Abstract
Inequities in cancer care and outcomes, including stage of diagnosis, treatment, survival, and mortality, are well documented. Despite private and federal initiatives and scientific advances that have contributed to improvements in early detection and mortality rates, disparities persist, indicating additional pathways through which inequities in cancer care manifest. Limited research has explored the care experiences of different racial and ethnic groups, even though experience of care is a critical indicator of quality linked to important health outcomes.This study investigated multilevel pathways contributing to racial disparities in the experience of care among Medicare beneficiaries diagnosed with cancer, examining the effects of race and ethnicity, demographic factors, clinical factors, and geographic location. Although geography is widely recognized as a determinant of disease exposure and healthcare access, its role in shaping patient-reported care experiences remains underexplored. The research focused on three questions: whether non-Hispanic Black and White adults with cancer report different care experiences, whether provider factors relate to care experience for cancer patients of different races, and whether residing in a racially segregated area amplifies disparities in patient-reported experience.
Four complementary theories underpin this study, highlighting the interplay between structural, systemic, and individual factors that shape patient experiences. The Social Ecological Model provides a macro-level lens to identify the multilevel contexts of health disparities. Fundamental Cause Theory builds on this foundation by identifying the factors that facilitate the persistence of inequities. Intersectionality adds nuance by addressing how intersecting identities intensify disparities, while Cultural Health Capital operationalizes these dynamics within patient-provider interactions at the point of care where experience of care manifests.
Using ordinal logistic regression, this study analyzed data from the National Cancer Institute (NCI) Surveillance Epidemiology End Results (SEER) registry linked to the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) database. The analytic sample included Medicare beneficiaries who identified as non-Hispanic White, non-Hispanic Black, or were of "Other" races and ethnicities, with a cancer diagnosis at one of four primary sites: lung/bronchus, colon/rectum, breast, or prostate. The outcomes of interest included patient-reported composite measures of access to needed and timely care, doctor communication, care coordination, and global ratings of personal doctors, specialists, and overall care.
Findings revealed that racial minorities, particularly those in the "Other" category, consistently reported lower care experiences across multiple measures, reflecting the influence of cultural, structural, and language barriers. Disparities between non-Hispanic Black and White patients were limited, with Black patients reporting lower experiences with their specialists, potentially suggesting distinct pathways for racial disparities in clinical outcomes versus care experiences. Provider characteristics had a minimal impact, except for medical specialty, where oncologists were associated with higher scores across several experience of care measures. Geographic factors also played a nuanced role: living in White concentrated areas had positive associations with care experiences for racial and ethnic minorities, while Black concentrated areas provided protective effects for Black residents, but not for other races and ethnicities.
Additional factors, including age, education, and self-rated health, also shaped care experiences. Notably, higher education was associated with lower care experience ratings, challenging assumptions about the relationship between education and health care outcomes. Older age was similarly linked to poorer care experiences, consistent with barriers such as health literacy and physical impairment.
These findings underscore the complex interplay of demographic, provider, and geographic factors in shaping cancer patients’ experiences, and highlight the need for targeted interventions to address disparities and improve care quality for diverse populations and geographic contexts.