Racial disparities in healthcare delivery have been associated with poorer outcomes in persons of color compared with their white counterparts. Data are emerging that factors affecting social determinants of health (SDOH) and racial disparities can adversely impact tumor biology and survival in BC. Racial disparities in BC can also affect treatment patterns and treatment-related adverse events.
Two recent articles on DEI (diversity, equity, and inclusion) identify the impact on racial disparities on BC in patients of color. The first study utilized information from the University Hospitals Seidman Cancer Center data repository in Northeast Ohio. Women aged 18 years or older with in situ, early-stage, or late-stage BC diagnosed between January 1, 2005, and March 31, 2022, were identified. Exclusion criteria included being a race other than black or white, ethnicity different than non-Hispanic, and gender different than female. The study outcomes included treatment and time-to-treatment following the BC diagnosis and the diagnosis and time-to event of a treatment-related adverse event.
Data were gathered on 17,454 non-Hispanic women with BC who had a median age of 63 years. The study group consisted of 82% non-Hispanic whites (NHWs) and 18% non-Hispanic blacks (NHBs). Among the differences noted included that NHBs were followed for a median of 4.4 years compared with a median follow-up period of 8.1 years for NHWs. NHBs were about 1 year younger at the time of diagnosis, were more likely to have a positive smoking history (13.5% vs. 9%, P <.001), and had a significantly higher Charlson comorbidity score. Both ductal carcinoma and stage IV BC were significantly more common in NHBs (48.8% vs. 39.9%, P <.001 and 6.4% vs. 4.9%, P <.001, respectively).
Disparities were also observed in treatment patterns with significantly higher rates of surgery (58% vs. 50.1%, P <.001), radiotherapy (42.1% vs. 28%, P <.001), chemotherapy (34.6% vs. 24.6%, P <.001), and immunotherapy (4.1% vs. 2.8%, P <.001) utilized in NHBs compared with NHWs. Despite these more aggressive treatments, NHBs also experienced longer delays for surgery, radiotherapy, chemotherapy, and time to initiation of endocrine therapy. Even though NHBs had a higher number of appointments per patient, they had a lower median appointment completion rate compared with NHWs.
NHBs had higher rates of treatment-related adverse events including chemotherapy-induced complications (20.9% vs. 12.2%, P <.001) such as cardiomyopathy, diarrhea/enteritis, fatigue, nausea/vomiting, neuropathy, lung disease, pain, dehydration/hypovolemia, rash, infusion reactions, and cognitive decline/dementia (13.6% vs. 6.7%, P <.001) compared with NHWs. While NHBs did not have a higher incidence of immune-related toxicities, they did experience higher rates of cardiac toxicities, acute myocardial infarction, and pneumonitis than their NHW counterparts.
In addition to disparities in treatment patterns and treatment-related adverse events, NHBs were less likely to undergo curative intent BC surgery (adjusted hazards ratio [HR] 0.92; 95% CI, 0.87-0.97) or receive endocrine therapy (adjusted HR 0.83; 95% CI, 0.79-0.89) than NHWs. Further, NHBs had a 19% lower risk of being diagnosed with a psychological disorder but a 30% higher risk of being diagnosed with cognitive decline/dementia following treatment for BC.
A second paper looked at the association of SDOH, tumor biology, and racial disparity on survival in early-stage, hormone-dependent BC. Using data from 60,137 women from the Surveillance, Epidemiology, and End Results (SEER) Oncotype Dx Database, investigators found that black women were more likely to have tumors with aggressive histopathologic characteristics, to have a higher recurrence score, to be diagnosed at stage 2, and to receive chemotherapy compared with white women. Black women were also 38% more likely than white women to die from BC (hazard ratio [HR] 1.38; 95% CI, 1.11-1.71). Based on census-track socioeconomic index (SEI) data, black women in each census tract SEI category were more likely than white women to die from BC, and this risk ranged from 50% higher in the most disadvantaged tract (age-adjusted HR 1.50; 95% CI, 1.10-2.05) to 88% higher in the middle tract (HR 1.88; 95% CI, 1.33-2.64). When census-track SEI data, health insurance status, recurrence score, tumor histopathologic characteristics, racial differences in tumor size and treatment were combined, they accounted for 44% of the disparity in BC survival between black and white women with ER-positive, axillary node–negative BC. Socioeconomic disadvantage was associated with greater recurrence score.
As greater focus is being place on DEI in healthcare, pharmacists should be aware of how these factors affect their patients with BC.
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Published March 28, 2023