- Email: [email protected]
Racial Disparities in the Use of Radiotherapy After Breast-Conserving Surgery: A National Medicare Study
in women with primary operable breast cancer. Of the 1069 patients enrolled in the main study, 516 (48%) had BMD data available for review, and 566 (53%) had serum and urine samples collected for analysis. After 2 years, spine BMD was 1.92% higher in patients who received clodronate compared to those who received a placebo, and total hip BMD was 1.29% higher. McCloskey and colleagues found that adding oral clodronate to standard adjuvant therapy for primary breast cancer prevented bone loss and reduced bone turnover in both pre- and postmenopausal women. McCloskey and colleagues also found that bone metabolism at the time of breast cancer diagnosis, as assessed by bone mass and turnover markers, is not significantly associated with the subsequent risk of bone metastasis. However, they noted that early changes in serum PINP were associated with changes in BMD and the likelihood of developing bone metastases. The relationship between PINP progression and the development of bone metastases persisted, with the incidence of bone disease in the progressive group being 17.6% compared with 5.2% in the other
groups combined (P ¼ 0.015). They concluded that serum PINP has the potential to be a marker of response to therapy and possibly provide early detection of skeletal metastases. Since this was a subset analysis, the number of patients was small, with only 230 women with paired measurements at baseline and 1 year. Another prospective study will be needed to confirm these observations and place them in a clinical context. It is important to understand how bone metabolism markers influence bone loss and bone metastases. There is evidence that bisphosphonates prevent bone loss,1,2 but whether or not bisphosphonates are appropriate adjuvant therapy and have antitumor effects is a controversial issue. If a bone marker that influences bone loss and the development of bone metastases were found, we could effectively select patients for whom bisphosphonate therapy prevents bone loss and bone metastases and prolongs survival. The results of this analysis add to the growing body of literature suggesting that there is a role for the adjuvant use of bisphosphonates. The proper selection of patients at risk of bone disease, avoidance of
bisphosphonate-associated toxicities, and the best agent and means of administration are subjects of ongoing research. In this study, McCloskey and colleagues used clodronate, a bisphosphonate not available in the United States, so American clinicians unfortunately cannot apply this approach to their practice.
Racial Disparities in the Use of Radiotherapy After BreastConserving Surgery: A National Medicare Study
analyses were not nationally representative. Therefore, in a comprehensive, national cohort of Medicare patients, racial disparities in the use of radiotherapy (RT) after breast-conserving surgery (BCS) for invasive breast cancer were quantified. Methods.—A national Medicare database was used to identify all beneficiaries (age >65 years) treated with BCS for incident invasive breast cancer in 2003. Claims codes identified RT use, and Medicare demographic data
indicated race. Logistic regression modeled RT use in white, black, and other-race patients, adjusted for demographic, clinical, and socioeconomic covariates. Results.—Of 34,080 women, 91% were white, 6% were black, and 3% were another race. The mean age of the patients was 76 € 7 years. Approximately 74% of whites, 65% of blacks, and 66% of other-race patients received RT (P < .001). After covariate adjustment, whites were found to be
Smith GL, Shih Y-CT, Xu Y, et al (Univ of Texas MD Anderson Cancer Ctr, Houston) Cancer 116:734-741, 2010
Background.—In prior studies, the use of standard breast cancer treatments has varied by race, but previous
N. Niikura, MD R. L. Theriault, DO, MBA
References 1. Eidtmann H, de Boer R, Bundred N, et al. Efficacy of zoledronic acid in postmenopausal women with early breast cancer receiving adjuvant letrozole: 36-month results of the ZO-FAST Study [published online ahead of print May 5, 2010]. Ann Oncol. doi:10.1093/annonc/mdq217. 2. Brufsky AM, Bosserman LD, Caradonna RR, et al. Zoledronic acid effectively prevents aromatase inhibitor-associated bone loss in postmenopausal women with early breast cancer receiving adjuvant letrozole: Z-FAST study at 36-month follow-up results. Clin Breast Cancer. 2009;9:77-85.
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
215
in single-institution clinical trial cohorts, making substantiated conclusions about racial disparities in BCS something ‘‘we believe’’ but not something ‘‘we really know.’’ Here, Smith and colleagues try to answer the question of racial disparities in BCS by examining a cohort of patients in which insurance coverage disparities are essentially eliminated. The cohort of women was identified via claims data in the Medicare database as having undergone BCS between January 1, 2003, and December 31, 2003. Initially, there were 853 273 women in the group. The authors excluded patients who (1) underwent mastectomy within 3 months of BCS to ensure that BCS was the intended primary cancer–directed surgery; (2) filed claims for metastatic breast cancer 3 months before or 3 months after the breast cancer diagnosis date; (3) had end-stage renal disease or a disability at the time of diagnosis; (4) lacked Medicare Part A or B coverage in the 9 months after or the year before their breast cancer diagnosis; and (5) had incomplete information in the year before diagnosis because they were younger than 66 years old. The final cohort consisted of 34 080 patients.
significantly more likely to receive RT than blacks (odds ratio, 1.48; 95% confidence interval, 1.34-1.63 [P < .001]). Disparities between white and black patients varied by geographic region, with blacks in areas of the northeastern and southern United States demonstrating the lowest rates of RT use (57% in these regions). In patients age <70 years, racial disparities persisted. Specifically, 83% of whites, 73% of blacks, and 78% of other races in this younger group received RT (P < .001). Conclusions.—In this comprehensive national sample of older breast cancer patients, substantial racial disparities were identified in RT use after BCS across much of the United States. Efforts to improve breast cancer care require overcoming these disparities, which exist on a national scale. In the United States, RT after BCS is not uniformly delivered. This may be secondary to limited access to care due to lack of insurance coverage or the highly technical nature of treatment delivery (both RT and chemotherapy), or it may represent barriers to care or differences in care based on race. Studies of differences in care based on race have been limited by small sample sizes, such as
Patients were considered to have received breast RT if a claim for RT occurred within 9 months of the breast cancer diagnosis date. Many covariates were examined, including treatment-related factors, preventive health screenings, and comorbidities. Socioeconomic determinants of care were also examined using the Area Resource files linked to the Medicare files. The results demonstrated a statistically significant racial difference in who received RT after BCS: 74% of white women, 65% of black women, and 66% of other-race women (P < 0.001). Variables such as greater access to radiation oncologists in higher-density areas as well as higher income and educational levels increased the receipt of RT. There were no differences in the completion rate of RT: 85% of white and black women and 82% of otherrace women. The use of RT varied by state as well as region, with the largest racial disparities seen between white and black women in the northeastern and southern United States (see Fig 2 in the original article and Table 4). In the discussion, the authors were unable to analyze the patterns of RT use in specific nonwhite, nonblack
TABLE 4.—Unadjusted and Adjusted Regional Variations in the Rate of Radiotherapy Usage Between White and Black Patients With Breast Cancer Unadjusted Region West, Pacific West West, Mountain West Midwest, West North Central Midwest, East North Central Northeast, New England Northeast, Mid-Atlantic South, South Atlantic South, West South Central South, East South Central
States
% Whites
% Blacks
P
% Whites
% Blacks
P
AK, CA, HI, OR, WA AZ, CO, ID, MT, NV, NM, UT, WY IA, KS, MN, MO, NE, ND, SD IL, IN, MI, OH, WI CT, MA, NH, ME, RI, VT NJ, NY, PA DE, DC, FL, GA, MD, NC, SC, VA, WV AR, LA, OK, TX AL, KY, MS, TN
72 77 74 76 72 71 76 74 72
54 78 73 72 69 57 68 63 57
<.001 .88 .94 .04 .53 <.001 <.001 .001 <.001
74 72 74 79 78 70 73 69 78
61 67 70 73 71 62 64 59 60
.07 .59 .67 .15 <.001 .01 .009 <.001 .001
*Adjusted for all covariates except state/region.
216
Adjusted*
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
ethnic groups because of the limited sample size of each ethnic group. The authors examined socioeconomic determinants of care, but after adjusting for markers of health care access, racial disparities persisted. The authors recognized the unmeasured potential explanatory factors, such as the physician-patient interaction in terms of what treatment a patient is offered, whether
substandard care occurs more frequently in predominantly nonwhite communities, and whether nonwhite patients are more likely to decline treatment. The authors recognized that the data for younger patients are not as readily available as those for Medicare Part A and B insured patients. The authors also recognized the tendency of nonwhite patients to receive mastectomy over BCS.
This study by Smith and colleagues is the first comprehensive national sampling of older breast cancer patients and has indeed identified that racial disparities exist in the administration of RT in BCS in this cohort of patients.
Disparities in Medical Care Among Commercially Insured Patients With Newly Diagnosed Breast Cancer: Opportunities for Intervention
ment (breast-conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and allcause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/ treatment. Results.—White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African-American women. More white women had positive ER/PR status (75% vs 56% African-American; P ¼ .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African-American; P < .001). White women received slightly more breast-conserving surgery and chemotherapy dose modification than African-American women (P value nonsignificant). African-American women had a higher mortality rate (8.1%) than white women (3.6%; P ¼ .06). In adjusted analyses, African-American women were diagnosed at later stages (odds ratio, 1.71; P ¼.02), and white women received more antiestrogen therapy (odds ratio, 2.1; P ¼.03). Conclusions.—Disparities in medical care among patients with newly diagnosed breast cancer were evident between African-American women and
white women despite health plan insurance coverage. Interventions that address the gaps identified are needed.
Short LJ, Fisher MD, Wahl PM, et al (HealthCore, Inc, Wilmington, DE; et al) Cancer 116:193-202, 2010
Background.—African-American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity. Methods.—In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n ¼ 476) and African-American women (n ¼ 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]-positive status), treat-
J. Dunmore-Griffith, MD O. E. Streeter, Jr, MD
The premise for this study by Short and colleagues is that although racial disparities in breast cancer diagnosis and treatment have been well documented, the majority of prior reports either did not specify the patients’ type of insurance coverage or were conducted largely in Medicaid/Medicare populations, and as such, less is known specifically about whether these racial differences exist in women with commercial insurance coverage. However, intuitively, one would suspect that this should not vary much from the substantial body of available population-based data, and accordingly, the study hypotheses reflect as much. Hence, the authors performed a historical cohort analysis using a medical claims database linked to medical charts for women with equivalent commercial insurance coverage in the southeast United States treated at community practice oncology offices (presumably, as the authors do not specifically define ‘‘office’’), and they were able to identify gaps in medical care between African-American and white
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
217
groups combined (P ¼ 0.015). They concluded that serum PINP has the potential to be a marker of response to therapy and possibly provide early detection of skeletal metastases. Since this was a subset analysis, the number of patients was small, with only 230 women with paired measurements at baseline and 1 year. Another prospective study will be needed to confirm these observations and place them in a clinical context. It is important to understand how bone metabolism markers influence bone loss and bone metastases. There is evidence that bisphosphonates prevent bone loss,1,2 but whether or not bisphosphonates are appropriate adjuvant therapy and have antitumor effects is a controversial issue. If a bone marker that influences bone loss and the development of bone metastases were found, we could effectively select patients for whom bisphosphonate therapy prevents bone loss and bone metastases and prolongs survival. The results of this analysis add to the growing body of literature suggesting that there is a role for the adjuvant use of bisphosphonates. The proper selection of patients at risk of bone disease, avoidance of
bisphosphonate-associated toxicities, and the best agent and means of administration are subjects of ongoing research. In this study, McCloskey and colleagues used clodronate, a bisphosphonate not available in the United States, so American clinicians unfortunately cannot apply this approach to their practice.
Racial Disparities in the Use of Radiotherapy After BreastConserving Surgery: A National Medicare Study
analyses were not nationally representative. Therefore, in a comprehensive, national cohort of Medicare patients, racial disparities in the use of radiotherapy (RT) after breast-conserving surgery (BCS) for invasive breast cancer were quantified. Methods.—A national Medicare database was used to identify all beneficiaries (age >65 years) treated with BCS for incident invasive breast cancer in 2003. Claims codes identified RT use, and Medicare demographic data
indicated race. Logistic regression modeled RT use in white, black, and other-race patients, adjusted for demographic, clinical, and socioeconomic covariates. Results.—Of 34,080 women, 91% were white, 6% were black, and 3% were another race. The mean age of the patients was 76 € 7 years. Approximately 74% of whites, 65% of blacks, and 66% of other-race patients received RT (P < .001). After covariate adjustment, whites were found to be
Smith GL, Shih Y-CT, Xu Y, et al (Univ of Texas MD Anderson Cancer Ctr, Houston) Cancer 116:734-741, 2010
Background.—In prior studies, the use of standard breast cancer treatments has varied by race, but previous
N. Niikura, MD R. L. Theriault, DO, MBA
References 1. Eidtmann H, de Boer R, Bundred N, et al. Efficacy of zoledronic acid in postmenopausal women with early breast cancer receiving adjuvant letrozole: 36-month results of the ZO-FAST Study [published online ahead of print May 5, 2010]. Ann Oncol. doi:10.1093/annonc/mdq217. 2. Brufsky AM, Bosserman LD, Caradonna RR, et al. Zoledronic acid effectively prevents aromatase inhibitor-associated bone loss in postmenopausal women with early breast cancer receiving adjuvant letrozole: Z-FAST study at 36-month follow-up results. Clin Breast Cancer. 2009;9:77-85.
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
215
in single-institution clinical trial cohorts, making substantiated conclusions about racial disparities in BCS something ‘‘we believe’’ but not something ‘‘we really know.’’ Here, Smith and colleagues try to answer the question of racial disparities in BCS by examining a cohort of patients in which insurance coverage disparities are essentially eliminated. The cohort of women was identified via claims data in the Medicare database as having undergone BCS between January 1, 2003, and December 31, 2003. Initially, there were 853 273 women in the group. The authors excluded patients who (1) underwent mastectomy within 3 months of BCS to ensure that BCS was the intended primary cancer–directed surgery; (2) filed claims for metastatic breast cancer 3 months before or 3 months after the breast cancer diagnosis date; (3) had end-stage renal disease or a disability at the time of diagnosis; (4) lacked Medicare Part A or B coverage in the 9 months after or the year before their breast cancer diagnosis; and (5) had incomplete information in the year before diagnosis because they were younger than 66 years old. The final cohort consisted of 34 080 patients.
significantly more likely to receive RT than blacks (odds ratio, 1.48; 95% confidence interval, 1.34-1.63 [P < .001]). Disparities between white and black patients varied by geographic region, with blacks in areas of the northeastern and southern United States demonstrating the lowest rates of RT use (57% in these regions). In patients age <70 years, racial disparities persisted. Specifically, 83% of whites, 73% of blacks, and 78% of other races in this younger group received RT (P < .001). Conclusions.—In this comprehensive national sample of older breast cancer patients, substantial racial disparities were identified in RT use after BCS across much of the United States. Efforts to improve breast cancer care require overcoming these disparities, which exist on a national scale. In the United States, RT after BCS is not uniformly delivered. This may be secondary to limited access to care due to lack of insurance coverage or the highly technical nature of treatment delivery (both RT and chemotherapy), or it may represent barriers to care or differences in care based on race. Studies of differences in care based on race have been limited by small sample sizes, such as
Patients were considered to have received breast RT if a claim for RT occurred within 9 months of the breast cancer diagnosis date. Many covariates were examined, including treatment-related factors, preventive health screenings, and comorbidities. Socioeconomic determinants of care were also examined using the Area Resource files linked to the Medicare files. The results demonstrated a statistically significant racial difference in who received RT after BCS: 74% of white women, 65% of black women, and 66% of other-race women (P < 0.001). Variables such as greater access to radiation oncologists in higher-density areas as well as higher income and educational levels increased the receipt of RT. There were no differences in the completion rate of RT: 85% of white and black women and 82% of otherrace women. The use of RT varied by state as well as region, with the largest racial disparities seen between white and black women in the northeastern and southern United States (see Fig 2 in the original article and Table 4). In the discussion, the authors were unable to analyze the patterns of RT use in specific nonwhite, nonblack
TABLE 4.—Unadjusted and Adjusted Regional Variations in the Rate of Radiotherapy Usage Between White and Black Patients With Breast Cancer Unadjusted Region West, Pacific West West, Mountain West Midwest, West North Central Midwest, East North Central Northeast, New England Northeast, Mid-Atlantic South, South Atlantic South, West South Central South, East South Central
States
% Whites
% Blacks
P
% Whites
% Blacks
P
AK, CA, HI, OR, WA AZ, CO, ID, MT, NV, NM, UT, WY IA, KS, MN, MO, NE, ND, SD IL, IN, MI, OH, WI CT, MA, NH, ME, RI, VT NJ, NY, PA DE, DC, FL, GA, MD, NC, SC, VA, WV AR, LA, OK, TX AL, KY, MS, TN
72 77 74 76 72 71 76 74 72
54 78 73 72 69 57 68 63 57
<.001 .88 .94 .04 .53 <.001 <.001 .001 <.001
74 72 74 79 78 70 73 69 78
61 67 70 73 71 62 64 59 60
.07 .59 .67 .15 <.001 .01 .009 <.001 .001
*Adjusted for all covariates except state/region.
216
Adjusted*
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
ethnic groups because of the limited sample size of each ethnic group. The authors examined socioeconomic determinants of care, but after adjusting for markers of health care access, racial disparities persisted. The authors recognized the unmeasured potential explanatory factors, such as the physician-patient interaction in terms of what treatment a patient is offered, whether
substandard care occurs more frequently in predominantly nonwhite communities, and whether nonwhite patients are more likely to decline treatment. The authors recognized that the data for younger patients are not as readily available as those for Medicare Part A and B insured patients. The authors also recognized the tendency of nonwhite patients to receive mastectomy over BCS.
This study by Smith and colleagues is the first comprehensive national sampling of older breast cancer patients and has indeed identified that racial disparities exist in the administration of RT in BCS in this cohort of patients.
Disparities in Medical Care Among Commercially Insured Patients With Newly Diagnosed Breast Cancer: Opportunities for Intervention
ment (breast-conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and allcause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/ treatment. Results.—White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African-American women. More white women had positive ER/PR status (75% vs 56% African-American; P ¼ .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African-American; P < .001). White women received slightly more breast-conserving surgery and chemotherapy dose modification than African-American women (P value nonsignificant). African-American women had a higher mortality rate (8.1%) than white women (3.6%; P ¼ .06). In adjusted analyses, African-American women were diagnosed at later stages (odds ratio, 1.71; P ¼.02), and white women received more antiestrogen therapy (odds ratio, 2.1; P ¼.03). Conclusions.—Disparities in medical care among patients with newly diagnosed breast cancer were evident between African-American women and
white women despite health plan insurance coverage. Interventions that address the gaps identified are needed.
Short LJ, Fisher MD, Wahl PM, et al (HealthCore, Inc, Wilmington, DE; et al) Cancer 116:193-202, 2010
Background.—African-American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity. Methods.—In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n ¼ 476) and African-American women (n ¼ 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]-positive status), treat-
J. Dunmore-Griffith, MD O. E. Streeter, Jr, MD
The premise for this study by Short and colleagues is that although racial disparities in breast cancer diagnosis and treatment have been well documented, the majority of prior reports either did not specify the patients’ type of insurance coverage or were conducted largely in Medicaid/Medicare populations, and as such, less is known specifically about whether these racial differences exist in women with commercial insurance coverage. However, intuitively, one would suspect that this should not vary much from the substantial body of available population-based data, and accordingly, the study hypotheses reflect as much. Hence, the authors performed a historical cohort analysis using a medical claims database linked to medical charts for women with equivalent commercial insurance coverage in the southeast United States treated at community practice oncology offices (presumably, as the authors do not specifically define ‘‘office’’), and they were able to identify gaps in medical care between African-American and white
Breast Diseases: A Year BookÒ Quarterly Vol 21 No 3 2010
217