Breast cancer care quality and survival are not associated with hospital safety-net burden

Safety-net hospitals anchor access for Medicaid/uninsured patients but operate under persistent financial pressure. Whether a higher safety-net burden influences breast cancer care quality or survival is unclear.

We conducted a retrospective cohort study using the National Cancer Database (2018-2022) for women aged ≥40 years with stage 0-IV breast cancer. Hospital safety-net burden (proportion of Medicaid/uninsured patients) was categorized as low (low-burden hospital), medium (medium-burden hospital), or high (high-burden hospital). The primary outcome was guideline-concordant care among stages I-III (concordant local therapy plus all indicated systemic components), evaluated using mixed-effects logistic regression (facility random intercept). Overall survival was assessed using Cox models in patients with stage 0-IV disease, with stage-stratified models as secondary analyses.

Among 599,643 patients, those treated at high-burden hospitals were younger and often from lower-income, less-educated neighborhoods, and minoritized groups. Guideline-concordant care rates were similar across hospital groups (73%-75%). After adjustment, safety-net burden was not associated with guideline-concordant care (medium-burden hospital versus low-burden hospital: adjusted odds ratio, 1.04; 95% confidence interval, 0.99-1.09; high-burden hospital versus low-burden hospital: 0.98; 0.93-1.04). Lower guideline-concordant care was associated with older age, greater comorbidity, and later diagnosis year; guideline-concordant care was higher in stage II and lower in stage III than in stage I. Overall survival did not differ by safety-net burden in adjusted or stage-stratified Cox models; it was instead driven by stage, age, comorbidity, facility type, and tumor subtype.

Hospital safety-net burden is not associated with lower guideline-concordant care or poorer overall survival in breast cancer. Preserving safety-net hospital capacity to deliver standardized, multidisciplinary care may help maintain high-quality outcomes for marginalized patients as policy environments evolve.