Date of Award

Summer 2019

Document Type

Open Access Thesis


Epidemiology and Biostatistics

First Advisor

Jan Eberth


INTRODUCTION: While improvements have been made in reducing breast cancer incidence and mortality over the past twenty years, disparities in breast cancer mortality remain. Understanding systematic differences in breast cancer treatment and quality of care remain at the epicenter of understanding breast cancer disparities. Needle biopsy is a less invasive and less expensive diagnostic test for breast cancer (as compared to excisional biopsy) and permits diagnosis while avoiding unnecessary surgery. This study was conducted to 1) examine how the National Quality Forum (NQF)-endorsed needle biopsy utilization measure varies geographically (i.e. state and region) and 2) determine the patient- and/or health system-level factors that predict guideline concordance among women with breast cancer who received treatment at Commission on Cancer-accredited facilities. METHODS: Patients who received a breast cancer diagnosis from January 1, 2004 to December 31, 2015 were selected from the National Cancer Database, which captures information from over 70% of newly diagnosed breast cancers in the United States. Patients whose breast cancer was diagnosed by needle biopsy were compared with patients who did not receive needle biopsy to diagnose their breast cancer by analyzing patient-, tumor-, and facility-level factors. Generalized linear mixed modeling was used to identify important predictors of needle biopsy receipt. RESULTS: Of 1,362,417 patients, 78.8% had received needle biopsy to diagnose their breast cancer. Patients were significantly more likely to undergo needle biopsy if they were nonwhite, had health insurance coverage through Medicaid or were uninsured/unknown form of insurance, had a comorbidity index score of 0, and were diagnosed with T3 lesions. Facility-level predictors of needle biopsy receipt were being diagnosed at a facility in the New England census region and being diagnosed at a medium/high case volume facility. Patients who resided in metropolitan areas of 1 million people or more had increased odds of receiving a needle biopsy as compared to individuals from smaller urban and rural areas. CONCLUSION: This study suggests the significant impact that individual- and facility-level predictors have in reducing health inequalities in breast cancer to support the optimization of facility access, thus reducing breast cancer treatment disparities across patient populations.


© 2019, Sarah Grace Barron

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Epidemiology Commons