Barriers to Breast Cancer Screening
A trio of important studies were just published in the American Journal of Public Health concerning the nagging breast cancer screening gap for minority women—and its subsequent impact on mortality.
An intriguing article by Drs. Emily White and Ashley Hedeen of the Fred Hutchinson Cancer Research Center in Seattle focused on the difference in level of breast cancer at diagnosis for first-generation Hispanic women (those born in Latin America but emigrated to the U.S.), compared with second-generation Hispanic women who were born in the United States.
The researchers noted a significantly higher average tumor size and advanced stage of disease at diagnosis for immigrant Hispanic women. Eighty-two percent of Hispanic women born in Latin America had tumors larger than 1 cm at diagnosis, compared with 75 percent of their second-generation counterparts. Fifty-four percent of Hispanic women born in Latin America had tumors larger than 2 cm, compared with 42 percent of Hispanic women born in the United States.
Hispanic women overall (both first- and second-generation) were also significantly more likely to have larger tumors at time of diagnosis than their white counterparts, especially tumors larger than 2 cm—45.9 percent, compared to 33.0 percent for white women.
The researchers said that Hispanic women appeared to have less knowledge of breast cancer symptoms and also reported waiting longer to see a physician after their symptoms were recognized. "In addition," they wrote, "Hispanics are less likely to have a regular source of healthcare, and they are more likely to have a fatalistic view of disease and to believe that cancer cannot be cured."
White and Hedeen culled their findings from the Surveillance, Epidemiology, and End Results (SEER) database. They recommended that "first-generation Hispanic women should be targeted in interventions designed to increase the use of breast cancer screening."
A second study in the same issue of the American Journal of Public Health focused on the dramatically lower levels of mammography screening rates for African-American women in eastern North Carolina.
Dr. Michael O’Malley of the University of North Carolina, Chapel Hill and colleagues compared approximately 2,000 African-American and white women aged 52 and older living in 10 rural North Carolina counties between 1993 and 1994. Their finding: The African-American women were only half as likely to have undergone mammography screening as their white counterparts.
Disturbingly, O’Malley’s team also found that doctors were only about half as likely to recommend screening mammography to their African-American patients as compared to their white patients. Fifty-five percent of the white women in the study said that a physician had recommended mammography to them within the past year, compared to only 45 percent of African-American women.
The researchers suggested that level of income—and to a lesser degree a woman’s level of formal education—might have contributed to this racial disparity. "If it is chiefly a matter of cost, we may be able in some way to help African-American women overcome these financial barriers and increase their mammography rates," they wrote.
However, they noted that a significant hurdle must still be overcome concerning doctors themselves. "Previous research has shown that when a doctor recommends a mammogram, the chance that a woman will actually get screened increases dramatically," they wrote. "This study underscores the need for healthcare providers to be aware of their influence. They need to recommend mammograms to all women, even those they perceive as of limited means."
What is the end result of such discouraging racial gaps in breast cancer screening? A higher mortality rate for minority women.
For example, as noted in a third article in the same issue of the American Journal of Public Health, total breast cancer mortality rates are finally decreasing for white women, but not for African-American women.
From 1993 to 1996, young African-American breast cancer patients (under age 35) had a two-fold higher mortality rate than white women of the same age, wrote Dr. Peter Layde and Anne Marbella from the Medical College of Wisconsin. For breast cancer patients between ages 40 and 50, African-American women had 1.5 times the mortality rate; for those 55 years and older, African-American women had similar or slightly higher rates.
The researchers came to an even more disturbing finding for older women. Prior to 1992, African-American women age 70 and older actually had lower breast cancer mortality rates than white women. "But from 1993 to 1996, their rates became equivalent to and, at times, slightly higher than rates for older white women," they wrote.
"Trends in risk factors, early detection, and treatment do not provide an obvious explanation for the substantial increase in breast cancer mortality for African-American women age 70 years and older," they commented. "Further research is needed to understand more fully the breast cancer mortality rate differences among the races and to determine whether changes in public health policy or clinical practice can decrease the racial disparity."
SOURCES:
American Journal of Public Health, January 2001; 91:122-125
American Journal of Public Health, January 2001; 91(1):00-00
American Journal of Public Health, January 2001; 91:118-121
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