Affiliation of authors: Health Services and Economic Branch, Applied Research Program, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD.
Correspondence to: Vickie L. Shavers, Ph.D., National Institutes of Health, 6130 Executive Blvd., EPN 4005, MSC 7344, Bethesda, MD 208927344 (e-mail: shaversv{at}mail.nih.gov).
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
BACKGROUND |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Approximately 552 000 Americans died of cancer in the year 2000 (1). A disproportionate number of these deaths occurred among racial/ethnic minorities, particularly African Americans, who have a 33% increased risk of dying of cancer compared with whites. Disproportionately high mortality rates are observed among African Americans for cancers of the lung, breast, prostate, colon and rectum, oral cavity and pharynx, cervix (2), and esophagus (3). In addition, the 5-year survival rates for African Americans are lower than those for whites for all of the major cancer sites (Table 1).
|
Racial/ethnic disparities in cancer outcomes are often attributed to a more advanced stage of disease at diagnosis among minorities (810). Differences in the stage of the cancer at diagnosis are thought to be primarily caused by the underutilization of cancer screening among racial/ethnic minorities (1113). As a consequence, increasing access to screening has been the mainstay of the battle against racial/ethnic disparities in cancer mortality. Results from the National Health Interview Survey for 1987, 1992, and 1998 show that racial gaps in screening for breast and cervical cancers are closing for white, African-American, and Hispanic women; however, screening rates for colorectal cancer among African Americans and Hispanics continue to be substantially lower than rates for whites (14). There is also evidence of racial differentials in diagnostic follow-up of abnormal screening examinations (1517) that might also contribute to higher disease stage at diagnosis among screened populations.
After adjusting for the stage of the cancer at diagnosis, however, several investigators (1826) have reported residual disparities in cancer survival and mortality by race/ethnic group. This observation suggests that factors other than the stage at diagnosis contribute to the disparate cancer mortality observed among racial/ethnic minority populations.
Ideally, once diagnosed, patients will receive the appropriate treatment given their disease severity, prognostic factors, and comorbid conditions/or other contraindications to treatment. Studies of access to and/or utilization of noncancer medical services have, however, found racial differences in treatment after controlling for these factors. Race/ethnicity have been found to influence quality of care (27,28), service delivery (29), disposition after treatment in the emergency room (30), intensity of care provided to hospitalized patients (31), receipt of antiretroviral therapy (32,33), management of psychiatric disorders (34), receipt of certain cardiovascular procedures (29,30,35), and receipt of diagnostic cancer services (36). These findings coupled with the disproportionately higher cancer mortality of racial/ethnic minorities raise questions about possible disparities in the receipt of cancer treatment.
There are three broad categories of factors that have the potential to influence the receipt of optimal cancer care: structural barriers, factors that influence physician recommendations, and factors that influence patient freedom of choice and/or decision making. Structural barriers include insurance coverage and type and geographic location of the institution where care is to be received. Physician recommendations are influenced by factors, such as stage of disease, presence of certain prognostic indicators, perception of the willingness or ability of the patients to comply with treatment recommendations, preferences, and personal biases. Patient decision making is influenced by their attitudes and beliefs about specific treatments, their ability to navigate the medical system and to overcome structural and other barriers, and their personal preferences and biases (Fig. 1).
|
To evaluate the existence of racial/ethnic disparities in the receipt of cancer treatment, we examined the published literature. We were interested in answering the following four questions: 1) Are there racial/ethnic variations in the receipt of cancer treatment? 2) If so, for which cancer diagnoses and types of treatment do these variations exist? 3) What is known about the specific mechanisms that explain these variations? 4) Do these treatment variations result in racial/ethnic disparities in cancer outcomes?
![]() |
METHODS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
This review focuses on the racial/ethnic variation in treatment given to patients with breast, cervical, colorectal, prostate, or lung cancer. These cancers are estimated to have accounted for about 55% of all cancer incidence and more than 52% of all cancer mortality in 2000 (1). Well-defined treatment options exist for each of these cancer sites, although the relative efficacy of these treatments has not been definitively established by clinical evidence in all cases. In addition, the majority of published studies of cancer treatment patterns focus on these sites.
This review describes findings by cancer site. Each section begins with a description of stage-specific treatment options, which were obtained from The National Cancer Institute's PDQ (3742). PDQ treatment summaries are peer reviewed and updated monthly by oncology specialists. Current literature on cancer treatment is reviewed from more than 70 biomedical journals. The section on treatment options is followed by one which provides results of articles on efficacy/effectiveness of specific treatments by race/ethnic group. Sections are also included on studies of trends in the patterns of care for specific treatments and studies that examine racial differences in access and utilization of specific treatments.
Both authors of this review independently reviewed all articles. Differences in the interpretation of findings were resolved by a consensus.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Eighty-seven studies were reviewed. Of these studies, 23 were clinical trials or equal treatment studies that provided data on treatment efficacy/effectiveness among racial/ethnic groups. We also reviewed eight studies that described treatment trends. The remaining 56 studies described racial/ethnic patterns of treatment. The majority of studies limited inclusion or analyses to African Americans and whites. Cancer-treatment patterns were described for Hispanics in 16 of the reviewed studies, for Asians in three, and for Native Americans in two.
Breast Cancer
Overview of Treatment Options
Clinical factors that influence breast cancer treatment selection include menopausal status, stage, axillary lymph node status, histologic and nuclear grade of the primary tumor, and estrogen receptor and progesterone receptor status. Specific PDQ recommendations for the treatment of breast cancer for patients not treated on a clinical trial protocol are provided in Table 2.
|
As seen in Table 2, systemic adjuvant chemotherapy or hormonal therapy is also recommended for women diagnosed with early-stage breast cancer, with specific types of adjuvant therapy depending on patient age, tumor size, nodal status and ER status.
Efficacy and Effectiveness We reviewed six studies that provided data on the efficacy and/or effectiveness of specific breast cancer treatment regimens by race/ethnic group. Roach et al. (47) reported that, after controlling for clinical prognostic factors, data from the Cancer and Leukemia Group B Trial, which began in 1985, show that African-American women, white women, and women of other races treated with adjuvant chemotherapy for stage II breast cancer had similar benefits. Data from the National Surgical and Adjuvant Breast and Bowel Project (NSABP) from 1981 through 1988 (48) and the Piedmont Oncology Association from 1974 through 1986 (22) also showed that African-American and white women with breast cancer received similar benefit from chemotherapy after surgical resection. A study comparing outcomes after breast-conserving surgery or mastectomy among African-American women treated at The University of Texas M. D. Anderson Cancer Center (Houston) from 1975 through 1994 revealed no differences in local recurrence, disease-free survival, and overall survival by type of treatment (49).
In contrast to these findings, Connor et al. (50) found higher systemic recurrence rates and shorter time to recurrence among African Americans than among whites treated from June 1982 through January 1998 with breast-conserving surgery and radiation therapy for stage II breast cancer at the University of Kansas Medical Center, Kansas City. There was, however, no statistically significant difference between African Americans and whites with regard to local recurrence rates for stage I or II breast cancer. In this study, African Americans treated from June 1982 through January 1998 were compared with white women treated from June 1982 through June 1990. In another study, Elias et al. (51) found that African-American women with stage I or II breast cancer had shorter overall survival and disease-free survival than white women who received similar treatment and had similar adjuvant chemotherapy compliance rates. Survival differences were confined to women with one to three positive lymph nodes.
There is also some evidence that suggests that the prevalence of estrogen receptor-positive breast tumors may be lower in African Americans and Hispanics than in whites (52,53), which might account for racial/ethnic differences in the use of tamoxifen. Furthermore, other evidence suggests that, because of the increased risk of stroke, pulmonary embolism, and deep vein thrombosis associated with tamoxifen, African Americans, who already have a higher prevalence of risk factors for these conditions, may receive less overall benefit from tamoxifen (54).
In general, however, there do not appear to be major racial/ethnic differences in the efficacy/effectiveness of breast cancer treatments. Among studies that did find differences, clinical factors that may have influenced the reported outcomes were often not examined in the analyses. For example, in studies by Elias et al. (51) and Connor et al. (50), comorbidity and other clinical prognostic indicators that might have explained the observed survival differences were not examined.
Trend Studies Since 1990, the use of breast-conserving surgery has increased among patients with early-stage breast cancer; however, mastectomy is still the most frequent therapeutic surgical procedure received (55,56). Data from the Detroit Cancer Surveillance System, a Surveillance, Epidemiology, and End Results (SEER)1 registry, show that use of breast-conserving surgery (57) increased from 5% from 1973 through 1977 to 42% from 1988 through 1992. Rates of breast-conserving surgery varied by age but were about the same for African Americans and whites. A more recent study (55) using data from the California Tumor Registry shows that, although breast-conserving surgery rates have increased among African-American women, they still lag behind utilization rates of similarly staged white women. An analysis of data from the SEER registries shows that the use of breast-conserving surgery for early-stage cancers ranges from a low of 26.7% in Iowa to a high of 55.6% in Connecticut (58). Receipt of recommended adjuvant therapy has also been shown to be declining among some rural African-American and white women (56).
Access/Utilization Studies Breast-conserving surgery. Several studies (5961) found racial variation in the receipt of breast-conserving surgery. Data from the Black/White Cancer Survival Study for 1985 and 1986 show that, after controlling for tumor size and comorbidity, African Americans were less likely than whites to receive breast-conserving surgery and radiation therapy instead of mastectomy (60). Medicare claims data for 1986 (62) and 1990 (61) indicated that elderly African Americans were significantly less likely than whites to receive breast-conserving surgery.
In contrast, analysis of SEER data from 1983 through 1986 showed no racial/ethnic differences in the receipt of breast-conserving surgery (63), as did a study of treatment for early-stage breast cancer diagnosed from 1985 through 1987 conducted by the Metropolitan Detroit Cancer Surveillance System (64). Although Ballard-Barbash et al. (65) found that the receipt of breast-conserving surgery was similar for African Americans and whites in SEER areas from 1985 through 1989, rates of breast-conserving surgery were somewhat lower for other nonwhite patients with breast cancer.
More recent studies (56,59,66,67), however, have demonstrated few differences between African Americans and whites in the receipt of appropriate surgical treatment of breast cancer among treated patients. Tropman et al. (56) reported that rural African-American and white women diagnosed with stage I or II breast cancer received breast-conserving surgery at a similar frequency in 1991 and 1996, after adjusting for comorbidity, estrogen receptor status, tumor size, and clinical trial enrollment. Data from the California Cancer Registry from 1988 through 1995 (55) and from SEERMedicare from 1988 through 1993 (68) show that the rate of breast-conserving surgery was higher among African Americans than among whites and other racial/ethnic groups examined. In contrast, data from the Carolina Breast Cancer Study from 1995 through 2000 showed that fewer African Americans than whites received breast-conserving surgery (59).
Racial/ethnic differences in the receipt of breast-conserving surgery seem to be more prevalent among other nonwhite populations, particularly Asians and Hispanics, than among African Americans. Morris et al. (55) noted that Asian and Hispanic women received breast-conserving surgery at a statistically significantly lower frequency than white women. Similarly, Lee et al. (69) found that, among women diagnosed from January 1990 through December 1992, Chinese women were less likely than African-American and white women to receive breast-conserving surgery and reconstructive surgery after mastectomy.
Adjuvant radiation therapy. Racial/ethnic disparity in breast cancer treatment is more evident in the receipt of adjuvant radiation therapy after breast-conserving surgery. Analysis of SEER data from 1983 through 1986 shows that African Americans were less likely than whites to receive radiation therapy after breast-conserving surgery (63), as did an analysis of SEER data from 1985 through 1989 (65) and SEER data from 1988 through 1993 (68). Similarly, data from a convenience sample of hospitals showed that, among elderly women diagnosed from November 1995 through September 1997, African Americans were two times more likely than whites not to receive radiation therapy after breast-conserving surgery (70).
Other studies. Several other studies of patterns of breast cancer care during the 1980s provide some evidence of racial variations in the receipt of breast cancer treatment. Included are differences in the receipt of appropriate diagnostic testing, definitive treatment, conservative surgery, and follow-up after diagnosis and initial treatment. When screened by the National Breast and Cervical Cancer Early Detection Program from July 1, 1991, through September 30, 1995, racial/ethnic minority women had longer periods from the first abnormal screening to diagnosis and from diagnosis to treatment initiation than white women (71). Data from the University of San Francisco Mobile Mammography Screening Program for women screened from July 1993 through May 1994 also show that nonwhite women have longer follow-up times after an abnormal mammogram than white women (15). In crude analyses of data from the Black-White Cancer Survival study for 1985 and 1986, African-American women were less likely than white women to receive minimum expected therapy (72). Racial differences in receipt of minimum expected therapy, however, were not statistically significant when data were stratified by stage at diagnosis (early/late). In addition, an analysis of SEERMedicare data for women diagnosed in 1991 showed that African Americans were significantly less likely than whites to have a mammogram after their diagnosis and treatment of breast cancer (73).
Studies reporting no racial/ethnic minority treatment disparities. Several studies reported no racial/ethnic disparities in treatment patterns. Although PDQ-recommended adjuvant chemotherapy and hormonal therapy were less frequently received than primary therapy (i.e., surgery and radiation therapy), Tropman et al. (56) found no racial differences in the receipt of these treatments between rural African-American and white women in data from the Reaching Communities for Cancer Care Project in 1991 or 1996. African-American, Hispanic, and Asian patients with breast cancer in selected California counties diagnosed from 1984 through 1990 were statistically significantly more likely than white patients to receive chemotherapy and less likely to receive hormone therapy as treatment of local and regional-stage breast cancer (24). Data from the New Mexico Tumor Registry for women diagnosed with breast cancer for 1994 and 1995 showed that racial/ethnic minorities were more likely than whites to receive radiation therapy after breast-conserving surgery (74). Siminoff et al. (75) found no difference between whites and nonwhites in the rate of referral to oncologists after surgical treatment of breast cancer in a population-based sample of data collected from 1993 through 1995.
Summary for breast cancer. We reviewed 23 studies that examined racial/ethnic patterns of care for breast cancer. Fourteen of these studies provided data on treatment patterns only, and eight provided data on both treatment and survival. Twelve of the 23 studies found racial variations in treatment (22,24,52, 5961,65,68,7073). Of these 12 studies, six found statistically significant differences (24,52,60,68,71,73). Two of the three studies (24,52) that reported statistically significant racial/ethnic treatment variations and provided survival data reported survival disparities.
The four largest population-based studies (24,61,65,68), with the greatest statistical power, analyzed data from 1985 through 1993. All studies performed multivariable analyses that adjusted for clinical and nonclinical factors, which varied between studies. Overall, results from these studies were mixed. There does, however, seem to be some consistency in the findings among studies that examined the receipt of radiation therapy after breast-conserving surgery, suggesting that African Americans less frequently receive radiation therapy after breast-conserving surgery (65,68).
Cervical Cancer
Overview of treatment options.
The selection of a specific treatment for stage IA1IA2 cervical cancer may be influenced by the desire for ovarian preservation, comorbid conditions, and potential late side effects. PDQ-recommended stage-specific treatment options for cervical cancer are provided in Table 2.
Efficacy and effectiveness.
No racial differences in outcomes were found among patients treated with radical hysterectomy for stage IB and IIA cervical cancers (76) (Table 3). African-American, Hispanic, and white women had similar response rates to treatment with chemotherapy for advanced cervical cancer (77). Postoperative radiation therapy provided similar survival for African-American and white women who had pathologic risk factors for recurrence (78). In contrast, Han et al. (79) found that African Americans treated with brachytherapy and external-beam radiation therapy had statistically significantly poorer survival than whites for stage II cervical cancer only. Analyses for this study did not control for the prevalence of comorbidity at baseline. The authors suggest that differences in patients with stage II disease may have contributed to the observed survival disparities.
|
Access/utilization studies. Racial/ethnic disparities in the receipt of treatment of cervical cancer were found in the receipt of clinical staging, any definitive treatment, surgery, and intracavitary irradiation. An analysis of SEER data from 1988 through 1994 showed that African Americans were more likely than whites to go untreated and to have radiation therapy alone and were less likely to have surgery alone as treatment of their cervical cancer after controlling for stage and age (82). Similarly, another analysis of SEER data from 1992 through 1996 (83) found that African Americans were less likely than whites to receive clinical staging, and unstaged patients were less likely to be treated. SEER data from 1990 through 1995 indicate that African-American women diagnosed with stage 1A11A2 cervical cancer and Hispanic women with stage 1A2 cervical cancer were more likely than white women with similar disease to be treated with the less adequate fertility-sparing procedures and less likely to be treated with hysterectomy. Among women over the age of 35 years, African Americans were still more likely than white women to receive fertility-sparing procedures than hysterectomy (84). African-American women with International Federation of Gynecology and Obstetrics stage IB cervical cancer were more likely than white women to be treated with radiation therapy alone and less likely to be treated with surgery or combined therapy (85). African Americans with cervical cancer less frequently received intracavitary radiation therapy as opposed to external-beam radiation therapy than white women (86).
Summary for cervical cancer. We reviewed five studies with information on racial patterns of cervical cancer care (8286). Three of these studies were population based (8284), and all three found racial variations in treatment. The two remaining studies analyzed data from medical records of single institutions. A study conducted at Grady Memorial Hospital (Atlanta, GA) found racial variations in cervical cancer treatment (86), whereas the study conducted at the University of Chicago Hospitals (IL) did not (85). In addition to racial treatment variations, Howell et al. (82) also found survival disparities as did Mundt et al. (86); however, findings in Mundt et al. were not statistically significant.
Findings from the limited evidence provided by the reviewed studies suggest that African Americans are less frequently treated for their cervical cancers (82,83). Some evidence also suggests that, when treated, African Americans may more frequently receive fertility-sparing treatment for stage 1A2 cervical cancer (83), which is not a PDQ-recommended treatment option for such patients (see Table 2).
Some factors that influenced racial/ethnic variations in treatment included differences in the prevalence of comorbid conditions (83,86), poorer health (86), patients' refusal of treatment (83,86), and lack of physician recommendation for treatment (83).
Colorectal Cancer
Overview of treatment options.
Surgical resection is recommended for all stages of colorectal cancer. Because failure rates differ by site (colon or rectum), adjuvant therapy recommendations differ by site. PDQ stage-specific treatment recommendations for cancers of the colon and rectum are provided in Table 2.
Efficacy and effectiveness. Trials conducted by the NSABP demonstrated similar efficacy for African Americans and whites for five adjuvant therapeutic regimens for colorectal cancer (87). No statistically significant differences in tumor response or disease progression were found among African Americans and whites with colon cancer enrolled in the Department of Veterans Affairs (VA) Cooperative Study 188 Chemotherapy Trial (88).
Trend studies. Use of anal sphincter-sparing surgery for the treatment of rectal cancer has been increasing, as has multimodal treatment of colon cancer (89).
Access/utilization studies. Racial/ethnic variations were found in the receipt of major therapeutic procedures, including surgical resection (8991). African Americans were less likely than whites with similar disease to receive a major colorectal cancer therapeutic procedure (90), cancer-directed surgery (89, 91), and sphincter-sparing surgery (89). African Americans also were less likely than whites to receive adjuvant therapy for stage III colon cancer (92,93) and resection for advanced colon cancer (94). Hispanics were less likely than non-Hispanics to receive chemotherapy (95). Although several studies found that racial/ethnic minority patients with colorectal cancer were less likely to receive endoscopic follow-up after potential curative surgical treatment (9698), their results were not statistically significant.
In contrast, data from the National Cancer Data Base showed few racial/ethnic differences in the type of treatment received (99). African Americans and Native Americans in this study, however, were more likely than other racial and ethnic groups to be untreated for their colon cancer.
Few racial/ethnic differences were found in treatment of colorectal cancer among patients treated in equal-access systems, where payment and referral patterns are not a barrier to receipt of treatment. For example, African Americans and whites treated for colorectal cancer at VA hospitals had similar rates of surgical resection, radiation therapy (88,100), and chemotherapy (100).
Only one study reported that racial/ethnic minorities more frequently received a specific treatment for colorectal cancer. In contrast to other study findings (8991,95), Roetzheim et al. (95) found that African Americans treated for colorectal cancer in Florida were more likely than whites with a similar stage disease to receive definitive surgery for their colorectal cancer.
Summary for colorectal cancer. The reviewed evidence on racial/ethnic differences in treatment of colorectal cancer is not totally consistent. Studies that did not find differences tended to be nonpopulation based, small studies of a single locality, or studies from institutions characterized as equal-access systems. In contrast, larger population-based studies (91,93,95) and national surveys (89) more frequently found differences in treatment patterns by racial/ethnic status. Four of the five population-based studies showed statistically significant racial/ethnic differences in the receipt of cancer treatment from 1984 through 1996. Evidence from the studies that show differences indicate a consistent pattern of the receipt of less aggressive treatment among nonwhites than among whites, including receipt of any colorectal cancer-directed treatment (8991,94,95), adjuvant therapy (92,93), and follow-up after initial potentially curative treatment (96,97).
Lung Cancer
We reviewed five studies that provided data on racial/ethnic patterns of treatment of lung cancer and three studies of efficacy/effectiveness. Treatment of lung cancer has remained relatively stable, and so we were unable to find studies that examined changes in treatment trends. Many new therapeutic regimens are still in clinical trials. The lack of any major changes in treatment coupled with the high fatality rate associated with lung cancer contributes to PDQ recommendations to enroll patients in clinical trials.
Overview of Treatment Options
Small-cell lung cancer.
Small-cell lung cancer (SCLC) can seldom be surgically resected at the time of diagnosis (101) because patients tend to present with disseminated disease. Neither surgery nor radiation therapy provides long-term survival. Addition of chemotherapy to the treatment regimen increases median survival fourfold to fivefold (42). Because SCLC tends to metastasize to the brain, prophylactic cranial irradiation is often recommended (Table 2). The designation of limited or extensive disease is used in lieu of tumornodemetastasis staging (178) to describe the extent of disease among patients with SCLC.
Non-small-cell lung cancer.
Approximately one third of non-small-cell lung cancers (NSCLCs) can be surgically resected at the time of diagnosis (101). PDQ stage-specific treatment recommendations for SCLC and NSCLC are provided separately in Table 2.
Efficacy and Effectiveness No statistically significant differences in tumor response or disease progression were found among African Americans and whites diagnosed with NSCLC or SCLC enrolled in the VA Cooperative Study 188 Chemotherapy Trial (88). Similarly, African Americans and whites treated with surgical resection for NSCLC experienced similar 5-year survival (102). Graham et al. (103) also found that African Americans and whites with NSCLC had similar survival after receiving radiation therapy.
Access/Utilization Studies African Americans less frequently received surgical resection (88,102,104106), radiation therapy (88), chemotherapy (107), or any definitive treatment (106) for their lung cancer.
SEERMedicare data from 1985 through 1993 show that African Americans were significantly less likely than whites to receive surgical resection for stage I and stage II NSCLC (102). Similarly, African Americans entering a chemotherapy trial from 1981 through 1986 were, at the time of trial enrollment, statistically significantly less likely than whites to have received surgical resection or radiation therapy for their lung cancer (88). African Americans were more likely than whites to have had metastases at the time of diagnosis. SEER data for Detroit (MI), San Francisco (CA), and SeattlePuget Sound (WA) from 1978 through 1982 (104) show that, among patients with early-stage NSCLC, whites were 20% more likely than African Americans to receive surgical resection of their lung cancer. In addition to race, median family income was also a predictor of the receipt of surgical resection. SEERMedicare data from 1991 through 1993 show that African Americans were the least likely of all other racial/ethnic groups to receive chemotherapy for metastatic NSCLC (107). In spite of having the same insurance, African Americans were about 30% less likely than whites to receive palliative chemotherapy. Other factors that negatively influenced the receipt of chemotherapy for metastatic NSCLC were lower socioeconomic status and treatment in a nonteaching hospital. SEER data from 1988 through 1995 indicate that, among patients diagnosed with NSCLC, African-American patients less frequently received a recommendation for surgery than whites (108). Similarly, an analysis of Medicare data from 1985 through 1989 showed lower surgical resection rates for local/regional stage NSCLC and higher rates of no definitive treatment of distant-stage NSCLC among African Americans than among whites; however, these differences were not statistically significant (105). Data from the National Cancer Data Base for 1986 and 1987 indicate that African Americans were less likely to receive treatment for NSCLC than all other racial/ethnic groups examined (106).
Summary for Lung Cancer African Americans were consistently found to less frequently receive treatment for their lung cancers and, when treated, to not receive surgery. Evidence from the reviewed studies suggests that racial differentials in the receipt of surgical resection have persisted throughout the period covered from 1978 through 1995 by the reviewed studies. All of the reviewed studies analyzed data from population-based databases, had large sample sizes, and provided evidence of racial/ethnic variation in the receipt of treatment of lung cancer. Results in one, however, were not statistically significant, and the majority reported survival disparities (102,104,105,108). In two of the studies, all patients also had Medicare insurance coverage (102,107), which should have reduced disparities in access to care.
Prostate Cancer
Overview of treatment options. Several factors should be considered in deciding appropriate treatment options for patients diagnosed with prostate cancer. These factors include stage, histologic grade, age, comorbid conditions, prostate-specific antigen (PSA) levels, and site of metastases (38).
Because of the many side effects associated with the various treatments, the definition of appropriate prostate cancer therapy remains somewhat controversial (109,110). The side effects associated with radical prostatectomy include urinary incontinence, urethral stricture, and impotence. Data from a case series from 1994 through 1997 suggest that new nerve-sparing surgical techniques have lower rates of incontinence and higher rates of potency preservation (111). Complications associated with the use of external-beam radiation therapy include acute cystitis, proctitis, and enteritis. Although potency may be initially preserved, it often diminishes over time. The side effects associated with the use of hormonal therapy include loss of libido, impotence, hot flashes, gynecomastia, and psychologic effects. Stage-specific treatment recommendations for prostate cancer from PDQ are provided in Table 2.
Efficacy and effectiveness. Of the 17 studies that focused on efficacy and effectiveness, 11 concluded that race/ethnicity were not independent predictors of treatment failure. Race/ethnicity were not predictive of poorer outcomes after treatment with radiation therapy (112115), radical prostatectomy (113,116118), hormone therapy (119,120), or chemotherapy. Disease progression (121) and risk of secondary treatment after initial management with "watchful waiting" were found to be similar between African Americans and whites (122). Disease-specific survival did not differ by race for patients treated with radiation therapy (117,123) or for patients with negative surgical margins (118). Incidence-based mortality was found not to differ statistically significantly between African Americans and whites after controlling for stage, grade, age, number of primary cancers, and treatment (124). Iselin et al. (118) found no statistically significant racial differences in cancer survival or time to increased PSA levels of patients treated with prostatectomy when stratified by Gleason grade or extent of disease. Similarly, after adjusting for stage and grade, Austin et al. (115) found no statistically significant racial differences in cause-specific survival after radiation therapy for prostate cancer. Results from Witte et al. (125) indicate that race/ethnicity are not independent predictors of positive surgical margins after radical prostatectomy.
Several other studies, however, have concluded that race/ethnicity did influence treatment outcomes. African Americans with palpable tumors were found to have statistically significantly lower median times to biochemical failure (PSA elevation and disease-specific survival among patients with positive surgical margins after radical prostatectomy) (118). Among patients treated with radiation therapy, African Americans were found to have a larger proportion of tumors with post-treatment PSA levels greater than 10 ng/mL and lower overall survival (126). After controlling for stage, however, statistically significant racial differences in overall and cause-specific survival were evident for stage C disease only. When the analysis was controlled for grade, racial differences were noted for overall but not cause-specific survival. In another study, African Americans had poorer survival after adjusting for stage and grade (127). In crude analyses, the risk of death for African Americans who received prostatectomy was more than four times higher than that for whites (128). Additional analyses revealed that the increased risk of death was limited to the first 12 months after diagnosis. Although not specifically examined, comorbidity was not believed to be a major contributor to racial disparities in overall survival because there were no statistically significant differences in the cause of death among deceased participants. Furthermore, Shekarriz et al. (129) concluded that race was an independent prognostic factor for disease-free survival among men who had tumors with positive surgical margins.
Racial disparities in treatment outcomes in these studies were believed to be associated with unmeasured cultural (128) and biologic (118,128) differences. Among studies that found racial disparities in survival in crude analyses, few statistically significant survival differences remained after controlling for stage and/or tumor grade (115,126).
Trend studies. Radical prostatectomy rates have been increasing among both whites and nonwhites (130). From 1973 through 1988 and from 1989 through 1996, Shaw et al. (131) found similar trends between African Americans and whites in the use of prostatectomy. The rate of radiation therapy was similar for African Americans and whites from 1973 through 1988 but was significantly higher for African Americans than whites from 1989 through 1996.
Access/utilization studies. Data from the reviewed studies suggest that whites more frequently receive aggressive treatment of prostate cancer than African Americans (25,109,132140). African Americans were statistically significantly more likely than whites to go untreated (25,109,128,133), less likely to receive definitive treatment (140) and radical prostatectomy (25,109,132134,136), and more likely to receive conservative management (watchful waiting) for prostate cancer (134). Native Americans and Hispanics were more likely than whites to go untreated and, when treated, to receive prostatectomy (128). An analysis of data from the California Cancer Registry found that treatment received by African Americans was more frequently in concordance with the PDQ recommendations than treatment received by whites because African Americans less frequently received prostatectomy, which is discouraged for older men with advanced disease (132).
In contrast, data from the Connecticut SEER registry from 1988 through 1992 showed that the receipt of prostatectomy for local/regional stage and endocrine surgery for distant-stage prostate cancer are similar among African-American and white patients with prostate cancer (141). In another study, data from the North Carolina Central Cancer Registry for 1994 and 1995 showed that African Americans were more than three times more likely than whites to have prostatectomy for distant-stage disease (142). An analysis of data in the Virginia Cancer Registry from 1985 through 1989 showed that African Americans were more frequently treated with orchiectomy than were whites (109).
Summary for prostate cancer. Prostate cancer is notable among cancer sites in that there is considerable evidence, albeit from the minority of published studies on the topic, that race may be an independent factor in prognosis after equivalent treatment. However, it is not clear whether this observation is caused by underlying behavioral, biologic, or genetic factors associated with race or because of incomplete or inaccurate measurement of clinical risk or quality-of-care factors. Furthermore, it is also not clear that systematic differences in treatment patterns can be explained by inherent differences in treatment outcomes. Just as there is a paucity of definitive evidence on the relative efficacy of the various treatment approaches for prostate cancer, there is also insufficient evidence to conclude that any one treatment modality is more preferable for African Americans than for other racial groups.
In general, relative to whites, African Americans and other minorities are less likely to receive the relatively expensive or more innovative treatments. Almost all published observational studies of treatment patterns, including several large, multisite, population-based studies (25,132,134,138,139), have found that, for any given time period, African Americans are less likely than whites to receive radical prostatectomy and more likely to receive conservative management, although there has been an increasing trend in radical prostatectomy for African Americans over time. Similarly, African Americans were more likely to receive orchiectomy rather than the newer and more expensive hormonal drug treatment. Generally, treatment differences were not explained by differences in clinical factors. For example, in analysis of data from the National Cancer Data Base, Mettlin et al. (136) concluded that, despite little variation in disease stage and tumor grade, prostate cancer treatment varied by age, race, and region. However, comorbidity was not controlled for in all studies and may not have been controlled for completely in any of the studies. Given the uncertainty about the comparative efficacy and quality-of-life effects associated with these competing treatment modalities, without more definitive clinical evidence than is now available, it cannot be concluded that African-American patients, on average, experience less effective or less appropriate treatment for prostate cancer than whites.
As noted with colorectal cancer, fewer racial/ethnic differences were found among patients treated in equal-access systems. After controlling for stage at diagnosis, there were no statistically significant differences between African Americans and whites with regard to prostate cancer treatment received by patients in the Department of Defense Tumor Registry, an equal-access treatment facility (8).
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
Several nonclinical factors were implicated as contributors to racial/ethnic disparities in the receipt of cancer treatment. These include socioeconomic status (55,61,72), patient concerns about body image (70), age at diagnosis (72), the size of the hospital where surgery is performed, the number of previous surgeries performed by the surgeon (64), geographic location (63), and insurance coverage (72). Patient preferences and decisions also contributed to treatment differences (82,83,86). For example, Merrill et al. (83) found that 7.4% of African-American women who did not receive cancer-directed surgery for cervical cancer refused it.
The reviewed studies also suggest that white patients receive more aggressive therapy than other racial/ethnic groups for lung, prostate, and colorectal cancers, even in cases where evidence for clinical benefit is less than definitive. For example, whites more frequently received inappropriately aggressive treatment for stage I colorectal cancer (94) and advanced prostate cancer (132,137). Conversely, whites are more likely to receive less aggressive therapy in cases where the clinical benefit of a less aggressive regimen is well established, for example, breast-conserving surgery (55,59,61).
Equal Treatment Equal Outcomes?
Studies of clinical trials and equal-access systems provide support for the idea that equal treatment will yield similar cancer outcomes between racial/ethnic minorities and whites with similar disease (47,67,77,87,88,103,150,151). Additional support is provided by studies that examine the survival experiences of similarly staged and treated cancer patients (66,76,78,118,122, 123,152,153). Racial/ethnic minority and white patients who receive similar care for the same stage of disease have been shown to have similar survival experiences for multiple myeloma (152) and cancers of the cervix (7678), lung (88,103), colon (87,88), and prostate (118,122,123,150,151,153). Data from the VA demonstrate that comparable cancer outcomes can be obtained among patients who receive similar treatment irrespective of socioeconomic status (88).
Limitations of the Current Literature
The current studies were limited in a number of ways, including insufficient sample sizes and the failure to control for relevant clinical factors in multivariable analyses. Twenty-three percent of the reviewed studies had fewer than 100 participants per race/ethnic group studied, and 13.2% had fewer than 200 participants per race/ethnic group studied. It is worthwhile to note that these studies less frequently reported statistically significant racial/ethnic treatment differences than studies with larger sample sizes. Comorbid conditions can influence both the type of treatment (154) and survival (150,154). Racial/ethnic minorities have a higher prevalence of comorbid conditions (154), which emphasizes the importance of evaluating the role of comorbidity in studies examining racial/ethnic differences in receipt of cancer treatment, particularly, adjuvant therapy.
Few of the studies were able to examine the role of patient preferences and patientphysician decision making in treatment patterns, especially where there are trade-offs between treatment effectiveness and treatment side effects. Similarly, few of the studies were able to examine the specific mechanisms that resulted in the observed disparities in treatment process or outcomes. Pathologic staging data were sometimes compared with clinical staging data. Patients are frequently upstaged after surgical resection (155); thus, the use of pathologic stage for the retrospective examination of treatment differences may not provide an accurate reflection of the decisions made on pretreatment clinical presentation, especially with regard to surgical resection rates.
Census tract or ZIP Code level data were often used to measure socioeconomic status, which may not be highly correlated with individual level data (156). In addition, racial/ethnic differentials in underreporting in census data (157) suggest that the reliability of these data may differ among racial/ethnic groups. Furthermore, it is not known whether socioeconomic status has the same relative meaning for different racial/ethnic groups (158). Racial bias modifies the influence of education and income so that racial/ethnic variations may exist within the same income and educational levels. Arbes et al. (159) argues that, because race represents a social construct and socioeconomic status is a consequence of race, socioeconomic status should not be modeled as a confounder because it would bias the hazard ratio for race toward the null. In contrast, others have found that race and socioeconomic status have independent effects on cancer mortality (160), survival (161), and receipt of medical services (162).
This review is not the first to note these limitations (163). Recognizing the need to obtain more informative data on health disparities in cancer, the NCI has initiated a number of efforts to expand its research base in this area (164). These efforts include expansion of SEER registries to improve coverage of racial, ethnic, and other groups who suffer from disproportionately high cancer mortality rates and linkage of these registries to census level and individual level data on socioeconomic status, the development of a cancer outcomes research group designed to study cancer processes of care and outcomes in large populations spanning diverse population groups and treatment settings (165), and the establishment of centers for population health designed to expand our understanding of social and environmental causes of cancer-related health disparities.
Future Research Directions and Study Design Considerations
The manner in which race/ethnicity and other nonclinical factors influence the receipt of cancer treatment is complex, as Fig. 1 shows. Whether racial/ethnic differences in receipt of cancer treatment noted in the reviewed studies reflect differing health-care needs, preferences, racial bias, or other intervening factors is not clear. Additional studies are needed to provide information on understudied racial/ethnic groups (i.e., Asians, Pacific Islanders, and Native Americans) and to examine the influence of access to care, socioeconomic status, and clinical staging, as well as beliefs and attitudes of patients and providers and their influence on racial/ethnic disparities in cancer treatment.
Access to care. Racial/ethnic differentials in the prevalence of barriers may influence the receipt of optimal cancer care (166,167). In a study of cost barriers to cancer treatment, African Americans more frequently than both Hispanics and whites reported that they lost their medical insurance coverage after their diagnosis, were denied coverage after changing jobs, and reached their insurance spending limits (167).
Socioeconomic status. The complex interaction between race/ethnicity and socioeconomic status makes it difficult to disentangle the independent effects of these two variables and may overshadow more proximal determinants of treatment. Therefore, knowledge about the influence of specific social or economically influenced barriers to cancer treatment, such as transportation to medical appointments, type of health insurance, type of health-care facility and provider, copayment amounts, availability for care (i.e., the ability to take time off work, availability of child care), support systems, knowledge of appropriate care, and attitudes toward cancer treatment may prove more informative for the development of interventions designed to reduce health disparities.
Clinical staging. Studies included in this review suggest that racial/ethnic minorities more frequently than whites have unknown/unstaged cancers (83,168), which influences whether they are treated (83) and/or which treatments are selected (169). It is not apparent whether the racial variations in clinical staging are caused by the refusal of patients to be staged, the failure of the clinician to perform clinical staging, or the failure to record stage in the medical record.
Patient's beliefs and attitudes. Health beliefs and attitudes influence health-care behavior (170). The prevalence of fatalistic and nihilistic attitudes is higher among racial/ethnic minority populations than white populations (171). Higher treatment refusal rates among racial/ethnic minorities (82,83,86), therefore, may reflect differences in attitudes toward treatment. Additional research is needed to further elucidate the origins of and role of patient preferences and decision making in racial/ethnic cancer treatment disparities.
Provider beliefs and attitudes. Findings from several studies suggest that a physician's perception of patients may be influenced by nonclinical characteristics (172174), which may be manifested in differences in patient referral patterns and treatment recommendations (172,174,175). In a survey of eight New York State hospitals, physicians were found to more frequently have negative perceptions of African Americans and persons of low or middle socioeconomic status than of whites and persons of high socioeconomic status (173). This finding and the fact that there is little information on how physician attitudes toward patients impact their care suggest the need for further research, particularly with regard to how such perceptions might contribute to racial/ethnic disparities in cancer treatment.
Biologic factors/tumor aggressiveness. Racial/ethnic differences in prevalence of adverse biologic characteristics and tumor aggressiveness may also contribute to disparities in cancer outcomes (52,79,126,133). Elledge et al. (52) found that, compared with white women, African American women more frequently have less favorable prognostic factors, such as fewer estrogen receptor- and progesterone receptor-positive tumors and higher S-phase fractions. Chen et al. (176), however, found that African Americans with colon cancer experienced poorer survival, despite less aggressive tumors. Other studies did not find statistically significant racial/ethnic differences in molecular prognostic indicators for breast cancer (177) or the burden or growth rate of androgen-independent prostate cancer (120). Therefore, it is important to determine the role, if any, that differences in tumor biology and other clinical factors play in racial/ethnic disparities in cancer treatment and outcomes.
![]() |
CONCLUSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Reducing the influence of nonclinical factors on the receipt of cancer treatment may provide an important means of reducing racial/ethnic disparities in health. New data resources and improved study methodology are needed to better identify and quantify the full spectrum of nonclinical factors that contribute to the disparate mortality of racial/ethnic minority populations and to develop strategies to facilitate appropriate cancer care for all patients.
![]() |
NOTES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
We thank Drs. Rachel-Ballard-Barbash, Robert Hiatt, and Jon Kerner from the NCI, Bethesda, MD, for their comments and suggestions on various drafts of this manuscript.
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
1 American Cancer Society. Cancer facts & figures; 2001.
2 Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK, editors. SEER cancer statistics review, 19731998. National Cancer Institute (Bethesda, MD); 2001.
3 Farrow DC, Vaughan TL. Determinants of survival following the diagnosis of esophageal adenocarcinoma (United States). Cancer Causes Control 1996;7:3227.[Medline]
4 Shinagawa SM. The excess burden of breast carcinoma in minority and medically underserved communities. Cancer 2000;88(5 Suppl):121723.[Medline]
5
Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin 2000;50:733.
6
Dignam JJ. Differences in breast cancer prognosis among African-American and Caucasian women. CA Cancer J Clin 2000;50:5064.
7
Chu KC, Tarone RE, Brawley OW. Breast cancer trends of black women compared with white women. Arch Fam Med 1999;8:5218.
8 Optenberg SA, Thompson IM, Friedrichs P, Wojcik B, Stein CR, Kramer B. Race, treatment, and long-term survival from prostate cancer in an equal-access medical care delivery system. JAMA 1995;274:1599605.[Abstract]
9 Eley JW, Hill HA, Chen VW, Austin DF, Wesley MN, Muss HB, et al. Racial differences in survival from breast cancer: Results of the National Cancer Institute Black/White Cancer Survival Study. J Natl Cancer Inst 1995;87:168693.[Abstract]
10 Liu WL, Kasl S, Flannery JT, Lindo A, Dubrow R. The accuracy of prostate cancer staging in a population-based tumor registry and its impact on the black-white stage difference. Cancer Causes Control 1995;6:42530.[Medline]
11 Suarez L. Comparing acculturation scales and their relationship to cancer screening among older Mexican-American women. J Natl Cancer Inst Monogr 1995;18:417.[Medline]
12 Hegarty V, Burchett BM, Gold DT, Cohen HJ. Racial differences in use of cancer prevention services among older Americans. J Am Geriatr Soc 2000;48:73540.[Medline]
13 Sung HY, Kearney KA, Miller M, Kinney W, Sawaya GF, Hiatt RA. Papanicolaou smear history and diagnosis of invasive cervical carcinoma among members of a large prepaid health plan. Cancer 2000;88:22839.[Medline]
14 Breen N, Wagener D, Brown ML, Davis WW, Ballard-Barbash R. Progress in cancer screening over a decade results of cancer screening from the 1987, 1992 and 1998 NHIS. National Health Interview Surveys. J Natl Cancer Inst 93:170413.
15 Chang SW, Kerlikowske K, Napoles-Springer A, Posner SF, Sickles EA, Perez-Stable EJ. Racial differences in timeliness of follow-up after abnormal screening mammography. Cancer 1996;78:1395402.[Medline]
16 McCarthy BD, Yood MU, Boohaker EA, Ward RE, Rebner M, Johnson CC. Inadequate follow-up of abnormal mammograms. Am J Prev Med 1996;12:2828.[Medline]
17 Carey P, Gjerdingen DK. Follow-up of abnormal Papanicolaou smears among women of different races. J Fam Pract 1993;37:5837.[Medline]
18 Cooper GS, Yuan Z, Rimm AA. Racial disparity in the incidence and case-fatality of colorectal cancer: Analysis of 329 United States Counties. Cancer Epidemiol Biomarkers Prev 1997:6:2835.[Abstract]
19 Vernon SW, Tilley BC, Neale AV, Steinfeldt L. Ethnicity, survival, and delay in seeking treatment for symptoms of breast cancer. Cancer 1985;55:156371.[Medline]
20 Bain RP, Greenberg RS, Whitaker JP. Racial differences in survival of women with breast cancer. J Chronic Dis 1986;39:63142.[Medline]
21 McWhorter WP, Mayer WJ. Black/white differences in type of initial breast cancer treatment and implications for survival. Am J Public Health 1987;77:15157.[Abstract]
22 Kimmick G, Muss HB, Case LD, Stanley V. A comparison of treatment outcomes for black patients and white patients with metastatic breast cancer. The Piedmont Oncology Association experience. Cancer 1991;67:28504.[Medline]
23 Fisher ER, Anderson S, Redmond C, Fisher B. Pathological findings from the National Surgical Adjuvant Breast Project protocol B-06. 10-year pathologic and clinical prognostic discriminants. Cancer 1993;71:250714.[Medline]
24 Boyer-Chammard A, Taylor TH, Anton-Culver H. Survival differences in breast cancer among racial/ethnic groups: a population-based study. Cancer Detect Prev 1999;23:46373.[Medline]
25 Jones GW, Mettlin C, Murphy GP, Guinan P, Herr HW, Hussey DH, et al. Patterns of care for carcinoma of the prostate gland: results of a national survey of 1984 and 1990. J Am Coll Surg 1995;180;54554.[Medline]
26 Aziz H, Hussain F, Edelman S, Cirrone J, Aral I, Fruchter R, et al. Age and race as prognostic factors in endometrial carcinoma. Am J Clin Oncol 1996;19:595600.[Medline]
27 Ayanian JZ, Weissman JS, Chasan-Taber S, Epstein AM. Quality of care by race and gender for congestive heart failure and pneumonia. Med Care 1999;37:12:12609.[Medline]
28 Kahn KL, Pearson ML, Harrison ER, Desmond KA, Rogers WH, Rubenstein LV, et al. Health care for black and poor hospitalized Medicare patients. JAMA 1994:271:116974.[Abstract]
29 Weddington WH, Gabbel LL, Peet GM, Stewart SO. Quality of care and African-American patients. J Natl Med Assoc 1992;84:56975.[Medline]
30 Perkoff GT, Anderson M. Relationship between demographic characteristics, patient's chief complaint, and medical disposition in an emergency room. Med Care 1970;8:30923.[Medline]
31 Yergan J, Flood AB, LoGerfo JP, Diehr P. Relationship between patient race and the intensity of hospital services. Med Care 1987;25:592603.[Medline]
32
Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med 1994;330:7638.
33 Hildago J, Sugland B, Moore R, Chaisson RE. Access, equity, and survival: use of ZVD and pentamidine by persons with AIDS. International Conference on AIDS 1990;6:148 [abstract Th.D. 59].
34 Chung H, Mahler JC, Kakuma T. Racial differences in the treatment of psychiatric inpatients. Psychiatr Serv 1995:46:58691.[Abstract]
35 Harris DR, Andrews R, Elixhauser A. Racial and gender differences in use of procedures for black and white hospitalized adults. Ethn Dis 1997;7:91105.[Medline]
36 McMahon LF Jr, Wolfe RA, Huang S, Tedeschi P, Manning W Jr, Edlund MJ. Racial and gender variation in the use of diagnostic colonic procedures in the Michigan Medicare population. Med Care 1999;37:7127.[Medline]
37 National Cancer Institute. Breast cancer (PDQTM) treatment-health professionals. http://www.cancer.gov/cancer_information/doc_pdq.aspx?version=provider&viewid=53d97cba-89a2-45d4-b55d-b7b5ad7dc2dd. January 30, 2002.
38 National Cancer Institute. Prostate cancer (PDQTM) treatment-health professionals. http://www.cancer.gov/cancer_information/doc_pdq.aspx?version=provider&viewid=f4c08184-f6a9-49d5-8521-7540e59224ac. January 30, 2002.
39 National Cancer Institute. Colon cancer (PDQTM) treatment-health professionals. http://www.cancer.gov/cancer_information/doc_pdq.aspx?version=provider&viewid=2cfe2c5f-9e61-4026-a62e-939e818fd165. January 30, 2002.
40 National Cancer Institute. Cervical cancer (PDQTM) treatment-health professionals. http://www.cancer.gov/cancer_information/doc_pdq.aspx?version=provider&viewid=862ac265-8ff9-4bc5-8b68-1458c603548d. January 30, 2002.
41 National Cancer Institute. Rectal cancer (PDQTM) treatment-health professionals. http://www.cancer.gov/cancer_information/doc_pdq.aspx?version=provider&viewid=5e7b4202-e2a2-4565-8510-39becf735fbf. January 30, 2002.
42 National Cancer Institute. Lung cancer (PDQTM) treatment-health professionals. http://www.cancer.gov/cancer_information/doc_pdq.aspx?version=provider&viewid=1b299ff5-e610-4d11-a121-b32aefc7ec2c. January 30, 2002.
43 Mitchell JM, Meehan KR, Kong J, Schulman KA. Access to bone marrow transplantation for leukemia and lymphoma: the role of sociodemographic factors. J Clin Oncol 1997;15:264451.[Abstract]
44 Treatment of early-stage breast cancer. NIH consensus statement. http://odp.od.nih.gov/consensus/cons/081/081_statement.htm. January 30, 2002.
45 Fodor J, Major T, Polgar C, Toth J, Nemeth G. The impact of radiotherapy on the incidence and time of occurrence of local recurrence in early-stage breast cancer after breast conserving therapy. Neoplasma 2000;47:1816.[Medline]
46 de Csepel J, Tartter PI, Gajdos C. When not to give radiation therapy after breast conservation surgery for breast cancer. J Surg Oncol 2000;74:2737.[Medline]
47 Roach M 3rd, Cirrincione C, Budman D, Hayes D, Berry D, Younger J, et al. Race and survival from breast cancer: based on Cancer and Leukemia Group B trial 8541. Cancer J Sci Am 1997;3:10712.[Medline]
48 Dignam JJ, Redmond CK, Fisher B, Costantino JP, Edwards BK. Prognosis among African-American women and white women with lymph node negative breast carcinoma: findings from two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP). Cancer 1997;80:8090.[Medline]
49
Newman LA, Kuerer HM, Junt KK, Singh G, Ames FC, Feig BW, et al. Local recurrence and survival among black women with early-stage breast cancer treated with breast-conservation therapy or mastectomy. Ann Surg Oncol 1999;6:2418.
50 Connor CS, Touijer AK, Krishnan L, Mayo MS. Local recurrence following breast conservation therapy in African-American women with invasive breast cancer. Am J Surg 2000;179:226.[Medline]
51 Elias EG, Suter CM, Brown SD, Buda BS, Vachon DA. Survival differences between black and white women with breast cancer. J Surg Oncol 1994;55:3741.[Medline]
52 Elledge RM, Clark GM, Chamness GC, Osborne CK. Tumor biologic factors and breast cancer prognosis among white, Hispanic, and black women in the United States. J Natl Cancer Inst 1994;86:70512.[Abstract]
53 Harlan LC, Coates RJ, Block G, Greenberg RS, Ershow A, Forman M, et al. Estrogen receptor status and dietary intakes in breast cancer patients. Epidemiology 1993;4:2531.[Medline]
54
Gail MH, Costantino JP, Bryant J, Croyle R, Freedman L, Helzlsouer K, et al. Weighing the risks and benefits of Tamoxifen treatment for preventing breast cancer. J Natl Cancer Inst 1999;91:182946.
55
Morris CR, Cohen R, Schlag R, Wright WE. Increasing trends in the use of breast-conserving surgery in California. Am J Public Health 2000;90:2814.
56 Tropman SE, Ricketts TC, Paskett E, Hatzell TA, Cooper MR, Aldrich T. Rural breast cancer treatment: evidence from the Reaching Communities for Cancer Care (REACH) project. Breast Cancer Res Treat 1999;56:5966.[Medline]
57 Chuba PJ, Simon MS. Trends in primary surgical and radiation therapy for localized breast cancer in the Detroit Metropolitan area 19731992. Int J Radiat Oncol Biol Phys 1997;38:1037.[Medline]
58 Lazovich D, Solomon CC, Thomas DB, Moe RE, White E. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer 1999;86:62837.[Medline]
59
Dunmore C, Plummer P, Regan G, Mattingly D, Jackson S, Milikan R. Re: race and differences in breast cancer survival in a managed care population [letter]. J Natl Cancer Inst 2000:92:16901.
60 Muss HB, Hunter CP, Wesley M, Correa P, Chen VW, Greenberg RS, et al. 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 1992;70:24607.[Medline]
61 Michalski TA, Nattinger AB. The influence of black race and socioeconomic status on the use of breast-conserving surgery for Medicare beneficiaries. Cancer 1997;79:3149.[Medline]
62 Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 1992;326:11027.[Abstract]
63 Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localized breast cancer. N Engl J Med 1992;326:1097101.[Abstract]
64 Satariano ER, Swanson GM, Moll PP. Nonclinical factors associated with surgery received for treatment of early-stage breast cancer. Am J Public Health 1992;82:1958.[Abstract]
65
Ballard-Barbash R, Potosky AL, Harlan LC, Nayfield SG, Kessler LG. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst 1996;88:71626.
66 Heimann R, Ferguson D, Powers C, Suri D, Weichselbaum RR, Hellman S. Race and clinical outcome in breast cancer in a series with long-term follow-up evaluation. J Clin Oncol 1997;15:232937.[Abstract]
67 Velanovich V, Yood MU, Bawle U, Nathanson SD, Strand VF, Talpos GB, et al. Racial differences in the presentation and surgical management of breast cancer. Surgery 1999;125:3759.[Medline]
68
Riley GF, Potosky AL, Klabunde CN, Warren JL, Ballard-Barbash R. Stage at diagnosis and treatment patterns among older women with breast cancer: an HMO and fee-for-service comparison. JAMA 1999;281:7206.
69
Lee MM, Lin SS, Wrensch MR, Adler SR, Eisenberg D. Alternative therapies used by women with breast cancer in four ethnic populations. J Natl Cancer Inst 2000;92:427.
70 Mandelblatt JS, Hadley J, Kerner JF, Schulman KA, Gold K, Dunmore-Griffith J, et al. Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences. Cancer 2000;89:56173.[Medline]
71
Caplan LS, May DS, Richardson LC. Time to diagnosis and treatment of breast cancer: results from the National Breast and Cervical Cancer Early Detection Program, 19911995. Am J Public Health 2000;90:1304.
72 Breen N, Wesley MN, Merrill RM, Johnson K. The relationship of socio-economic status and access to minimum expected therapy among female breast cancer patients in the Black-White Cancer Survival Study. Ethn Dis 1999;9:11125.[Medline]
73 Schapira MM, McAuliffe TL, Nattinger AB. Underutilization of mammography in older breast cancer survivors. Med Care 2000;38:2819.[Medline]
74
Athas WF, Adams-Cameron M, Hunt WC, Amir-Fazli A, Key CR. Travel distance to radiation therapy and receipt of radiotherapy following breast-conserving surgery. J Natl Cancer Inst 2000;92:26971.
75 Siminoff LA, Zhang A, Saunders-Sturm CM, Colabianchi N. Referral of breast cancer patients to medical oncologist after initial surgical management. Med Care 2000;38:696704.[Medline]
76 Sevin BU, Nadji M, Lampe B, Lu Y, Hilsenbeck S, Koechli OR, et al. Prognostic factors of early stage cervical cancer treated by radical hysterectomy. Cancer 1995;76(10 Suppl):197886.[Medline]
77 Brader KR, Morris M, Levenback C, Levy L, Lucas KR, Gershenson DM. Chemotherapy for cervical carcinoma: factors determining response and implications for clinical trial design. J Clin Oncol 1998;16:187984.[Abstract]
78 Hart K, Han I, Deppe G, Malviya V, Malone J Jr, Christensen C, et al. Postoperative radiation for cervical cancer with pathologic risk factors. Int J Radiat Oncol Biol Phys 1997;37:8338.[Medline]
79 Han I, Orton C, Shamsa F, Hart K, Strowbridge A, Deppe G, et al. Combined low-dose-rate brachytherapy and external beam radiation for cervical cancer: experience over ten years. Radiat Oncol Investig 1999;7:28996.[Medline]
80 Polednak AP. Declining use of radiotherapy for invasive cervical cancer in Connecticut: 19831990. Gynecol Oncol 1995;58:2269.[Medline]
81 Russell AH, Shingleton HM, Jones WB, Stewart AK, Fremgen A, Winchester DP, et al. Trends in the use of radiation and chemotherapy in the initial management of patients with carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys 1998:40:60513.[Medline]
82
Howell EA, Chen YT, Concato J. Differences in cervical cancer mortality among black and white women. Obstet Gynecol 1999;94:50915.
83 Merrill RM, Merrill AV, Mayer LS. Factors associated with no surgery or radiation therapy for invasive cervical cancer in Black and White women. Ethn Dis 2000;10:24856.[Medline]
84 del Carmen MG, Montz FJ, Bristow RE, Bovicelli A, Cornelison T, Trimble E. Ethnic differences in patterns of care of stage 1A(1) and stage 1A(2) cervical cancer: a SEER database study. Gynecol Oncol 1999;75:1137.[Medline]
85 Thoms WW, Unger ER, Carisio R, Nisenbaum R, Spann CO, Horowitz IR, et al. Clinical determinants of survival from stage Ib cervical cancer in an inner-city hospital. J Natl Med Assoc 1998;90:3038.[Medline]
86 Mundt AJ, Connell PP, Campbell T, Hwang JH, Rotmensch J, Waggoner S. Race and clinical outcome in patients with carcinoma of the uterine cervix treated with radiation therapy. Gynecol Oncol 1998;71:1518.[Medline]
87
Dignam JJ, Colangelo L, Tian W, Jones J, Smith R, Wickerham DL, et al. Outcomes among African-Americans and Caucasians in colon cancer adjuvant therapy trials: findings from the National Surgical Adjuvant Breast and Bowel Project. J Natl Cancer Inst 1999;91:193340.
88 Akerley WL 3rd, Moritz TE, Ryan LS, Henderson WG, Zacharski LR. Racial comparison of outcomes of male Department of Veterans Affairs patients with lung and colon cancer. Arch Intern Med 1993;153:16818.[Abstract]
89 Beart RW, Steele GD Jr, Menck HR, Chmiel JS, Ocwieja KE, Winchester DP. Management and survival of patients with adenocarcinoma of the colon and rectum: a national survey of the Commission on Cancer. J Am Coll Surg 1995;181:22536.[Medline]
90 Ball JK, Elixhauser A. Treatment differences between blacks and whites with colorectal cancer. Med Care 1996;34:97084.[Medline]
91 Cooper GS, Yuan Z, Landefeld CS, Rimm AA. Surgery for colorectal cancer: race-related differences in rates and survival among Medicare beneficiaries. Am J Pub Health 1996;86:5826.[Abstract]
92 Tropman SE, Hatzell T, Paskett E, Ricketts T, Cooper MR, Aldrich T. Colon cancer treatment in rural North and South Carolina. Cancer Detect Prev 1999:23:42834.[Medline]
93
Schrag D, Cramer LD, Bach PB, Begg CB. Age and adjuvant chemotherapy use after surgery for stage III colon cancer. J Natl Cancer Inst 2001;93:8507.
94 Mayberry RM, Coates RJ, Hill HA, Click LA, Chen VW, Austin DF, et al. Determinants of black/white differences in colon cancer survival. J Natl Cancer Inst 1995;87:168693.[Abstract]
95
Roetzheim RG, Pal N, Gonzalez E, Ferrante JM, Van Durme DJ, Krisher JP. Effects of health insurance and race on colorectal cancer treatments and outcomes. Am J Public Health 2000;90:174654.
96 Elston Lafata J, Cole Johnson C, Ben-Menachem T, Morlock RJ. Sociodemographic differences in the receipt of colorectal cancer surveillance care following treatment with curative intent. Med Care 2001;39:36172.[Medline]
97 Cooper GS, Yuan Z, Chak A, Rimm AA. Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer. Gastrointest Endosc 2000;52:338.[Medline]
98 Cooper GS, Yuan Z, Chak A, Rimm AA. Geographic and patient variation among Medicare beneficiaries in the use of follow-up testing after surgery for nonmetastatic colorectal carcinoma. Cancer 1999;85:212431.[Medline]
99 Jessup JM, McGinnis LS, Steele GD Jr, Menck HR, Winchester DP. The National Cancer Data Base Report on colon cancer. Cancer 1996;76:91826.
100 Dominitz JA, Samsa GP, Landsman P, Provenzale D. Race, treatment, and survival among colorectal carcinoma patients in an equal-access medical system. Cancer 1998;82:231220.[Medline]
101 Lin AY, Ihde DC. Recent developments in the treatment of lung cancer. JAMA 1992;267:16614.[Medline]
102
Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med 1999;341:1198205.
103 Graham MV, Geitz LM, Byhardt R, Asbell S, Roach M 3rd, Urtasun RC, et al. Comparison of prognostic factors and survival among black patients and white patients treated with irradiation for non-small-cell lung cancer. J Natl Cancer Inst 1992;84:17315.[Abstract]
104 Greenwald HP, Polissar NL, Borgatta EF, McCorkle R, Goodman G. Social factors, treatment, and survival in early-stage non-small cell lung cancer. Am J Public Health 1998;88:16814.[Abstract]
105 Smith TJ, Penberthy L, Desch CE, Whittemore M, Newschaffer C, Hillner BE, et al. Differences in initial treatment patterns and outcomes of lung cancer in the elderly. Lung Cancer 1995;13:23552.[Medline]
106 Fry WA, Menck HR, Winchester DP. The National Cancer Data Base report on lung cancer. Cancer 1996;77:194755.[Medline]
107
Earle CC, Venditti LN, Neumann PJ, Gelber RD, Weinstein MC, Potosky AL, et al. Who gets chemotherapy for metastatic lung cancer? Chest 2000;117:123946.
108
Polednak AP. Racial differences in the treatment of early-stage lung cancer [letter]. N Engl J Med 2000;342:5178.
109 Desch CE, Penberthy L, Newschaffer CJ, Hillner BE, Whittemore M, McClish D, et al. Factors that determine the treatment for local and regional prostate cancer. Med Care 1996;34:15262.[Medline]
110
Potosky AL, Legler J, Albertsen PC, Stanford JL, Gilliland FD, Hamilton AS, et al. Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2000;92:158292.
111 Gralnek D, Wessells H, Cui H, Dalkin BL. Differences in sexual function and quality of life after nerve sparing and nonnerve sparing radical retropubic prostatectomy. J Urol 2000;163:116670.[Medline]
112 Young CD, Lewis P, Weinberg V, Lee TT, Coleman CW, Roach M 3rd. The impact of race on freedom from prostate-specific antigen failure in prostate cancer patients treated with definitive radiation therapy. Semin Urol Oncol 2000;18:1216.[Medline]
113 Hart KB, Wood DP Jr, Tekyi-Mensah S, Porter AT, Pontes JE, Forman JD. The impact of race on biochemical disease-free survival in early-stage prostate cancer patients treated with surgery or radiation therapy. Int J Radiat Oncol Biol Phys 1999;45:12358.[Medline]
114 Roach M 3rd, Krall J, Keller JW, Perez CA, Sause WT, Doggett RL, et al. The prognostic significance of race and survival from prostate cancer based on patients irradiated on Radiation Therapy Oncology Group protocols (19761985). Int J Radiat Oncol Biol Phys 1992;24:4419.[Medline]
115 Austin JP, Aziz H, Potters L, Thelmo W, Chen P, Choi K, et al. Diminished survival of young blacks with adenocarcinoma of the prostate. Am J Clin Oncol 1990;13:4659.[Medline]
116 Freedland SJ, Jalkut M, Dorey F, Sutter ME, Aronson WJ. Race is not an independent predictor of biochemical recurrence after radical prostatectomy in an equal access medical center. Urology 2000;56:8791.
117 Fowler JE Jr, Terrell FL, Renfroe DL. Co-morbidities and survival of men with localized prostate cancer treated with surgery or radiation therapy. J Urol 1996;156:17148.[Medline]
118 Iselin CE, Box JW, Vollmer RT, Layfield LJ, Robertson JE, Paulson DF. Surgical control of clinically localized prostate carcinoma is equivalent in African-American and white males. Cancer 1998;83:235360.[Medline]
119 McLeod DG, Schellhammer PF, Vogelzang NJ, Soloway MS, Sharifi R, Block NL, et al. Exploratory analysis on the effect of race on clinical outcome in patients with advanced prostate cancer receiving bicalutamide or flutamide, each in combination with LHRH analogues. The Casodex Combination Study Group. Prostate 1999;40:21824.[Medline]
120 Fowler JE, Bigler SA, Renfroe DL, Dabagia MD. Prostate specific antigen in black and white men after hormonal therapies for prostate cancer. J Urol 1997;158:1504.[Medline]
121 Krishnan R, Basrawala ZK, Benevides MD, Freeman JA, Mohler JL. Progression by race in men choosing observation of prostate cancer [abstract]. J Urol 1999;161:72.[Medline]
122 Koppie TM, Grossfeld GD, Miller D, Yu J, Stier D, Broering JM, et al. Patterns of treatment of patients with prostate cancer initially managed with surveillance: Results from the CaPsure database. Cancer of the Prostate Strategic Urological Research Endeavor. J Urol 2000;164:818.[Medline]
123 Hart KB, Porter AT, Shamsa F, Chuba PJ, Pontes JE, Forman JD. The influence of race on the efficacy of curative radiation therapy for carcinoma of the prostate. Semin Urol Oncol 1998;16:22731.[Medline]
124 Merrill RM, Lyon JL. Explaining the difference in prostate cancer mortality rates between white and black men in the United States. Urology 2000;55:7305.[Medline]
125 Witte MN, Kattan MW, Albani J, Sharp DS, Eastham JA, Morton RA Jr. Race is not an independent predictor of positive surgical margins after radical prostatectomy. Urology 1999;54:86974.[Medline]
126 Kim JA, Kuban DA, el-Mahdi AM, Schellhammer PF. Carcinoma of the prostate: race as a prognostic indicator in definitive radiation therapy. Radiology 1995;194:5459.[Abstract]
127 Austin JP, Convery K. Agerace interaction in prostatic adenocarcinoma treated with external beam irradiation. Am J Clin Oncol 1993;16:1405.[Medline]
128 Gilliland FD, Hunt WC, Key CR. Ethnic variation in prostate cancer survival in New Mexico. Cancer Epidemiol Biomarkers Prev 1996;5:24751.[Abstract]
129 Shekarriz B, Tiguert R, Upadhyay J, Gheiler E, Powell IJ, Pontes JE, et al. Impact of location and multifocality of positive surgical margins on disease-free survival following radical prostatectomy: a comparison between African-American and white men. Urology 2000;55:899903.[Medline]
130 Imperato PJ, Nenner RP, Will TO. Radical prostatectomy: lower rates among African-American men. J Natl Med Assoc 1996:88:58994.[Medline]
131 Shaw M, Elterman L, Rubenstein M, McKiel CF, Guinan P. Changes in radical prostatectomy and radiation therapy rates for African Americans and whites. J Natl Med Assoc 2000;92:2814.[Medline]
132 Morris CR, Snipes KP, Schlag R, Wright WE. Sociodemographic factors associated with prostatectomy utilization and concordance with the physician data query for prostate cancer (United States). Cancer Causes Control 1999;10:50311.[Medline]
133 Fowler JE Jr, Bigler SA, Bowman G, Kilambi NR. Race and cause specific survival with prostate cancer: influence of clinical stage, Gleason score, age and treatment. J Urol 2000;163:13742.[Medline]
134 Klabunde C, Potosky AL, Harlan LC, Kramer BS. Trends and black/white differences in treatment for nonmetastatic prostate cancer. Med Care 1998;36:133748.[Medline]
135
Robbins AS, Whittemore AS, Van Den Eeden SK. Race, prostate cancer survival, and membership in a large health maintenance organization. J Natl Cancer Inst 1998;90:98690.
136 Mettlin CJ, Murphy GP, Cunningham MP, Menck HR. The National Cancer Data Base report on race, age, and region variations in prostate cancer treatment. Cancer 1997;80:12616.[Medline]
137 Poldenak AP, Flannery JT. Black versus white racial differences in clinical stage at diagnosis and treatment of prostatic cancer in Connecticut. Cancer 1992;70:21528.[Medline]
138 Schapira MM, McAuliffe TL, Nattinger AB. Treatment of localized prostate cancer in African-American compared with Caucasian men. Med Care 1995;33:107988.[Medline]
139 Harlan L, Brawley O, Pommerenke F, Wali P, Kramer B. Geographic, age, and racial variation in the treatment of local/regional carcinoma of the prostate. J Clin Oncol 1995;13:93100.[Abstract]
140 Robbins AS, Whittemore AS, Thom DH. Differences in socioeconomic status and survival among white and black men with prostate cancer. Am J Epidemiol 2000;151:40916.[Abstract]
141 Polednak AP. Prostate cancer treatment in black and white men: the need to consider both stage at diagnosis and socioeconomic status. J Natl Med Assoc 1998;90:1014.[Medline]
142 Demark-Wahnefried W, Schildkraut JM, Iselin CE, Conlisk E, Kavee A, Aldrich TE, et al. Treatment options, selection, and satisfaction among African American men with prostate carcinoma in North Carolina. Cancer 1998;83:32030.[Medline]
143 Franzini L, Williams AF, Franklin J, Singletary SE, Theriault RL. Effects of race and socioeconomic status on survival of 1,332 black, Hispanic, and white women with breast cancer. Ann Surg Oncol 1997;4:1118.[Abstract]
144 Logsdon MD, Eifel PJ. FIGO IIIB squamous cell carcinoma of the cervix: an analysis of prognostic factors emphasizing the balance between external beam and intracavitary radiation therapy. Int J Radiat Oncol Phys 1999;43:76375.[Medline]
145 Simons AJ, Ker R, Groshen S, Gee C, Anthone GJ, Ortega AE, et al. Variations in treatment of rectal cancer: the influence of hospital type and caseload. Dis Colon Rectum 1997;40:6416.[Medline]
146 Diehr P, Yergan J, Chu J, Feigl P, Glaefke G, Moe R, et al. Treatment modality and quality differences for black and white breast-cancer patients treated in community hospitals. Med Care 1989;27:94258.[Medline]
147 Crawford K, Fisher WH, McDermeit M. Racial/ethnic disparities in admissions to public and private psychiatric inpatient settings: the effect of managed care. Adm Policy Ment Health 1998;26:1019.[Medline]
148 Smith DB. The racial segregation of hospital care revisited: Medicare discharge patterns and their implications. Am J Public Health 1998;88:4613.[Abstract]
149 Darnell J, Rosenbaum JD, Scarpulla-Nolan L, Zuvekas A, Budetti P. Access for low-income, inner city, minority populations: How has managed care affected the urban minority poor and essential community providers. Health Policy & Child Health. Special report. Washington (DC): George Washington University; 1995.
150 Fowler JE Jr, Terrell F. Survival in blacks and whites after treatment for localized prostate cancer. J Urol 1996;156:1336.[Medline]
151 Bergan RC, Walls RG, Figg WD, Dawson NA, Headlee D, Tompkins A, et al. Similar clinical outcomes in African-American and non-African-American males treated with suramin for metastatic prostate cancer. J Natl Med Assoc 1997;89:6228.[Medline]
152 Modiano MR, Villar-Werstler P, Crowley J, Salmon SE. Evaluation of race as a prognostic factor in multiple myeloma. An ancillary of Southwest Oncology Group Study 8229. J Clin Oncol 1996;14:9747.[Abstract]
153 Lawton CA, Cantrell JE, Derus SW, Murray KJ, Byhardt RW, Wilson JF. Prostate cancer: are racial differences in clinical stage and survival explained by differences in symptoms? Radiology 1994;192:3740.[Abstract]
154 West DW, Satariano WA, Ragland DR, Hiatt RA. Comorbidity and breast cancer survival: a comparison between black and white women. Ann Epidemiol 1996;6:4139.[Medline]
155 Meltzer D, Egleston B, Abdulla I. Patterns of prostate cancer treatment by clinical stage and age. Am J Public Health 2001;91:1268.[Abstract]
156 Greenwald HP, Polissar NL, Borgatta EF, McCorkle R. Detecting survival effects of socioeconomic status: problems in the use of aggregate measures. J Clin Epidemiol 1994;47:9039.[Medline]
157 Feinleib M. Data needed for improving the health of minorities. Ann Epidemiol 1993;3:199202.[Medline]
158 Mutchler JE, Burr JA. Racial differences in health and health care service utilization in later life: the effect of socioeconomic status. J Health Soc Behav 1991;32:34256.[Medline]
159 Arbes SJ Jr, Olshan AF, Caplan DJ, Schoenbach VJ, Slade GD, Symons MJ. Factors contributing to the poorer survival of black Americans diagnosed with oral cancer (United States). Cancer Causes Control 1999;10:51323.[Medline]
160 Greenwald HP, Polissar NL, Dayal HH. Race, socioeconomic status and survival in three female cancers. Ethn Health 1996;1:6575.[Medline]
161 Cella DF, Orav EJ, Kornblith AB, Holland JC, Silberfarb PM, Lee KW, et al. Socioeconomic status and cancer survival. J Clin Oncol 1991:9:15009.[Abstract]
162
Gornick ME. The association of race/socioeconomic status and the use of Medicare services. A little-known failure in access to care. Ann N Y Acad Sci 1999;896:497500.
163 Hewitt M, Simone JV, editors. Enhancing data systems to improve the quality of cancer care. National Cancer Policy Board, Institute of Medicine and Commission on Life Sciences, National Research Council. Washington (DC): National Academy Press; 2000.
164 National Cancer Institute. Bypass budget 2002. http://plan2002.cancer.gov/infreduce.htm. May 14, 2001.
165 National Cancer Institute. CANCORS. http://www.dccps.ims.nci.nih.gov/ARP/cancors.html. April 20, 2001.
166 Guidry JJ, Aday L, Zhang D, Winn RJ. Transportation as a barrier to cancer treatment. Cancer Pract 1997;5:3616.[Medline]
167 Guidry JJ, Aday LA, Zhang D, Winn RJ. Cost considerations as potential barriers to cancer treatment. Cancer Pract 1998;6:1827.[Medline]
168
Hsu JL, Glaser SL, West DW. Racial/ethnic differences in breast cancer survival among San Francisco Bay Area women. J Natl Cancer Inst 1997;89:13112.
169 Plant P, Muers MF. Investigation and staging of lung cancer. Br J Hosp Med 1996;55:62730.[Medline]
170 Goodwin JS, Black SA, Satish S. Aging versus disease: the opinions of older black, Hispanic, and non-Hispanic white Americans about the causes and treatment of common medical conditions. J Am Geriatr Soc 1999;47:9739.[Medline]
171 Powe BD. Fatalism among elderly African Americans. Effects on colorectal cancer screening. Cancer Nurs 1995;18:38592.[Medline]
172 Rathore SS, Lenert LA, Weinfurt KP, Tinoco A, Taleghani CK, Harless W, et al. The effects of patient sex and race on medical students' ratings of quality of life. Am J Med 2000:108:5616.[Medline]
173 van Ryn M, Burke J. The effect of patient race and socio-economic status on physician perceptions of patients. Soc Sci Med 2000;50:81328.[Medline]
174 Einbinder LC, Schulman KA. The effect of race of the referral process for invasive cardiac procedures. Med Care Res Rev 2000;57 Suppl 1:16280.[Medline]
175
Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med 1999;340:61826.
176 Chen VW, Fenoglio-Preiser CM, Wu XC, Coates RJ, Reynolds P, Wickerham DL, et al. Aggressiveness of colon carcinoma in blacks and whites. National Cancer Institute Black/White Cancer Survival Study Group. Cancer Epidemiol Biomarkers Prev 1997;5:108793.
177 Weiss SE, Tartter PI, Ahmed S, Brower ST, Brusco C, Bossolt K, et al. Ethnic differences in risk and prognostic factors for breast cancer. Cancer 1995;76:26874.[Medline]
178 Fleming ID, Cooper JS, Henson DE, Hutter RV, Kennedy BJ, Murphy GP, et al. AJCC Cancer Staging Manual, 5th ed. Philadelphia (PA): Lippincott; 1997.
Manuscript received August 23, 2001; revised January 9, 2002; accepted January 11, 2002.
This article has been cited by other articles in HighWire Press-hosted journals:
![]() |
||||
|
Oxford University Press Privacy Policy and Legal Statement |