Association of Diabetes and Other Clinical and Sociodemographic Factors with Guideline-concordant Breast Cancer Treatment for Breast Cancer

Heather T. Gold, Huibo Shao, Ruth Oratz, Onchee Yu, Marilyn Hammer, Stephen Richardson, Denise Boudreau

Research output: Contribution to journalArticlepeer-review


BACKGROUND: Women with breast cancer have worse health outcomes with co-occurring type 2 diabetes, possibly due to suboptimal breast cancer treatment.

METHODS: We created a cohort of women ages 66 to 85 y with stage I to III breast cancer from 1993 to 2012 from an integrated health care delivery system (n=1612) and fee-for-service Medicare beneficiaries (n=98,915), linked to Surveillance, Epidemiology, and End Results (SEER) data (total n=100,527). We evaluated associations between type 2 diabetes and other factors with undergoing guideline-concordant cancer treatment. We estimated χ tests for univariate analysis and relative risks (RRs) using multivariable log-binomial models for outcomes of (1) overall guideline-concordant treatment, (2) definitive surgical therapy (mastectomy or lumpectomy with radiation), (3) chemotherapy if indicated, and (4) endocrine therapy.

RESULTS: Our cohort included 60% of subjects with stage 1 tumors, one quarter below 70 years old, 23% had diabetes, 35% underwent overall guideline-concordant treatment, 24% chemotherapy, and 83% endocrine therapy. Women with diabetes were less likely to undergo overall guideline-concordant treatment (RR: 0.96; 95% confidence interval: 0.94-0.98), and only slightly less likely to undergo guideline-concordant definitive surgical therapy (RR: 0.99; 95% confidence interval: 0.99-1.00). No differences were found for chemotherapy or endocrine therapy. Other factors significantly associated with a lower risk of guideline-concordant care were cancer stages II to III (vs. I; RR=0.47-0.69, P<0.0001), older age (vs. 66 to 69 y; RR=0.56-0.90, P<0.0001), higher comorbidity burden, and Medicaid dual-eligibility.

CONCLUSIONS: Diabetes was associated with lower adherence to overall guideline-concordant breast cancer treatment. However, higher stage, older age, higher comorbidity burden, and Medicaid insurance were more strongly associated with lower use of guideline-concordant treatment. Given the heavy burden of breast cancer and diabetes, long-term outcomes analysis should consider guideline-concordant treatment.

IMPACT: Other factors besides diabetes are more strongly associated with guideline-concordant breast cancer treatment.

Original languageEnglish (US)
Pages (from-to)101-106
Number of pages6
JournalAmerican Journal of Clinical Oncology: Cancer Clinical Trials
Issue number2
StatePublished - Feb 1 2020


  • breast cancer
  • clinical guidelines
  • diabetes
  • health services research
  • Multivariate Analysis
  • Age Factors
  • Humans
  • Diabetes Mellitus, Type 2/epidemiology
  • United States/epidemiology
  • Mastectomy, Segmental
  • Aged, 80 and over
  • Mastectomy
  • Female
  • Chemotherapy, Adjuvant
  • Medicaid
  • Radiotherapy, Adjuvant
  • Antineoplastic Agents, Hormonal/therapeutic use
  • SEER Program
  • Medicare
  • Comorbidity
  • Breast Neoplasms/epidemiology
  • Guideline Adherence
  • Aged
  • Neoplasm Staging
  • Practice Guidelines as Topic

ASJC Scopus subject areas

  • Oncology
  • Cancer Research


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