A study in the June 1 issue of Cancer found significantly lower stage-specific survival rates for black women under the age of 50 even when the type and stage of the breast cancer were identical. On the other hand, there were no significant differences in women over the age of 65, suggesting the universal availability of Medicare might iron out earlier disparities.
"If you have a high percentage of people covered with Medicare, the differences that you see in the younger age groups need to be thought of not only in the parameters of biology and aggressiveness, but also in the parameters of the health-care system," says study author Kenneth C. Chu, program director of the Center to Reduce Cancer Health Disparities at the National Cancer Institute. "We're trying to open up that door so that discussion can begin."
The issue of racial disparities in health care has been a subject of increased interest and scrutiny, and the picture emerging is an incredibly complex one.
According to Barbara Krimgold, director of the health disparities project at the Center for the Advancement of Health, there appear to be four broad reasons why black women have higher mortality rates from breast cancer, even though white women have a higher incidence. Those areas are socioeconomic status, racism, access to insurance and health care and treatment.
Previous studies have shown black women are less likely to get mammograms and are therefore diagnosed later than white women. They are also less likely to receive the same treatments.
"As the Institute of Medicine reported, even where African-Americans have equal incomes or equal insurance, the treatment is different and the outcomes are different. So you frequently get less aggressive treatment, and it's sometimes less awareness on the part of the patients and probably unconscious discrimination in most cases on the part of providers, who don't seem to act as quickly or as aggressively in treating their black patients," Krimgold says.
Clinical trials, however, have shown that when black and white women receive equal treatment for their particular type of breast cancer, they have similar survival rates.
Using breast cancer data from the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program, Chu and his colleagues compared survival rates in black and white women at specific stages of breast cancer and according to ER status. In other words, a white woman with stage 3 ER-positive breast cancer would be compared only to a black woman with stage 3 ER-positive breast cancer.
"The ER status is related to the types of treatment you have," Chu explains. ""What I tried to do was remove the fact that black women present at a later stage from their actual survival."
In general, black women had lower six-year survival rates for each stage of breast cancer. The differences were more pronounced in younger groups, however. Black women under the age of 50 with ER-positive cancers, for instance, had significantly lower six-year survival rates. In the over-65 group, there were no real differences.
Most other researchers have used the age of 50 as a cut-off point, to coincide roughly with the beginning of menopause. "When you look at that break, you'll see differences in both age groups," Chu says. "We looked at the older age group because we were interested in knowing not the biology, but whether or not Medicare may in fact have some potential impact."
This study suggests an association, but it doesn't prove a cause-and-effect link.
And the association has been noted before. "When we compare the U.S. to other countries, we see the U.S. hovering around 20th among all industrialized nations for almost all health status indicators: infant mortality, life expectancy and potential years of life lost prematurely," Krimgold says. "But once people in the U.S. make it to age 65, the U.S. rises near the top of the health indicator tables. With universal health care and income support through Medicare and Social Security, elderly people in the U.S. have better prospects for health and life expectancy compared with their counterparts in other countries than do younger Americans."
But the prospects of middle-age black women shown in this study were troubling to Dr. Alfred R. Ashford, a professor of clinical medicine at Columbia University College of Physicians and Surgeons and director of the department of medicine at Harlem Hospital, both in New York City.
"I think that's very tragic in our society that all the pieces of a modern treatment package are not always there for women of various backgrounds but perhaps, in particular, the poor and ethnic minority groups. It has to be corrected," Ashford says. "We call this an access-to-care problem. We have public safety net hospitals, which usually can provide this care."
People are probably not accessing this safety net because they are not aware they exist, adds Ashford, who is also director of the cancer center for Lincoln, Metropolitan and Harlem hospitals, all of which are part of the New York City public hospital network.