Further assessment of structural and social determinant of health effects on breast cancer care timelines: a qualitative study.

Background: Time to treatment initiation (TTI) delays result in worse cancer outcomes. Patients in under-resourced communities may experience TTI delays due to structural challenges and social determinants of health (SDOH), impacting access to timely care. We conducted a qualitative study in breast cancer patients with and without delayed TTI from an under-served community to explore barriers and facilitators to TTI from the patient perspective. Methods: We interviewed 30 patients who received curative intent breast cancer treatment at Montefiore Medical Center from 2019 to 2024. Half of the patients had delayed TTI (≥45 days), while the other half were not delayed. Interviews addressed barriers and facilitators of timely TTI, perceived timeliness of care, emotional well-being, and perceptions of the healthcare team and communication. Interviews were coded based on recurring ideas and patterns, and framework analysis was used to finalize themes. Results: Our cohort (n=30) had a mean age of 60.9 years, all whom identified as female. Most participants identified as Black or African-American (56.7%), and 16.7% identified as Hispanic/Latino. Age, race, ethnicity, tumor stage, and first treatment modality were similar between delayed and non-delayed TTI groups, whereas the distribution of pathologic diagnoses approached borderline significance. The mean TTI in delayed participants was 55.1 days and 32.7 days in the non-delayed group. Three main themes were identified: (1) Facilitators and Barriers, (2) Coping in the Interim: Waiting for Treatment Initiation, and (3) Patient Perceptions of Timeliness. Delayed patients faced financial burdens, transportation issues, and childcare challenges, hindering ability to adhere to schedules. Approximately half of the full cohort (delayed and non-delayed patients) wished their treatment began sooner, while half of the delayed TTI group expressed preference for longer TTI that afforded them time to prepare for treatment, make important decisions and seek opinions. Frequently participants found significant emotional and logistical support through family, social networks, and religion as well. Conclusions: Our study revealed that delayed patients faced financial and logistical barriers to initiating treatment. Findings from our work highlight the need for healthcare systems to better equip and engage patients in the care timeline to avoid delayed TTI.