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 About 23 percent of black women diagnosed with breast cancer in
2004-2013 had either no health insurance or had Medicaid coverage,
versus 8 percent of white breast cancer patients, Dr. Ahmedin Jemal
of the American Cancer Society in Atlanta and colleagues report in
the Journal of Clinical Oncology.
That insurance difference explained about 37 percent of the excess
mortality among black women, the researchers calculated. The next
most important factor was actual differences in the tumors, which
accounted for 23 percent of the mortality disparity.
Black women’s breast cancer mortality is now 40 percent higher than
white women’s, but up until the early 1980s, white women were
actually more likely to die after a breast cancer diagnosis, Jemal
noted in a telephone interview. That’s because screening for and
treatment of breast cancer has been getting better, he explained,
but white women have benefited more than black women from these
advances.
“What has changed is we have these scientific advances in early
detection and treatment, we have mammography, we have adjuvant
chemotherapy for breast cancer, we have hormone therapy, we have now
even targeted therapy,” Jemal said. “We know that black women are
less likely to receive high-quality mammograms, less likely to
receive a follow-up after an abnormal mammogram, and are less likely
to receive targeted therapy.”
In the new study, Jemal and his team looked at records for 563,497
women ages 18 to 64 who had been diagnosed with early-stage breast
cancer, meaning the disease had not spread beyond the breast. Among
the more than three-quarters who had hormone-sensitive disease, the
risk of dying during follow-up was twice as high for black women as
for white women.
Insurance accounted for the largest portion of black women’s
increased risk, followed by tumor characteristics, co-existing
illnesses (11 percent) and treatment differences (5 percent).
The study looked at younger women because women over 65 are more
likely to have similar health coverage under the Medicare program
for seniors, the authors note. Indeed, previous research has found
smaller disparities in survival among older black and white women
and a much larger role for tumor biology in that disparity, they
write.
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“In this country if you don’t have health insurance you are out of
luck,” Jemal said. “It’s a barrier to prevention, early detection
and receipt of standard-of-care treatment.”
Many of the women on Medicaid in the current study had been signed
up after being diagnosed with cancer, Jamal noted.
“Survival disparities between black and white breast cancer patients
are largely driven by differences in insurance,” he said. “Policy
makers should make sure that all the scientific advances we have had
over the years are accessible to all patients regardless of their
socioeconomic status or race or ethnicity.”
“This puts it in black and white, literally, and shows you that
there are survival differences that are based on insurance and there
are racial differences based on insurance, so if you give people
insurance and get them the care that’s needed, you can have an
impact and reduce this excess risk,” said Dr. Nina Bickell of The
Mount Sinai Hospital in New York, who wasn’t involved in the study.
“The wonder of the Affordable Care Act is it really tried to take a
more universal approach to enabling access,” Bickell added, noting
that studies are already showing improved health outcomes in states
that have opted for Medicare expansion.
“What’s so important about this study is that it’s showing that when
you gain access via coverage, via insurance, you can improve
survival,” she said in a telephone interview. “One can only hope,”
she added, that the new findings will help build public support for
continuing the Affordable Care Act, rather than dismantling it.
SOURCE: http://bit.ly/2xOFbfX Journal of Clinical Oncology, online
October 16, 2017
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