Disparities in breast cancer prognostic factors by race, insurance status, and education

Black women are more likely to be diagnosed with advanced stage and other less favorable breast cancer prognostic factors than white women. The aim of this study was to examine the extent to which markers of socioeconomic position accounts for black–white differences in these factors. Our study included 193,969 women diagnosed with invasive breast cancers during 2004–2005 from the National Cancer Database, which represents about 72% of all patients with cancer treated in the United States. Compared to white women, black women are more likely to be diagnosed with breast tumors that are less differentiated (odds ratio (OR) = 2.55, 95% confidence interval (CI) 2.44–2.66), hormone receptor negative (OR = 2.29, 95% CI 2.22–2.37), large (OR = 1.87, 95% CI 1.80–1.95), metastatic (OR = 1.89, 95% CI 1.78–2.00), and lymph node-positive (OR = 1.44, 95% CI 1.40–1.48). In multivariable analyses, adjustment for insurance and area-level educational attainment explained 31–39% of the differences in tumor size and metastasis, but only about 14% of the differences in grade and hormone receptors. After accounting for race and other covariates, uninsured women remained 3.66 (95% CI 3.30–4.07) times more likely to have metastasis and 2.37 (95% CI 2.17–2.58) times more likely to have large tumors compared to privately insured women. Similarly, the risk of having breast cancer with less favorable prognostic factors increased as area-level educational attainment decreased. Extending health insurance coverage to all women is likely to have an effect on reducing racial disparities in the development of breast cancers with poor prognostic factors.     

Racial segregation and disparities in breast cancer care and mortality

BACKGROUND.

Questions have existed as to whether residential segregation is a mediator of racial/ethnic disparities in breast cancer care and breast cancer mortality, or has a differential effect by race/ethnicity.

METHODS.

Data from the Surveillance, Epidemiology, and End Results–Medicare database on white, black, and Hispanic women aged 66 to 85 years with breast cancer were examined for the receipt of adequate breast cancer care.

RESULTS.

Blacks were less likely than whites to receive adequate breast cancer care (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.71‐0.86). Individuals, both black and white, who lived in areas with greater black segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.64‐0.82). Black segregation was a mediator of the black/white disparity in breast cancer care, explaining 8.9% of the difference. After adjustment, adequate care for Hispanics did not significantly differ from whites, but individuals, both Hispanic and white, who lived in areas with greater Hispanic segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.61‐0.89). Although Blacks experienced greater breast cancer mortality than whites, black segregation did not substantially mediate the black‐white disparity in survival, and was not significantly associated with mortality (hazards ratio, 1.03; 95% CI, 0.87‐1.21). Breast cancer mortality did not differ between Hispanics and whites.

CONCLUSIONS.

Among seniors, segregation mediates some of the black‐white disparity in breast cancer care, but not mortality. Individuals who live in more segregated areas are less likely to receive adequate breast cancer care. Cancer 2008. © 2008 American Cancer Society.     

Racial and ethnic disparities in the diagnosis of breast cancer: changes in presenting stage in minority populations in Florida during 1981–2009

We assessed whether presenting breast cancer stage has changed over time in Florida, and whether there is variation in this change with respect to race, ethnicity, and socioeconomic status (SES). Data were obtained from the Florida Cancer Data System. We included females with invasive breast cancer and complete information on race, ethnicity, and SES during 1981–2009 (n = 226,651). Associations between categorical variables were examined using Chi-square tests. Predictors of SEER stage at diagnosis (local, regional, and distant) were modeled with multinomial ordinal logistic regression models. There was a significant increase in local disease and a decrease in regional and distant disease at presentation (p < 0.0001) over the time period assessed. Compared to whites, black patients continue to have lower odds of local presentation (OR 0.73, 95 % CI 0.63, 0.85), as do Hispanic patients (OR 0.80, 95 % CI 0.76, 0.84) compared to non-Hispanics. The increase in local stage at diagnosis was greater for black than white patients, as was the decrease in regional and distant disease (p < 0.001). Hispanic women also had significant increase in localized disease and decrease in regional and distant disease (p < 0.001), but there was little difference in the change compared to non-Hispanic women. Localized breast cancer stage at diagnosis has become more common over time in all groups. Significant disparity persists, with black and Hispanic patients being less likely to present with localized disease than white patients overall. There was a greater change for black versus white patients, resulting in a narrowing in the racial gap in stage at diagnosis.     

Prognostic factors for the survival of patients with esophageal carcinoma in the U.S.: the importance of tumor length and lymph node status

BACKGROUND: The current TNM classification system does not consider tumor length or the number of lymph nodes in the staging and classification scheme for patients with esophageal carcinoma. Using data from the National Cancer Institute SEER Program, the authors explored the effect of tumor length and number of positive lymph nodes on survival in patients with esophageal carcinoma. METHODS: Patients with esophageal adenocarcinoma or squamous cell carcinoma were subgrouped according to historic stage with localized, regional, or distant disease. Demographic factors (age at diagnosis, race, and gender) and tumor characteristics (morphology, histologic grade, tumor length, primary site, depth of invasion, number of positive lymph nodes, proportion of positive lymph nodes dissected, and distant metastatic sites) were examined. RESULTS: Overall factors that were associated with an increased mortality risk included increasing age at diagnosis, black race versus white race, histologic grade, primary tumor site in the lower esophagus and abdomen versus upper regions, and increasing depth of invasion. Among patients with regional disease, the number of positive lymph nodes (>/= 5 vs. < 5) was related to an increasing risk (hazard ratio [HR], 1.29; 95% confidence interval [95%CI], 1.06-1.56). The proportion of positive lymph nodes compared with the number of lymph nodes dissected conferred an increased risk (HR, 1.63; 95%CI, 1.26-2.11). Among patients with distant disease, sites other than distant lymph nodes implied an increased mortality risk (HR, 1.37; 95%CI, 1.37-1.65). Tumor length was an independent predictor of mortality when controlling for depth of invasion in patients with localized disease (HR, 1.15; 95%CI, 1.08-1.21). CONCLUSIONS: Tumor length, the number of involved lymph nodes, and the ratio of positive lymph nodes are important prognostic factors for survival in patients with esophageal carcinoma. A revised TNM classification system for patients with esophageal carcinoma might consider adding tumor length and number of positive lymph nodes as two important prognostic factors.     

Widening disparity in survival between white and African-American patients with breast carcinoma treated in the U. S. Department of Defense Healthcare system

BACKGROUND: In the U. S., age-adjusted breast carcinoma mortality rates among white and African-American women have been diverging during the last 20 years. Some investigators speculate that the widening disparity is due to inequalities in access to healthcare, with African Americans having less access to necessary healthcare and improved therapies. Others argue that differences in tumor biology or some extrinsic influences on cancer etiology and behavior may account for the widening disparity. To examine this issue further, the authors compared trends in survival among white and African-American women diagnosed with breast carcinoma in the U. S. Department of Defense (DoD), an equal access healthcare system. METHODS: The medical records of all women diagnosed with primary breast carcinoma between 1980-1999 were retrieved from the U. S. DoD Automated Central Tumor Registry (ACTUR). Variables selected for further analysis were date of diagnosis, date of birth, vital status and date of death if applicable, race (black, white, and others), and stage of tumor. Because the database does not contain causes of death, overall survival was investigated. The effect of year of diagnosis and race on overall survival was analyzed using the Cox proportional hazards model stratified by age at diagnosis (1-year age groups). Calculations were performed separately by disease stage for all stages combined and stratified by stage. Statistical analyses were performed using the statistical software package SAS. RESULTS: After deleting observations with missing or implausible information regarding patient age, gender, and follow-up time, the final dataset was comprised of 23,612 women with primary breast carcinoma. The survival of African-American women compared with white women demonstrated an increasing ratio with calendar period. Although the hazard ratio was 1.269 for women diagnosed with breast carcinoma during the calendar period 1980-1984, it increased to 1.849 for those diagnosed between 1995-1999, which is a ratio of 1.46. For this period, the interaction between race and period was found to be significant (P = 0.04). CONCLUSIONS: The results of the current study demonstrated that breast carcinoma survival rates among white and African-American patients, adjusted for age and stage, are diverging in the U. S. DoD healthcare system. Thus, inequalities in access to healthcare most likely are not solely responsible for the widening racial disparities in outcome reported among women diagnosed with breast carcinoma.     

Racial and ethnic differences in breast cancer survival

BACKGROUND: The reasons for race/ethnicity (R/E) differences in breast cancer survival have been difficult to disentangle. METHODS: Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify 41,020 women aged > or =68 years with incident breast cancer between 1994-1999 including African American (2479), Hispanic (1172), Asian/Pacific Island (1086), and white women (35,878). A Cox proportional hazards model assessed overall and stage-specific (0/I, II/III, and IV) R/E differences in breast cancer survival after adjusting for mammography screening, tumor characteristics at diagnosis, biologic markers, treatment, comorbidity, and demographics. RESULTS: African American women had worse survival than white women, although controlling for predictor variables reduced this difference among all stage breast cancer (hazards ratio [HR], 1.08; 95% confidence interval [95% CI], 0.97-1.20). Adjustment for predictors reduced, but did not eliminate, disparities in the analysis limited to women diagnosed with stage II/III disease (HR, 1.30; 95% CI, 1.10-1.54). Screening mammography, tumor characteristics at diagnosis, biologic markers, and treatment each produced a similar reduction in HRs for women with stage II/III cancers. Asian and Pacific Island women had better survival than white women before and after accounting for all predictors (adjusted all stages HR, 0.61 [95% CI, 0.47-0.79]; adjusted stage II/III HR, 0.61 [95% CI, 0.47-0.79]). Hispanic women had better survival than white women in all and stage II/III analysis (all stage HR, 0.88; 95% CI, 0.75-1.04) and stage II/III analysis (HR, 0.88; 95% CI, 0.75-1.04), although these findings did not reach statistical significance. There was no significant difference in survival by R/E noted among women diagnosed with stage IV disease. CONCLUSIONS: Predictor variables contribute to, but do not fully explain, R/E differences in breast cancer survival for elderly American women. Future analyses should further investigate the role of biology, demographics, and disparities in quality of care.     

Assessment of mediators of racial disparities in cervical cancer survival in the United States

Cervical cancer (CC) morbidity and mortality have decreased in the United States, but they remain high among black women. We assessed racial disparities in CC mortality, accounting for socioeconomic status (SES). We linked data from the 1988 to 2007 Surveillance Epidemiology and End Results (SEER) database to the US Census. Additional SES information was obtained through linkage with Area Resource Files. We used the Kaplan–Meier method for estimating probabilities following CC diagnosis and Cox proportional hazards regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CC mortality by race. The models were incrementally adjusted for marital status, registry, period, stage, age at diagnosis, histology, treatment, household income, poverty and unemployment rates. We stratified the analyses by disease stage and American state. A total of 44,554 women with CC were identified. Compared to white women, black women had a higher risk of dying from CC; crude and adjusted HRs were 1.41 (CI: 1.34–1.48) and 1.09 (CI: 1.03–1.15), respectively. Corresponding estimates for Hispanic women were 0.85 (CI: 0.80–0.89) and 0.75 (CI: 0.71–0.80). Black women diagnosed at late disease stages had a higher risk of CC death, whereas Hispanic women diagnosed at early and late stages had significantly lower risks. Black CC patients in California experienced poorer survival relative to white women. Conversely, longer CC survival was seen among Hispanic women in California, Georgia and Utah. While crude estimates indicated an increased CC death risk among black women, risks diminished upon adjustment for clinical and sociodemographic characteristics.     

Racial/ethnic differences in receipt of pelvic lymph node dissection among men with localized/regional prostate cancer

BACKGROUND:

Black and Hispanic men have a lower prostate cancer (PCa) survival rate than white men. This racial/ethnic survival gap has been explained in part by differences in tumor characteristics, stage at diagnosis, and disparities in receipt of definitive treatment. Another potential contributing factor is racial/ethnic differences in the timely and accurate detection of lymph node metastases. The current study was conducted to examine the association between race/ethnicity and the receipt of pelvic lymph node dissection (PLND) among men with localized/regional PCa.

METHODS:

Logistic regression was used to estimate the adjusted odds of undergoing PLND among men who were diagnosed during 2000 to 2002 with PCa, who underwent radical prostatectomy or PLND without radical prostatectomy, and who were diagnosed in regions covered by the Surveillance, Epidemiology, and End Results database (n = 40,848).

RESULTS:

Black men were less likely to undergo PLND than white men (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84‐0.98). When the analysis was stratified by PCa grade, black men with well differentiated PCa (OR, 0.48; 95% CI, 0.27‐0.84) and poorly differentiated PCa (OR, 0.73; 95% CI, 0.60‐0.89) were less likely to undergo PLND than their white counterparts, but racial differences were not observed among men with moderately differentiated PCa (OR, 0.96; 95% CI, 0.88‐1.05).

CONCLUSIONS:

Among men with poorly differentiated PCa, failure to undergo PLND was associated with worse survival. Racial disparities in the receipt of PLND, especially among men with poorly differentiated PCa, may contribute to racial differences in prostate cancer survival. Cancer 2011;. © 2011 American Cancer Society.     

Race, socioeconomic status, and breast cancer treatment and survival

BACKGROUND: Previous studies have found that African-American women are more likely than white women to have late-stage breast cancer at diagnosis and shortened survival. However, there is considerable controversy as to whether these differences in diagnosis and survival are attributable to race or socioeconomic status. Our goal was to disentangle the influence of race and socioeconomic status on breast cancer stage, treatment, and survival. METHODS: We linked data from the Metropolitan Detroit Surveillance, Epidemiology, and End Results (SEER)(1) registry to Michigan Medicaid enrollment files and identified 5719 women diagnosed with breast cancer, of whom 593 were insured by Medicaid. We first calculated the unadjusted odds ratios (ORs) associated with race, Medicaid insurance, and poverty for breast cancer stage at diagnosis, breast cancer treatment, and death. We then estimated the ORs of having late-stage breast cancer at diagnosis, breast-conserving surgery, no surgery, and death using logistic regression after controlling for clinical and nonclinical factors. All statistical tests were two-sided. RESULTS: Before controlling for Medicaid enrollment and poverty, African-American women had a higher likelihood than white women of each unfavorable breast cancer outcome. However, after controlling for covariates, African-American women were not statistically significantly different from white women on most outcomes except for surgical choice. African-American women were more likely than white women to have no surgery (adjusted OR = 1.62; 95% confidence interval [CI] = 1.11 to 2.37). Among women who had surgery, African-American women were more likely to have breast-conserving surgery than were white women (adjusted OR = 1.63; 95% CI = 1.33 to 1.98). CONCLUSIONS: The linkage of Medicaid and SEER data provides more in-depth information on low-income women than has been available in past studies. In our Metropolitan Detroit study population, race was not statistically significantly associated with unfavorable breast cancer outcomes. However, low socioeconomic status was associated with late-stage breast cancer at diagnosis, type of treatment received, and death.     

Diminished survival in patients with inner versus outer quadrant breast cancers.

PURPOSE: To evaluate the role of breast tumor location on survival in patients with breast cancer. PATIENTS AND METHODS: We evaluated tumor location within the breast on breast cancer-specific survival (BCSS) and overall survival (OS) in patients with invasive breast cancer using the Surveillance, Epidemiology, and End-Results (SEER) registries in the United States. Effects on survival were evaluated according to age, stage, tumor site, tumor size, grade, axillary lymph node status, extent of surgery, and radiotherapy (RT). A multivariate model was used with complete data on 45,880 patients. The median follow-up was 59 months. RESULTS: Patients with outer tumor location demonstrated superior BCSS on Kaplan-Meier analysis for both local stage (node-negative, P <.001) and regional stage disease (node-positive, P =.0002). For BCSS, the hazard ratio (HR) for inner quadrant location compared with outer quadrant was 1.31 (95% confidence interval [CI], 1.19 to 1.37; P <.001); and for OS, the HR was 1.12 (95% CI, 1.05 to 1.17; P <.001). When ER and PR status were included in the model, the HR for inner quadrant location compared with outer quadrant was 1.27 for BCSS (95% CI, 1.16 to 1.40; P <.001) and 1.11 for OS (95% CI, 1.03 to 1.19; P =.004). Patients treated by lumpectomy that received RT had a superior OS compared with patients that did not receive RT in both local (HR, 0.52; 95% CI, 0.48 to 0.61; P <.001) and regional (HR, 0.63; 95% CI, 0.56 to 0.72; P <.001) stage disease. Mastectomy patients with local stage disease that received RT had a diminished OS (HR, 1.24; 95% CI, 1.02 to 1.50; P =.033). CONCLUSION: On multivariate analysis, incorporating data on age, stage, tumor site, tumor size, grade, ER and PR status, axillary lymph node status, extent of surgery, and RT, this SEER registry-based study demonstrates that medial tumor location adversely impacts BCSS and OS.     

Prognosis after rectal cancer in blacks and whites participating in adjuvant therapy randomized trials.

PURPOSE: National health statistics indicate that blacks have lower survival rates from colorectal cancer than do whites. This disparity has been attributed to differences in stage at diagnosis and other disease features, extent and quality of treatment, and socioeconomic factors. We evaluated outcomes for blacks and whites with rectal cancer who participated in randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP). The randomized trial setting enhances uniformity in disease stage and treatment plan among all participants. PATIENTS AND METHODS: The study included black (N = 104) or white (N = 1,070) patients from two serially conducted NSABP randomized trials for operable rectal cancer. Recurrence-free survival and survival were compared using statistical modeling to account for differences in patient and disease characteristics between the groups. RESULTS: Blacks and whites had largely similar disease features at diagnosis. After adjustment for patient and tumor prognostic covariates, the black/white recurrence hazard ratio (HR) was 1.25 (95% confidence interval [CI], 0.94 to 1.66). The mortality HR was somewhat larger at 1.45 (95% CI = 1.09 to 1.93). Outcomes were improved for both groups in the more recent trial, which employed systemic adjuvant chemotherapy in all treatment arms. CONCLUSION: Recurrence-free survival was modestly less favorable for blacks, whereas overall survival was more disparate. Outcomes between groups were more comparable than those noted in national health statistics surveys and other studies. Adequate treatment access and the identification of new prognostic factors that can identify patients at high risk of recurrence are needed to ensure optimal outcomes for rectal cancer patients of all racial/ethnic backgrounds.     

Poor compliance with breast cancer treatment guidelines in men undergoing breast-conserving surgery

Lumpectomy is performed in a small but growing proportion of men with breast cancer. It is unknown whether men undergoing breast-conserving surgery (BCS) receive care compliant with breast cancer treatment guidelines. Patients with breast cancer in the surveillance, epidemiology, and end results (SEER) database who underwent lumpectomy between 1983 and 2009 were identified. Gender differences in the receipt of lymph node staging and adjuvant radiation therapy were assessed. Multivariate logistic regression was utilized to evaluate the independent association of gender on these outcomes. The influence of gender on breast cancer-specific survival (BCSS) was analyzed. 382,030 of 824,408 (46.3 %) women compared to 712 of 6,039 (11.8 %) men with breast cancer underwent lumpectomy. Men were older, more likely to be black, less likely to have stage I disease and more likely to have stage IV disease. Only 59.2 % of men had lymph nodes sampled at the time of surgery compared to 81.6 % of women (p < 0.0001). In addition, only 35.4 % of men received adjuvant breast radiation therapy compared to 69.8 % of women (p < 0.0001). After controlling for age, race, stage, grade, and year of diagnosis, female gender was significantly associated with receiving adjuvant radiation therapy (OR 2.9, 95 % CI 2.4–3.4) and lymph node staging (OR 1.6, 95 % CI 1.3–1.90). Five- and ten-year BCSS were 88.0 and 83.5 % for men compared to 93.2 and 88.2 % for women (p < 0.001). Men with breast cancer are less likely to receive lymph node staging or adjuvant radiation therapy following BCS compared to women.     

Race as an Independent Risk Factor for Breast Cancer Survival: Breast Cancer Outcomes From the Medical College of Georgia Tumor Registry

BackgroundCauses of racial disparities in breast cancer survival remain unclear. This study assesses overall survival (OS) after diagnosis between black and white women and examines factors that might correlate with this disparity.Patients and MethodsData were obtained from the Medical College of Georgia Tumor Registry. Cases included those diagnosed between 1990 and 2005. We analyzed race, stage, age of diagnosis, and treatment received: chemotherapy, radiation, surgery, and hormonal therapy. A Cox proportional hazards model was used to determine differences in OS.ResultsCompared with 670 white women, 489 black women were more likely to be younger, have later-stage disease at diagnosis, and were less likely to have received hormonal therapy. Both groups received similar rates of radiation, surgery, and chemotherapy. Black women had significantly poorer OS (adjusted hazard ratio, 1.35; 95% CI, 1.12–1.63). White women had a 5-year OS of 54% compared with 45% in black women (P = .0031). Having received radiation, surgery, or chemotherapy was not associated with OS. White women were more likely to have received hormonal therapy, which had a significant protective effect. However, a stratified analysis (between those who received hormonal therapy and those who did not) showed similar results, whereas black women experienced poorer OS in both strata.ConclusionBlack women with breast cancer had a significantly poorer OS compared with white women. White women received more hormonal therapy, which had a protective effect. There were no differences in treatment received regarding radiation, surgery, or chemotherapy, and these treatments were not associated with OS. The reasons for racial disparities in breast cancer OS remain complex.     

Racial disparities in treatment and survival of women with stage I–III breast cancer at a large academic medical center in metropolitan Detroit

Summary African-American (AA) women with breast cancer have higher mortality rates than Caucasian woman, and some studies have suggested that this disparity may be partly explained by unequal access to medical care. The purpose of this study was to analyze racial differences in patterns and costs of care and survival among women treated for invasive breast cancer at a large academic medical center. Subjects included 331 AA and 257 Caucasian women diagnosed with stage I–III breast cancer between 1994 and 1997. Clinical, socio-demographic, and cost data were obtained from the medical record, cancer registry, and hospital financial database. Data were collected on the use of cancer directed treatments (surgery, radiation, chemo and hormonal therapy) up to 1-year post-diagnosis. Survival analyses compared disease-free and overall survival by race adjusting for age, stage, nodal involvement, ER/PR status and a diagnosis of hypertension, diabetes, heart disease and cerebral vascular accident. There were no significant racial differences in treatment utilization and costs. The mean total 1-year treatment costs were $16,348 for AAs and $15,120 for Caucasians. While AAs had a significantly higher unadjusted relative risk (RR) of recurrence 2.09 (95% CI: 1.41–3.10) and death 1.56 (95% CI: 1.09–2.25), the multivariate adjusted analyses resulted in no significant differences in recurrence 1.38 (95% CI: 0.85–2.26) or death 1.06 (95% CI: 0.64–1.75). There was no obvious racial disparity in treatment and costs noted. Our findings support the theory that equal treatments produce equal outcomes. Improvement in screening may have an important impact on survival among minority women with breast cancer.     

Black/white differences in treatment and survival among women with stage IIIB–IV breast cancer at diagnosis: a US population-based study

Introduction

Non-Hispanic black (NHB) women with breast cancer have poorer survival than non-Hispanic white (NHW) women. Although NHB women are more often diagnosed at later stages, it is less established whether racial disparities exist among women diagnosed with late-stage breast cancer, particularly when care is provided in the community setting.

Methods

Treatment and survival were examined by race/ethnicity among women diagnosed in 2012 with stage IIIB–IV breast cancer using the National Cancer Institute’s population-based Patterns of Care Study. Medical records were re-abstracted and treating physicians were contacted to verify therapy. Vital status was available through 2014.

Results

A total of 533 women with stage IIIB–C and 625 with stage IV tumors were included; NHW women comprised about 70% of each group. Among women with stage IIIB–C disease, racial/ethnicity variations in systemic treatment were not observed but there was a borderline association indicating worse all-cause mortality among NHB women (hazard ratio 1.52; 95% confidence interval (CI) 0.96–2.41). In contrast, among women with stage IV disease, borderline associations indicating NHB women were more likely to receive chemotherapy (OR 1.44, 95% CI 0.90–2.30) and, among those with hormone receptor-positive tumors, less likely to receive endocrine therapy (OR 0.60, 95% CI 0.35–1.04). All-cause mortality did not vary by race/ethnicity for stage IV disease (hazard ratio 0.92; 95% CI 0.68–1.25).

Conclusions

More research is needed to identify additional factors associated with the potential survival disparities among women with stage IIIB–C disease and potential treatment disparities among women with stage IV disease.

     

Racial differences in breast cancer survival in the Detroit Metropolitan area

Summary African American (AA) women have poorer breast cancer survival compared to Caucasian American (CA) women. The purpose of this analysis was to determine whether socioeconomic status (SES) and treatment differences influence racial differences in breast cancer survival. The study population included 9,321 women (82% CA, 18% AA) diagnosed with local (63%) or regional (37%) stage disease between 1988 and 1992, identified through the Metropolitan Detroit SEER registry. Data on SES were obtained through linkage with the 1990 Census of Population and Housing Summary Tape and cases were geocoded to census block groups. Pathology, treatment and survival data were obtained through SEER. Cox proportional hazards models were used to compare survival for AA versus CA women after adjusting for age, SES, tumor size, number of involved lymph nodes, and treatment. AA␣women were more likely to live in a geographic area classified as working poor than were CA women (p<0.001). AA women were less likely to have lumpectomy and radiation and more likely to have mastectomy with radiation (p<0.001). After multivariable adjusted analysis, there were no significant racial differences in survival among women with local stage disease, although AA women with regional stage disease had persistent but attenuated poorer survival compared to CA women. After adjusting for known clinical and SES predictors of survival, AA and CA women who are diagnosed with local disease demonstrate similar overall and breast cancer-specific survival, while race continues to have an independent effect among women presenting at a later stage of disease.     

Racial variation in breast cancer treatment among Department of Defense beneficiaries

BACKGROUND:

Although the overall age‐adjusted incidence rates for female breast cancer are higher among whites than blacks, mortality rates are higher among blacks. Many attribute this discrepancy to disparities in health care access and to blacks presenting with later stage disease. Within the Department of Defense (DoD) Military Health System, all beneficiaries have equal access to health care. The aim of this study was to determine whether female breast cancer treatment varied between white and black patients in the DoD system.

METHODS:

The study data were drawn from the DoD cancer registry and medical claims databases. Study subjects included 2308 white and 391 black women diagnosed with breast cancer between 1998 and 2000. Multivariate logistic regression analyses that controlled for demographic factors, tumor characteristics, and comorbidities were used to assess racial differences in the receipt of surgery, chemotherapy, and hormonal therapy.

RESULTS:

There was no significant difference in surgery type, particularly when mastectomy was compared with breast‐conserving surgery plus radiation (blacks vs whites: odds ratio [OR], 1.1; 95% confidence interval [CI], 0.8‐1.5). Among those with local stage tumors, blacks were as likely as whites to receive chemotherapy (OR, 1.2; 95% CI, 0.9‐1.7) and hormonal therapy (OR, 1.0; 95% CI, 0.6‐1.4). Among those with regional stage tumors, blacks were significantly less likely than whites to receive chemotherapy (OR, 0.4; 95% CI, 0.2‐0.7) and hormonal therapy (OR, 0.5; 95% CI, 0.3‐0.8).

CONCLUSIONS:

Even within an equal access health care system, stage‐related racial variations in breast cancer treatment are evident. Studies that identify driving factors behind these within‐stage racial disparities are warranted. Cancer 2012;. © 2011 American Cancer Society.     

Do radiation use disparities influence survival in patients with advanced breast cancer?

BACKGROUND:

The authors previously identified racial/ethnic disparities in the use of radiation therapy (RT) in patients with advanced breast cancer (BC). They hypothesized that disparities in the use of RT were associated with survival differences favoring white patients.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results database to identify white, black, Hispanic, and Asian patients with BC associated with ≥10 metastatic lymph nodes diagnosed between 1988 and 2005. Multivariate analyses of overall survival (OS) and disease‐specific survival (DSS) assessed age, sex, race, tumor size, histology, estrogen receptor status, progesterone receptor status, RT, and type of surgery. The authors further stratified for use of RT and type of surgery. Risk of mortality was reported as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS:

Of 15,895 patients with advanced BC, 12,653 met entry criteria. On multivariate analysis, RT was associated with a decreased risk of all‐cause (HR, 0.78; 95% CI 0.74‐0.83; P < .001) and disease‐specific (HR, 0.81; 95% CI, 0.76‐0.86; P < .001) mortality; black race was associated with an increased risk of all‐cause (HR, 1.54; 95% CI, 1.42‐1.68; P < .001) and disease‐specific (HR, 1.53; 95% CI, 1.39‐1.68; P < .001) mortality. After stratifying by type of surgery and use of RT, blacks demonstrated poorer survival than their white counterparts, regardless of surgery type or receipt of RT.

CONCLUSIONS:

Only black patients had poorer OS and DSS relative to whites. When stratified by type of surgery and use of RT, blacks continued to demonstrate poorer survival. This survival disparity is unlikely to be because of lack of RT. Cancer 2012;. © 2011 American Cancer Society.     

Racial/ethnic differences in breast cancer survival by inflammatory status and hormonal receptor status: an analysis of the Surveillance,Epidemiology, and End Results data

Background

Compared to non-inflammatory breast cancer (non-IBC), inflammatory breast cancer (IBC) has less favorable survival and is more likely to be estrogen receptor (ER) and progesterone receptor (PR) negative. ER?/PR? tumors, regardless of histology, have less favorable survival. While black women are more likely to have IBC and ER?/PR? tumors than white women, it is unclear whether the racial disparity in survival is explained by these factors. The objective of this study was to assess racial/ethnic differences in breast cancer survival by inflammatory status and hormone receptor status.

Methods

This study examined breast cancer mortality among non-Hispanic white (NHW), Hispanic white, black, and Asian/Pacific Islander (API) women diagnosed between 1990 and 2004 using the National Cancer Institute’s Surveillance, Epidemiology, and End Results data. Kaplan–Meier survival curves and Cox proportional hazard ratios (HRs) assessed the relationship between race/ethnicity and survival.

Results

Black women had significantly poorer survival than NHW women regardless of inflammatory status and hormone receptor status. Compared to NHWs, the HRs for black women were 1.32 (95 % confidence interval (CI) 1.21–1.44), 1.43 (95 % CI 1.20–1.69), and 1.30 (95 % CI 1.16–1.47) for IBC, IBC with ER+/PR+, and with ER?/PR?, respectively. Similar HRs were found for non-IBC, non-IBC with ER+/PR?, and non-IBC with ER?/PR?. API women had significantly better survival than NHW women regardless of inflammatory status and hormone receptor status.

Conclusion

Compared to NHW women, black women had poorer survival regardless of inflammatory status and hormone receptor status and API women had better survival. These results suggest that factors other than inflammatory status and hormone receptor status may play a role in racial/ethnic disparities in breast cancer survival.     

The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care

BACKGROUND:

Few data are available on how race/ethnicity, insurance, and socioeconomic status (SES) interrelate to influence breast cancer treatment. The authors examined care for a national cohort of breast cancer patients to assess whether insurance and SES were associated with racial/ethnic differences in care.

METHODS:

The authors used multivariate logistic regression to assess the probability of definitive locoregional therapy, hormone receptor testing, and adjuvant systemic therapy among 662,117 white, black, and Hispanic women diagnosed with invasive breast cancer during 1998‐2005 at National Cancer Data Base hospitals. In additional models, the authors included insurance and area‐level SES to determine whether these variables were associated with observed racial/ethnic disparities.

RESULTS:

Most women were white (86%), 10% were black, and 4% were Hispanic. Most had private insurance (51%) or Medicare (41%). Among eligible patients, 80.0% (stage I/II) had definitive locoregional therapy, 98.5% (stage I‐IV) had hormone receptor testing, and 53.1% and 50.2% (stage I‐III) received adjuvant hormonal therapy and chemotherapy, respectively. After adjustment, black (vs white) women had less definitive locoregional therapy (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.88‐0.94), hormonal therapy (OR, 0.90; 95% CI, 0.87‐0.93), and chemotherapy (OR, 0.87; 95% CI, 0.84‐0.91). Hispanic (vs white) women were also less likely to receive hormonal therapy. Hormone receptor testing did not differ by race/ethnicity. Racial disparities persisted despite adjusting for insurance and SES.

CONCLUSIONS:

The modest association between black (vs white) race and guideline‐recommended breast cancer care was insensitive to adjustment for insurance and area‐level SES. Further study is required to better understand disparities and to ensure receipt of care. Cancer 2011. © 2010 American Cancer Society.