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Racial Disparities in Breast Cancer Stage at Diagnosis Linked to Lack of Insurance

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A large percentage of the difference in breast cancer stage at diagnosis between white women and women of other ethnicities seems to be linked to whether or not a woman has insurance, according to a study.

The research was published online on Jan. 9, 2020, by JAMA Oncology. Read the abstract of “Association of Insurance Status and Racial Disparities With the Detection of Early-Stage Breast Cancer.”

Breast cancer in Black and other minority women

Research has shown that Black women are more likely to die from breast cancer than any other ethnic group. Black women:

  • are more likely to be diagnosed with triple-negative breast cancer, which means the cancer has no receptors for the hormones estrogen and progesterone, as well as no receptors for the HER2 protein; this limits the medicines that can be used to treat the cancer
  • are more likely to be diagnosed with later-stage disease than other women
  • have the lowest survival rates in each stage of diagnosis

Experts have suggested that these racial disparities in breast cancer diagnoses and outcomes are likely a combination of factors. Research suggests that the biology of breast cancer is different in Black women. Rising obesity rates among Black women, coupled with statistics showing that more Black women are having fewer children and having children later in life could play a role. We also know that Black women are less likely to participate in clinical trials testing new breast cancer treatments. Some doctors think that it’s possible that some medicines work differently or less effectively in Black women.

Other research has shown that compared to white women, women of all other ethnic groups are more likely to have breast cancer that is at a later stage at diagnosis.

For the study reviewed here, the researchers looked specifically at breast cancer stage at diagnosis in different ethnicities and the factors that may be linked to this difference in stage at diagnosis.

About the study

To do the study, the researchers looked at information from 177,075 women age 40 to 64 who were diagnosed with stage I to stage III breast cancer between Jan. 1, 2010, and Dec. 31, 2016.

The information came from the SEER databases, large registries of cancer cases from sources throughout the United States maintained by the National Institutes of Health.

The researchers compared information on women diagnosed with stage I or stage II breast cancer to women diagnosed with stage III breast cancer to see if any factors were associated with a higher risk of being diagnosed with later-stage disease.

Of the 177,075 women:

  • 148,124 had insurance
  • 28,951 had no insurance or were receiving Medicaid

Compared to women without insurance or who were receiving Medicaid, women with insurance were:

  • slightly older at diagnosis
  • less likely to be diagnosed with stage III breast cancer vs. stage I or stage II breast cancer
  • more likely to be diagnosed with hormone-receptor-positive, HER2-negative breast cancer

Compared to women with insurance, women without insurance or who were receiving Medicaid were:

  • more likely to be unmarried
  • more likely to be living in areas with the lowest average income
  • more likely to be living in areas with a high percentage of adults who had less than a high school education
  • more likely to be living in areas where English was not the main language spoken

The researchers also found:

  • Black women, Native American/Alaskan Native women, and Hispanic women were more likely to be diagnosed with stage III breast cancer than stage I or stage II breast cancer.
  • White women were more likely to have insurance compared to Black women, Native American/Alaskan Native women, Asian/Pacific Islander women, and Hispanic women.

When the researchers included insurance status and other socioeconomic factors in their analysis, they found that nearly half of the racial difference in the risk of being diagnosed with stage III breast cancer, compared to stage I or stage II disease, was linked to health insurance.

“We’re seeing up to half of the disparity mediated by insurance,” said lead author Naomi Ko, M.D., MPH, assistant professor of medicine at the Boston University School of Medicine, in an interview. “That may not be surprising, but it’s nice to have the data and the evidence so we can have a thoughtful discussion.

“People say they care about minority women dying from cancer,” she added. “We’re saying if you have insurance, you’re going to get your cancer caught at an earlier stage. This is something that really might help move the needle.”

What this means for you

All women — no matter their age, ethnicity, economic status, or other health conditions — deserve the best breast cancer care and the best prognosis possible. Any socioeconomic differences that affect prognosis should be eliminated.

Regular doctor visits and breast cancer screening are a good place to start. Breast cancer that is diagnosed early is typically easier to treat and offers the best survival chances. Regular screening for breast cancer, including annual mammograms and breast exams by a medical professional, is important for everyone.

Paying for healthcare can be difficult, especially if you have limited income or are covered only by Medicaid. But if you're older than 40, skipping regular mammograms is not an option. Stick with the screening plan you and your doctor decide is best for you. If scheduling problems or cost concerns are stopping you from getting a mammogram, talk to your doctor, a hospital social worker, or a staff member at a mammogram center. Ask about free mammogram programs and healthcare services in your area. It's your health and your future, and you deserve the best care possible.

Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, M.D., medical advisor

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