ORLANDO, FL—The disparity in medical treatment for blacks versus whites is well known, although there has been little formal study in this area. A large systematic review presented at the ASCO Annual Meeting found that black women age 64 and older have longer delays in being diagnosed with breast cancer after an abnormal screening and longer delays in breast cancer treatment compared with white women of the same age.
“These findings in older women are similar to studies that included larger age ranges,” said Sherri Sheinfeld Gorin, PhD, of Columbia University Mailman School of Public Health. “The magnitude and direction of the findings are consistent with other studies showing that black women have more delays, which has implications for survival. The degree of clinical delay experienced by black breast cancer patients was surprising to us.”
She noted that studies have shown that a delay in follow-up treatment is associated with a lower rate of survival in breast cancer patients.
The analysis was based on the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database for women aged 64 and older who were diagnosed with breast cancer between 1992 and 1999.
The study population included 49,865 women with primary breast cancer who were alive one year following diagnosis. The ethnic groups analyzed included blacks, whites, Hispanics, and Asian/Pacific Islanders. Of the 49,865 women diagnosed with breast cancer, 2,982 were black.
Dr. Gorin pointed out that although the incidence of breast cancer is highest among white women, black women are at greater risk of death due to breast cancer because of the delay in time to follow-up after an abnormal screening compared with other racial groups.
Longer Delays for All Intervals
Three intervals were analyzed:
▪ The delay in diagnosis—i.e., the time from initial medical consultation to biopsy.
▪ The delay in treatment—the time from biopsy to treatment.
▪ Clinical management—combined diagnosis and treatment times.
Blacks had longer delays at all three intervals compared with whites and other ethnic groups. Twenty-four percent of blacks had a delay in diagnosis, averaging 52 days, compared with 13% of whites, 2% of Hispanics, and 15% of Asians/Pacific Islanders.
Treatment delays averaging 32 days were experienced by 30% of blacks compared with 19% of whites, 22% of Hispanics, and 20% of Asians/Pacific Islanders.
Clinical delays of more than three months (in both diagnosis and treatment) were experienced by 27% of blacks (average delay, 86 days) compared with 15% of whites, 18% of Hispanics, and 17% of Asians/Pacific Islanders.
Compared with the other ethnic groups, more blacks were widowed, tended to live in large metropolitan areas; and had Stage IV breast cancer, positive lymph nodes, and large tumors.
Asian/Pacific Islander women were diagnosed at younger ages and had a higher number of ductal carcinomas in situ and stage I cancers compared with the other ethnic groups.
Dr. Gorin pointed out that higher death rates from breast cancer in black women have been attributed to several potential factors including less patient awareness of signs and symptoms, differences in treatment, and more fear and fatalism.
Dr. Gorin noted that a number of confounding factors were not analyzed for the study, including fear, anxiety, body mass index, smoking, and breast size. In addition, oral medications such as tamoxifen were not accounted for, even though most older women with hormone receptor-positive breast cancer receive tamoxifen.
The Discussant for the paper, Stephen B. Edge, MD, of the Department of Surgery at Roswell Park Cancer Institute, explained that racial differences in treatment and outcome are well known and that ethnic minorities fail to receive care more often than white women. The delays revealed in the analysis presented by Dr. Gorin may be a marker for people who receive no care at all, he suggested.
“Ten to 20 percent of women with abnormal mammograms don't receive an appropriate referral,” Dr. Edge said.
He said that these findings related to substandard care of minorities point out the need for community-wide intervention and the development of data systems and real-time monitoring of patients.