Journal of Urban Health

, Volume 92, Issue 1, pp 67–82 | Cite as

Breast Cancer Treatment among African American Women in North St. Louis, Missouri

  • Shahnjayla K. Connors
  • Melody S. Goodman
  • Lailea Noel
  • Neeraja N. Chavakula
  • Dwayne Butler
  • Sandi Kenkel
  • Cheryl Oliver
  • Isaac McCullough
  • Sarah Gehlert


Similar to disparities seen at the national and state levels, African American women in St. Louis, Missouri have higher breast cancer mortality rates than their Caucasian counterparts. We examined breast cancer treatment (regimens and timing) in a sample of African American breast cancer patients diagnosed between 2000 and 2008 while residing in a North St. Louis cluster (eight zip codes) of late stage at diagnosis. Data were obtained from medical record extractions of women participating in a mixed-method study of breast cancer treatment experiences. The median time between diagnosis and initiation of treatment was 27 days; 12.2 % of the women had treatment delay over 60 days. These findings suggest that treatment delay and regimens are unlikely contributors to excess mortality rates for African American women diagnosed in early stages. Conflicting research findings on treatment delay may result from the inconsistent definitions of treatment delay and variations among study populations. Breast cancer treatment delay may reduce breast cancer survival; additional research is needed to better understand the points at which delays are most likely to occur and develop policies, programs, and interventions to address disparities in treatment delay. There may also be differences in treatment-related survivorship quality of life; approximately 54 % of the women in this sample treated with mastectomies received breast reconstruction surgery. Despite the high reconstruction rates, most women did not receive definitive completion. African American women have higher reconstruction complication rates than Caucasian women; these data provide additional evidence to suggest a disparity in breast reconstruction outcomes by race.


St. Louis Breast cancer African American women Treatment delay Breast reconstruction 



A Community-Based Approach to Improving Breast Cancer Services for African American Women Living in St. Louis is funded by a Susan G. Komen For The Cure® Vulnerable Community Grant (Grant SG-11-10005, Colditz, PI). This project was also supported by the Program for the Elimination for Cancer Disparities (PECaD) (National Institutes of Health-National Cancer Institute Community Network Program, U54 CA153460; Colditz, PI) and the Barnes-Jewish Foundation. We would like to thank the Executive Committee and community partners for the A Community-Based Approach to Improving Breast Cancer Services for African American Women Living in St. Louis. We would also like to thank the breast cancer survivors who participated in this study.


  1. 1.
    American Cancer Society. Breast cancer facts and figures 2011–2012. Atlanta, GA: American Cancer Society; 2011.Google Scholar
  2. 2.
    American Cancer Society. Cancer facts and figures for African Americans 2013–2014. Atlanta, GA: American Cancer Society; 2013.Google Scholar
  3. 3.
    Schootman M, Jeffe DB, Gillanders WE, Yan Y, Jenkins B, Aft R. Geographic clustering of adequate diagnostic follow-up after abnormal screening results for breast cancer among low-income women in Missouri. Ann Epidemiol. 2007; 17(9): 704–712.CrossRefPubMedGoogle Scholar
  4. 4.
    St. Louis Regional Health Commission. Progress towards building a healthier St. Louis: 2012 access to care data book. St. Louis, MO: St. Louis Regional Health Commission; 2012Google Scholar
  5. 5.
    Fayanju OM, Jeffe DB, Elmore L, Ksiazek DN, Margenthaler JA. Patient and process factors associated with late-stage breast cancer diagnosis in safety-net patients: a pilot prospective study. Ann Surg Oncol. 2013; 20(3): 723–732.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Fayanju OM, Jeffe DB, Tappenden JR, et al. Breast cancer presentation in an urban health care safety net system. Mo Med. 2012; 109(5): 405–411.PubMedCentralPubMedGoogle Scholar
  7. 7.
    Carey LA, Perou CM, Livasy CA, et al. Race, breast cancer subtypes, and survival in the Carolina breast cancer study. JAMA. 2006; 295(21): 2492–2502.CrossRefPubMedGoogle Scholar
  8. 8.
    Millikan RC, Newman B, Tse CK, et al. Epidemiology of basal-like breast cancer. Breast Cancer Res Treat. 2008; 109(1): 123–139.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Newman LA. Breast cancer in African-American women. Oncologist. 2005; 10(1): 1–14.CrossRefPubMedGoogle Scholar
  10. 10.
    van Ravesteyn NT, Schechter CB, Near AM, et al. Race-specific impact of natural history, mammography screening, and adjuvant treatment on breast cancer mortality rates in the United States. Cancer Epidemiol Biomarkers Prev. 2011; 20(1): 112–122.CrossRefPubMedCentralPubMedGoogle Scholar
  11. 11.
    Vona-Davis L, Rose DP. The influence of socioeconomic disparities on breast cancer tumor biology and prognosis: a review. J Womens Health (Larchmt). 2009; 18(6): 883–893.CrossRefGoogle Scholar
  12. 12.
    Hershman DL, Wang X, McBride R, Jacobson JS, Grann VR, Neugut AI. Delay in initiating adjuvant radiotherapy following breast conservation surgery and its impact on survival. Int J Radiat Oncol Biol Phys. 2006; 65(5): 1353–1360.CrossRefPubMedGoogle Scholar
  13. 13.
    McLaughlin JM, Anderson RT, Ferketich AK, Seiber EE, Balkrishnan R, Paskett ED. Effect on survival of longer intervals between confirmed diagnosis and treatment initiation among low-income women with breast cancer. J Clin Oncol. 2012; 30(36): 4493–4500.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Nurgalieva ZZ, Franzini L, Morgan RO, Vernon SW, Liu CC, Du XL. Impact of timing of adjuvant chemotherapy initiation and completion after surgery on racial disparities in survival among women with breast cancer. Med Oncol. 2013; 30(1): 419.CrossRefPubMedGoogle Scholar
  15. 15.
    Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ. Influence of delay on survival in patients with breast cancer: a systematic review. Lancet. 1999; 353(9159): 1119–1126.CrossRefPubMedGoogle Scholar
  16. 16.
    Caplan LS, May DS, Richardson LC. 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. 2000; 90(1): 130–134.CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Fedewa SA, Edge SB, Stewart AK, Halpern MT, Marlow NM, Ward EM. Race and ethnicity are associated with delays in breast cancer treatment (2003–2006). J Health Care Poor Underserved. 2011; 22(1): 128–141.PubMedGoogle Scholar
  18. 18.
    Freedman RA, He Y, Winer EP, Keating NL. Racial/ethnic differences in receipt of timely adjuvant therapy for older women with breast cancer: are delays influenced by the hospitals where patients obtain surgical care? Health Serv Res. 2013; 48(5): 1669–1683.PubMedGoogle Scholar
  19. 19.
    Gwyn K, Bondy ML, Cohen DS, et al. Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer. 2004; 100(8): 1595–1604.CrossRefPubMedGoogle Scholar
  20. 20.
    Lund MJ, Brawley OP, Ward KC, Young JL, Gabram SS, Eley JW. Parity and disparity in first course treatment of invasive breast cancer. Breast Cancer Res Treat. 2008; 109(3): 545–557.CrossRefPubMedGoogle Scholar
  21. 21.
    McGee SA, Durham DD, Tse CK, Millikan RC. Determinants of breast cancer treatment delay differ for African American and White women. Cancer Epidemiol Biomarkers Prev. 2013; 22(7): 1227–1238.CrossRefPubMedCentralPubMedGoogle Scholar
  22. 22.
    Pocock B, Nash S, Klein L, El-Tamer M, Schnabel FR, Joseph KA. Disparities in time to definitive surgical treatment between black and white women diagnosed with ductal carcinoma in situ. Am J Surg. 2007; 194(4): 521–523.CrossRefPubMedGoogle Scholar
  23. 23.
    Caplan LS, Helzlsouer KJ. Delay in breast cancer: a review of the literature. Public Health Rev. 1992; 20(3–4): 187–214.PubMedGoogle Scholar
  24. 24.
    Williams DL, Tortu S, Thomson J. Factors associated with delays to diagnosis and treatment of breast cancer in women in a Louisiana urban safety net hospital. Women Health. 2010; 50(8): 705–718.CrossRefPubMedGoogle Scholar
  25. 25.
    Alderman AK, Hawley ST, Janz NK, et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population- based study. J Clin Oncol. 2009; 27(32): 5325–5330.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Jagsi R, Jiang J, Momoh AO et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol. 2014.Google Scholar
  27. 27.
    Kruper L, Holt A, Xu XX, et al. Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California. Ann Surg Oncol. 2011; 18(8): 2158–2165.CrossRefPubMedGoogle Scholar
  28. 28.
    Atisha D, Alderman AK, Lowery JC, Kuhn LE, Davis J, Wilkins EG. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan breast reconstruction outcomes study. Ann Surg. 2008; 247(6): 1019–1028.CrossRefPubMedGoogle Scholar
  29. 29.
    Eltahir Y, Werners LL, Dreise MM, et al. Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg. 2013; 132(2): 201–209.CrossRefGoogle Scholar
  30. 30.
    Harcourt DM, Rumsey NJ, Ambler NR, et al. The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg. 2003; 111(3): 1060–1068.CrossRefPubMedGoogle Scholar
  31. 31.
    Rowland JH, Holland JC, Chaglassian T, Kinne D. Psychological response to breast reconstruction. Expectations for and impact on postmastectomy functioning. Psychosom. 1993; 34(3): 241–250.CrossRefGoogle Scholar
  32. 32.
    Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2000; 106(5): 1014–1025. discussion 1026–1017.CrossRefPubMedGoogle Scholar
  33. 33.
    Sisco M, Du H, Warner JP, Howard MA, Winchester DP, Yao K. Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the National Cancer Data Base. J Am Coll Surg. 2012; 215(5): 658–666. discussion 666.CrossRefPubMedGoogle Scholar
  34. 34.
    Alderman AK, Hawley ST, Morrow M, et al. Receipt of delayed breast reconstruction after mastectomy: do women revisit the decision? Ann Surg Oncol. 2011; 18(6): 1748–1756.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.
    Greenberg CC, Schneider EC, Lipsitz SR, et al. Do variations in provider discussions explain socioeconomic disparities in postmastectomy breast reconstruction? J Am Coll Surg. 2008; 206(4): 605–615.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Morrow M, Mujahid M, Lantz PM, et al. Correlates of breast reconstruction: results from a population-based study. Cancer. 2005; 104(11): 2340–2346.CrossRefPubMedGoogle Scholar
  37. 37.
    Reuben BC, Manwaring J, Neumayer LA. Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States. Am J Surg. 2009; 198(2): 237–243.CrossRefPubMedGoogle Scholar
  38. 38.
    Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. 2000; 92(17): 1422–1429.CrossRefPubMedGoogle Scholar
  39. 39.
    Tseng JF, Kronowitz SJ, Sun CC, et al. The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer. Cancer. 2004; 101(7): 1514–1523.CrossRefPubMedGoogle Scholar
  40. 40.
    Elmore L, Myckatyn TM, Gao F, et al. Reconstruction patterns in a single institution cohort of women undergoing mastectomy for breast cancer. Ann Surg Oncol. 2012; 19(10): 3223–3229.CrossRefPubMedGoogle Scholar
  41. 41.
    Mitchem J, Herrmann D, Margenthaler JA, Aft RL. Impact of neoadjuvant chemotherapy on rate of tissue expander/implant loss and progression to successful breast reconstruction following mastectomy. Am J Surg. 2008; 196(4): 519–522.CrossRefPubMedGoogle Scholar
  42. 42.
    Gorin SS, Heck JE, Cheng B, Smith SJ. Delays in breast cancer diagnosis and treatment by racial/ethnic group. Arch Intern Med. 2006; 166(20): 2244–2252.CrossRefPubMedGoogle Scholar
  43. 43.
    Fedewa SA, Ward EM, Stewart AK, Edge SB. Delays in adjuvant chemotherapy treatment among patients with breast cancer are more likely in African American and Hispanic populations: a national cohort study 2004–2006. J Clin Oncol. 2010; 28(27): 4135–4141.CrossRefPubMedGoogle Scholar
  44. 44.
    Missouri Department of Health and Senior Services. Provider manual: Show Me Healthy Women (SMHW) and Wisewoman 2013–2014. Jefferson City, MO: Missouri Department of Health and Senior Services; 2013.Google Scholar
  45. 45.
    Balasubramanian BA, Demissie K, Crabtree BF, Strickland PA, Pawlish K, Rhoads GG. Black medicaid beneficiaries experience breast cancer treatment delays more frequently than whites. Ethn Dis. 2012; 22(3): 288–294.PubMedGoogle Scholar
  46. 46.
    Gold HT, Do HT, Dick AW. Correlates and effect of suboptimal radiotherapy in women with ductal carcinoma in situ or early invasive breast cancer. Cancer. 2008; 113(11): 3108–3115.CrossRefPubMedGoogle Scholar
  47. 47.
    Sheppard VB, Isaacs C, Luta G, et al. Narrowing racial gaps in breast cancer chemotherapy initiation: the role of the patient-provider relationship. Breast Cancer Res Treat. 2013; 139(1): 207–216.CrossRefPubMedCentralPubMedGoogle Scholar
  48. 48.
    Vandergrift JL, Niland JC, Theriault RL, et al. Time to adjuvant chemotherapy for breast cancer in national comprehensive cancer network institutions. J Natl Cancer Inst. 2013; 105(2): 104–112.CrossRefPubMedCentralPubMedGoogle Scholar
  49. 49.
    Hershman DL, Wang X, McBride R, Jacobson JS, Grann VR, Neugut AI. Delay of adjuvant chemotherapy initiation following breast cancer surgery among elderly women. Breast Cancer Res Treat. 2006; 99(3): 313–321.CrossRefPubMedGoogle Scholar
  50. 50.
    Lohrisch C, Paltiel C, Gelmon K, et al. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol. 2006; 24(30): 4888–4894.CrossRefPubMedGoogle Scholar
  51. 51.
    Chevray PM. Timing of breast reconstruction: immediate versus delayed. Cancer J. 2008; 14(4): 223–229.CrossRefPubMedGoogle Scholar
  52. 52.
    Fernandez-Frias AM, Aguilar J, Sanchez JA, Merck B, Pinero A, Calpena R. Immediate reconstruction after mastectomy for breast cancer: which factors affect its course and final outcome? J Am Coll Surg. 2009; 208(1): 126–133.CrossRefPubMedGoogle Scholar
  53. 53.
    Bradley PK. The delay and worry experience of African American women with breast cancer. Oncol Nurs Forum. 2005; 32(2): 243–249.CrossRefPubMedGoogle Scholar
  54. 54.
    Gregorio DI, Cummings KM, Michalek A. Delay, stage of disease, and survival among White and Black women with breast cancer. Am J Public Health. 1983; 73(5): 590–593.CrossRefPubMedCentralPubMedGoogle Scholar
  55. 55.
    Smith ER, Adams SA, Das IP, Bottai M, Fulton J, Hebert JR. Breast cancer survival among economically disadvantaged women: the influences of delayed diagnosis and treatment on mortality. Cancer Epidemiol Biomarkers Prev. 2008; 17(10): 2882–2890.CrossRefPubMedCentralPubMedGoogle Scholar
  56. 56.
    Agarwal S, Pappas L, Neumayer L, Agarwal J. An analysis of immediate postmastectomy breast reconstruction frequency using the Surveillance, Epidemiology, and End Results database. Breast J. 2011; 17(4): 352–358.CrossRefPubMedGoogle Scholar
  57. 57.
    Alderman AK, McMahon L Jr, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg. 2003; 111(2): 695–703.CrossRefPubMedGoogle Scholar
  58. 58.
    Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women’s Health and Cancer Rights Act. JAMA. 2006; 295(4): 387–388.PubMedGoogle Scholar
  59. 59.
    Bradley CJ, Dahman B, Shickle LM, Lee W. Surgery wait times and specialty services for insured and uninsured breast cancer patients: does hospital safety net status matter? Health Serv Res. 2012; 47(2): 677–697.CrossRefPubMedCentralPubMedGoogle Scholar
  60. 60.
    Jackson LC, Camacho F, Levine EA, Anderson RT, Stewart JHT. Patterns of care analysis among women with ductal carcinoma in situ in North Carolina. Am J Surg. 2008; 195(2): 164–169.CrossRefPubMedGoogle Scholar
  61. 61.
    Joslyn SA. Patterns of care for immediate and early delayed breast reconstruction following mastectomy. Plast Reconstr Surg. 2005; 115(5): 1289–1296.CrossRefPubMedGoogle Scholar
  62. 62.
    Morrow M, Scott SK, Menck HR, Mustoe TA, Winchester DP. Factors influencing the use of breast reconstruction postmastectomy: a national cancer database study. J Am Coll Surg. 2001; 192(1): 1–8.CrossRefPubMedGoogle Scholar
  63. 63.
    Rosson GD, Singh NK, Ahuja N, Jacobs LK, Chang DC. Multilevel analysis of the impact of community vs. patient factors on access to immediate breast reconstruction following mastectomy in Maryland. Arch Surg. 2008; 143(11): 1076–1081.CrossRefPubMedGoogle Scholar
  64. 64.
    Tseng WH, Stevenson TR, Canter RJ, et al. Sacramento area breast cancer epidemiology study: use of postmastectomy breast reconstruction along the rural-to-urban continuum. Plast Reconstr Surg. 2010; 126(6): 1815–1824.CrossRefPubMedCentralPubMedGoogle Scholar
  65. 65.
    Yang RL, Newman AS, Lin IC, et al. Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation. Cancer. 2013; 119(13): 2462–2468.CrossRefPubMedGoogle Scholar
  66. 66.
    Yang RL, Newman AS, Reinke CE, et al. Racial disparities in immediate breast reconstruction after mastectomy: impact of state and federal health policy changes. Ann Surg Oncol. 2013; 20(2): 399–406.CrossRefPubMedGoogle Scholar
  67. 67.
    Hershman DL, Richards CA, Kalinsky K, et al. Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer. Breast Cancer Res Treat. 2012; 136(2): 535–545.CrossRefPubMedCentralPubMedGoogle Scholar
  68. 68.
    Katz SJ, Lantz PM, Paredes Y, et al. Breast cancer treatment experiences of Latinas in Los Angeles County. Am J Public Health. 2005; 95(12): 2225–2230.CrossRefPubMedCentralPubMedGoogle Scholar
  69. 69.
    Kruper L, Xu X, Henderson K, Bernstein L. Disparities in reconstruction rates after mastectomy for ductal carcinoma in situ (DCIS): patterns of care and factors associated with the use of breast reconstruction for DCIS compared with invasive cancer. Ann Surg Oncol. 2011; 18(11): 3210–3219.CrossRefPubMedGoogle Scholar
  70. 70.
    Fischer JP, Wes AM, Tuggle CT, Serletti JM, Wu LC. Risk analysis and stratification of surgical morbidity after immediate breast reconstruction. J Am Coll Surg. 2013; 217(5): 780–787.CrossRefPubMedGoogle Scholar
  71. 71.
    Fischer JP, Nelson JA, Au A, Ct T 3rd, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction—a review of 16,063 cases from the 2005–2010 NSQIP datasets. J Plast Surg Hand Surg. 2014; 48(2): 104–114.CrossRefPubMedGoogle Scholar
  72. 72.
    Lee C, Sunu C, Pignone M. Patient-reported outcomes of breast reconstruction after mastectomy: a systematic review. J Am Coll Surg. 2009; 209(1): 123–133.CrossRefPubMedCentralPubMedGoogle Scholar
  73. 73.
    Metcalfe KA, Semple J, Quan ML, et al. Changes in psychosocial functioning 1 year after mastectomy alone, delayed breast reconstruction, or immediate breast reconstruction. Ann Surg Oncol. 2012; 19(1): 233–241.CrossRefPubMedGoogle Scholar
  74. 74.
    Rubin LR, Chavez J, Alderman A, Pusic AL. ‘Use what God has given me’: difference and disparity in breast reconstruction. Psychol Health. 2013.Google Scholar

Copyright information

© The New York Academy of Medicine 2014

Authors and Affiliations

  • Shahnjayla K. Connors
    • 1
  • Melody S. Goodman
    • 1
  • Lailea Noel
    • 2
  • Neeraja N. Chavakula
    • 2
  • Dwayne Butler
    • 3
  • Sandi Kenkel
    • 4
  • Cheryl Oliver
    • 5
  • Isaac McCullough
    • 6
  • Sarah Gehlert
    • 1
    • 2
  1. 1.Department of Surgery, Division of Public Health SciencesWashington University in St. Louis School of MedicineSt. LouisUSA
  2. 2.George Warren Brown of Social WorkWashington University in St. LouisSt. LouisUSA
  3. 3.Betty Jean Kerr People’s Health CentersSt. LouisUSA
  4. 4.Christian HospitalSt. LouisUSA
  5. 5.St. Louis Effort for AIDSSt. LouisUSA
  6. 6.Committed Caring Faith CommunitiesSt. LouisUSA

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