It has long been said that white women of European ancestry are more likely to be diagnosed with breast cancer, but African American women are more likely to die of it. This statement has introduced multiple articles on the topic of the racial survival disparity in breast cancer, including our own recent analysis.1 However, this assertion no longer holds true.
Recent work by DeSantis et al2 employing the Surveillance, Epidemiology, and End Results (SEER) program, summarized in this issue of The ASCO Post, has found that the 2012 incidence of breast cancer in white and African American women is now equivalent at 135 cases/100,000 women. The import of this convergence of incidence is its effect on breast cancer mortality and the racial survival chasm. The mortality disparity between African American and white women has continued to increase, with a death rate 42% higher in African American than white patients in 2012.
In their analysis, DeSantis et al underscored positive trends and noted the remarkable strides in breast cancer screening and treatment, with a decrease in breast cancer mortality by 36% from 1989–2012—representing 249,000 breast cancer deaths averted in U.S. women. Examples of treatment breakthroughs include HER2-targeted therapies that benefit both white and African American women, who have a similar incidence of HER2-positive tumors. However, although breast cancer death rates declined in both African American and white women, the long-term breast cancer mortality gap between these groups continues to widen.2
Survival and Research Differences
When examined geographically, these survival differences are striking. Hunt et al3 looked at the racial disparity in breast cancer mortality for the 50 largest U.S. cities using rate ratios. (A rate ratio of 1.00 indicates no disparity between black and white mortality rates, whereas a ratio greater than 1.00 indicates the black mortality rate is higher than the white mortality rate.)
For example, in a stark contrast to New York, with a rate ratio of 1.19, Memphis had a rate ratio of 2.11. Of the 41 cities included in the analysis, 35 saw an increase in the black:white rate ratio between 1990–1994 and 2005–2009. Contributing to the survival disparity is a confluence of factors that has been discussed in the literature; but where is the medical establishment with regard to interventions to close this disparity gap? Lurie succinctly put it in the title of an editorial in The New England Journal of Medicine: “Health Disparities—Less Talk, More Action,” emphasizing that “those of us within the health care system need to test and implement effective strategies for the reduction of disparities.”4
Clarke et al5 attempted to answer this question in their article examining 30 years of disparities intervention research. The authors’ systematic scan of the disparities intervention literature found that interventions targeting providers (7%), the microsystem (immediate care team; 9%), organizations (3%), and policies (0.1%) were lacking, whereas the interventions employed most commonly targeted the patient (50%). Thus, most interventions charged patients with reducing disparities in their care rather than creating system interventions aimed at delivering more equitable care to patients.
It has been argued that successful health disparities interventions are those that are multifaceted and address multiple stakeholders in the continuum of care. As Chin et al6 wrote, successful health disparities interventions are “culturally tailored to meet patients’ needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient’s pathway of care.”
Making Strides in Chicago
An illustrative case is that of patients with breast cancer in Chicago, where a system-wide intervention succeeded in making strides to close the breast cancer racial survival disparity. Hirschman et al7 examined the racial disparity in breast cancer mortality in Chicago in 2003 and found that African American women had a 68% higher breast cancer mortality rate than white women. The authors’ hypothesis was that the disparities in breast cancer mortality were due to “differential access to mammography, differential quality in mammography, and differential access to treatment for breast cancer.” The study sparked a conflagration of community effort in Chicago to address this disparity.8
A total of 102 individuals from 74 Chicago area organizations participated in the Metropolitan Chicago Breast Cancer Task Force. The Task Force found that “facilities that served predominantly minority women were less likely to be academic or private institutions (P < .03), less likely to have digital mammography (P < .003), and less likely to have breast imaging specialists reading films (P < .003).”8 In addition, African American women and their providers reported significant barriers to accessing quality care for breast cancer treatment.
The objective of the Task Force was to improve the quality of care delivered to minority patients from screening to treatment through follow-up. These initiatives included a cohesive and comprehensive patient navigation project to improve access to quality cancer care; a Mammography Quality Initiative to improve the quality of mammography for women statewide; public policy work to advocate for the Illinois Breast and Cervical Cancer program, which provides screening and treatment for uninsured women; and community organizing to engage and build relationships with grassroots organizations and academic health-care institutions.9
To date, the Task Force has been successful in reversing the trend of growing disparity and decreasing the mortality gap to 40%, attributed to a pronounced reduction in mortality for African American women. Other system-wide interventions to reduce the racial survival disparity in cancer care have met with success in New York10 and Delaware.11
Improving Access to Endocrine Therapy
As system-wide approaches are considered to address this survival disparity, health-care leaders must consider interventions that improve access to endocrine therapy. DeSantis et al noted that the increase in incidence in African American woman has been driven largely by an increase in estrogen receptor–positive breast cancers.2 Oral endocrine therapy has been demonstrated in clinical trials to be effective in preventing breast cancer recurrence and death in women with early-stage breast cancer.12
However, in a large study examining the days covered by filled prescriptions of tamoxifen in the first year of therapy for primary breast cancer patients, Partridge et al13 found that nonwhite patients had significantly lower adherence rates than white patients (odds ratio = 1.62, 95% confidence interval = 1.26–2.09). More research in this area will be needed to understand the barriers to endocrine therapy for African American patients, including financial toxicity assessments, to ensure they have access to these lifesaving treatments.
In addition, the authors contended that the surge in estrogen receptor–positive breast cancer might reflect changes in lifestyle, including rising obesity and metabolic syndrome in U.S. women. This would be a modifiable risk factor, and health policy aimed at promoting exercise and nutrition could reverse this trend.
Changes to the Health-Care System
As the example of Chicago demonstrates, there is an opportunity to close the survival disparity gap by focusing on changes to the health-care system—not to the individual patient—to improve the quality of care for minority populations. With the noted decline in the rates of breast cancer mortality, DeSantis et al give us much reason to hope there will be continued innovation in breast cancer screening and treatment; as these improvements arrive, we must ensure there is equity of dissemination. The convergence of the incidence lines should serve as a further call for stakeholders across the continuum of breast cancer care to continue to support rigorous research to inform policy and improve on the models for system change demonstrated in Chicago, New York, and elsewhere. ■
Disclosure: Dr. Daly serves on the Board of Directors for and received compensation from Quadrant Healthcare. Dr. Olopade has served on the Medical Advisory Board for CancerIQ.
References
1. Daly B, Olopade OI: A perfect storm: How tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change. CA Cancer J Clin 65:221-238, 2015.
2. DeSantis CE, Fedewa SA, Goding Sauer A, et al: Breast cancer statistics, 2015: Convergence of incidence rates between black and white women. CA Cancer J Clin. October 29, 2015 (early release online).
3. Hunt BR, Whitman S, Hurlbert MS: Increasing black:white disparities in breast cancer mortality in the 50 largest cities in the United States. Cancer Epidemiol 38:118-123, 2014.
4. Lurie N: Health disparities—Less talk, more action. N Engl J Med 353:727-729, 2005.
5. Clarke AR, Goddu AP, Nocon RS, et al: Thirty years of disparities intervention research: What are we doing to close racial and ethnic gaps in health care? Med Care 51:1020-1026, 2013.
6. Chin MH, Clarke AR, Nocon RS, et al: A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med 27:992-1000, 2012.
7. Hirschman J, Whitman S, Ansell D: The black:white disparity in breast cancer mortality: The example of Chicago. Cancer Causes Control 18:323-333, 2007.
8. Ansell D, Grabler P, Whitman S, et al: A community effort to reduce the black/white breast cancer mortality disparity in Chicago. Cancer Causes Control 20:1681-1688, 2009.
9. Metropolitan Chicago Breast Cancer Task Force: Beyond October how far have we come? Breast cancer disparities: Improving access to and quality of breast health services in Chicago. October 2014. Available at http://www.chicagobreastcancer.org/site/files/904/93199/353837/718237/State_of_Breast_Cancer_Disparties_Report_Final_11.pdf. Accessed November 24, 2015.
10. Bickell NA, Shastri K, Fei K, et al: A tracking and feedback registry to reduce racial disparities in breast cancer care. J Natl Cancer Inst 100:1717-1723, 2008.
11. Grubbs SS, Polite BN, Carney J Jr, et al: Eliminating racial disparities in colorectal cancer in the real world: It took a village. J Clin Oncol 31:1928-1930, 2013.
12. Fisher B, Costantino J, Redmond C, et al: A randomized clinical trial evaluating tamoxifen in the treatment of patients with node-negative breast cancer who have estrogen-receptor-positive tumors. N Engl J Med 320:479-484, 1989.
13. Partridge AH, Wang PS, Winer EP, et al: Nonadherence to adjuvant tamoxifen therapy in women with primary breast cancer. J Clin Oncol 21:602-606, 2003.
Dr. Daly is a medical oncology fellow and Dr. Olopade is Director, Center for Clinical Cancer Genetics, University of Chicago Medical Center.
