Evaluation of Surgical Disparities Between African American and European American Women Treated for Breast Cancer Within an Equal-Access Military Hospital

  • Leann A. Lovejoy
  • Yvonne L. Eaglehouse
  • Matthew T. Hueman
  • Bradley J. Mostoller
  • Craig D. Shriver
  • Rachel E. EllsworthEmail author
Health Services Research and Global Oncology



Survival disparities between African American women (AAW) and European American women (EAW) with invasive breast cancer may be attributable, in part, to access to or quality of medical care. In this study, we evaluated surgical disparities between AAW and EAW treated within an equal-access military treatment facility (MTF).


All AAW (N = 271) and EAW (N = 628) with Stage I–III breast cancer who had their initial diagnosis performed at Murtha Cancer Center at Walter Reed National Military Medical Center were identified. Differences in surgical interval (time between diagnosis and definitive breast surgery) and surgical procedures were evaluated using χ2 and Student t-tests while survival was analyzed using Kaplan–Meier survival estimates and log-rank tests. A P value < 0.05 was used to define significance.


Surgical intervals did not differ significantly between populations with an average of 36.3 days in AAW and 33.9 days in EAW. Frequency of the percentage of women undergoing reexcision, mastectomy, and prophylactic removal of the contralateral breast did not differ significantly between populations. Likewise, frequency of sentinel lymph node biopsy and 5-year survival were not significantly different between AAW compared to EAW.


Surgical intervals and procedures were similar between AAW and EAW treated within an equal-access MTF. These data demonstrate that the availability of quality surgical care to all patients with stage I–III breast cancer may eliminate survival disparities between AAW and EAW, emphasizing the importance of equalizing access to breast care.



The authors thank Dr. Darrell Ellsworth for his critical review of this manuscript. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD), the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.


This research was supported by a cooperative agreement from the Uniformed Services University of the Health Sciences HU0001-16-2-0004 through the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.


  1. 1.
    DeSantis CE, Fedewa SA, Goding Sauer A, Kramer JL, Smith RA, Jemal A. Breast cancer statistics, 2015: convergence of incidence rates between black and white women. CA Cancer J Clin. 2016;66(1):31–42.CrossRefPubMedGoogle Scholar
  2. 2.
    Huo D, Hu H, Rhie SK, et al. Comparison of breast cancer molecular features and survival by African and European Ancestry in The Cancer Genome Atlas. JAMA Oncol. 2017;3(12):1654–62.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Danforth DN Jr. Disparities in breast cancer outcomes between Caucasian and African American women: a model for describing the relationship of biological and nonbiological factors. Breast Cancer Res. 2013;15(3):208.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    DeLancey JO, Thun MJ, Jemal A, Ward EM. Recent trends in black-white disparities in cancer mortality. Cancer Epidemiol Biomarker Prev. 2008;17(11):2908–12.CrossRefGoogle Scholar
  5. 5.
    Press R, Carrasquillo O, Sciacca RR, Giardina EG. Racial/ethnic disparities in time to follow-up after an abnormal mammogram. J Womens Health (Larchmt). 2008;17(6):923–30.CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Silber JH, Rosenbaum PR, Clark AS, et al. Characteristics associated with differences in survival among black and white women with breast cancer. JAMA. 2013;310(4):389–97.CrossRefPubMedGoogle Scholar
  7. 7.
    Griggs JJ, Culakova E, Sorbero ME, Poniewierski MS, Wolff DA, Crawford J, Dale DC, Lyman GH. Social and racial differences in selection of breast cancer adjuvant chemotherapy regimens. J Clin Oncol. 2007;25(18):2522–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Bustami RT, Shulkin DB, O’Donnell N, Whitman ED. Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study. JRSM Open. 2014;5(7):2042533313515863.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Sheppard VB, Oppong BA, Hampton R, et al. Disparities in breast cancer surgery delay: the lingering effect of race. Ann Surg Oncol. 2015;22(9):2902–11.CrossRefPubMedGoogle Scholar
  10. 10.
    Selove R, Kilbourne B, Fadden MK, et al. Time from screening mammography to biopsy and from biopsy to breast cancer treatment among black and white, women medicare beneficiaries not participating in a health maintenance organization. Womens Health Issues. 2016;26(6):642–7.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    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 Biomarker Prev. 2008;17(10):2882–90.CrossRefGoogle Scholar
  12. 12.
    Akinyemiju TF, Vin-Raviv N, Chavez-Yenter D, Zhao X, Budhwani H. Race/ethnicity and socio-economic differences in breast cancer surgery outcomes. Cancer Epidemiol. 2015;39(5):745–51.CrossRefPubMedGoogle Scholar
  13. 13.
    Thomas P, Killelea BK, Horowitz N, Chagpar AB, Lannin DR. Racial differences in utilization of breast conservation surgery: results from the National Cancer Data Base (NCDB). Ann Surg Oncol. 2016;23(10):3272–83.CrossRefPubMedGoogle Scholar
  14. 14.
    Shen Y, Dong W, Esteva FJ, Kau SW, Theriault RL, Bevers TB. Are there racial differences in breast cancer treatments and clinical outcomes for women treated at M.D. Anderson Cancer Center? Breast Cancer Res Treat. 2007;102(3):347–56.CrossRefPubMedGoogle Scholar
  15. 15.
    Banerjee M, George J, Yee C, Hryniuk W, Schwartz K. Disentangling the effects of race on breast cancer treatment. Cancer. 2007;110(10):2169–77.CrossRefPubMedGoogle Scholar
  16. 16.
    Sabel MS, Kraft CT, Griffith KA, Bensenhaver JM, Newman LA, Hawley ST, Momoh AO. Differences between breast conservation-eligible patients and unilateral mastectomy patients in choosing contralateral prophylactic mastectomies. Breast J. 2016;22(6):607–15.CrossRefPubMedGoogle Scholar
  17. 17.
    American Joint Committee on Cacner. AJCC Cancer Staging Manual, vol. 7th edn. New York: Springer; 2010.CrossRefGoogle Scholar
  18. 18.
    Albano JD, Ward E, Jemal A, Anderson R, Cokkinides VE, Murray T, Henley J, Liff J, Thun MJ. Cancer mortality in the United States by education level and race. J Natl Cancer Inst. 2007;99(18):1384–94.CrossRefPubMedGoogle Scholar
  19. 19.
    Bates T, Evans T, Lagord C, Monypenny I, Kearins O, Lawrence G. A population based study of variations in operation rates for breast cancer, of comorbidity and prognosis at diagnosis: failure to operate for early breast cancer in older women. Eur J Surg Oncol. 2014;40(10):1230–6.CrossRefPubMedGoogle Scholar
  20. 20.
    Polverini AC, Nelson RA, Marcinkowski E, Jones VC, Lai L, Mortimer JE, Taylor L, Vito C, Yim J, Kruper L. Time to treatment: measuring quality breast cancer care. Ann Surg Oncol. 2016;23(10):3392–402.CrossRefPubMedGoogle Scholar
  21. 21.
    Martinez ME, Unkart JT, Tao L, Kroenke CH, Schwab R, Komenaka I, Gomez SL. Prognostic significance of marital status in breast cancer survival: a population-based study. PLoS One. 2017;12(5):e0175515.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Lee K, Kruper L, Dieli-Conwright CM, Mortimer JE. The impact of obesity on breast cancer diagnosis and treatment. Curr Oncol Rep. 2019;21(5):41.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Anders CK, Johnson R, Litton J, Phillips M, Bleyer A. Breast cancer before age 40 years. Semin Oncol. 2009;36(3):237–49.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47(11):1245–51.CrossRefPubMedGoogle Scholar
  25. 25.
    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):1119–26.CrossRefPubMedGoogle Scholar
  26. 26.
    Richardson LC, Royalty J, Howe W, Helsel W, Kammerer W, Benard VB. Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996–2005. Am J Public Health. 2010;100(9):1769–76.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Shippee TP, Kozhimannil KB, Rowan K, Virnig BA. Health insurance coverage and racial disparities in breast reconstruction after mastectomy. Womens Health Issues. 2014;24(3):e261–9.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Ashikaga T, Krag DN, Land SE, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102:111–8.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Black DM, Jiang J, Kuerer HM, Buchholz TA, Smith BD. Racial disparities in adoption of axillary sentinel lymph node biopsy and lymphedema risk in women with breast cancer. JAMA Surg. 2014;149(8):788–96.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Bleicher RJ, Ruth K, Sigurdson ER, et al. Time to surgery and breast cancer survival in the United States. JAMA Oncol. 2016;2(3):330–9.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Foy KC, Fisher JL, Lustberg MB, Gray DM, DeGraffinreid CR, Paskett ED. Disparities in breast cancer tumor characteristics, treatment, time to treatment, and survival probability among African American and white women. NPJ Breast Cancer. 2018;4:7.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Shi R, Taylor H, McLarty J, Liu L, Mills G, Burton G. Effects of payer status on breast cancer survival: a retrospective study. BMC Cancer. 2015;15:211.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Komenaka IK, Martinez ME, Pennington RE Jr, Hsu CH, Clare SE, Thompson PA, Murphy C, Zork NM, Goulet RJ Jr. Race and ethnicity and breast cancer outcomes in an underinsured population. J Natl Cancer Inst. 2010;102(15):1178–87.CrossRefPubMedGoogle Scholar
  34. 34.
    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):677–97.CrossRefPubMedGoogle Scholar
  35. 35.
    Rizzo JA, Sherman WE, Arciero CA. Racial disparity in survival from early breast cancer in the department of defense healthcare system. J Surg Oncol. 2015;111(7):819–23.CrossRefPubMedGoogle Scholar
  36. 36.
    Enewold L, Zhou J, McGlynn KA, Anderson WF, Shriver CD, Potter JF, Zahm SH, Zhu K. Racial variation in breast cancer treatment among Department of Defense beneficiaries. Cancer. 2012;118(3):812–20.CrossRefPubMedGoogle Scholar
  37. 37.
    American Cancer Society: Breast Cancer Facts and Figures 2017–2018. Atlanta; 2017.Google Scholar
  38. 38.
    Deshpande AD, Jeffe DB, Gnerlich J, Iqbal AZ, Thummalakunta A, Margenthaler JA. Racial disparities in breast cancer survival: an analysis by age and stage. J Surg Res. 2009;153(1):105–13.CrossRefPubMedGoogle Scholar
  39. 39.
    Enewold LR, McGlynn KA, Zahm SH, Poudrier J, Anderson WF, Shriver CD, Zhu K. Breast reconstruction after mastectomy among Department of Defense beneficiaries by race. Cancer. 2014;120(19):3033–9.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Smith SK, Dixon A, Trevena L, Nutbeam D, McCaffery KJ. Exploring patient involvement in healthcare decision making across different education and functional health literacy groups. Social Sci Med. 2009;69(12):1805–12.CrossRefGoogle Scholar
  41. 41.
    Akinyemiju T, Meng Q, Vin-Raviv N. Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample. BMC Cancer. 2016;16:715.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Tammemagi CM, Nerenz D, Neslund-Dudas C, Feldkamp C, Nathanson D. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005;294(14):1765–72.CrossRefPubMedGoogle Scholar
  43. 43.
    Enewold L, McGlynn KA, Shriver CD, Zhu K. Mammography screening by race/ethnicity among US servicewomen, 2009–2010. Mil Med. 2012;177(12):1513–8.Google Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Leann A. Lovejoy
    • 1
  • Yvonne L. Eaglehouse
    • 2
  • Matthew T. Hueman
    • 3
  • Bradley J. Mostoller
    • 1
  • Craig D. Shriver
    • 3
  • Rachel E. Ellsworth
    • 2
    • 4
    Email author
  1. 1.Chan Soon-Shiong Institute of Molecular MedicineWindberUSA
  2. 2.Clinical Breast Care Project, Murtha Cancer Center Research ProgramUniformed Services University of the Health Sciences, and Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaUSA
  3. 3.Clinical Breast Care Project, Murtha Cancer Center Research ProgramUniformed Services University and Walter Reed National Military Medical CenterBethesdaUSA
  4. 4.Clinical Breast Care ProjectMurtha Cancer Center Research Program, Uniformed Services University of the Health Sciences, and Henry M. Jackson Foundation for the Advancement of Military MedicineWindberUSA

Personalised recommendations