Maria Del Mar Estupiñan Fernandez De Mesa

Background: Mapping factors that sustain the care equity gap and identifying pathways into action have the potential to improve outcomes for minority ethnic women with breast cancer.

Aim: To integrate the narratives of women with breast cancer with survey data to understand what factors drive inequities across the care pathway. To use these findings to identify measures to improve breast cancer services and reduce inequities.

Methods: Qualitative-oriented, sequential-explanatory, mixed methods design underpinned by the transformative, intersectionality, and candidacy frameworks. Secondary data analysis using the 2017/2018 English National Cancer Patient Experience Survey to examine differences in care experienced among women with breast cancer, followed by semi-structured interviews. Mixed data were integrated into a joint display table.

Quantitative results: In adjusted multivariable analyses, Black (OR=0.67 [0.46, 0.97]) and Asian women (OR=0.52 [0.41, 0.67]) were more likely to rate their overall care experience less favourably than White British women. Subsequent analyses of all survey questions suggested that care inequities extended along the cancer pathway and may be driven by individual, interpersonal, and system-level factors.

Qualitative results: Four qualitative themes elucidated the processes influencing differences in care experienced by minority ethnic women, including feeling stereotyped by healthcare professionals (HCPs) and social networks, perceived barriers in healthcare services, HCPs’ knowledge, attitudes, and behaviours, and influence of cultural beliefs.

Mixed methods results: Minority ethnic women negotiated complex systems of discrimination relating to the intersection of their gender, ethnicity, and social position with structural power within the healthcare system. These multidimensional systems partially explained the exacerbated inequities in care experienced by UK Black and Asian women with breast cancer.

Conclusion: Policymakers, commissioners, and clinicians should be cognisant of minority ethnic women’s intersecting experiences within the cancer care system. By evaluating and reformulating policies and services through an intersectional lens, reducing inequities in breast care can be achieved.

Background
Persistent inequities in breast cancer outcomes exist. Understanding women’s experiences along the care pathway is the first step to finding solutions to tackle these inequities.
Methods
Secondary data analysis of the 2017/2018 English National Cancer Patient Experience Survey (
n
 = 25,408) using logistic regression to explore inequities in care experience by sociodemographic factors (age, ethnicity, socioeconomic position, sexual orientation) across 59 survey questions. We used the Candidacy Framework to interpret and organise our findings.
Results
Compared to older (65–74) and White British women, young (35-44, OR = 0.55 [0.44, 0.69]), Asian (OR = 0.52 [0.41, 0.67]), Black (OR = 0.67 [0.46, 0.97]) and White Other (OR = 0.63 [0.49, 0.81]) women were more likely to rate their overall care experience less positively, respectively. Similar findings were observed along all domains of the cancer pathway. Through a candidacy lens, we identified multilevel factors related to this variation including prolonged help-seeking behaviours (individual), poor patient-provider communication (interpersonal), and variation in access to healthcare professionals and resources (system level).
Conclusion
Multilevel factors influence inequities in the experience of care along the breast cancer pathway for young women and women from minoritised groups. Interventions are necessary to ensure cancer care systems are responsive to women’s health needs and provide equity of care to all patients.

Problem identification
We summarised the international evidence relating to the role of intersectionality in patients’ lived experience of inequities along the cancer care pathway. We produced guidance to use intersectionality in future research.

Literature search
We included 42 articles published between 1989 to 2023 that used intersectionality to guide the study and interpretation of inequities in cancer care.

Data evaluation/synthesis
Articles predominantly comprised North American (n = 37), followed by European (n = 4) and Asian (n = 1) studies. Similar compounding effects of racism, homophobia, and discrimination across countries exacerbated inequities in cancer care experience and cancer outcomes particularly for women of color and sexual/gender minority groups. Professionals’ knowledge, attitudes, and behaviors toward minoritised groups affected patient-provider relationships and influenced cancer patients’ psychosocial responses.

Conclusion
Intersectionality provides a framework to assess the personal, interpersonal, and structural processes through which cancer inequities manifest within and across countries.

Purpose: Guided by the Intersectionality Framework, we examined the differential in breast cancer care experience across population subgroups in England.

Methods: Secondary data analysis using the 2017/2018 National Cancer Patient Experience Surveys. We used disaggregated descriptive statistics (mean, standard errors, 95% confidence interval) to analyse 26,030 responses from female breast cancer patients to a question relating to overall care experience categorised by age, ethnicity, and sexual orientation in their intersection with social position. We then used logistic regression to investigate  the odds  (Odds Ratio (OR), 95% confidence intervals) of reporting positive care experience adjusting for patient, clinical, and Trust level factors.

Results: Poorer care experience was predominantly reported by the most deprived younger and minoritised ethnic groups. Statistically significant findings were observed in adjusted multivariable analyses. Compared to patients aged 64-74 years, younger respondents were less likely to rate their care favourably (16-34 years old OR_adj.=0.55 (0.36-0.84). Compared to White British, Asian (OR_adj.=0.51 (0.39-0.66)) and Black African women (OR_adj.=0.53 (0.33-0.88)) were less likely to rate their care favourably. The least affluent respondents were less likely to rate their care favourably (OR_adj.=0.79 (0.64-0.97)).

Conclusion: There is evidence of inequity in overall cancer care experience among female breast cancer patients in England, particularly among women living at the specific intersection of age, ethnicity, and socioeconomic position. Future research is necessary to understand the mechanisms underlying breast cancer inequities. Policymakers, commissioners, and providers should consider the existence of multiple forms of marginalisation to inform improvement initiatives targeting patients at higher risk of vulnerability.

Background . There are well-established, persistent inequities in cancer care and cancer outcomes within and between countries. The aim of this article is to explore how implementation theory, specifically the Consolidated Framework for Implementation Research (CFIR), alongside coproduction principles, could be used to maximise the effectiveness of innovations with a vision of reducing inequity in cancer care. Methods. Workshops were conducted with partners from US, Australia, and UK, participating in the University Global Partnership Network (UGPN), which funded the collaboration. From these workshops, three case studies were identified and the framework was applied to identify ways of using CFIR to maximise the effectiveness of innovations. Results. The three case studies focused on human papillomavirus (HPV) testing and vaccination, participation in clinical trials, and use of translation services. We identified opportunities, for each of the case studies, where CFIR could be applied to improve implementation and proposed recommendations to ensure effective implementation of innovations using CFIR domains, including individual constructs (e.g., awareness and cultural competence), inner setting constructs (e.g., technology infrastructure), and outer setting constructs (e.g., how services are monitored, evaluated, and commissioned). Conclusions. Applying CFIR as an implementation framework offers a structured and holistic approach to consider how to maximise the effectiveness of innovations in the context of reducing inequities in cancer care. Working with other countries to apply this framework also provides a uniform approach to understand and reduce inequities across a range of innovations and address the global mission to improve cancer care for all.

IntroductionPersistent inequalities in cancer care and cancer outcomes exist within and between countries. However, the evidence pertaining to the root causes driving cancer inequalities is mixed. This may be explained by the inadequate attention paid to experiences of patients with cancer living at the intersection of multiple social categories (eg, social class, ethnicity). This is supported by the intersectionality framework. This framework offers an alternative lens through which to analyse and understand how these interlocking systems of oppression uniquely shape the experiences of patients with cancer and drive inequalities. In this protocol, we outline a scoping review that will systematically map what is known about the relationship between intersectionality and inequalities in care experience and cancer outcomes of patients with cancer; and to determine how the intersectionality framework has been applied in studies across the cancer care pathway and across countries.Methods and analysisThis study will be guided by Arksey and O’Malley’s, and Levac et al’s frameworks for scoping reviews. We will identify and map the evidence on cancer inequalities and intersectionality from 1989 to present date. Electronic databases (EMBASE, PsychINFO, CINAHL, Medline, Web of Science, ProQuest) and a systematic search strategy using a combination of keywords and Boolean operators AND/OR will be used to identify relevant studies. Screening of eligible papers and data extraction will be conducted by two independent reviewers, and disagreements resolved by discussion with the research team. We will use an iterative process to data charting using a piloted form. Findings will be collated into a narrative report.Ethics and disseminationEthical approval is not required since data used are from publicly available secondary sources. Findings will be disseminated through peer-reviewed journals, conferences and stakeholder meetings. Further, findings will inform the next phases of a multistage research project aimed at understanding inequalities among patients with breast cancer.