Disparities in Cervical and Breast Cancer Prevention and Detection

1
Disparities in Cervical and Breast Cancer
Prevention and Detection

• Carin Perkins, PhD
• Minnesota Cancer Surveillance System
• Minnesota Department of Health
• carin.perkins_at_state.mn.us
• [phone]

2
Breast and cervical cancer in Minnesota
average cases and deaths per year by
age,1995-1998
Source Minnesota Cancer Surveillance System.
http//www.health.state.mn.us/divs/dpc/cdee/mcss.
htm
3
Cervical cancer screening a success story in
cancer control
Rate per 100,000 women
Incidence
Mortality
Year of Diagnosis or Death
Source Minnesota Cancer Surveillance System and
SEER Cancer Statistics Review, 1973-1998. All
rates are age-adjusted to the 1970 US population.
SEER data covers 10 of the US population.
4
Women of color in Minnesota are three times more
likely to be diagnosed with invasive cervical
cancer than white women
Rate per 100,000 women
Cases 645
23 35
15
Source Minnesota Cancer Surveillance System,
cases diagnosed 1995-1998. All rates are
age-adjusted to the 1970 US population.
5
Race/ethnic disparities in cervical cancer
incidence are greater in Minnesota than reported
by SEER
Rate per 100,000 women
N/A
Source Minnesota Cancer Surveillance System and
SEER Cancer Statistics Review, 1973-1998. All
rates are age-adjusted to the 1970 US population.
The number of Minnesota cases are White (645),
Asian/PI (23), African American (35), and
American Indian (15).
6
Race/ethnic disparities in cervical cancer are
greatest among women ages 50 years and older
Rate per 100,000 women
Age at Diagnosis
Source Minnesota Cancer Surveillance System,
cases diagnosed 1995-1998. Women of color
include African American, Asian/PI, and American
Indian women.
7
In addition, women of color are more likely to be
diagnosed at a later stage
Percent
Stage at Diagnosis
Source Minnesota Cancer Surveillance System,
cases diagnosed 1995-1998. Women of color
include African American, Asian/PI, and American
Indian women.
8
Women of color in Minnesota are six times more
likely to die of cervical cancer than white women
Rate per 100,000 women
Cases/Deaths 645 73
161 33
Source Minnesota Cancer Surveillance System,
cases and deaths from 1995-1998. Rates are
age-adjusted to the 1970 US population. Women of
color include African American, Asian/PI, and
American Indian women.
9
Within each race/ethnic group, disadvantaged
women have higher rates of invasive cervical
cancer
Rate per 100,000 women
SES
Source Liu L et al. Socioeconomic status and
cancers of the female breast and
reproductive organs a comparison across
racial/ethnic populations in Los Angeles County,
California. Cancer Cause Control 1998 9369-380.
10
How is Minnesota Doing?
Percent had Pap test within 3 years
Healthy Minnesotans 2004 Objective 99
Source Minnesota Behavioral Risk Factor Survey.
Obtained from data query at http//www.cdc.gov/brf
ss, 06/04/02.
11
Poor women in Minnesota are stillless likely to
be screened
Percent had Pap test within 3 years
Annual Household Income
Source Minnesota Behavioral Risk Factor Survey,
2000. Obtained from data query at http//www.cdc.g
ov/brfss, 06/04/02.
12
Nationally, race/ethnic disparities in cervical
cancer screening are largest for younger women
Percent had Pap test within 3 years
Age
Source NHIS 1998. Breen et al. Progress in
cancer screening over a decade results of cancer
screening from the 1987, 1992, and 1998 National
Health Interview Surveys. J Natl Cancer Inst
2001931704-13.
13
Breast cancer mortality another success story
in cancer control
Rate per 100,000 women
Year of Death
Source Minnesota data are from the Minnesota
Cancer Surveillance System. US data are from the
SEER Cancer Statistics Review, 1973-1998. All
rates are age-adjusted to the 1970 US population.
14
Nationally, late-stage breast cancer incidence
has declined
Rate per 100,000 women
Year of Diagnosis
Source SEER rates were calculated from the
August 2000 SEER public use file. All rates are
age-adjusted to the 1970 US population.
15
Women of color in Minnesota die of breast cancer
out of proportion to its occurrence
Rate per 100,000 women
N/A
Cases/Deaths 43 108 181 14,535
11 15 43 14 2,811
Source Minnesota Cancer Surveillance System,
1995-1998. Rates are age-adjusted to the 1970 US
population. Cancer incidence includes in situ and
invasive tumors.
16
Women of color in Minnesota have a higher
proportion of breast cancers diagnosed at
late-stage
Rate per 100,000 women
Source Minnesota Cancer Surveillance System,
1995-1998. Rates are age-adjusted to the 1970 US
population. Early stage cancers are in situ or
localized (confined to the breast). Late stage
cancers have spread to lymph nodes or other
organs.
17
Within each stage, breast cancer survival is
poorer for African American women
Five-year Relative Survival (percent)
Note Based on cases diagnosed 1985-1991 and
followed through December 1993. Survival
differences for distant disease are not
statistically significant. Source Hsu et al.
Racial/ethnic differences in breast cancer
survival among San Francisco Bay Area women. J
Natl Cancer Inst 1997891311-1312.
18
How is Minnesota Doing?
Percent of Women 40 had Mammogram within 2 years
Healthy Minnesotans 2004 Objective 90
Source Minnesota Behavioral Risk Factor Survey.
Obtained from data query at http//www.cdc.gov/brf
ss, 06/04/02.
19
Nationally, race/ethnic differences in
mammography use have decreased
Percent of Women 40 had Mammogram within 2 years
Source Breen et al. Progress in cancer screening
over a decade results of cancer screening from
the 1987, 1992, and 1998 National Health
Interview Surveys. J Natl Cancer Inst
2001931704-13.
20
Disparities in mammography use



are
more strongly related to income than
race/ethnicity
Percent Women 40 had Mammogram within 2 years
Age
Source NHIS 1998. Poor is less than the federal
poverty level, Near Poor is 100-199 of FPL.
Breen et al. Progress in cancer screening over a
decade results of cancer screening from the
1987, 1992, and 1998 National Health Interview
Surveys. J Natl Cancer Inst 2001931704-13.
21
Conclusions

• Women of color and poor women are at greater risk
  of being diagnosed with invasive cervical cancer
  than white women and better-off women.
• Women of color and poor women are more likely to
  be diagnosed with late-stage breast and cervical
  cancer than white women and better-off women, and
  experience poorer survival.
• For both cancers, inadequate screening is more
  associated with poverty, lack of education and
  insurance, and failure to have a usual source of
  care than race/ethnicity.

22
Cochrane Review of Mammography --Their
Conclusions

• All but two of the eight mammography trials were
  flawed. The best studies found no decrease in
  breast cancer mortality.
• breast cancer screening is unjustified
• Being screened decreases the likelihood that
  breast cancer is listed as the underlying cause
  of death.
• breast cancer mortality should not be used to
  measure the effect of mammography
• Screening leads to treatment of clinically
  irrelevant disease and increases non-breast
  cancer deaths.
• only all-cause mortality is a valid outcome

23
Response to Review

• Little solid evidence of substantial flaws in
  randomization or bias in assigning the underlying
  cause of death.
• gt mammography benefits women
• Screening may lead to treatment of some
  clinically irrelevant disease, but there
  currently are no reliable methods to predict
  which tumors will progress.
• gt further research is needed to identify
  predictors
• gt mortality associated with treatment needs to
  be better
• assessed
• Increased appreciation that breast cancer is a
  heterogeneous disease.
• gt mammography cannot prevent all advanced
  disease