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. 2009 Jul 15;101(14):993-1000.
doi: 10.1093/jnci/djp176. Epub 2009 Jul 7.

Underlying causes of the black-white racial disparity in breast cancer mortality: a population-based analysis

Idan Menashe  1 , William F Anderson, Ismail Jatoi, Philip S Rosenberg
Affiliations

Underlying causes of the black-white racial disparity in breast cancer mortality: a population-based analysis

Idan Menashe et al. J Natl Cancer Inst. .

Abstract

Background: In the United States, a black-to-white disparity in age-standardized breast cancer mortality rates emerged in the 1980s and has widened since then.

Methods: To further explore this racial disparity, black-to-white rate ratios (RRs(BW)) for mortality, incidence, hazard of breast cancer death, and incidence-based mortality (IBM) were investigated using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program on 244 786 women who were diagnosed with breast cancer from January 1990 through December 2003 and followed through December 2004. A counterfactual approach was used to examine the expected IBM RRs(BW), assuming equal distributions for estrogen receptor (ER) expression, and/or equal hazard rates of breast cancer death, among black and white women.

Results: From 1990 through 2004, mortality RR(BW) was greater than 1.0 and widened over time (age-standardized breast cancer mortality rates fell from 36 to 29 per 100 000 for blacks and from 30 to 22 per 100 000 for whites). In contrast, incidence RR(BW) was generally less than 1.0. Absolute hazard rates of breast cancer death declined substantially for ER-positive tumors and modestly for ER-negative tumors but were persistently higher for blacks than whites. Equalizing the distributions of ER expression in blacks and whites decreased the IBM RR(BW) slightly. Interestingly, the black-to-white disparity in IBM RR(BW) was essentially eliminated when hazard rates of breast cancer death were matched within each ER category.

Conclusions: The black-to-white disparity in age-standardized breast cancer mortality was largely driven by the higher hazard rates of breast cancer death among black women, diagnosed with the disease, irrespective of ER expression, and especially in the first few years following diagnosis. Greater emphasis should be placed on identifying the etiology of these excess hazards and developing therapeutic strategies to address them.

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Figures

Figure 1
Figure 1
Age-standardized breast cancer mortality rates. Age-standardized breast cancer mortality rates in the National Cancer Institute's Surveillance, Epidemiology, and End Results 9 are plotted for black (solid squares) and white (open squares) women between the years 1990 and 2004 by 3-year period. Dashed lines indicate 95% confidence intervals (CIs).
Figure 2
Figure 2
Black-to-white breast cancer mortality and incidence rate ratios (RRsBW) for three age groups. A) Mortality RRBW. B) Incidence RRBW. Observed values (dots, age ≥70 years; squares, ages 50–69 years; and triangles, ages 30–49 years) are shown along with the corresponding fitted trends (solid line, dashed line, and dot–dash line, respectively) with 95% confidence intervals (shaded areas). Broken black line indicates an RRBW = 1.
Figure 3
Figure 3
Annual hazard rates of breast cancer death (percentage of breast cancer dying per year among women living with the disease) are plotted against years since diagnosis for black women (orange) and white women (blue) for two calendar periods: 1990–1996 (broken lines) and 1997–2004 (solid lines). A) Hazard rates among case subjects with estrogen receptor–negative (ER−) tumors. B) Hazard rates among case subjects with estrogen receptor–positive (ER+) tumors.
Figure 4
Figure 4
Black-to-white breast cancer hazard rate ratios (RRsBW). Hazard RRsBW are plotted for three age groups. A) Estrogen receptor–negative (ER−) tumors. B) Estrogen receptor–positive (ER+) tumors. In each panel, observed values (dots, ages ≥70 years; squares, ages 50–69 years; and triangles, ages 30–49 years) are shown along with the corresponding fitted trends (solid line, dashed line, and dot–dash line, respectively) with 95% confidence intervals (shaded areas). Broken black line indicates an RRBW = 1.
Figure 5
Figure 5
Black-to-white incidence–based mortality rate ratios (IBM RRsBW). Black-to-white IBM RRsBW with 95% confidence intervals were calculated and plotted under four different scenarios: 1) observed IBM RRsBW (solid squares), 2) expected IBM RRsBW after equalizing the proportions of estrogen receptor–negative and estrogen receptor–positive (ER− and ER+) breast cancers in black women to the proportions in white women (open circles), 3) expected IBM RRsBW assuming that annual hazard rates for death from ER+ and ER− breast cancers in blacks were equal to the corresponding rates in whites (solid diamonds), and 4) expected IBM RRsBW after equalizing the proportions of ER− and ER+ breast cancers and annual hazard rates for death from ER+ and ER− breast cancers (open triangles).
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References

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