Breast Cancer Research and Treatment

, Volume 81, Issue 1, pp 21–31 | Cite as

Racial Disparity in the Dose and Dose Intensity of Breast Cancer Adjuvant Chemotherapy

  • Jennifer J. Griggs
  • Melony E.S. Sorbero
  • Azadeh T. Stark
  • Susanne E. Heininger
  • Andrew W. Dick
Article

Abstract

Purpose. The purpose of this study was to investigate the impact of race and obesity on dose and dose intensity of adjuvant chemotherapy.

Methods. We abstracted data on patient/tumor characteristics, treatment course, physicians' intention to give a first cycle dose reduction, and reasons for dose reductions/delays from oncology records of 489 women treated from 1985 to 1997 in 10 treatment sites in two geographical regions. Administered doses and dose intensity were compared to standard regimens. Multivariate regression models determined the impact of race and body mass index (BMI) on dose proportion (actual:expected doses) and relative dose intensity (RDI) controlling for patient characteristics, comorbidity, chemotherapy regimen, site, and year of treatment. Logistic regressions explored race and BMI versus use of first cycle dose reductions.

Results. African-Americans received lower chemotherapy dose proportion and RDI than whites (0.80 vs. 0.85, p = 0.03 and 0.76 vs. 0.80, p = 0.01). In multivariate analyses, dose proportion was 0.09 lower (p = 0.002), and RDI was 0.10 (p < 0.001) lower in non-overweight African-Americans than whites. Obesity was associated with lower dose proportion (p < 0.01) and RDI (p < 0.03). Race and BMI were independently associated with first cycle dose reductions. Non-overweight African-Americans (p < 0.05) and overweight and obese African-American and white women (p < 0.001) were more likely to have first cycle dose reductions than non-overweight whites.

Conclusion. We identified systematic differences in the administration of chemotherapy given to African-Americans and to overweight and obese women. These differences may contribute to documented disparities in outcome.

breast cancer chemotherapy obesity racial disparity 

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References

  1. 1.
    SEER website. See http://www.census.gov. SEER website 2003Google Scholar
  2. 2.
    Newman LA, Mason J, Cote D, Vin Y, Carolin K, Bouwman D, Colditz GA: African-American ethnicity, socioeconomic status, and breast cancer survival: A meta-analysis of 14 studies involving over 10,000 African-American and 40,000White American patients with carcinoma of the breast. Cancer 94: 2844–2854, 2002Google Scholar
  3. 3.
    Eley JW, Hill HA, Chen VW, Austin DF, Wesley MN, Muss HB, Greenberg RS, Coates RJ, Correa P, Redmond CK, et al.: Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA 272: 947–954, 1994Google Scholar
  4. 4.
    Joslyn SA, West MM: Racial differences in breast carcinoma survival. Cancer 88: 114–123, 2000Google Scholar
  5. 5.
    Bradley CJ, Given CW, Roberts C: Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst 94: 490–496, 2002Google Scholar
  6. 6.
    Yood MU, Johnson CC, Blount A, Abrams J, Wolman E, McCarthy BD, Raju U, Nathanson DS, Worsham M, Wolman SR: Race and differences in breast cancer survival in a managed care population. J Natl Cancer Inst 91: 1487–1491, 1999Google Scholar
  7. 7.
    Perkins P, Cooksley CD, Cox JD: Breast cancer. Is ethnicity an independent prognostic factor for survival? Cancer 78: 1241–1247, 1996Google Scholar
  8. 8.
    Bassett MT, rieger N:. Am J Public Health 76: 1400–1403, 1986Google Scholar
  9. 9.
    Cross CK, Harris J, Recht A: Race, socioeconomic status, and breast carcinoma in the US: What have we learned from clinical studies. Cancer 95: 1988–99, 2002Google Scholar
  10. 10.
    Shavers VL, Harlan LC, Stevens JL: Racial/ethnic variation in clinical presentation, treatment, and survival among breast cancer patients under age 35. Cancer 97: 134–147, 2003Google Scholar
  11. 11.
    Roach III M, Cirrincione C, Budman D, Hayes D, Berry D, Younger J, Hart R, Henderson IC: Race and survival from breast cancer: Based on Cancer and Leukemia Group B trial 8541. Cancer J Sci Am 3: 107–112, 1997Google Scholar
  12. 12.
    Dignam JJ: Efficacy of systemic adjuvant therapy for breast cancer in African-American and Caucasian women. J Natl Cancer Inst Monogr 36–43, 2001Google Scholar
  13. 13.
    Bonadonna G, Valagussa P: Dose-response effect of adjuvant chemotherapy in breast cancer. New Engl J Med 304: 10–15, 1981Google Scholar
  14. 14.
    Bonadonna G, Valagussa P, Moliterni A, Zambetti M, Brambilla C: Adjuvant cyclophosphamide, methotrexate, and fluorouracil in node-positive breast cancer: the results of 20 years of follow-up. New Engl J Med 332: 901–906, 1995Google Scholar
  15. 15.
    Wood WC, Budman DR, Korzun AH, Cooper MR, Younger J, Hart RD, Moore A, Ellerton JA, Norton L, Ferree CR, et al.: Dose and dose intensity of adjuvant chemotherapy for Stage II, node-positive breast carcinoma. New Engl J Med 330: 1253–1259, 1994Google Scholar
  16. 16.
    Budman DR, Berry DA, Cirrincione CT, Henderson IC, Wood WC, Weiss RB, Ferree CR, Muss HB, Green MR, Norton L, Frei E3: Dose and dose intensity as determinants of outcome in the adjuvant treatment of breast cancer. J Natl Cancer Inst 90: 1205–1211, 1998Google Scholar
  17. 17.
    Colleoni M, Price K, Castiglione-Gertsch M, Goldhirsch A, Coates A, Lindtner J, Collins J, Gelber RD, Thurlimann B, Rudenstam CM: Dose-response effect of adjuvant cyclophosphamide, methotrexate, 5-fluorouracil (CMF) in node-positive breast cancer. International Breast Cancer Study Group. Eur J Cancer 34: 1693–1700, 1998Google Scholar
  18. 18.
    Muss HB, Hunter CP, Wesley M, Correa P, Chen VW, Greenberg RS, Eley JW, Austin DF, Kurman R, Edwards BK: 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: 2460–2467, 1992Google Scholar
  19. 19.
    Kiefe CI: Race/ethnicity and cancer survival: the elusive target of biological differences. JAMA 287: 2138–2139, 2002Google Scholar
  20. 20.
    Madarnas Y, Sawka CA, Franssen E, Bjarnason GA: Are medical oncologists biased in their treatment of the large woman with breast cancer? Breast Cancer Res Treat 66: 123–133, 2001Google Scholar
  21. 21.
    Rosner GL, Hargis JB, Hollis DR, Budman DR, Weiss RB, Henderson IC, Schilsky RL: Relationship between toxicity and obesity in women receiving adjuvant chemotherapy for breast cancer: results from Cancer and Leukemia Group B Study 8541. J Clin Oncol 14: 3000–3008, 1996Google Scholar
  22. 022.
    Smith TJ, Desch CE: Neutropenia-wise and pound-foolish: Safe and effective chemotherapy in massively obese patients. South Med J 84: 883–885, 1991Google Scholar
  23. 23.
    Flegal KM, Carroll MD, Ogden CL, Johnson CJ: Prevalence and trends in obesity among US adults, 1999-2000. JAMA 288: 1723–1727, 2002Google Scholar
  24. 24.
    Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS: Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 289: 76–79, 2003Google Scholar
  25. 25.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40: 373–383, 1987Google Scholar
  26. 26.
    Krieger N: Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health 82: 703–710, 1992Google Scholar
  27. 27.
    nhlbisupport.com/bmi 2003Google Scholar
  28. 28.
    Greene WH: Econometric Analysis. 2nd edn, 1993Google Scholar
  29. 29.
    McCollum AD, Catalano PJ, Haller DG, Mayer RJ, MacDonald JS, Benson AB3, Fuchs CS: Outcomes and toxicity in African-American and Caucasian patients in a randomized adjuvant chemotherapy trial for colon cancer. J Natl Cancer Inst 94: 1160–1167, 2002Google Scholar
  30. 30.
    Reed WW, Diehl LF: Leukopenia, neutropenia, and reduced hemoglobin levels in healthy American blacks. Arch Int Med 151: 501–505, 1991Google Scholar
  31. 31.
    Castro OL, Haddy TB, Rana SR: Age-and sex-related blood cell values in healthy black Americans. Public Health Rep 102: 232–237, 1987Google Scholar
  32. 32.
    Bach PB, Cramer LD, Warren JL, Begg CB: Racial differences in the treatment of early-stage lung cancer. N Engl J Med 341: 1198–1205, 1999Google Scholar
  33. 33.
    Mandelblatt JS, Kerner JF, Hadley J, Hwang YT, Eggert L, Johnson LE, Gold K: Variations in breast carcinoma treatment in older Medicare beneficiaries: Is it black or white? Cancer 95: 1401–1414, 2002Google Scholar
  34. 34.
    Mandelblatt JS, Yabroff KR, Kerner JF: Equitable access to cancer services: a review of barriers to quality care. Cancer 86: 2378–2390, 1999Google Scholar
  35. 35.
    Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2002Google Scholar
  36. 36.
    van Ryn M: Research on the provider contribution to race/ethnicity disparities in medical care. Med Care 40: I140–I151, 2002Google Scholar
  37. 37.
    van Ryn M, Burke J: The effect of patient race and socioeconomic status on physicians' perceptions of patients. Soc Sci Med 50: 813–828, 2000Google Scholar
  38. 38.
    Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE: Race, gender, and partnership in the patient-physician relationship. JAMA 282: 583–589, 1999Google Scholar
  39. 39.
    Balsa AI, McGuire TG: Statistical discrimination in health care. J Health Econ 20: 881–907, 2001Google Scholar
  40. 40.
    Poikonen P, Blomqvist C, Joensuu H: Effect of obesity on the leukocyte nadir in women treated with adjuvant Racial disparity in adjuvant chemotherapy 31 cyclophosphamide, methotrexate, and fluorouracil dosed according to body surface area. Acta Oncol 40: 67–71, 2001Google Scholar
  41. 41.
    Gelman RS, Tormey DC, Betensky R, Mansour EG, Falkson HC, Falkson G, Creech RH, Haller DG: Actual versus ideal weight in the calculation of surface area: effects on dose of 11 chemotherapy agents. Cancer Treat Rep 71: 907–911, 1987Google Scholar
  42. 42.
    Hryniuk W, Frei III E, Wright FA: A single scale for comparing dose-intensity of all chemotherapy regimens in breast cancer: summation dose-intensity. J Clin Oncol 16: 3137–3147, 1998Google Scholar
  43. 43.
    Morrow T, Siegel M, Boone S, Lawless G, Carter W: Chemotherapy dose intensity determination as a quality of care measure for managed care organizations in the treatment of early-stage breast cancer. Am J Med Qual 17: 218–224, 2002Google Scholar

Copyright information

© Kluwer Academic Publishers 2003

Authors and Affiliations

  • Jennifer J. Griggs
    • 1
    • 2
  • Melony E.S. Sorbero
    • 3
  • Azadeh T. Stark
    • 4
  • Susanne E. Heininger
    • 1
  • Andrew W. Dick
    • 2
  1. 1.Department of Medicine, Hematology/OncologyUniversity of RochesterRochesterUSA
  2. 2.Department of Community and Preventive MedicineUniversity of RochesterRochesterUSA
  3. 3.RANDPittsburghUSA
  4. 4.Henry Ford Health SystemJosephine Ford Cancer CenterDetroitUSA

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