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Blacks more likely to die of breast cancer than whites, even with identical care
Mortality rate for blacks remained higher, even as disease-specific deaths declined.
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Though breast cancer mortality has decreased in the United States since 1990, black women are still more likely to die of the disease.
The findings of two studies, published online July 7 in Journal of the National Cancer Institute, demonstrated different conclusions about the reasons behind that disparity. The results of one, an epidemiological study conducted by Menashe and colleagues, indicated that black women have a consistently higher hazard of death.
The other, a retrospective review of data from 25 years of stage III trials conducted by Albain and colleagues, had results that suggested the disparity remains even when black patients receive the same treatment as white women and when factors such as income and access to insurance are taken into account. The researchers said these findings cast doubt on poverty and access to quality care as the reasons black women have poorer outcomes.
Menashe and colleagues reviewed breast cancer incidence and population data collected in the NCI SEER 9 Registries Database from 1973 to 2004. The database recorded 244,786 cases of women with breast cancer during that period; 8.3% of those patients were black and 84.9% were white.
Overall, the rate of deaths from breast cancer decreased from 1990 to 2004, but mortality remained more prevalent among black women. During the two periods under review — 1990 to 1996 and 1997 to 2004 — peak hazard rate declined by 31.6% for whites (95% CI, 28.1%-32.7%) but 27.7% for blacks (95% CI, 26.7%-28.8%). The researchers found that the absolute annual hazard rates remained higher for black women, regardless of ER status.
“For example, between the years 1997 and 2004, absolute hazard rates in black women with ER–negative tumors peaked at 11% per year (95% CI, 10.0%-12.3%) approximately 1.5 years after diagnosis,” the researchers wrote. “In contrast, among white women, the peak hazard rate occurred at the same time after diagnosis but was only 6.6% per year (95% CI, 6.2%-6.9%).”
However, as noted by Otis W. Brawley, MD, in his accompanying editorial, the black–white disparity disappeared when the researchers compared hazard rates for death according to ER status and adjusted for quality of care.
“Whether someone was black or white did not matter in terms of their outcomes. What was important was ER status,” Brawley, chief medical officer for the American Cancer Society, told HemOnc Today. “There are a few different kinds of breast cancer. Black women have a higher proportion of the bad kind of breast cancer. The Menashe study did find that the patterns of care for black women were not as good as the patterns of care for white women.”
In the second study, Albain and colleagues evaluated results from 35 consecutive phase-3 SWOG trials conducted from 1974 to 2001 and found that black women with adjuvant breast cancer had poorer outcomes compared with white women despite having access to the same care.
The studies involved 6,676 women with adjuvant breast cancer. The studies included 2,360 women with breast cancer in the studies, 10.6% of whom were black, and 4,316 women with postmenopausal breast cancer, 9.6% of whom were black.
The researchers said there was a strong association between race and mortality among both premenopausal (HR=1.41; 95% CI, 1.10-1.82) and postmenopausal black women (HR=1.49; 95% CI, 1.28-1.73).
Ten-year OS for black women with premenopausal breast cancer was 68% vs. 77% for all other races and 52% vs. 62% for postmenopausal disease.
Additionally, the researchers found that black women were more likely to die of disease-specific mortality regardless of ER status (see chart). Albain and colleagues found the association between race and mortality held even after adjusting for income and education.
Breast Cancer Mortality for Pre and Postmenopausal Black Women by ER status |
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“Patients of all races had the same doctors and received the same state-of-the-art treatments,” Kathy S. Albain, MD, professor of medicine at Loyola University Medical Center in Maywood, Ill., said in a press release. “It was a level playing field for everyone, so our findings cast doubt on a widely accepted theory that African Americans’ lower survival rates for certain cancers are solely due to such factors as poverty and poor access to quality health care.”
Brawley disagreed with Albain’s conclusion, noting that although patients in Albain’s study were at similar socioeconomic levels during the study period, they were not necessarily at the same levels throughout their lives. Brawley added that studies conducted in Scotland and the United States had results that showed that poor women had a higher prevalence of ER–negative tumors, which tend to produce worse outcomes.
“There is a series of studies of blacks in the United States military databases — these patients have access to the Bethesda Naval Hospital, Walter Reed or Brooke Army Medical Center,” Brawley said. “In breast cancer, where it’s been best studied, black women in those databases have lost two-thirds of the disparities that blacks in the United States have. Granted, there is still a black–white disparity, but the military database tells us that at least two-thirds of the disparity is an access to quality care/socioeconomic problem. The other one-third might be access to quality care; it might be biology. But as I tried to point out in my editorial, the majority problem is access to care. It’s OK to talk about biologic differences, but let’s not downplay access to quality care.” – by Jason Harris
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