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Mind the gap: racial differences in breast cancer incidence and biologic phenotype, but not stage, among low-income women participating in a government-funded screening program

  • Epidemiology
  • Published:
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Abstract

Breast cancer mortality rates in South Carolina (SC) are 40 % higher among African-American (AA) than European-American (EA) women. Proposed reasons include race-associated variations in care and/or tumor characteristics, which may be subject to income effects. We evaluated race-associated differences in tumor biologic phenotype and stage among low-income participants in a government-funded screening program. Best Chance Network (BCN) data were linked with the SC Central Cancer Registry. Characteristics of breast cancers diagnosed in BCN participants aged 47–64 years during 1996–2006 were abstracted. Race-specific case proportions and incidence rates based on estrogen receptor (ER) status and histologic grade were estimated. Among 33,880 low-income women accessing BCN services, repeat breast cancer screening utilization was poor, especially among EAs. Proportionally, stage at diagnosis did not differ by race (607 cancers, 53 % among AAs), with about 40 % advanced stage. Compared to EAs, invasive tumors in AAs were 67 % more likely (proportions) to be of poor-prognosis phenotype (both ER-negative and high-grade); this was more a result of the 46 % lesser AA incidence (rates) of better-prognosis (ER+ lower-grade) cancer than the 32 % greater incidence of poor-prognosis disease (p values <0.01). When compared to the general SC population, racial disparities in poor-prognostic features within the BCN population were attenuated; this was due to more frequent adverse tumor features in EAs rather than improvements for AAs. Among low-income women in SC, closing the breast cancer racial and income mortality gaps will require improved early diagnosis, addressing causes of racial differences in tumor biology, and improved care for cancers of poor-prognosis biology.

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Abbreviations

AA:

African-American

BCCEDP:

Breast and Cervical Early Detection Program

BCN:

Best Chance Network

CDC:

Centers for Disease Control and Prevention

EA:

European-American

ER:

Estrogen receptor

ER-:

ER-negative

ER+:

ER-positive

G:

Grade

IRB:

Institutional Review Board

MAR:

Missing at random

MCAR:

Missing completely at random

PR:

Progesterone receptor

RR:

Incidence rate ratio (AA/EA)

SC:

South Carolina

SCCCR:

SC Central Cancer Registry

SEER:

Surveillance, Epidemiology and End Results

SES:

Socio-economic status

US:

United States

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Acknowledgments

We particularly thank Irene Prabhu Das, PhD (NIH) for bringing our attention to the need to examine race-associated differences in incidence using BCN data. We also thank Phoenix Do, PhD (University of South Carolina Arnold School of Public Health) for help with the geospatial considerations and editorial assistance. Thanks are also due to Dianne Lydiard, PhD (SC BCN), to Susan Bolick, MSPH, CTR, and the staff of the SCCCR (Margaret Ehlers, MSPH, and Deborah Hurley, MSPH) for providing the data, and to Mike Byrd, PhD (University of South Carolina) and Anthony Alberg, PhD (Medical University of South Carolina) for their encouragement. JEC and CAW were partially supported by general funds from the Hollings Cancer Center at the Medical University of South Carolina. JEC and TB-E were partially supported by general funds from the University of South Carolina. JEC and EGH were partially supported by NIH grant number 5R03CA137826-02. BCN data were provided by the SC BCCEDP funded through the Centers for Disease Control and Prevention, National BCCEDP grant number 5U58DP000770-05.

Conflict of interest

The authors state they have no conflicts of interest.

Ethical standards

The study presented here complies with the current laws of the US, in which it was performed. This study has not been presented outside the institutions of the authors. Some of this study was conducted by Ms. Tiffany Baker-Elamin toward her MSPH Thesis.

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Authors and Affiliations

  1. Division of Biostatistics and Epidemiology, Department of Medicine, College of Medicine, Medical University of South Carolina, and Hollings Cancer Center, 135 Cannon Street, Suite 300, Charleston, SC, 29425, USA

    Joan E. Cunningham

  2. Office of the Dean, Faculty of Medical Sciences, University of the West Indies at Mona, Jamaica, West Indies

    Christine A. Walters

  3. Division of Biostatistics and Epidemiology, Department of Medicine, College of Medicine, Medical University of South Carolina, and Hollings Cancer Center, 86 Jonathan Lucas St., Charleston, SC, 29425, USA

    Elizabeth G. Hill

  4. Division of Biostatistics and Epidemiology, Department of Medicine, College of Medicine, Medical University of South Carolina, and Hollings Cancer Center, 68 President St., Charleston, SC, 29425, USA

    Marvella E. Ford

  5. Bureau of Disease Control, South Carolina Department of Health and Environmental Control, Columbia, SC, USA

    Tiffany Barker-Elamin

  6. South Carolina College of Pharmacy, University of South Carolina Campus, 280 Calhoun St., Columbia, SC, 29208, USA

    Charles L. Bennett

Authors
  1. Joan E. Cunningham
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  2. Christine A. Walters
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  3. Elizabeth G. Hill
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  4. Marvella E. Ford
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  5. Tiffany Barker-Elamin
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  6. Charles L. Bennett
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Corresponding author

Correspondence to Joan E. Cunningham.

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Dedication

This manuscript is dedicated to one of the authors, Ms. Tiffany Barker-Elamin, MSPH, whose thesis formed the basis for this study, and whose recent death is mourned by all who knew her.

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Cunningham, J.E., Walters, C.A., Hill, E.G. et al. Mind the gap: racial differences in breast cancer incidence and biologic phenotype, but not stage, among low-income women participating in a government-funded screening program. Breast Cancer Res Treat 137, 589–598 (2013). https://doi.org/10.1007/s10549-012-2305-0

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