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ABSTRACT & COMMENTARY
Synopsis: In conjunction with socioeconomic variables, cultural beliefs and psychosocial factors may account for most of the racial differences in late-stage presentation of breast cancer.
Source: Lannin DR, et al. JAMA 1998;279:1801-1807.
Breast cancer incidence is lower in african-American women than in Caucasian women, yet breast cancer mortality is disproportionately higher among African-Americans. Lannin and colleagues from East Carolina University looked at this complex issue with a large, case-controlled study. From 1985 to 1992, the investigators collected data on 540 women with newly diagnosed breast cancer and 743 matched controls from a low-income, rural community in North Carolina with one-third of its population African-American.
Of the 540 women with newly diagnosed breast cancer, 17.4% presented with advanced stage disease (TNM stage III or IV). This group tended to be African-American, to have low income, and to lack private health insurance. Many women who presented with advanced stage disease had never been married; many others had delayed seeing a physician because they lacked funds or transportation. Interestingly, education and age were not correlated with stage at presentation.
Women who agreed with statements reflecting certain cultural or religious beliefs were overrepresented in the group who presented with advanced breast cancer:
· "If a lump in the breast is not bothersome, there is no need to consult a doctor" (OR 4.4, 95%; CI 1.6-12.4).
· "Surgery causes a cancer to grow faster" (OR 1.5, 95%; CI 1.0-2.3).
· "Someone can give you cancer by putting a root or spell on you" (OR 3.9, 95%; CI 1.4-10.8).
· "People with thin blood are more likely to get cancer" (OR 2.2, 95%; CI 1.3-3.9).
· "The devil can cause a person to get cancer" (OR 2.1, 95%; CI 1.2-3.5).
· "Women who have surgery for breast cancer are no longer attractive to men" (OR 1.9, 95%; CI 1.1-3.5).
Agreement with these statements was correlated most strongly with African-American ethnicity and less so with low income. The cultural beliefs were as prevalent in the control group as in the patient group, clarifying that the beliefs did not result from patients' experiences during breast cancer care.
We already knew that African-American women with breast cancer have a higher mortality than other breast cancer patients primarily because they tend to present at a later tumor stage. Until now, however, we did not have a clear understanding of why this trend occurs. Previous work has shown that socioeconomic factors contribute to delaying breast cancer presentation among African-Americans. Yet, these factors do not fully account for the excess mortality seen in this population.
Lannin et al have broadened our understanding of other factors that delay breast cancer diagnosis among African-American women. These investigators are among the first to show that cultural and psychosocial factors directly influence stage at breast cancer diagnosis. Their methods appear valid, with careful demographic matching of distinct case and control groups not subject to apparent selection bias.
I agree with the authors that one of their most important findings is that women with certain cultural beliefs tend not only to defer screening mammography, but to delay presentation for care even when there is a palpable breast mass. This observation has clear implications for public health interventions and for individual clinicians as we counsel patients about health screening. While this study's specific findings may not apply to women of other geographic regions and cultures, they equip us with new perspectives to tailor more effective breast cancer screening to women of varied cultural backgrounds.