Breast Cancer Deadlier for Black Women, Despite Same Treatments

THURSDAY, Dec. 6, 2018 — Even with the same treatment, black women with the most common form of breast cancer experience higher recurrence and death rates than white women, a new trial reveals.

The finding pokes holes in the prevailing notion that black women with breast cancer fare worse due to less access to quality medical care, experts said. While that factor may contribute to poorer outcomes, other factors — such as the way drugs are metabolized based on race — may be at play.

“Going way back, there’s always been the concern about blacks in terms of cancer outcomes over time, but a lot of that was based on population [studies] where treatment wasn’t controlled,” said study author Dr. Kathy Albain. She’s chair of oncology research at Loyola University Chicago Stritch School of Medicine.

But “leveling the playing field by bringing women to the same doctors and getting the same treatment” didn’t equalize breast cancer outcomes between black and white women, Albain added.

More than 250,000 women in the United States were diagnosed with invasive breast cancer in 2017, according to the American Cancer Society. The disease claims the lives of about 40,000 people each year.

Albain and her colleagues evaluated the link between clinical outcomes and race in more than 10,000 women with early stage hormone receptor-positive, HER2-negative breast cancer, the most common type of the disease.

Findings from the same multinational research, known as the TAILORx trial, were released in June showing that most women with early breast cancer don’t benefit from chemotherapy. Treating them with chemotherapy and hormone therapy after surgery doesn’t improve outcomes more than hormone therapy alone.

In this latest analysis, patients’ tumors were analyzed using a molecular test that looks at the expression of 21 genes associated with breast cancer recurrence. About 84 percent of the patients were white, 7 percent were black, 4 percent Asian and 4 percent were of other or unknown race. Ethnically, 79 percent were non-Hispanic, 9 percent were Hispanic and 12 percent were of unknown ethnicity.

The types, use and length of treatments were similar between both black and white patients and between Hispanic and non-Hispanic patients.

But outcomes were significantly different: Black women experienced a 39 percent higher risk of breast cancer recurrence compared to white women and a 52 percent higher risk of dying.

These marked outcome disparities were not explained by reported adherence to therapy, or by factors such as age or tumor size or aggression level, Albain said. But she said it’s possible that differences in the way racial groups metabolize drugs could play a role.

“We inherit genes from our parents and the genes that metabolize drugs … differ,” Albain said. “It’s not any sort of racial bias, it’s just a fact.”

Also, because hormone therapy pill adherence was self-reported, she noted, the study authors don’t know if black and white patients actually took the pills according to directions, or in the same way.

“Patients will tell me all the time they’re taking their pills, and they’re not taking their pills,” Albain said. “Pill-counting wasn’t done in this trial” to confirm what patients reported.

Dr. Ann Partridge is a breast medical oncologist at Dana-Farber Cancer Institute in Boston and wasn’t involved in the new research. But she said she wasn’t surprised by the findings and agreed that black and white patients in the study may have adhered to hormonal pill therapy differently.

“We know that young people and African-Americans are less adherent with hormonal therapy — that’s been shown over and over again,” she said.

Partridge also noted that exercise behaviors have been shown to differ by race, and that white women tend to exercise more than black women, which could “have a profound impact” on cancer outcomes.

“This is also true for obesity and diet … which also tends to be different by race,” added Partridge, who’s also a professor of medicine at Harvard Medical School.

Albain and Partridge agreed that more research is needed to pinpoint all the reasons breast cancer outcomes differ according to race.

“We have to chip away at it all, increase our understanding of disease differences and not lump [factors together] as much as we do,” Partridge said.

The research is to be presented Thursday at the San Antonio Breast Cancer Symposium in Texas. Research presented at scientific conferences typically hasn’t been peer-reviewed or published, and results are considered preliminary.

More information

The U.S. National Cancer Institute offers more information on breast cancer treatment.

Posted: December 2018

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COPD patients rarely receive pulmonary rehabilitation despite its health benefits

Only a tiny fraction of patients hospitalized for COPD, or chronic obstructive pulmonary disease, participate in a pulmonary rehabilitation program following hospitalization, even though such programs are recommended and Medicare covers their cost, according to new research published online in the Annals of the American Thoracic Society.

In “Participation in Pulmonary Rehabilitation Following Hospitalization for COPD among Medicare Beneficiaries,” Kerry A. Spitzer, Ph.D., MPA, and co-authors report that in 2012 only 1.9 percent of COPD patients nationally started a pulmonary rehabilitation within six months of being hospitalized for a COPD exacerbation. This despite the fact that two years earlier Medicare’s policy changed to provide coverage for pulmonary rehabilitation services, effectively offering pulmonary rehabilitation to millions of U.S. patients for the first time.

COPD is a chronic disease and the fourth leading cause of death in the U.S. Pulmonary rehabilitation provides exercise training, self-management advice, nutrition counseling and emotional support. Despite its proven benefits, an ATS-commissioned survey by Wakefield Research found that 62 percent of people diagnosed with COPD have never heard of pulmonary rehabilitation.

The patient-tailored intervention has been shown to improve physical and psychological well-being and quality of life. Other studies have shown that pulmonary rehabilitation reduces COPD exacerbations that often lead to hospitalization. Clinical guidelines recommend that patients begin pulmonary rehabilitation within three weeks following discharge from the hospital.

According to study senior author Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center and director of the Institute for Healthcare Delivery and Population Science at the University of Massachusetts Medical School, there has been growing recognition of the benefits of pulmonary rehabilitation.

As hospitals and health systems, like ours, increase efforts to keep patients with COPD healthy and out of the hospital, we have prioritized enrolling patients into our rehabilitation program prior to hospital discharge,” Dr. Lindeauer said. “As a result, we are seeing improvements in readmission rates among patients with COPD.”

After reviewing the records of 223,832 patients hospitalized for COPD in 2012, the researchers found:

  • 4,225 (1.9 percent) received pulmonary rehabilitation within six months of being discharged from the hospital.
  • 6,111 (2.7 percent) received pulmonary rehabilitation within one year of being discharged from the hospital.
  • Whites, males, younger patients and those on home oxygen were more likely to receive pulmonary rehabilitation.
  • Smokers and those living farther than 10 miles away from a pulmonary rehabilitation program, belonging to lower socioeconomic groups and coping with additional chronic diseases and prior hospitalizations were less likely to receive pulmonary rehabilitation.
  • Among those who started pulmonary rehabilitation, more than half completed at least 16 sessions. Medicare will typically pay for up to 36 sessions.

Study limitations include the fact that researchers could not determine whether the low rates of pulmonary rehabilitation utilization were due to lack of physician referrals, patients choosing not to attend or a combination of the two factors.Dr. Spitzer, the lead study author and senior clinical research coordinator at Baystate, believes more research is needed to understand why patients are not receiving pulmonary rehabilitation.

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