THE EFFECT OF LANGUAGE BARRIERS ON VARIATION AND RECEIPT OF EARLY STAGE BREAST CANCER TREATMENT

59 The Effect of Language Barriers on Variation and Receipt of Early Stage Breast Cancer Treatment Madans et al. Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019, pp. 59-70 © 2011 Center for Health Disparities Research School of Community Health Sciences University of Nevada, Las Vegas The Effect of Language Barriers on Variation and Receipt of Early State Breast Cancer Treatment: A Single Center Study at a Midwestern, Metropolitan, Safety Net Hospital Abigail R. Madans, DO; Hennepin Healthcare Richard T. Zera, MD, PhD; Hennepin Healthcare Rachel M. Nygaard, PhD; Hennepin Healthcare Corresponding Author: Richard T. Zera, MD, PhD, ABSTRACT Background: Arriving at and implementing an appropriate patient centered treatment plan for early stage breast cancer requires significant dialogue between healthcare providers and patients. How language barriers affect this process has not been thoroughly explored in the literature. The aim of this paper is to examine the effect of language barrier on variation and receipt of early stage breast cancer treatment. Methods: Rates of lumpectomy, mastectomy, and contralateral prophylactic mastectomy (CPM) with or without reconstruction were compared between English speaking and Low English Proficiency (LEP) cohorts. Patients with recurrent or bilateral breast cancer, male patients, and/or known genetic mutations were excluded. Receipt of recommended treatments including chemotherapy, hormonal therapy and radiation were compared between the two groups, as well as patient refusal and loss of follow-up. Regression analysis for all-cause mortality within this time period was tabulated for each group. Results: There were no significant differences between receipt of recommended treatments, patient refusal or loss of follow up between the cohorts. LEP patients had a greater proportion of lumpectomies (79.7 versus 70.7%) while 9.2% of English-speaking patients had CPM or CPM with reconstruction compared to none of the LEP patients. These trends, however, did not rise to statistical significance within our small population sample. Age, insurance type, and LEP were associated with significant difference in all-cause mortality, however only age and insurance remained significant in adjusted analysis. Conclusion: Our results indicate a non-statistically significant trend towards less variation of surgical treatment variation for early stage breast cancer in the LEP population, including a greater frequency of lumpectomy and less utilization of CPM. Larger, multicenter studies would be needed to affirm and further investigate these trends. Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 60 The Effect of Language Barriers on Variation and Receipt of Early Stage Breast Cancer Treatment Madans et al. Keywords: Breast cancer; disparities; low English proficiency; underserved INTRODUCTION The surgical treatment of early stage breast cancer is, in part, determined by a patient’s health literacy and understanding of treatment options. Loco-regional breast cancer treatment, compared to other cancer treatments, is particularly dependent on communication between surgeon and patient and, therefore, particularly dependent on a shared language. The surgical treatment of early stage breast cancer can be done through a variety of techniques including lumpectomy with radiation, mastectomy, or contralateral prophylactic mastectomy (CPM) with or without reconstruction. The surgical treatment a woman receives depends on various factors including: National Comprehensive Cancer Network (NCCN) guidelines, surgeon bias, need for symmetry with regards to breast anatomy, perception of radiation therapy, and their level of anxiety around their diagnosis and possible recurrence (Gu et al., 2018; Halpern et al., 2015; Warner et al., 2015). In some sense, the surgical plan is negotiated between the surgeon and the breast cancer patient (Halpern et al., 2015). This plan is not only based on rational treatment guidelines, but also on subtle realities affecting the patient that could be difficult for even the most articulate patient to express in their native language. In 2011, a study published in the Journal of Cancer Education examined the quality of life of Latina breast cancer survivors in the US. The study detailed the poignant and critical effects of language barriers on an immigrant patient’s experience. Quotations from their interviews include the following statements: “Sometimes they put you with an interpreter, but I understand a little bit, and the interpreter does not say what you are saying.” “...I bless the doctor, but the truth is that I do not know why he made another surgery there.” (Lopez-Class et al., 2011). Delivering adequate health care to the immigrant population is a unique challenge. Cultural barriers, lack of insurance coverage, and the legal ramifications of immigration status lead to health care disparities in this population (Cheung et al., 2017; Karliner, Kim, Meltzer, & Auerbach, 2010; Karliner, Ma, Hofmann, & Kerlikowske, 2012; Naghavi et al., 2016). There is evidence that patients with low English proficiency have higher hospital readmission rates, higher local recurrence rates with certain cancers, are less likely to see cancer specialists, and are less likely to perceive that their health care providers are addressing their individual needs (Karliner et al., 2010; Qureshi et al., 2014; Rosales, Ashing, & Napoles, 2014). Understanding the variables that affect health care delivery in the immigrant population becomes even more critical as the debate over allotment of government resources continues to impact health care delivery to this population. Our institution is a public safety net hospital and accredited cancer center that serves a diverse population with several large immigrant cohorts. Our interpretive services department is one of the largest in the country with 21 different languages represented by on-site staff and over 40 languages available with the addition of off-site video interpreters. Even with the robust cultural and language services offered, whether this makes up for the complex communications required to deliver breast cancer care within these Low English Proficiency (LEP) communities is unknown. The aim of this study is to describe the influence of language on breast cancer care, specifically variation in surgical treatment choice, receipt of recommended treatments, and continuity of care. Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 61 The Effect of Language Barriers on Variation and Receipt of Early Stage Breast Cancer Treatment Madans et al. METHODS Upon institutional review board (IRB) f (...truncated)