Racial Disparities in Breast Cancer Care: What we know and what we can do
Rachel Freedman, MD, MPH, of the Breast Oncology Center at Dana Farber Cancer Institute
Dr. Rachel Freedman has predominantly focused her research on racial disparities in breast cancer care. Dr. Freedman presented key components of her own research as well as published studies by other experts relative to breast cancer prevention, screening, treatment and outcomes across racail and ethnic groups.
- Black women have a lower incidence but a higher mortality rate for breast cancer
- Evidence reflects that screening rates and stage of diagnosis don't seem to be the major problem contributing to the disparities between Black and White women
- Evidence suggests that Black women have lower rates of treatment, experience more delays in care, and are less likely to adhere and/or complete a full treatment regimen
- Patient factors, provider factors and systematic factors all seem to contribute to lower rates of completed primary therapy among Black women
- The literature reflects that social factors such as education, poverty, demographics and socio-economic statis impact cancer risk and contribute to lower rates of treatment for Black women with breast cancer
- In addition, behavioral factors such as physical activity and nutritoin were linked to other co-morbid conditions including obesity that have proven to increase cancer risk
- One highlighted article, Freedman et al (2011), demonstrates that Black women have more limited knowledge of their cancer characteristics, such as stage, grade and HER2 status compared to White women, which may have impacted on whether and to what extent Black women recieve or complete treatment *Best practices for intervention models were highlighted and included in patient navigation programs and case management strategies that help reduce time from diagnosis to resolution and streamline treatment throughout the continuum of care
Incidence and Staging Disparities
Dr. Susan Gershman, Director of the Massachusetts Cancer Registry at the Department of Public Health
Dr. Susan Gershman presented data on incidence and staging of breast cancer in the City of Boston
- White, non-Hispanic females were significantly more likely to be diagnosed at the local stage compared to Black, non-Hispanic females
- Black, non-Hispanic females were significantly more likely to be diagnosed at the regional or distant stage compared to White, non-Hispanic females
- There were no significant differences for stage when White, non-Hispanic females were compared to Asian, non-Hispanic and Hispanic females
The Increasing Disparity in Breast Cancer Mortality
A recent article in Cancer Epidemiology by Hunt et al has triggered renewed interest in developing a coordinated city response to persistent disparities in female breast cancer mortality between Blacks and Whites. The Boston Public Health Commission's Research and Evaluation Office conducted an independent analysis reviewing Boston data form a 12-year period and confirmed the findings of Hunt et al. Despite the targeted efforts to address the identified inequities in breast cancer mortality during the time-period reviewed between 2001-2012, the Commission's analysis found that there is an expanding breast cancer mortality gap between Black and White women in the City of Boston and that Black women are dying from breast cancer at a younger age than White women.
The Boston Public Health Commission's Research and Evaluation Office's analysis yielded the following key findings:
- Mortality Disparity: The overall female breast cancer mortality in the City of Boston has decreased for all races/ethnicities. However, the decreases in mortality for white women are statistically
- Age-Adjusted Mortality: BPHC data reflects that between 2007-2012, Black women between the ages if 35-44 experienced a 166% higher mortality rate compared to White women of the same ages. Similarly, Black women between the ages of 45-54 experienced at 68% higher mortality rate than their White counterparts
- Screening Rates: Black women ages 40+ in the City of Boston have a higher mammography screening rate than White women (88% vs. 83%, respectively)
- Excess Deaths: In calculating excess deaths from the expected and observed mortality of Black and White women in the City of Boston during the 12 year period reviewed, Black women experienced 74 excess deaths among women under the age of 65
Data on Breast Cancer Mortality in Boston
Black Women have the Highest Breast Cancer Mortality in Boston
Between 2001-2012 black women in Boston died due to breast cancer at a rate 25% higher than for white women. Black and white women had much higher mortality rates than Latina and Asian Boston residents. The Boston Breast Cancer Equity Coalition (BBCEC) aims to identify factors that contribute to this mortality gap and implement interventions to reduce it.
Figure 1. Female Breast Cancer Mortality by Race/Ethnicity Boston Residents, 2001-2012
NOTE: Death data for 2012 are preliminary and should be interpreted with caution. Until data are final, some changes in data values may occur during data quality processes. DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
Disparities in Breast Cancer Mortality Rates in Boston are Increasing
Breast cancer mortality rates in Boston decreased between 2001 and 2012, with the greatest decrease occurring among Latina women. Though breast cancer mortality rates among Latina women remain relatively low, the rate for 2007-2012 was more than 2.5 times the rate for 2001-2006.
Figure 2. Boston Female Breast Cancer Mortality according to race and time period 2001-2006 and 2007-2012
NOTE: average annual (i.e. annualized 6-year) age-adjusted rates. Bold data labels indicate significant T1:T2 difference. Death data for 2012 are preliminary and should be interpreted with caution. Until data are final, some changes in data values may occur during data quality processes. DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
Mammography Screening Rates are Similar Between Racial Groups
Higher mortality among black female Boston residents does not appear to be driven by differences in obtaining mammography screening. According to data from the Boston Behavioral Risk Factor Survey, black and white women have very similar rates of mammography, and screening rates have been stable over time. While Asian women have the lowest breast cancer mortality rates in Boston, they also have the lowest rates of mammography. Because of data like this, the BBCEC will focus our efforts to reduce mortality disparities on factors after screening, like follow-up of abnormal mammograms, delays in treatment, and treatment quality.
Figure 3. Proportion of Female Boston Residents Ages 40+ Reporting a Mammogram During Past 2 Years
DATA SOURCE: Boston Behavioral Risk Factor Survey 2001, 2003, 2005, 2006, 2008, 2010, 2013, Boston Public Health Commission DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office