According to the first national study looking at racial disparity in breast cancer mortality rates at the city level in the United States, societal factors—especially poverty and residential segregation—are resulting in the unnecessary deaths of five black women every day—more than 1,700 deaths a year. The study, published in a recent issue of Cancer Epidemiology,1 examined data from 2005 to 2007 on the deaths from malignant neoplasm of the breast within 25 of the largest U.S. cities culled from national death files maintained by the Centers for Disease Control and Prevention. The study findings show that 21 of 24 cities (breast cancer mortality data for Indianapolis was unavailable for the final analysis) have a black/white disparity in breast cancer mortality, with Memphis having the highest disparity and San Francisco, the lowest.
Seven Risk Factors Analyzed
The study researchers analyzed seven city-level ecologic risk factors, including population size, the proportion of the population that was white, the proportion of the population that was black, median household income, proportion of the population living below the federal poverty line, the Gini Index (a measure of income inequality) and the Index of Dissimilarity (a measure of racial segregation). As a final observation, the study authors noted that while black women are diagnosed more often than white women with aggressive types of breast cancer (eg, triple-negative disease), resulting in poorer overall survival rates, that factor alone does not account for the mortality disparities among cities.
“The best estimates I’ve read suggest that about 8% to 10% of mortality differences between black and white women might be due to genetics. In our study, we found death rates for black women that are twice as high as those for white women—for example, in Memphis—which means that the black rate is 100% higher than the white rate. If you remove genetics from the equation, there is still a disparity of 90%,” said Steven Whitman, PhD, Director of the Sinai Urban Health Institute in Chicago and the lead author of the study.
“When you look at mortality disparities in Chicago and nationwide you see that the gap opened up in the early 1990s, just when advances were being made in the early detection and treatment of breast cancer,” he said. “Between 1980 and 1990, the death rates from breast cancer in Chicago for white and black women were the same.” Because white women with breast cancer are more often able to access better health care than black women, said Dr. Whitman, the death rates for black women have remained largely unchanged over the past 3 decades, whereas the death rates for white women have decreased significantly.
Economic Obstacles to Quality Care
Another study by Dr. Whitman and colleagues, published in the Journal of Women’s Health,2 analyzed data from a mammography facility survey of screening centers in Chicago. The study found that black and Hispanic women and women without private health insurance are more likely than white women and women with private insurance to have a mammogram at public rather than academic screening facilities. Academic centers have more radiologists specializing in breast imaging and use digital mammography rather than analog mammography, which may be less accurate in detecting cancers, especially in younger women and in women with dense breasts.
“The quality of care that black women receive is often inferior to what white women experience. Fewer cancers are found in black women during mammography screening, treatment is started later, and it often goes uncompleted, so everything bad you can imagine is part of the phenomenon,” said Dr. Whitman.
Factors such as the detection of more advanced breast cancers at the time of diagnosis and higher rates of obesity and comorbid illnesses in minority women, as well as more missed treatment appointments due to inadequate or no health insurance, a lack of a support system, job-related barriers, including limited or no sick leave, and difficulties with transportation all contribute to poorer survival outcomes among women of lower socioeconomic status. Disparities in the quality of cancer care given to black women and women of lower socioeconomic status, including reduced rates of adjuvant therapy, are also leading to lower survival rates.
In a follow-up to her study on social and racial differences in adjuvant chemotherapy decisions for breast cancer, published in the Journal of Clinical Oncology,3 Jennifer J. Griggs, MD, MPH, Associate Professor in the Department of Internal Medicine and Health Management and Policy at the University of Michigan, Ann Arbor, and a member of ASCO’s Health Disparities Advisory Group, will further examine the association between socioeconomic status and the quality of cancer care. In two new investigations, Dr. Griggs is following more than 2,000 patients who were diagnosed with breast cancer between 1998 and 2004 to examine the type of care they received, chemotherapy regimens, and outcome.
“We’re looking at every aspect of care, including tumor margins, chemotherapy doses and regimens, radiation therapy doses, and how many days of treatment patients missed. If you miss 5 or more days of radiation therapy, even if they are not consecutively missed days, the benefit of radiation may be compromised,” said Dr. Griggs.
‘Misguided Benevolence’
Certain assumptions oncologists make about different patient groups, including the patient’s likelihood to adhere to medical advice, level of social support, or ability to tolerate chemotherapy, and difficulties conveying complex information such as treatment regimens, management of side effects, and therapy goals may also be factors contributing to disparities in cancer care.
“Because of the legacy of the Tuskegee syphilis experiments and other research abuses of black people, some physicians may assume that their black patients do not trust them and may bend over backwards to minimize side effects by administering lower chemotherapy doses. This behavior, which has been seen in the treatment of other complicated diseases, is what I have termed ‘misguided benevolence.’ That is, the intention is directed at helping the patient but, in fact, compromises quality of care,” said Dr. Griggs.
To close the quality gap in cancer care for minority patients, last year ASCO issued a policy statement, “Opportunities in the Patient Protection and Affordable Care Act to Reduce Cancer Care Disparities” in the Journal of Clinical Oncology,4 which builds on ASCO’s policy on disparities in cancer care released in 2009. One of the recommendations was to encourage oncologists and medical facilities, including screening mammography centers, to participate in ASCO’s Quality Oncology Practice Initiative (QOPI), which provides tools for improving cancer care (qopi.asco.org/program). New quality measures to help eliminate disparities in patient care have recently been added to the certification process.
“We’re trying to get an idea of the mix of each practice, including how many patients are on Medicare, Medicaid, or are uninsured,” said Beverly Moy, MD, MPH, Clinical Director of the Breast Oncology Program at Massachusetts General Hospital in Boston and Chair of ASCO’s Health Disparities Advisory Group. “But what we are moving toward is making it feasible for more practices that care for vulnerable patients to participate in QOPI so we can ensure good quality in all practices.”
ASCO is also launching a major new mentoring program as part of its Diversity in Oncology Initiative directed at medical students and residents from underrepresented minority populations to encourage them to specialize in oncology. “It’s the responsibility of organizations like ASCO to take the lead on these issues,” said Dr. Moy.
Affordable Care Act
Many of the recommendations in ASCO’s policy statement are meant to build upon the provisions in the 2010 Patient Protection and Affordable Care Act for improving health care, including increasing Medicaid eligibility to reduce the number of uninsured low-income patients and to reimburse doctors who treat cancer patients on Medicaid at Medicare rates. While the Supreme Court ruled in June that the Affordable Care Act is constitutional (see pages 1, 8, and 9), it did limit the law's Medicaid provision, and it's not clear what the impact will be on these issues. ■
Disclosure: Drs. Whitman, Griggs, and Moy reported no potential conflicts of interest.
References
1. Whitman S, Orsi J, Hurlbert M: The racial disparity in breast cancer mortality in the 25 largest cities in the United States. Cancer Epidemiol 36:e147-e151, 2012.
2. Rauscher GH, Allgood KL, Whitman S, et al: Unequal distribution of screening mammography services by race/ethnicity and health insurance. J Womens Health (Larchmt) 21:154-160, 2012.
3. Griggs JJ, Culakova E, Sorbero ME, et al: Social and racial differences in selection of breast cancer adjuvant chemotherapy regimens. J Clin Oncol 25:2522-2527, 2007.
4. Moy B, Polite BN, Halpern MT, et al: American Society of Clinical Oncology Policy Statement: Opportunities in the Patient Protection and Affordable Care Act to Reduce Cancer Care Disparities. J Clin Oncol 29:3816-3824, 2011.
