By Katrina Woznicki
Thursday, February 27, 2003
A new study sheds light on disparities in diagnosis, treatment and survival among women of different race and class backgrounds.
WOMENSENEWS)--A patient's ethnic background is a solid factor in her breast cancer diagnosis, treatment and survival, according to a new study by the world-renowned Fred Hutchinson Cancer Research Center in Seattle.
The research, published in the Archives of Internal Medicine last month, confirms what women's health advocates have known for years: Race and socioeconomic status can have a direct effect on whether breast cancer becomes a manageable disease or ends a woman's life.
Lead researcher and professor of epidemiology Dr. Christopher Li set out to document these factors. His study is one of the first to look at specific ethnic populations, such as Japanese women and Indian-Pakistani women, as opposed to generalizing women under categories such as "Asian-Pacific" or "Southeast Asian."
"Many of the disparities we identified we believe to be preventable," Li said. "A lot of people don't have resources to get health care in our country and, on top of that, our health care system doesn't have a lot of physicians or a lot of professionals who have that cultural sensitivity."
Li examined data collected from 1992 to 1998 on 124,934 women from across the United States, including Washington, California, Georgia, Michigan, Connecticut, Hawaii, Iowa, New Mexico and Utah. The study separates the findings into three parts: the stage of disease at detection, treatment, and survival.
Li found significant differences in cancer stage at the time of diagnosis, signaling how advanced the disease had spread before it was detected. The more advanced the disease, the greater the challenge of effectively treating it. Japanese women were 30 percent less likely to be diagnosed with late-stage breast cancer compared to other women. Blacks, Native Americans and Hispanic whites were roughly twice as likely to be diagnosed with later-stage tumors, with Puerto Rican women faring the worst, with a late-stage diagnosis 3.6 times higher than the rest of the women in the study.
There were also racial differences in treatment. Mexican and Puerto Rican women were 50 percent more likely to receive substandard care when compared to non-Hispanic whites, and black women were 40 percent more likely to undergo initial therapy that was below national standards.
Asian women fared better. Japanese, Filipino, Chinese, Korean and Vietnamese women were much more likely than other ethnic groups to receive appropriate medical treatment.
The right treatment means better odds for survival. Blacks, Native Americans and Hispanic whites faced a 10 to 70 percent greater risk of dying after a breast-cancer diagnosis compared to non-Hispanic whites. Japanese and Chinese women had better breast cancer survival rates, while Hawaiian and Mexican women had a 30 percent poorer survival rate when compared to non-Hispanic whites.
Roshan Bastani, professor of health services at the School of Public Health at the University of California at Los Angeles and associate director of the division of cancer prevention and control research in the UCLA Jonsson Comprehensive Cancer Center, said that many factors explain why racial disparities exist among breast cancer patients. In addition to socioeconomic status, access to health care, language barriers and the length of time the woman or her family has lived in the United States are factors. The more recent their arrival to this country, Bastani explains, the less likely they have health insurance or access to health care.
Also, cultural beliefs are a factor and can affect how comfortable a woman feels about discussing such a private subject as the health of her breasts, Bastani says, or whether she thinks about preventive health care. Remembering these differences is important in attempting to narrow racial gaps in medicine, she explains, because a one-size breast cancer treatment approach won't fit all women in America.
"Some programs might work well in South Carolina, and you might want to adapt it to L.A. but then it doesn't work," says Bastani. "Women in South Carolina are different than the women in L.A. Transportation is different. Access to transportation can be an issue in getting the right health care, and reaching out to women in rural areas can be more of a challenge," she says.
The Susan G. Komen Breast Cancer Foundation, one of the nation's largest breast cancer advocacy groups, has been testing possible solutions to this problem.
"Each group is unique and you have to be patient and learn your way in and learn the gatekeeper of that group," says Cheryl Kidd, director of education at Susan G. Komen's national headquarters in Dallas. Establishing rapport with a cultural group's gatekeeper, Kidd explains, could dramatically increase her chances of survival.
For example, the foundation has found that Latinas prefer more face-to-face time when learning about breast cancer. "You can't just come in with fliers," Kidd said
Trust matters immensely when disseminating breast cancer awareness information and many Susan G. Komen representatives have found the church an ideal place to talk to women about breast health. That's proved true for the Russian Orthodox community in Oregon, says Kidd, and also for African American church-goers in the South.
Native Americans, a group that reported a poor outcome in Li's study, are "generally very closed," Kidd says, and express a distrust toward Western medicine. Their homes are also often in remote locations, making access to medical care difficult. Susan G. Komen representatives try to find individuals living on Native American reservations to work as liaisons. Currently, the foundation is testing a pilot program on Navajo reservations in Arizona. The program brings digital mammography to the reservation and sends the digital screenings to Walter Reed Army Medical Center in Washington, D.C. and The Johns Hopkins Medical Institutions in Baltimore.
"There's no such thing as a cookie-cutter," Kidd says.
Katrina Woznicki is a freelance journalist in Washington, D.C.
Fred Hutchinson Cancer Research Center--"Breast-cancer Treatments and Outcomes Differ Widely Among Women of Different Races, Ethnicities":
Susan G. Komen Breast Cancer Foundation:
Archives of Internal Medicine--"Differences in Breast Cancer Stage, Treatment, and Survival by Race and Ethnicity":
National Breast Cancer Coalition: