Should Place of Death be Added to the Index of Disparities Between Black and White Breast Cancer Patients?

Background: Compared to their white counterparts, Black women with breast cancer suffer from earlier onset of diagnosis, higher mortality rates, and are at risk of racial bias from healthcare providers and treatment plans that do not align with the standard of care. Place of death can be considered a metric for high quality end-of-life care as hospital death is associated with both physical and emotional distress. Given Black patients’ particular vulnerability, the purpose of this study was to investigate place of death as a surrogate for end of-life healthcare disparities.
Methods: The National Center for Health Statistics database was used to determine the place of death for all US women with primary-breast cancer death from 1999-2019. Place of death (home, hospital, and hospice) and race (white and Black) were considered; the subset of women who died <40 were also analyzed. Trends in place of death in the 20-year period were evaluated via linear regression with comparisons by Chi-square test.
Results: From 1999 to 2019, there were 867, 213 women who died due to breast cancer; 718,437 (82.8%) were white and 125,040 (14.4%) were Black women. Home death increased an absolute 5.7% (38.4 to 44.1%) in white women and 6.2% (29.3 to 35.5%) in Black women, p<0.0001 trend for both. Hospital deaths decreased -11.4% (31.9 to 20.5%) in white women and -14.4 (48.2 to 33.8%) in Black women, p<0.0001 trend for both. Hospice death was introduced as a database category in 2003; from 2003-2019, hospice death increased similarly in both white (0.6 to 14.5%) and Black patient populations (0.5 to 14.2%), p<0.0001 trend for both. For women <40 from 1999 to 2019, home deaths decreased 4.6% (40.0 to 35.4%, p=0.016) for white women without significant changes in home deaths (26.9 to 25.2%, p=NS) in Black women. In 2019, white women <40 were 1.40x more likely to die at home than Black women with breast cancer (35.4 vs 25.2%, p = 0.0009).
Conclusions: Despite gradual improvements in home deaths, racial place of death disparities persist with Black women facing disproportionately higher hospital deaths and lower home deaths than white women with breast cancer. These differences may be due to cultural preference, poor physician communication about end-of-life options, or lack of resource access. As home death has been associated with more favorable outcomes for patients, further research is needed to develop targeted interventions to improve communication and culturally competent end-of-life care.

2022 UVA Health Disparities Conference - Breakout Session 1: Health Outcomes in Disadvantaged Populations