Racial Disparities in the Initiation and Intensity of Adjuvant Therapy for Breast Cancer

PUBLIC ABSTRACT

In the past few decades, the use of adjuvant chemotherapy and hormonal therapy following surgery has dramatically improved survival in nonmetastatic breast cancer. Recent studies have shown that the survival benefit is greater among patients who receive a complete course of chemotherapy or hormonal therapy than among those who do not. A substantial number of patients fail to receive complete treatment, but little is known about the reasons for this failure.

Among those diagnosed with breast cancer, women of predominantly African descent (black women) have poorer survival than women of predominantly European descent (white women), in part because they are diagnosed at later stages. Our proposed Breast Cancer Center of Excellence will study the biological, toxicity-related, behavioral, communication, economic, psychosocial, cultural, and molecular genetic factors that may create barriers to optimal adjuvant breast cancer systemic therapy.

Our Center will utilize 900 black and 900 white breast cancer patients from two already funded studies. One is a Department of Defense-funded Center of Excellence at Mount Sinai School of Medicine under the direction of Dr. Dana Bovbjerg, which will recruit 1,200 black and 1,200 white breast cancer patients in conjunction with a grant funded by the National Cancer Institute (NCI) at Roswell Park Cancer Center under the direction of Dr. Christine Ambrosone, as part of a case-control study of etiologic factors for breast cancer in black and white women. A second study, headed by Dr. Larry Kushi of Kaiser Permanente in California, is funded by the NCI to recruit 5,000 breast cancer patients over a period of 4 years. This study will include 378 black and 4,000 white patients and is designed to assess the impact of lifestyle risk factors on survival outcomes.

We will obtain consent from the women in these studies to participate in our study. We will interview them at diagnosis and collect new information on clinical status, referral to oncologists, recommended therapy, psychological status, cultural and personal values and preferences, and perceptions of physician-patient interaction. We will re-interview the subjects at 1 month and at the completion of the planned chemotherapy to ascertain their adherence to the recommended chemotherapy, dose-intensity, and toxicities. We will interview those who do not receive chemotherapy at 1 and 6 months. We also will survey the treating oncologists once about their attitudes toward treatment and review patient medical records for data on incomplete treatment and the reasons for it. Among patients who are hormone receptor-positive, we will assess recommendations for and adherence to hormonal therapy. We will seek funding elsewhere to assess long-term survival in the entire cohort.

Our Center will bring together experts in medical and surgical oncology, epidemiology, biostatistics, behavioral oncology, communications research, consumer advocates, health outcomes research, and molecular genetics to address these issues. Identifying the barriers to optimal treatment will enable us to intervene to reduce racial disparities and to improve survival for all women with breast cancer.