativity status on quality of care. Despite opposing opinions on immigration, the sociopolitical and economic forces of globalization continue to drive population movement across borders. Immigration is not just an issue in the United States; it is a global issue, with international migration becoming a daily occurrence. This leads to a growing population that needs a health care system and public health measures to account for the challenges that immigrants face as they transition to a new host country and the effect these hardships have on the quality of health care that they receive. The fact that “most of us were once foreigners”⁵ is a unique and unifying facet of the United States, which demands that we do not turn a blind eye to marginalized patients in need. Therefore, immigration’s effect on health remains a novel way through which we can further understand disparities.

Corresponding Author: David C. Chang, PhD, MPH, MBA, Department of Surgery, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital,165 Cambridge St, Ste 403, Boston, MA 02114 (dchang8@mgh.harvard.edu).

Published Online: February 8, 2017. doi:10.1001/jamasurg.2016.5536

Author Contributions: Ms Acosta Saavedra and Dr Chang had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Acosta Saavedra, Chang.

Acquisition, analysis, or interpretation of data: Acosta Saavedra, Loehrer.

Drafting of the manuscript: Acosta Saavedra, Chang.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Chang.

Administrative, technical, or material support: Acosta Saavedra, Chang.

Supervision: Loehrer, Chang.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This paper was presented at the 69th Annual Cancer Symposium of the Society of Surgical Oncology; March 2-5 2016; Boston, Massachusetts.

Funding/Support: Department of Surgery via the Massachusetts General Hospital’s The Center for Diversity and Inclusion.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.