Breast Cancer Research and Treatment

, Volume 109, Issue 3, pp 545–557 | Cite as

Parity and disparity in first course treatment of invasive breast cancer

  • Mary Jo Lund
  • Otis P. Brawley
  • Kevin C. Ward
  • John L. Young
  • Sheryl S. G. Gabram
  • J. William Eley


Background Adherence to first course treatment guidelines for breast cancer may not be uniform across racial/ethnic groups and could be a major contributing factor to disparities in outcome. In this population-based study, we assessed racial differences in initial treatment of breast cancer. Methods Surveillance, Epidemiology, and End Results (SEER) program data were used to study all primary invasive breast cancers diagnosed during 2000–2001 among Black (n = 877) and White (n = 2437) female residents of the five Atlanta SEER counties, counties with several large teaching hospitals. Differences in treatment delay, cancer directed surgery, and receipt of chemotherapy, radiotherapy, or hormonal therapy were analyzed according to guidelines for treatment. Analyses utilized frequency distributions, χ2 tests of independence and statistics in and across strata. Results Black women experienced longer treatment delays, regardless of stage at diagnosis, and were 4–5 fold more likely to experience delays greater than 60 days (P < 0.001). For local–regional disease, more Black women did not receive cancer directed surgery (7.5% vs. 1.5% of white women, P < 0.001), but did receive breast conserving surgery (BCS) equivalently. Only 61% of Black vs. 72% of White women received radiation with BCS (P < 0.001). Black women eligible for hormonal therapy were less likely to receive it (P < 0.001). Conclusion Our findings suggest treatment standards are not adequately or equivalently met among Black and White women, even in an area where teaching hospitals provide a substantial portion of breast cancer care. Treatment differences can adversely affect outcome and reasons for the differences need to be addressed.


Breast neoplasms Racial disparity Treatment 



Breast Conserving Surgery


Estrogen Receptor


Progesterone Receptor




Surveillance, Epidemiology, and End Results


Not otherwise specified


  1. 1.
    Anonymous (2006) Cancer Facts and Figures 2006. American Cancer Society, Atlanta, GAGoogle Scholar
  2. 2.
    Ries LAG, Eisner MP, Kosary CL et al (2004) SEER Cancer Statistics Review, 1975–2002. National Cancer Institute, Bethesda, MDGoogle Scholar
  3. 3.
    Clegg LX, Li FP, Hankey BF et al (2002) Cancer survival among US whites and minorities: a SEER (Surveillance, Epidemiology, and End Results) Program population-based study. Arch Intern Med 162(17):1985–1993PubMedCrossRefGoogle Scholar
  4. 4.
    Joslyn SA, West MM (2000) Racial differences in breast carcinoma survival. Cancer 88(1):114–123PubMedCrossRefGoogle Scholar
  5. 5.
    Chu KC, Lamar CA, Freeman HP (2003) Racial disparities in breast carcinoma survival rates, Separating factors that affect diagnosis from factors that affect treatment. Cancer 97(11):2853–2860PubMedCrossRefGoogle Scholar
  6. 6.
    Swanson GM, Hazlam SZ, Azzouz F (2003) Breast cancer among young African-American women. Summit Meeting on Breast Cancer. Cancer 97 (1 Suppl):273–279CrossRefGoogle Scholar
  7. 7.
    Li CI, Malone KE, Daling JRM (2002) Differences in breast cancer hormone receptor status and histology by race and ethnicity among women 50 years of age and older. Cancer Epidemiol Biomarkers Prev 11(7):601–607PubMedGoogle Scholar
  8. 8.
    Bach PB, Schrag D, Brawley OW et al (2002) Survival of blacks and whites after a cancer diagnosis. JAMA 287(16):2106–2113PubMedCrossRefGoogle Scholar
  9. 9.
    Hunter CP, Redmond CK, Chen VW, et al (1993) Breast cancer: factors associated with stage at diagnosis in black and white women. Black/White Cancer Survival Study Group. J Natl Cancer Inst 85(14):1129–1137PubMedCrossRefGoogle Scholar
  10. 10.
    Eley JW, Hill HA, Chen VW et al (1994) Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA 272(12):947–954PubMedCrossRefGoogle Scholar
  11. 11.
    West DW, Satariano WA, Ragland DR et al (1996) Comorbidity and breast cancer survival: a comparison between black and white women. Ann Epidemiol 6(5):413–419PubMedCrossRefGoogle Scholar
  12. 12.
    Yood MU, Johnson CC, Blount A et al (1999) Race and differences in breast cancer survival in a managed care population. J Natl Cancer Inst 91(17):1487–1491PubMedCrossRefGoogle Scholar
  13. 13.
    Jatoi I, Becher H, Leake CR (2003) Widening disparity in survival between white and African-American patients with breast carcinoma treated in the U.S. Department of Defense Healthcare system. Cancer 98(5):894–899PubMedCrossRefGoogle Scholar
  14. 14.
    Dignam JJ (2000) Differences in breast cancer prognosis among African-American and Caucasian women. CA Cancer J Clin 50(1):50–64PubMedCrossRefGoogle Scholar
  15. 15.
    Roetzheim RG, Gonzalez EC, Ferrante JM et al (2000) Effects of health insurance and race on breast carcinoma treatments and outcomes. Cancer 89(11):2202–2213PubMedCrossRefGoogle Scholar
  16. 16.
    Brawley OW (2002) Disaggregating the effects of race and poverty on breast cancer outcomes [comment]. J Natl Cancer Inst 94(7):471–473PubMedGoogle Scholar
  17. 17.
    Wojcik BE, Spinks MK, Optenberg SA (1998) Breast carcinoma survival analysis for African American and white women in an equal-access health care system. Cancer 82(7):1310–1318PubMedCrossRefGoogle Scholar
  18. 18.
    Chlebowski RT, Chen Z, Anderson GL et al (2005) Ethnicity and breast cancer: factors influencing differences in incidence and outcome. J Natl Cancer Inst 97(6):439–448PubMedCrossRefGoogle Scholar
  19. 19.
    Newman LA, Mason J, Cote D et al (2002) African-American ethnicity, socioeconomic status, and breast cancer survival. Cancer 94(11):2844–2854PubMedCrossRefGoogle Scholar
  20. 20.
    Li CI, Malone KE, Daling JR (2003) Differences in breast cancer stage, treatment, and survival by race and ethnicity. Arch Intern Med 163(1):49–56PubMedCrossRefGoogle Scholar
  21. 21.
    McWhorter WP, Mayer WJ (1987) Black/white differences in type of initial breast cancer treatment and implications for survival. Am J Public Health 77(12):1515–1517PubMedGoogle Scholar
  22. 22.
    Newman LA, Theriault R, Clendinnin N et al (2003) Treatment choices and response rates in African-American women with breast carcinoma. Cancer 97(1 Suppl):246–252PubMedCrossRefGoogle Scholar
  23. 23.
    National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology - V.1; 2000Google Scholar
  24. 24.
    NIH Consensus Statement—Adjuvant Therapy for Breast Cancer (2000) 17(4):1–42Google Scholar
  25. 25.
    Bast RC Jr, Ravdin P, Hayes DF et al (2001) 2000 update of recommendations for the use of tumor markers in breast and colorectal cancer: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 19(6):1865–1878PubMedGoogle Scholar
  26. 26.
    Breen N, Wesley MN, Merrill RM et al (1999) The relationship of socio-economic status and access to minimum expected therapy among female breast cancer patients in the National Cancer Institute Black-White Cancer Survival Study. Ethn Dis 9(1):111–125PubMedGoogle Scholar
  27. 27.
    Ayanian JZ, Guadagnoli E (1996) Variations in breast cancer treatment by patient and provider characteristics. Breast Cancer Res Treat 40(1):65–74PubMedCrossRefGoogle Scholar
  28. 28.
    White J, Morrow M, Moughan J et al (2003) Compliance with breast-conservation standards for patients with early-stage breast carcinoma. Cancer 97(4):893–904PubMedCrossRefGoogle Scholar
  29. 29.
    Caplan LS, May DS, Richardson LC (2000) Time to diagnosis and treatment of breast cancer: results from the National Breast and Cervical Cancer Early Detection Program, 1991–1995. Am J Public Health 90(1):130–134PubMedGoogle Scholar
  30. 30.
    Dennis CR, Gardner B, Lim B (1975)Analysis of survival and recurrence vs. patient and doctor delay in treatment of breast cancer. Cancer 35(3):714–720PubMedCrossRefGoogle Scholar
  31. 31.
    Gwyn K, Bondy ML, Cohen DS et al (2004) Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer 100(8):1595–1604PubMedCrossRefGoogle Scholar
  32. 32.
    Ramirez AJ, Westcombe AM, Burgess CC et al (1999) Factors predicting delayed presentation of symptomatic breast cancer: a systematic review. Lancet 353(9159):1127–1131PubMedCrossRefGoogle Scholar
  33. 33.
    Joslyn SA (2002) Racial differences in treatment and survival from early-stage breast carcinoma. Cancer 95(8):1759–1766PubMedCrossRefGoogle Scholar
  34. 34.
    Shavers VL, Harlan LC, Stevens JL (2003) Racial/ethnic variation in clinical presentation, treatment, and survival among breast cancer patients under age 35. Cancer 97(1):134–147PubMedCrossRefGoogle Scholar
  35. 35.
    Mincey BA, Palmieri FM, Perez EA (2002) Adjuvant therapy for breast cancer: recommendations for management based on consensus review and recent clinical trials. Oncologist 7(3):246–250PubMedCrossRefGoogle Scholar
  36. 36.
    Aapro MS (2001) Adjuvant therapy of primary breast cancer: a review of key findings from the 7th international conference, St. Gallen, February 2001. Oncologist 6(4):376–385PubMedCrossRefGoogle Scholar
  37. 37.
    Ownby HE, Frederick J, Russo J et al (1985) Racial differences in breast cancer patients. J Natl Cancer Inst 75(1):55–60PubMedGoogle Scholar
  38. 38.
    Griggs JJ, Sorbero ME, Stark AT et al (2003) Racial disparity in the dose and dose intensity of breast cancer adjuvant chemotherapy. Breast Cancer Res Treat 81(1):21–31PubMedCrossRefGoogle Scholar
  39. 39.
    Muss HB, Hunter CP, Wesley M et al (1992) Treatment plans for black and white women with stage II node-positive breast cancer. The National Cancer Institute Black/White Cancer Survival Study experience. Cancer 70(10):2460–2467PubMedCrossRefGoogle Scholar
  40. 40.
    Elledge RM, Clark GM, Chamness GC et al (1994) Tumor biologic factors and breast cancer prognosis among white, Hispanic, and black women in the United States.[comment]. J Natl Cancer Inst 86(9):705–712PubMedCrossRefGoogle Scholar
  41. 41.
    Diehr P, Yergan J, Chu J et al (1989) Treatment modality and quality differences for black and white breast-cancer patients treated in community hospitals. Med Care 27(10):942–958PubMedCrossRefGoogle Scholar
  42. 42.
    Bickell NA, Wang JJ, Oluwole S et al (2006) Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol 24(9):1357–1362PubMedCrossRefGoogle Scholar
  43. 43.
    English WP, Cleveland KE, Barber WH (2002) There is no difference in survival between African-American and white women with breast cancer. Am Surg 68(6):594–597PubMedGoogle Scholar
  44. 44.
    Gapstur SM, Dupuis J, Gann P et al (1996) Hormone receptor status of breast tumors in black, Hispanic, and non-Hispanic white women. An analysis of 13,239 cases. Cancer 77(8):1465–1471PubMedCrossRefGoogle Scholar
  45. 45.
    Chu KC, Anderson WF, Fritz A et al (2001) Frequency distributions of breast cancer characteristics classified by estrogen receptor and progesterone receptor status for eight racial/ethnic groups. Cancer 92(1):37–45PubMedCrossRefGoogle Scholar
  46. 46.
    Anderson WF, Chatterjee N, Ershler WB et al (2002) Estrogen receptor breast cancer phenotypes in the Surveillance, Epidemiology, and End Results database. Breast Cancer Res Treat 76(1):27–36PubMedCrossRefGoogle Scholar
  47. 47.
    ICD-O (2000) International Classification of Diseases for Oncology, 3rd edn. World Health Organization, GenevaGoogle Scholar
  48. 48.
    Goldhirsch A, Glick JH, Gelber RD et al (1998) International Consensus Panel on the treatment of primary breast cancer. J Natl Cancer Inst 90:1601–1608PubMedCrossRefGoogle Scholar
  49. 49.
    Anonymous (2001) NIH consensus panel recommends a range of adjuvant therapies for women with breast cancer. J Am Coll Surg 192(2):288CrossRefGoogle Scholar
  50. 50.
    Young JL, Roffers SD, Ries LAG, et al (eds) (2001) SEER Summary Staging Manual—2000: codes and coding instructions. National Cancer Institute, Bethesda, MDGoogle Scholar
  51. 51.
    Fritz A, Ries LAG (eds) (1998) SEER extent of disease, codes and coding instructions, 3rd edn. National Cancer Institute, Bethesda, MDGoogle Scholar
  52. 52.
    Fleming ID, Cooper JS, Henson DE et al (1997) AJCC Cancer Staging Manual, 5th edn. Chicago, ILGoogle Scholar
  53. 53.
    Fitzgibbons PL, Page DL, Weaver D et al (2000) Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med 124(7):966–978Google Scholar
  54. 54.
    Porter PL, Lund MJ, Lin MG et al (2004) Racial differences in the expression of cell cycle-regulatory proteins in breast carcinoma. Cancer 100(12):2533–2542PubMedCrossRefGoogle Scholar
  55. 55.
    Richards MA, Westcombe AM, Love SB et al (1999) Influence of delay on survival in patients with breast cancer: a systematic review [see comment]. Lancet 353(9159):1119–1126PubMedCrossRefGoogle Scholar
  56. 56.
    Richards MA, Smith P, Ramirez AJ et al (1999) The influence on survival of delay in the presentation and treatment of symptomatic breast cancer. Br J Cancer 79(5–6):858–864PubMedCrossRefGoogle Scholar
  57. 57.
    Gregorio DI, Cummings KM, Michalek A (1983) Delay, stage of disease, and survival among White and Black women with breast cancer. Am J Public Health 73(5):590–593PubMedCrossRefGoogle Scholar
  58. 58.
    Bradley CJ, Given CW, Roberts C (2002) Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst 94(7):490–496PubMedGoogle Scholar
  59. 59.
    Shavers VL, Brown ML (2002) Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst 94(5):334–357PubMedGoogle Scholar
  60. 60.
    Hewitt M, Simone J (eds) (2005) Assessing the quality of cancer care: An approach to measurement in Georgia. Institute of Medicine, The National Academies Press, Washington, DCGoogle Scholar
  61. 61.
    Nattinger AB, Hoffmann RG, Kneusel RT et al (2000) Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery. Lancet 356(9236):1148–1153PubMedCrossRefGoogle Scholar
  62. 62.
    Harlan LC, Clegg LX, Abrams J et al (2006) Community-based use of chemotherapy and hormonal therapy for early-stage breast cancer: 1987–2000. J Clin Oncol 24(6):872–877PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Mary Jo Lund
    • 1
    • 2
    • 3
    • 4
  • Otis P. Brawley
    • 1
    • 2
    • 3
    • 4
  • Kevin C. Ward
    • 1
    • 5
  • John L. Young
    • 1
    • 5
  • Sheryl S. G. Gabram
    • 3
    • 4
  • J. William Eley
    • 2
    • 4
  1. 1.Department of EpidemiologyRollins School of Public Health, Emory UniversityAtlantaUSA
  2. 2.Winship Cancer InstituteEmory University School of MedicineAtlantaUSA
  3. 3.Georgia Cancer Center for Excellence at GradyAtlantaUSA
  4. 4.Emory University School of MedicineAtlantaUSA
  5. 5.Georgia Center for Cancer StatisticsAtlantaUSA

Personalised recommendations