Why Are Many Older Women and Black Women Not Treated With Herceptin?

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Herceptin (chemical name: trastuzumab) is a targeted therapy medicine used to treat HER2-positive breast cancer.

Large studies have confirmed that adding Herceptin to chemotherapy to treat women diagnosed with early-stage, HER2-positive breast cancer improves overall survival and disease-free survival compared to chemotherapy alone.

Overall survival is how long a woman lives, with or without the cancer growing. Disease-free survival is how long a woman lives without the cancer growing.

So it’s extremely troubling that a study found that half of women age 65 and older who would benefit from Herceptin didn’t receive it; black women were 25% less likely to receive Herceptin than white women.

The research was published online on April 11, 2016 by the Journal of Clinical Oncology. Read the abstract of “Disparities in Use of Human Epidermal Growth Hormone Receptor 2-Targeted Therapy for Early-Stage Breast Cancer.”

To do the study, the researchers looked at a SEER-Medicare database. For people age 65 and older who have Medicare insurance, about 95% of cancer cases are included in the database. The SEER databases are maintained by the National Institutes of Health.

The researchers gathered diagnosis information for the 1,362 women who were diagnosed with stage I to stage III HER2-positive breast cancer in 2010 and 2011:

  • 85% were white
  • 7.6% were black
  • 7% were other races
  • 52.6% were age 65 to 74; 47.4% were 75 or older
  • 69% had node-negative disease (no cancer was found in the lymph nodes)
  • 73% had hormone-receptor-positive and HER2-positive disease
  • 52% had high-grade cancers
  • 42% had cancers that were 2 cm or larger

Using insurance claim information, the researchers recorded the women who were treated with Herceptin within 1 year of diagnosis. Overall:

  • 50% of white women
  • 40% of black women
  • 52% of other minority women

were treated with Herceptin.

When the researchers looked at Herceptin use by cancer stage, they found that black women consistently were less likely to be treated with Herceptin:

  • stage I disease: 37.5% of white women and 24.4% of black women were treated with Herceptin
  • stage II disease: 57.2% of white women and 48.9% of black women were treated with Herceptin
  • stage III disease: 73.9% of white women and 56.3% of black women were treated with Herceptin

To get the most accurate idea of any discrepancies in Herceptin use, the researchers adjusted their data for age, any other diseases the women might have had, cancer characteristics, any other treatments the women had, and income level. All of these factors could affect whether Herceptin was recommended for a specific woman. For example, Herceptin is known to cause heart problems, so Herceptin would probably not be recommended for a woman with a history of heart disease.

The adjusted data showed that black women were 25% less likely to receive Herceptin within 1 year of diagnosis than white women.

"This is significant because we know that there is a large number of women here who are not receiving a therapy that we know would give them a better chance of survival," said the study's first author Katherine Reeder-Hayes, M.D., MBA, clinical assistant professor at the University of North Carolina School of Medicine.

Women diagnosed with breast cancer that was:

  • larger than 5 mm
  • node-positive
  • moderately or poorly differentiated; this means the cancer cells look and behave much differently than normal cells and usually means the cancer is more aggressive

were more likely to be treated with Herceptin.

Women who were older than 74 and had other medical issues were less likely to be treated with Herceptin.

"Fifty percent of white women and 60% of black women didn’t get a drug that improves survival by nearly 40%," said study coauthor Dr. Lisa Carey, Marilyn Jacobs Preyer Distinguished Professor in Breast Cancer Research at the University of North Carolina School of Medicine. "If confirmed, these are terrible numbers. There was underutilization broadly of what is very effective therapy -- we must find out why."

"In many ways, this is not surprising because we know that across many types of breast cancer therapy, black women are less likely to receive treatment for a clinically similar disease," Dr. Reeder-Hayes added. "But one might hope that having a clear biological marker of eligibility for a treatment in this case -- having overexpression of the HER2 receptor -- would mitigate disparities because it would be an objective measure of who should receive the therapy."

The researchers said that their study couldn’t account for several factors that might affect a woman's ability to be treated with Herceptin. For example, Herceptin is expensive, and although the women in the study all were insured by Medicare, the women could have had different supplemental insurance plans.

"Herceptin costs about $5,000 per infusion, so women without supplemental Medicare insurance would have to pay about 20% of that amount out of pocket," said Stacie Dusetzina, Ph.D., assistant professor of pharmacy at the University of North Carolina. "However, we're not sure the cost sufficiently explains the shocking under use of what is a highly effective treatment for this type of cancer."

The disturbing results of this study echo the results of a 2015 study that found that minority women, especially black and American Indian/Alaska Native women, are more likely to be diagnosed with more advanced stage breast cancer and also more likely to receive treatment below the standard of care than white women.

If you’ve been diagnosed with breast cancer, you and your doctors will put together a treatment plan that meets the needs of your unique situation and takes into account your overall medical condition and your personal style of making decisions.

If you’re not comfortable with the treatment plan your doctor recommends or want to see if another doctor recommends the same options, you may want to consider getting a second opinion from another doctor.

Many women diagnosed with breast cancer feel a sense of urgency about jumping right in and starting treatment immediately. In most cases, though, there’s time to do some research to make sure your diagnosis is correct and your treatment plan makes sense -- and this may include getting a second opinion.

Getting a second opinion means asking another breast cancer specialist, or a team of specialists, to review all of your medical reports and test results, give an opinion about your diagnosis, and suggest treatment options. A second opinion may confirm your original doctor’s diagnosis and treatment plan, provide more details about the type and stage of breast cancer, raise additional treatment options you hadn’t considered, or recommend a different course of action. Even if you’ve already had treatment, it’s not too late to get a second opinion. A second doctor can weigh in on your diagnosis and treatment plan to date, offering any additional thoughts or recommendations.

No matter your age or ethnicity, you absolutely deserve the best medical care possible. Don’t be afraid to ask questions and advocate for your care.

For more information on planning your treatment and getting a second opinion, visit the Breastcancer.org Treatment & Side Effects section.

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