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Breast cancer care disparities not wholly explained by insurance or socioeconomic factors, study finds


Rachel FreedmanRachel Freedman, MD, MPH 

Researchers at Dana-Farber Cancer Institute have found that modest racial disparities remain in breast cancer care even when socioeconomic and insurance differences are accounted for.

The findings, reported online by the journal Cancer, are the first to examine these factors in a large-scale, national study of a diverse patient population, said the scientists, led by Rachel Freedman, MD, MPH, of Dana-Farber's Breast Oncology Center. Freedman said that further study is needed to identify other explanations for the treatment gap.

"We found that there are modest racial disparities in receiving recommended treatments for early breast cancer," said Freedman. "These disparities didn't go away when we accounted for differences in health insurance coverage or the socioeconomic status of areas where the women live.

"This is a reminder that, even with the current movements to expand health insurance coverage, some racial disparities in care may remain."

Using a national, hospital-based database of 662,117 white, black and Hispanic women diagnosed with early stage invasive breast cancer. The study focused on comparisons of white and black women.

In general, the black women were younger, had more advanced cancer at diagnosis, and were more often uninsured or had Medicaid coverage. They also tended to live in areas with lower high-school graduation rates and lower median incomes.

The scientists computed the percentage of women who had received care according to a set of professional guidelines. These guidelines contained four recommended elements in treating women with early-stage breast cancer:

  • Appropriate local-regional treatment, a combination of surgery and radiation;
  • Testing all patients for the tumor's hormone receptor status – ER and PR positive or negative – to predict whether hormone-blocking treatment would be effective.
  • Administration of hormone therapy for ER-positive tumors;
  • Chemotherapy for women when indicated.

As expected from previous studies, the analysis revealed significant racial differences – around 10 percent – in receipt of recommended treatments except for hormone receptor status testing, which was almost always performed and was equal across the groups.

In a subsequent analysis, the researchers asked whether blacks might be less likely to receive optimal care because of inferior insurance coverage or having lower incomes and education levels (socioeconomic status, or SES).

For both blacks and whites, SES factors were not associated with differences in any of the treatment categories. The type of insurance coverage did affect the odds of receiving recommended treatments; lower odds were associated with lack of insurance, Medicaid coverage, and younger Medicare patients compared with those privately insured.

"These differences are modest, but they are important given the large number of women who are diagnosed with early stage breast cancer," said Freedman.

The findings leave the researchers wondering what else might be responsible for the persistent disparities.

Previous studies in the field have pointed to a number of potential contributing factors, Freedman said, including blacks' personal preferences and mistrust of the medical system; doctors' biases in recommending treatments; access to care even when insurance coverage is the same; and characteristics of the facilities in which whites and blacks tend to receive their care.

Whatever the causes, said Freeman, greater efforts are needed to ensure that all women receive the most effective breast cancer care regardless of their race or ethnicity. Dana-Farber investigators are participating in a follow-up study that will explore some of these issues, she said.

Other authors of the paper include senior author Nancy Keating of Brigham and Women's Hospital and Harvard Medical School; Elizabeth Ward of the American Cancer Society, and Eric Winer of Dana-Farber.

The research was supported by a grant from Susan G. Komen for the Cure.

Anne Doerr
617-632-4090 

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