Correspondence to: Lisa Richardson, MD, MPH, Centers for Disease Control & Prevention, Division of Cancer Prevention and Control, 4770 Buford Highway NE, MS K-55, Atlanta, GA 30341 (e-mail: lfr8{at}cdc.gov).
I read with interest the article by Cheblowski et al. (1) regarding race/ethnicity and breast cancer characteristics and mortality among participants in the Women's Health Initiative (WHI) study. The authors concluded that the higher breast cancer mortality in black women than in white women may be due to black women's cancers being more likely than those of white women to be estrogen receptor negative, progesterone receptor negative, and poorly differentiatedall characteristics that are associated with poorer prognosis (2).
Although racial/ethnic differences in breast cancer mortality may be partially attributable to differences in tumor characteristics, the authors did not give adequate attention to two well-known sources of disparities in mortality; differences in access to health care services and differences in the quality of care that is delivered once access is attained (3). That is, the authors assume that, because most women in the WHI were insured, they had equivalent access to diagnostic and treatment services for breast cancer. However, this was not necessarily the case: even though most women enrolled in the WHI were insured, there was evidence in the report of differential delivery of services to black women, who received, on average, fewer mammograms than white women (even though they were part of the clinical trial). In addition, the study did not examine differences in treatment.
There is also evidence of differential delivery of adjuvant radiation therapy and chemotherapy after surgery for black women as compared with white women (4). Black women are less likely to receive radiation therapy after breast-conserving surgery and more likely to receive reductions in chemotherapy dose before beginning chemotherapy as well as during treatment, which affects outcome. Examination of the impact of receipt of less than definitive stage-appropriate treatment for breast cancer indicated that women who do not receive appropriate therapy have higher recurrence rates and poorer survival (5). Population-based studies using Surveillance, Epidemiology and End Results data to examine the contribution of incidence and survival to observed mortality differences in breast cancer have implicated less-than-optimal breast cancer care as the culprit (6).
I believe that the conclusions of the Chlebowski et al. study must be tempered in light of a lack of information presented in the paper on access to treatment and quality of the care received. Because there is no reason to believe that breast cancers in black women respond differently to cancer therapy than those in white women, treatment must be accounted for in any analysis that seeks to explain mortality differences between black and white women. If the tumors in black women have more aggressive biologic characteristics than those in white women, perhaps more aggressive treatment is needed. At a minimum, we need to consider the quality of the health care delivered when examining disparities in cancer outcomes (7).
REFERENCES
(1) Chlebowski RT, Chen Z, Anderson GL, Rohan T, Aragaki A, Lane D, et al. Ethnicity and breast cancer: factors influencing differences in incidence and outcome. J Natl Cancer Inst 2005;97:43948.
(2) Fisher B, Jeong JH, Anderson S, Wolmark N. Treatment of axillary lymph node-negative, estrogen receptor-negative breast cancer: updated findings from national surgical adjuvant breast and bowel project clinical trials. J Natl Cancer Inst 2004;96:182331.
(3) Hargraves JL, Cunningham PJ, Hughes RG. Racial and ethnic differences in access to medical care in managed care plans. Health Serv Res 2001;36:85368.[ISI][Medline]
(4) Griggs JJ, Sorbrero ME, Stark AT, Heininger SE, Dick AW. Racial disparity in the dose and dose intensity of breast cancer adjuvant chemotherapy. Breast Cancer Res Treat 2003;81:2131.[CrossRef][ISI][Medline]
(5) Lash TL, Silliman RA, Guadagnoli E, Mor V. The effect of less than definitive care on breast carcinoma recurrence and mortality. Cancer 2000;89:173947.[CrossRef][ISI][Medline]
(6) Goodwin JS, Freeman JL, Mahnken JD, Freeman DH, Nattinger AB. Geographic variations in breast cancer survival among older women: implications for quality of breast cancer care. J Gerontol 2002;57:M4016.[ISI]
(7) Institute of Medicine. Ensuring Quality Cancer Care. Hewitt M, Simone JV, editors. Washington D.C.: National Academy Press; 1999.
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