Researchers from the National Cancer Institute (NCI) have found
significant differences in how black and white breast cancer patients
are treated during their illness. The results were reported in
the April 29, 1999 issue of the journal Ethnicity and Disease.
Using a new method of analysis developed by the authors, the study
confirms and adds knowledge to previous findings about the impact
of socioeconomic differences on breast cancer treatment for black
and white women. This method examines the first course of treatment
(that is, the first three months of treatment) recommended for
stage-specific diagnoses of breast cancer, rather than only individual
types of treatment, such as surgery, radiation, or chemotherapy.
Each woman's actual treatment was compared against the "minimum
expected treatment," which was defined in the study using
National Institutes of Health Consensus Conferences for each stage
of diagnosis.
"It's disconcerting, as these results show, that older patients
are not receiving chemotherapy, as NCI Consensus Conferences advise,"
said Otis W. Brawley, M.D., NCI assistant director, Office of
Special Populations Research. "We need more research to determine
how cancer treatment for different groups is influenced by social
and economic factors. I commend the authors on developing a method
that evaluates whether patients received the course of treatment
advised for their stage. This sort of study should be conducted
more often."
Since the distribution of nearly all characteristics were significantly
different for black and white women, black and white cases were
examined separately to evaluate factors most likely to be associated
with early or late stage of disease at diagnosis. Income was associated
with stage only for white women. For black women, who were concentrated
in low-income groups, the significant predictors of late stage
of disease were: no usual source of care and lack of screening.
The study then examined only those breast cancer patients who
were diagnosed with a later stage of disease and found that age
was most strongly associated with not receiving minimum expected
treatment. These older women were also likely to report having
lower income, less education, public health insurance, and no
usual source of health care.
When results for all diagnostic stages were combined for each
race, 21 percent of black women and 15 percent of white women
did not receive the minimum expected treatment. The shorter survival
and higher mortality observed for black women compared to white
women was attributed to a "cumulative process," whereby
race was correlated with lower social class and the lack of a
usual provider, less screening, later stage at diagnosis, and
consequently, less likelihood of receiving the minimum expected
therapy. Data were not adjusted for comorbidity. An appendix to
the paper details the rationale for the expected minimum treatment
for each stage of disease.
Data from NCI's Black-White Cancer Survival Study (BWCSS) were
examined for this analysis. Patients in the BWCSS were diagnosed
during 1985 to 1986, but this is one of the few data sets in the
United States with clinical staging and medical treatment on enough
black and white patients to allow analysis by race and socioeconomic
status of health services differences over breast cancer diagnosis
and the first course of treatment.
The BWCSS used age, race, gender, and staging data on breast cancer
patients reported to local cancer registries in three metropolitan
areas, then matched black patients by age to white patients. This
group of black and white patients were interviewed about their
income, insurance, screening, and usual source of care. Data were
also obtained from medical records. Patients were between the
ages of 20 and 79 years old and lived in Atlanta, New Orleans,
or San Francisco.
"This study found that disparities in breast cancer diagnosis
and treatment most adversely affected women who are black, or
older, or poor," said lead author Nancy Breen, Ph.D., NCI
Division of Cancer Control and Population Sciences, Applied Research
Branch. "These data were collected in 1986, before screening
for breast cancer was widespread. This raises the question of
whether these same inequalities still prevail. It may be time
to monitor this again."
Brawley added, "it would be useful to monitor other racial
and ethnic groups in which disparities in cancer care are suspected
as well. Differences in treatment, as shown in this paper, clearly
contribute to racial disparities in disease outcomes."
Having health insurance facilitates access to a regular health
care provider, which in turn may facilitate screening and early
diagnosis, the paper notes. The health insurance situations of
BWCSS participants mirrored national employee benefits studies
conducted in the mid-1980s, which showed whites were more often
covered by employer-based health plans than blacks. Of the under-age
65 group of women studied, 68 percent of blacks and 94 percent
of whites had private health insurance; 16 percent of blacks and
3 percent of whites had public insurance; and 16 percent of blacks
and 4 percent of whites had no insurance. For the 65 and older
group, 50 percent of black women in the sample depended on unsupplemented
public insurance compared to 8 percent of white women.
Reference:
from the National Cancer Institute
press release
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