HEALTH CARE DISPARITIES. Bhuvana Ramaswamy MD MRCP The Ohio State University Comprehensive Cancer Center

Transcription

1 HEALTH CARE DISPARITIES Bhuvana Ramaswamy MD MRCP The Ohio State University Comprehensive Cancer Center

2 Goals Understand the epidemiology of breast cancer Understand the broad management of breast cancer Delineate the disparities in outcomes in breast cancer Outline the possible reasons for the disparities Discuss potential solutions

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20 AA women have a 44% higher rate of breast cancer mortality than white women

21 WHY this disparity? Is the risk of developing breast cancer higher in non-white population? WHAT ARE THE RISKS FOR DEVELOPING BREAST CANCER?

22 RISK FACTORS Age Family History 1-1 st relative=1.8 fold 2-1 st relatives=2.93 fold Prolonged Estrogen Exposure Relative < 40 yrs= 5.7 fold Exposure to ionizing radiation Abnormal breast biopsies Obesity Alcohol

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24 LIFETIME RISK : ETHNICITY Race and ethnicity Lifetime risk of breast cancer (up to age 80) White 13% African-American 11% Hispanic (may include other ethnic groups) 10% American Indian or Alaska Native 8% Asian-American or Pacific Islander 10% Adapted from SEER data [5].

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26 MORTALITY vs RACE Hispanic/Latina women White (non-hispanic) women African- American women Incidence (new cases) 91.1 per 100, per 100, per 100,000 Mortality (deaths) 14.8 per 100, per 100, per 100,000

27 Delays in diagnosis WHY the DISPARITY? RISK is NOT HIGHER A. Screening to identify an abnormality B. Diagnosis of the abnormality

28 SCREENING RATES Percentage of women 40 and older who had a mammogram in the past two years White (non-hispanic) 67% African-American (non-hispanic) 66% Hispanic/Latina 64% Asian-American (non-hispanic) 62% American Indian and Alaska Native 69% Adapted from American Cancer Society materials [1].

29 BREAST CANCER MORTALITY BY STAGE

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31 Stages of Breast Cancer Localized Disease: Distribution - 60% 5-Year Survival 98% Metastatic Disease Distribution 5-7% 5-year survival 23% Locally Advanced Distribution 33% 5-year Survival 84% Based on Survaillance Epidemiology and End Result Database

32 IMPACT OF RESEARCH ON BREAST CANCER SCREENING AND RISK-REDUCTION Estimated reduction in US overall breast cancer mortality is 28-65% (Breast cancer mortality RR >50 y and y- 0.85) Berry et al NEJM 2005

33 IS THERE A DELAY FROM SCREENING TO DIAGNOSIS Timely diagnosis and receiving care HOSPITALS CONTRIBUTED TO DELAY IN CARE Freedman et al, HSR: 48.5, 2013

34 Choice of Hospitals and Doctors Studies conducted by Kevin Fiscella et al (J of healthcare for the poor and underserved, Feb 2011) demonstrated that AA and Hispanic women were less likely to choose a hospital or doctor based on reputation than white women and more likely chose a center based on referral by PCP.

35 Barriers to address for screening and prompt delivery of care Health insurance (32% screening rate vs 71% screening rate in insured) Low income /Socioeconomic status Lack of access to care Lack of PCP/health care provider Lack of recommendation by PCP or HCP Lack of awareness of breast cancer risks Cultural and language differences

36 Differences in Breast Cancer Stage at Diagnosis and Cancer- Specific Survival by Race and Ethnicity in the United States Iqbal et al, JAMA 2015 It is important to identify factors associated with the diagnosis of stage I breast cancers and the groups for whom the proportion of cancers detected at stage I is less than optimal. These investigators found that probability of small-sized breast cancer tumors having spread to the regional lymph nodes or distantly varied between women with different racial/ethnic backgrounds and may reflect variations in the intrinsic biology of their tumors. In all age groups, black race/ethnicity was associated with being diagnosed beyond stage I. This observation suggests that the stage disparity at diagnosis is not likely to be attributed to screening trends; rather, the paucity of stage I cancers appears to be explainable in large part by inherent biological factors. In support of this hypothesis, a black woman with small-sized breast cancer tumors was more likely to present with lymph node metastases, was more likely to have triple-negative cancer, and was more likely to present with distant metastases than a non-hispanic white woman with tumors of similar size.

37 WHAT HOST FACTORS COULD PLAY A ROLE? Biological factors may not entirely account for the association with aggressive early-stage diagnosis in all racial/ethnic groups South Asian women were less likely to be diagnosed with stage I breast cancers but did not have similar aggressive biology as AA

38 Most Important Paradigm Shift: Breast Cancer is not one disease ER- Breast Cancer ER + ER % HER % Basaloid 15% A B Triple Negative BRCA 1 P53 STAGE SIZE

39 Basal-like HER-2 Normal Luminal B Luminal A Sorlie T et al, PNAS 2001

40 Outcomes based on Molecular Subtype Brenton, J. D. et al. J Clin Oncol; 23:

41 Breast Cancer Systemic Therapy Options Depend on Tumor Biology Breast Cancer Hormone Receptor Positive HER-2/neu Positive Triple Negative Endocrine Therapy Chemotherapy Anti-HER-2/neu Agents with chemotherapy or endocrine therapy Chemotherapy 41

42 Race, Breast Cancer Subtypes, and Survival in the Carolina Breast Cancer Study Carey et al, JAMA. 2006

43 Race, Breast Cancer Subtypes, and Survival in the Carolina Breast Cancer Study Carey et al, JAMA. 2006

44 Race, Breast Cancer Subtypes, and Survival in the Carolina Breast Cancer Study Carey et al, JAMA. 2006

45 Race, Breast Cancer Subtypes, and Survival in the Carolina Breast Cancer Study Carey et al, JAMA. 2006

46 Race, Breast Cancer Subtypes, and Survival in the Carolina Breast Cancer Study Carey et al, JAMA The breast cancer specific survival by racial and menopausal subsets without basal-like breast cancers still differed significantly: premenopausal African American 64%, postmenopausal African American 81%, premenopausal non African American 81% postmenopausal non African American 91% (P<.001). ACCESS TO QUALITY HEALTHCARE DISPARITIES IN MANAGEMENT- (Freedman et al JCO- 2009)

47 Potential causes for the more aggressive phenotype Age at diagnosis Age at menopause Age at childbirth Body weight Number of child births Postmenopausal hormone therapy

48 Potential causes for the more aggressive phenotype Compared to white women, AA women Lower rates of breast-feeding Tend to carry more abdominal weight Compared to white women, AA women have certain factors that may protect from ER positive tumors First birth at younger age More children Be overweight or obese before menopause

49 COULD DIETARY FACTORS CONTRIBUTE TO BIOLOGY? Studies suggest that Japanese women develop less aggressive breast cancers and exhibit a more vigorous host response, resulting in fewer tumors diagnosed at 2.0 cm or larger in diameter and fewer with lymph node metastases. It is possible that dietary factors are relevant, such as the consumption of green tea, isoflavone, or soy products. Various studies suggest that green tea consumption among Japanese women is associated with decreased nodal metastasis, increased expression of ERs, and a reduction in the risk of recurrence for stage I breast cancers (risk ratio, 0.56; 95% CI, ). Others have shown an inverse relationship between increased soy (isoflavone) consumption and the risk of breast cancer in Japanese women..

50 SHOULD WE BE TREATING BREAST CANCER IN ALL RACES THE SAME WAY

51 AA and other minorities are underrepresented in clinical trials Lack of awareness Lack of access Economic factors Communication issues Mistrust CRITICAL TO UNDERSTAND THE PHARMACOKINETICS AND PHARMACODYNAMICS OF THE NEW AGENTS CONSIDER ALTERNATE SCREENING

52 OBESITY- Major public health concern Overweight, obesity and cancer: epidemiological evidence and proposed mechanisms. (Calle et al, Nature reviews, 2004) : Insulin resistance and resultant chronic hyperinsulinaemia, increased bioavailability of steroid hormones and localized inflammation. Increased body weight was associated with increased death rates for all cancers combined and for cancers at multiple specific sites. (Calle et al NEJM 2003) Obesity is an independent prognostic factor for the development of distant metastases and death after the diagnosis of breast cancer. (Ewertz et al, JCO 2010)

53 Breast Cancer: Then and Now Then ~75% of women survived 5 years Mastectomy was the only surgical option Single-agent chemotherapy was standard of care Hormonal therapy with tamoxifen was under investigation only Genes involved in breast cancer development have not yet been identified Now ~95% of women survive 5 years Lumpectomy is available Combination chemotherapy is the standard of care Hormonal therapy is widely used Receptor-based therapy is widely used Understanding of genetic components have expanded National Cancer Institute. Available at:

54 LANDSCAPE OF BREAST CANCER ,840 new cases of invasive breast 60,290 new cases of in situ breast cancer 40,290 breast cancer deaths

55 WHY??? WHY are we still dealing with failures??? WHY do not we cure 100% of patients with breast cancer? Why are there persistent inequalities of outcomes and care?

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58 Russens et al, JCI, 2011

59 NEW SUBTYPES OF BREAST CANCER Russens et al, JCI, 2011

60 MULTILEVEL APPROACH FOR DYNAMIC CLASSIFICATION Russens et al, JCI, 2011

61 Disparities across breast cancer care continuum Prevention- Obesity, exercise Screening-? Earlier / Access/ PCP referral Diagnosis- Choice of hospital/expert Appropriate therapy- More trials with participation of minorities Compliance Financial concerns- Insurance (ACA)

62 HOW DO WE DO THIS? ENGAGE EDUCATE EMPOWER PATIENTS, FAMILY, PRIMARY CARE PHYSICIANS, REFERRING PHYSICIAN, COMMUNITY, PROMINENT PERSONALITIES, NURSES, NURSE PRACTIONERS, PATIENT CARE ADVOCATE MEDIA CULTURAL CHANGE FROM GRASSROOTS-

63 WHO IS RESPONSIBLE TO CURE CANCER for ALL? ALL OF WE US ENGAGE

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