Continuing Treatment Gap for African Americans
A bevy of recent reports have highlighted the continuing gap in breast cancer care for African-American women. Most prominently, the American Cancer Society (ACS) has just released findings indicating that general cancer incidence rates are finally falling among African-Americans. But they are still dying from their disease at unacceptably higher rates.
For the first time in 20 years, the incidence of newly diagnosed cancers among African Americans fell, as measured during the period 1993 - 1997. Similarly, the cancer mortality rate fell during the period 1991 - 1997, reversing a 30-year trend.
However, despite this progress, the ACS said, "African-American women continue to have a higher death rate from breast cancer than Caucasian women, despite lower breast cancer incidence rates." Overall, the cancer death rate for African-American women was 22 percent higher than that for Caucasian women.
And yet, numerous studies have shown that if African-American patients are diagnosed at a similar stage of disease-and given similar treatment opportunities-differences in recurrence and mortality rates effectively disappear.
For example, a recent study presented at the annual meeting of the American Society for Therapeutic Radiation and Oncology in Boston concluded that post-lumpectomy radiation provides equal benefits to African-American and Caucasian women.
Dr. Stuart Burri and colleagues from the Emory University School of Medicine reported that 5-year local tumor control and disease-free survival rates are statistically indistinguishable between African-American and Caucasian breast cancer patients given the same course of radiation treatment after undergoing breast-conserving surgery (lumpectomy).
They evaluated 102 African-American and 162 Caucasian women treated between 1993 and 1996 and found that African-American women who detected their tumors early did just as well as Caucasian women. However, African Americans were more likely to be diagnosed with more advanced disease; 43.1 percent of the African-American women had stage II disease at initial diagnosis, compared with 32.1 percent of the Caucasian women. Furthermore, approximately 29 percent of the African-American women were node-positive (the cancer had spread to the lymph nodes), compared to 15 percent of the Caucasian women.
When the patients were diagnosed at similar stages of disease, however, Burri's team documented local tumor control in 95.5 percent of the African-American women and 94.8 percent of the Caucasian women during the five-year follow-up period. Similarly, disease-free survival was also comparable-90.3 percent in African-American women versus 91.7 percent in Caucasians.
An important paper published in the journal CA - A Cancer Journal for Clinicians also concluded that African-American breast cancer patients had similar outcomes to white patients when their treatment and follow-up care were equal and appropriate for their disease conditions.
According to the lead author, Dr. James Dignam of the University of Pittsburgh, the reason for the increased mortality rates for African-American breast cancer patients compared to their Caucasian counterparts must therefore lie beyond simple biological differences between the races.
What causes for the disparity did Dignam identify? He suggested the fact that cancer was discovered late was a prime factor in less favorable outcomes. And this delay was due to less access to or utilization of health care resources that would result in earlier detection.
Dignam's study showed that African-American women were often first seen by doctors with larger tumors, greater nodal involvement, and estrogen receptor negative tumors. Even obesity, found in demographic studies to be more prevalent among African-American breast cancer patients, was associated with a more advanced stage of the disease. This was possibly due to obesity's effect on estrogen, which can accelerate disease progression.
Dignam further noted that studies in some urban hospitals, which are likely to treat a disproportionate share of African-American breast cancer patients, have a greater rate of late-stage diagnosis as well as a higher degree of non-standard care. This included less frequent radiation therapy after surgery, fewer diagnostic tests to determine the best therapy, and lower use of more aggressive chemotherapy and/or tamoxifen.
In addition, Dignam cited studies in which African-American women were much more likely to have received total mastectomy rather than lumpectomy with radiation therapy in cases where either procedure would have been acceptable.
At the recent annual meeting of the American Public Health Association, Dr. Beth Jones of the Yale School of Public Health concurred that survival from breast cancer was lower among African-American women, and there was a higher likelihood that they would be initially diagnosed with tumors that were stage II or greater. She based her conclusions on a study of 145 African-American and 177 Caucasian breast cancer survivors in Connecticut.
Jones noted that the tumors in African Americans were more likely to be aggressive. Specifically, this included a greater tendency to be p53 positive, estrogen receptor negative, and have a higher nuclear grade-all indicators of greater risk. Because of this, Jones recommended that physicians be especially vigilant when performing clinical breast exams and tracking follow-up screening for their African-American breast cancer patients.
Finally, a study by researchers at the University of Northern Iowa found that African-American women with breast cancer are 67 percent more likely to die from the disease than Caucasian women. Writing in the journal Cancer, Sue Joslyn, Ph.D. and Michele West, Ph.D. attributed the disparity to a number of cultural and socioeconomic factors, including less access to mammography screening opportunities as well as being provided with less aggressive treatment options. In addition, they said African-American women were less likely to report concerns or symptoms of breast cancer to their doctors.
Interestingly, the researchers also noted differences in tumor characteristics between the races. They found that African American women were more likely to be diagnosed with estrogen and progesterone receptor-negative tumors, which tend toward a poorer prognosis compared with hormone receptor-positive tumors.
The higher mortality rate for African-American women with breast cancer is unfortunately a fact, regardless of the cause. To remedy this, increased screening programs that overcome economic and social barriers, and equal access to the highest quality treatment options, are objectives that must be aggressively pursued in the coming years.
SOURCES:
National Cancer Institute (http://www.cancer.org)
Cancer, 2000; Vol. 88, No. 1
CA - A Cancer Journal, Jan/Feb 2000
Journal of the National Cancer Institute, 1999; Vol. 91, No. 16
Journal of Epidemiology and Community Health, 2000; 54:200-206
128th Annual Meeting of the American Public Health Association, Nov. 15, 2000
Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 25, 2000
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