Influence of Socioeconomic and Cultural Factors on Racial Differences in Late-Stage Presentation of Breast Cancer

Abstract

Context.-Breast cancer mortality is higher among African American women than among white women in the United States, but the reasons for the racial difference are not known. Objective.-To evaluate the influence of socioeconomic and cultural factors on the racial difference in breast cancer stage at diagnosis. Design.-Case-control study of patients diagnosed as having breast cancer at the University Medical Center of Eastern Carolina from 1985 through 1992. Setting.-The major health care facility for 2 rural counties in eastern North Carolina. Subjects.-Five hundred forty of 743 patients with newly diagnosed breast cancer and 414 control women from the community matched by age, race, and area of residence. Main Outcome Measures.-Breast cancer stage at diagnosis. Results.-Of the 540 patients, 94 (17.4%) presented with TNM stage III or IV disease. The following demographic and socioeconomic factors were significant predictors of advanced stage: being African American (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.7); having low income (OR, 3.7; 95% CI, 2.1-6.5); never having been married (OR, 2.9; 95% CI, 1.4-5.9); having no private health insurance (OR, 2.5; 95% CI, 1.6-4.0); delaying seeing a physician because of money (OR, 1.6; 95% CI, 1.1-2.5); or lacking transportation (OR, 2.0; 95% CI, 1.2-3.6). Univariate analysis also revealed a large number of cultural beliefs to be significant predictors. Examples include the following beliefs: air causes a cancer to spread (OR, 2.8; 95% CI, 1.8-4.3); the devil can cause a person to get cancer (OR, 2.1; 95% CI, 1.2-3.5); women who have breast surgery are no longer attractive to men (OR, 1.9; 95% CI, 1.1-3.5); and chiropractic is an effective treatment for breast cancer (OR, 2.4; 95% CI, 1.4-4.4). When the demographic and socioeconomic variables were included in a multivariate logistic regression model, the OR for late stage among African Americans decreased to 1.8 (95% CI, 1.1-3.2) compared with 3.0 (95% CI, 1.9-4.7) for race alone. However, when the belief measures were included with the demographic and socioeconomic variables, the OR for late stage among African Americans decreased further to 1.2 (95% CI, 0.6-2.5). Conclusions.-Socioeconomic factors alone were not sufficient to explain the dramatic effect of race on breast cancer stage; however, socioeconomic variables in conjunction with cultural beliefs and attitudes could largely account for the observed effect.

Variations in breast carcinoma treatment in older medicare beneficiaries

“…48 Others have suggested that differential race effects on cancer treatment and outcomes are mediated by culturally based attitudes. 6 For instance, it is possible that the omission of radiation after breast conservation or the higher rates of mastectomy than breast conservation and radiation among black women may be due to culturally based attitudes toward radiation. Alternatively, unmeasured aspects of race-specific patient preferences may have contributed to our findings.…”

“…However, rates failed to decline for older women, and older black women actually experienced an increase in mortality rates. [1][2][3] The observed excess mortality rates among older black women may be due to the interaction of several complex phenomena, including poverty, 4,5 culturally based attitudes, 6,7 bias in treatment, 5,8,9 stage at presentation, 10 -12 access to, or adequacy of treatment, 10,[13][14][15][16][17] tumor biology, 18 -23 and comorbid medical conditions. 24 In this study, data from a random sample of black and white Medicare beneficiaries treated in fee-forservice settings for local breast carcinoma are used to describe the associations between race and local treatment.…”

The Role of Culture in Health Literacy and Chronic Disease Screening and Management

“…Cultural barriers to care include language, religious beliefs, family ties, interactional styles, gender norms, and misconceptions about Western medicine [38]. Beliefs about cancer and its treatment may affect patients' willingness to seek screening tests and professional care [39]. Disparities have been identified in cancer screening tests [40] related to access to health care [41] and other factors [42].…”

A nationwide analysis of incidence and outcome of breast cancer in the country of Surinam, during 1994–2003

“…More advanced stage at diagnosis is commonly found in developing countries [14], and is thought to be related to lack of universal coverage, lack of screening programs, and fear of cancer in general. Tumor size and stage decreased in the western world since the introduction of mammography in the Netherlands in the last decades of the twentieth century [16][17][18], and this went hand in hand with increased public awareness and reduced taboo status of the disease [19,20]. In Surinam, the vivid culture of traditional medicine and taboo status of BC, almost certainly, contribute to a more advanced stage at diagnosis.…”