Editor's note: We're overjoyed to welcome Ardena Flippin, MD, MBA to the netdoc community. Dr. Flippin brings a wealth of experience, starting with her long tenure as an attending physician at the Cook County Hospital Emergency Department (the hospital and department that inspired the TV show "E.R.").
Dr. Flippin will write regularly on issues of interest to physicians and the medical community. Among her interests are healthcare disparities (the topic of this first post), and physician practice management (the topic of her next post).
A recent meta-analysis of breast cancer data made a surprising finding and that is that breast cancer morbidity is the same across races when patients have the same mammogram history. This means that the main factor underlying the racial disparity in breast cancer morbidity and mortality is that African-American women have less access to medical care.
The difference in life expectancy has been well documented: African-American women have a 20 percent higher likelihood of dying than white women after being diagnosed with breast cancer. The median age of death for white breast cancer patients is 70 years; for black breast cancer patients it is 61 years. According to the most recent cancer statistics review, black women are less likely than white women to survive 5 years after a breast cancer diagnosis (77.3% versus 89.7%, respectively). (Breast Cancer Actionâ: The Facts and Nothing But the Facts).
Despite the clear disparity in survival, it’s not clear why the disparity exists. That’s where Dr. Smith-Bindman’s review of mammography utilization comes in (Annals of Internal Medicine, 18 April 2006. Does Utilization of Screening Mammography Explain Racial and Ethnic Differences in Breast Cancer?). Dr. Smith-Bindman looked at patterns of mammography and the probability of inadequate mammography screening, and whether overall and advanced cancer rates were similar across racial and ethnic groups and whether these rates were affected by the use of mammography. The study found that there was no difference in size, advanced-stage or lymph node involvement in women who have similar mammography screening histories.
That means that the difference revolves around mammography screening. A lack of medical insurance and poor access to screening and treatment decreases survival.“Compared to their middle-class and wealthy counter-parts, low-income women have the lowest rates of breast cancer screening, even when adjusted for race, ethnicity and insurance status. Low-income women had 20.7% lower reports of recent mammography use than those of women living in households with higher incomes.” (Monica E. Peek, MD. J Gen Intern Med 2004; 19:184-194). Low-income breast cancer patients have a 5-year relative survival rate that is 9% lower than higher-income patients. Low–income African-American women are three times more likely than higher-income African-American women to be diagnosed with advanced disease.
Over 600 million taxpayer-funded dollars goes into basic science research on breast cancer every year. The great promise, of course, is that it will lead to major improvements in diagnosis and treatment. However, if women don’t have access to these therapies, the research cannot benefit them. In essence, the boon in basic science research bypasses those most in need of it.
It might be too simplistic to suggest that the revenue-compliance approach of fixing “front-end” concerns first, i.e., access to quality mammography obviates the need to address the more complex “back-end” concerns, i.e., tumor characteristics, response to hormone therapy and other less basic issues.
In spite of our advances in clinical diagnosis and treatment capabilities, we still haven’t figured how to get equal access to mammograms to all women. Rather than chase the exotic and esoteric subtleties of cancer biology, let’s concentrate first on the obvious fundamental: access saves lives.