Nativity and ethnicity may influence quality of breast cancer care

[February 15, 2017]  By Lisa Rapaport

(Reuters Health) - Doctors may diagnose breast cancer later and be less likely to offer needed radiation for Hispanic immigrants than for Hispanic women born in the U.S. and white women, a recent study suggests.

The results indicate that disparities in care and biases that influence treatment may be based not just on immigration status but also on race, said senior study author Dr. David Chang of Harvard University and Massachusetts General Hospital in Boston.

Compared to white women born in the U.S., Hispanic women born in the country were 18 percent more likely to be diagnosed when tumors had already advanced to become more difficult to treat, and Hispanic immigrants were 26 percent more likely to get a later diagnosis.

Hispanic immigrants were also 20 percent less likely to receive radiation than white women born in the U.S., the study found.

"We will never be able to conclusively prove bias, but by identifying disparities in treatment we are building strong circumstantial evidence that human bias may play at least a partial role," Chang added by email.

That's because the study didn't look at outcomes, which can be influenced by genetics and a variety of other individual patient characteristics. It looked at treatment choices doctors made.

Most early-stage breast cancer patients have surgery – either a lumpectomy that removes malignant tissue while sparing the rest of the breast or a mastectomy that removes the entire breast. After surgery, they may also get chemotherapy or radiation to destroy any remaining abnormal cells and reduce the risk of cancer coming back.

Treatment options can be more limited when tumors aren't caught until the cancer is more advanced.

For the study, researchers examined data on about 296,000 women diagnosed with breast cancer in the U.S. from 1988 to 2009.

They found U.S.-born Hispanic women had 15 percent lower odds of receiving any form of radiation than white women born in the country.

To separate the effects of ethnicity or race from the effect of having been born outside the U.S., researchers also compared foreign-born Hispanic women to foreign-born white women.

Immigration seemed to have the opposite effect for Hispanic and white women, researchers report in JAMA Surgery. Among immigrants, Hispanic women were significantly less likely to get radiation than white patients. But white immigrant women were 26 percent more likely to receive radiation than white women born in the U.S.

The study didn't examine treatment outcomes or explore how factors such as insurance status or access to care close to home might influence treatment options. The study also didn't look at other things that may determine what care women get such as income, education and English fluency.

"Low income, low education immigrant groups are less likely to be insured, have lower access to care and poorer outcomes," said Roshan Bastani, director of cancer disparities research at the University of California Los Angeles Jonsson Comprehensive Cancer Center.

"This study shows that among Latinas, being foreign born is an added burden with regard to poor outcomes," Bastani, who wasn't involved with the study, added by email.

Breast cancer treatment or outcomes might also vary for Hispanic immigrants depending on their legal status in the U.S., said Dr. Katherine Reeder-Hayes of the University of North Carolina Chapel Hill Lineberger Comprehensive Cancer Center.

"The authors' findings confirm the logical hypothesis that Hispanic patients born outside the United States may have more difficulty accessing the U.S. healthcare system compared to other groups including U.S.-born Hispanics," Reeder-Hayes, who wasn't involved in the study, said by email.

"In the current climate it is also possible that undocumented immigrants who presumably make up part but not all of the foreign-born group may fear contact with the health system because of their perception that it would create problems related to their immigration status," Reeder-Hayes added. "Unfortunately, we should probably worry that some foreign born patients may delay seeking care due to these types of concerns."

SOURCE: http://bit.ly/2ldGpPn JAMA Surgery, online February 8, 2017.

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