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NEWS: Roger Dobson Black women in US have lower survival rates from breast cancer than white women BMJ 2008; 337: a586 [Full text]

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Black Women in US are Less Likely than White Women to Survive Breast Cancer

Ismail Jatoi, Michael Baum, Romano Demicheli, Michael W. Retsky, William J.M. Hrushesky, Isaac D. Gukas   (29 July 2008)

Black Women in US are Less Likely than White Women to Survive Breast Cancer 29 July 2008
Ismail Jatoi, Department Head, Breast Care Center National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889, USA, Michael Baum, Romano Demicheli, Michael W. Retsky, William J.M. Hrushesky, Isaac D. Gukas Send response to journal: Re: Black Women in US are Less Likely than White Women to Survive Breast Cancer	Dear Sirs: Roger Dobson reports on a study showing that Black women in the USA are less likely to survive breast cancer than White women, regardless of the stage of diagnosis (1,2). The racial disparity in breast cancer mortality rates has generated considerable interest in recent years, but several salient features of this disparity are often overlooked. Firstly, although White women in the USA generally have better access to healthcare (better insurance coverage) than Black women, this alone can not account for the disparity. Indeed, a widening racial disparity in breast cancer survival rates is also evident in the US Department of Defense Healthcare system, where all beneficiaries receive free and equal access to healthcare (3). Secondly, the racial disparity in breast cancer mortality rates did not become evident until the late 1970s, which coincided with the introduction of mammography screening in the USA (4). Prior to this period, breast cancer mortality rates among Blacks and Whites were virtually identical. We and others have drawn attention to the mortality paradox associated with mammography screening for women aged 40 to 49 (4, 5). In randomized trials, an increase in breast cancer mortality is evident 3 to 10 years after initiation of screening in women aged 40-49 compared to controls, with declines in mortality thereafter. This anomaly has not been associated with mammography screening in older women. Given that Black women have higher rates of pre-menopausal breast cancers than do White women, this anomaly may partly account for the racial divergence in breast cancer mortality rates following the introduction of mammography screening in the late 1970s. Mammography screening leads to the diagnosis of a large reservoir of occult cancers, and in pre-menopausal women, it has been suggested that extirpation of these lesions may transiently accelerate the appearance of distant metastasis (5). Yet, breast cancer mortality rates between Black and White women in the USA continue to diverge, even though mammography screening was introduced almost 30 years ago. We believe that this continued trend might partly be explained by the wider use of endocrine therapy (tamoxifen and the aromatase inhibitors) over the last 20 years (4). Black women are less likely to have ER-positive tumors than White women, and are therefore less likely to benefit from endocrine therapy. Also, many Black women are underinsured, and might not have access to these newer therapies. Thus, a combination of factors, including response to screening and adjuvant therapies as well as access to care, are likely responsible for the racial divergence in breast cancer mortality rates in the USA since the late 1970s. References 1. Dobson R. Breast cancer: Black women in US are less likely than white women to survive with same stage. BMJ 2008; 337: a586 2. Deshpande AD, Jeffe DB, Gnerlich J, et al. Racial disparities in breast cancer survival: an analysis by age and stage. J Surg Res 2008 June 23; doi: 10.1016/j.jss.2008.05.020 3. Jatoi I, Becher H, Leake CR. Widening disparity in survival between White and African American patients with breast carcinoma treated in the U.S. Department of Defense Healthcare System. Cancer 2003; 98: 894 -899. 4. Jatoi I, Anderson WF, Rao SR, Devesa SS. Breast cancer trends among Black and White women in the United States. J Clin Oncol 2005; 23: 7836-7841. 5. Demicheli R, Retsky MW, Hrushesky WJM, Baum M, Gukas ID, Jatoi I. Racial disparities in breast cancer outcome: insights into host-tumor interactions. Cancer 2007; 110 (9): 1880-1888. Competing interests: The views or opinions expressed in this letter are those of the authors and should not be construed as representing the official views of the Departments of the Army, Navy, or Defense.