Black/White Disparities in Receipt of Treatment and Survival Among Men With Early-Stage Breast Cancer
Sineshaw HM, Freedman RA, Ward EM, Flanders WD, Jemal A
J Clin Oncol. 2015 May 4. pii: JCO.2014.60.5584. [Epub ahead of print]
Background
There is evidence that black men have a higher incidence of breast cancer, and are diagnosed at a younger age than white men. This begs the question of whether the outcomes for black men with this disease are the same or different. Here the authors used data from the National Cancer Database, sponsored by the American Cancer Society and the American College of Surgeons. This registry collects data from hospitals across the US, and captures around 70% of newly diagnosed cancer in the country. They divided the nearly six thousand men they studied into men between 18 and 64 and those 65 and over.
Findings
While moderate differences were found between black and white men in different age groups when it comes to specific elements of treatment (see below) the overall finding is that survival, when adjusted for insurance and area-level median income, was not significantly different between the groups.
Overall 5-year survival curves for non-Hispanic (NH) black vs NH white men with early-stage breast cancer by age group – These curves do not include adjustments for income or insurance.
(http://jco.ascopubs.org/content/early/2015/04/29/JCO.2014.60.5584/F2.expansion.html)
It is well established that socioeconomics is an important factor in health care outcomes, as it influences access to care. As is unfortunately still often the case in the US, race is a surrogate marker for economic status. In that sense the key finding of this paper is good news: there is no evidence that black men are receiving inferior care based on their race. However, in another sense it is further evidence that wealth, and the access to health care that it brings, is unevenly divided and that black people are disproportionally on the lower end of the spectrum.
Some residual increased risk was still detected after the adjustment for insurance and income, suggesting that perhaps among younger black men outcomes are marginally worse – meaning that young black men with breast cancer die sooner than their white counterparts. This does not appear to be because they receive different treatments – here no differences were observed. While not definitive – probably not enough data points – it could point to a biological difference.
As far as treatment goes, the main difference that was observed was that older black men had lower rates of hormonal therapy (53.4% vs 60.5%). Whether this contributes significantly to the outcomes is unclear at this stage. Personally I wonder what the adherence rate to hormonal therapy is among men in any case – recent data from women suggests it is far from optimal… and I can’t help thinking that the men are likely to do even worse.
Comment
This important study lays a concern to rest that there is an inherently racial disparity in care delivery. It shows that improvement in health care for the relatively disadvantaged must still be achieved in the US.
In relation to the biology of male breast cancer, the indication of moderately poorer outcomes for young black men allows that their disease is more aggressive and that there is perhaps a biological basis for this. Coupled with the observation that the incidence of breast cancer is higher in black men than white men, this provides a good rationale for a comparative study. Genome sequencing and gene expression analysis of the tumors from several hundred black and white men may lead to some insight – a good research project.
Entering a World of Pink 