Cancer Causes & Control

, Volume 21, Issue 9, pp 1445–1450 | Cite as

Disparities in breast cancer prognostic factors by race, insurance status, and education

Original paper

Abstract

Black women are more likely to be diagnosed with advanced stage and other less favorable breast cancer prognostic factors than white women. The aim of this study was to examine the extent to which markers of socioeconomic position accounts for black–white differences in these factors. Our study included 193,969 women diagnosed with invasive breast cancers during 2004–2005 from the National Cancer Database, which represents about 72% of all patients with cancer treated in the United States. Compared to white women, black women are more likely to be diagnosed with breast tumors that are less differentiated (odds ratio (OR) = 2.55, 95% confidence interval (CI) 2.44–2.66), hormone receptor negative (OR = 2.29, 95% CI 2.22–2.37), large (OR = 1.87, 95% CI 1.80–1.95), metastatic (OR = 1.89, 95% CI 1.78–2.00), and lymph node-positive (OR = 1.44, 95% CI 1.40–1.48). In multivariable analyses, adjustment for insurance and area-level educational attainment explained 31–39% of the differences in tumor size and metastasis, but only about 14% of the differences in grade and hormone receptors. After accounting for race and other covariates, uninsured women remained 3.66 (95% CI 3.30–4.07) times more likely to have metastasis and 2.37 (95% CI 2.17–2.58) times more likely to have large tumors compared to privately insured women. Similarly, the risk of having breast cancer with less favorable prognostic factors increased as area-level educational attainment decreased. Extending health insurance coverage to all women is likely to have an effect on reducing racial disparities in the development of breast cancers with poor prognostic factors.

Keywords

Breast neoplasms Health disparities Race Insurance Socioeconomic factors Prognostic factors 

References

  1. 1.
    Carey LA, Perou CM, Livasy CA et al (2006) Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA 295:2492–2502CrossRefPubMedGoogle Scholar
  2. 2.
    Joslyn SA (2002) Hormone receptors in breast cancer: racial differences in distribution and survival. Breast Cancer Res Treat 73:45–59CrossRefPubMedGoogle Scholar
  3. 3.
    Li CI, Malone KE, Daling JR (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 11:601–607PubMedGoogle Scholar
  4. 4.
    Elledge RM, Clark GM, Chamness GC, Osborne CK (1994) Tumor biologic factors and breast cancer prognosis among white, Hispanic, and black women in the United States. J Natl Cancer Inst 86:705–712CrossRefPubMedGoogle Scholar
  5. 5.
    Elmore JG, Moceri VM, Carter D, Larson EB (1998) Breast carcinoma tumor characteristics in black and white women. Cancer 83:2509–2515CrossRefPubMedGoogle Scholar
  6. 6.
    Krieger N, Chen JT, Ware JH, Kaddour A (2008) Race/ethnicity and breast cancer estrogen receptor status: impact of class, missing data, and modeling assumptions. Cancer Causes Control 19:1305–1318CrossRefPubMedGoogle Scholar
  7. 7.
    Gordon NH (2003) Socioeconomic factors and breast cancer in black and white Americans. Cancer Metastasis Rev 22:55–65CrossRefPubMedGoogle Scholar
  8. 8.
    Roetzheim RG, Pal N, Tennant C et al (1999) Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst 91:1409–1415CrossRefPubMedGoogle Scholar
  9. 9.
    Gordon NH (1995) Association of education and income with estrogen receptor status in primary breast cancer. Am J Epidemiol 142:796–803PubMedGoogle Scholar
  10. 10.
    Halpern MT, Bian J, Ward EM, Schrag NM, Chen AY (2007) Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer 110:403–411CrossRefPubMedGoogle Scholar
  11. 11.
    Lantz PM, Mujahid M, Schwartz K et al (2006) The influence of race, ethnicity, and individual socioeconomic factors on breast cancer stage at diagnosis. Am J Public Health 96:2173–2178CrossRefPubMedGoogle Scholar
  12. 12.
    Hahn KM, Bondy ML, Selvan M et al (2007) Factors associated with advanced disease stage at diagnosis in a population-based study of patients with newly diagnosed breast cancer. Am J Epidemiol 166:1035–1044CrossRefPubMedGoogle Scholar
  13. 13.
    Bibb SC (2001) The relationship between access and stage at diagnosis of breast cancer in African American and Caucasian women. Oncol Nurs Forum 28:711–719PubMedGoogle Scholar
  14. 14.
    Lannin DR, Mathews HF, Mitchell J, Swanson MS, Swanson FH, Edwards MS (1998) Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. JAMA 279:1801–1807CrossRefPubMedGoogle Scholar
  15. 15.
    Wells BL, Horm JW (1992) Stage at diagnosis in breast cancer: race and socioeconomic factors. Am J Public Health 82:1383–1385CrossRefPubMedGoogle Scholar
  16. 16.
    Mandelblatt J, Andrews H, Kerner J, Zauber A, Burnett W (1991) Determinants of late stage diagnosis of breast and cervical cancer: the impact of age, race, social class, and hospital type. Am J Public Health 81:646–649CrossRefPubMedGoogle Scholar
  17. 17.
    Bauer KR, Brown M, Cress RD, Parise CA, Caggiano V (2007) Descriptive analysis of estrogen receptor (ER)-negative, progesterone receptor (PR)-negative, and HER2-negative invasive breast cancer, the so-called triple-negative phenotype: a population-based study from the California Cancer Registry. Cancer 109:1721–1728CrossRefPubMedGoogle Scholar
  18. 18.
    Krieger N, van den Eeden SK, Zava D, Okamoto A (1997) Race/ethnicity, social class, and prevalence of breast cancer prognostic biomarkers: a study of white, black, and Asian women in the San Francisco bay area. Ethn Dis 7:137–149PubMedGoogle Scholar
  19. 19.
    Chen VW, Correa P, Kurman RJ et al (1994) Histological characteristics of breast carcinoma in blacks and whites. Cancer Epidemiol Biomarkers Prev 3:127–135PubMedGoogle Scholar
  20. 20.
    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 85:1129–1137CrossRefPubMedGoogle Scholar
  21. 21.
    Bradley CJ, Given CW, Roberts C (2002) Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst 94:490–496PubMedGoogle Scholar
  22. 22.
    Miller BA, Hankey BF, Thomas TL (2002) Impact of sociodemographic factors, hormone receptor status, and tumor grade on ethnic differences in tumor stage and size for breast cancer in US women. Am J Epidemiol 155:534–545CrossRefPubMedGoogle Scholar
  23. 23.
    Clegg LX, Reichman ME, Miller BA et al (2009) Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Cancer Causes Control 20:417–435CrossRefPubMedGoogle Scholar
  24. 24.
    American College of Surgeons (2009) What is the National Cancer Data Base? Available from URL: http://www.facs.org/cancer/ncdb/ncdbabout.html. Accessed 10 December 2009
  25. 25.
    Swan J, Breen N, Coates RJ, Rimer BK, Lee NC (2003) Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer 97:1528–1540CrossRefPubMedGoogle Scholar
  26. 26.
    National Center for Health Statistics (2009) Health, United States, 2008 with special feature on the health of young adults. National Center for Health Statistics, Hyattsville, p 349Google Scholar
  27. 27.
    Elmore JG, Nakano CY, Linden HM, Reisch LM, Ayanian JZ, Larson EB (2005) Racial inequities in the timing of breast cancer detection, diagnosis, and initiation of treatment. Med Care 43:141–148CrossRefPubMedGoogle Scholar
  28. 28.
    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 100:1595–1604CrossRefPubMedGoogle Scholar
  29. 29.
    DeNavas-Walt C, Proctor BD, Smith JC (2009) Income, poverty, and health insurance coverage in the United States: 2008. US Census Bureau, Current Population Reports, P60–236. U.S. Government Printing Office, Washington, DCGoogle Scholar
  30. 30.
    Chlebowski RT, Chen Z, Anderson GL et al (2005) Ethnicity and breast cancer: factors influencing differences in incidence and outcome. J Natl Cancer Inst 97:439–448CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2010

Authors and Affiliations

  1. 1.Surveillance and Health Policy ResearchAmerican Cancer SocietyAtlantaUSA

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