Disaggregating the effects of race and poverty on breast cancer outcomes.
Disaggregating the effects of race and poverty on breast cancer outcomes.
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分解种族和贫困对乳腺癌结果的影响。
DOI：
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发表时间：
2002
期刊：
影响因子：
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通讯作者：
O. Brawley
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文献类型：
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作者：
O. Brawley
过去 20 年来，乳腺癌死亡率的种族差异日益加大 (1)（图 1）。尽管非裔美国女性的死亡率最近开始下降，但白人女性的死亡率下降速度更快，这意味着自1981年以来，黑人和白人女性之间的差距每年都在持续扩大。如果我们要有效缩小这种差距，找到造成这种差距的真正原因很重要。很多时候，我们看到种族问题真相的能力被我们对处理种族问题的恐惧所掩盖。布拉德利等人。 (2) 在他们题为“种族、社会经济地位以及乳腺癌治疗和生存”的研究中，朝着寻找真相迈出了一大步。他们的研究表明，主要通过种族发挥作用并与种族相关的社会经济因素是造成黑人和白人女性之间差距的主要原因。许多决定社会经济地位的因素都与种族密切相关。然而，在之前的癌症结果研究中，很难区分贫困的影响和种族的影响 (3,4)。大多数病例对照研究没有招募足够多的富有的黑人或贫穷的白人来表明贫困是一个独立于种族的不良预后因素。社会经济地位不仅反映收入，还反映一个人的生育年龄、饮食以及其他对癌症病因和行为的外在影响。仍然需要对这些因素进行更好的定义。 Bradley 等人报告的基于人群的研究中。 (2)、所有种族的低收入女性，尤其是没有保险或保险不足的黑人女性，在接受癌症诊断后更有可能获得不够充分的护理。这些妇女能够获得医疗服务，以至于她们被诊断出患有癌症，因此缺乏医疗服务并不是接受不充分护理的原因。显然，国家研究议程应包括研究以确定为什么向穷人提供这种不够充分的护理以及如何为他们提供最佳护理。这项研究的结果推翻了种族是乳腺疾病生物学行为的固有决定因素的假设。在过去的十年中，一些善意的人认为种族差异的存在是因为乳腺癌在黑人中比在白人中更具侵袭性。有些人甚至认为，黑人乳腺癌与白人乳腺癌是不同的疾病 (5,6)。有些人甚至认为用于治疗乳腺癌的药物在黑人中的测试不如在白人中得到充分的测试 (7)。 1993 年美国国立卫生研究院振兴法案甚至包含这样的立法：临床试验的设计必须能够确定测试干预措施在不同种族中的效果 (8)。种族是一个社会变量，而不是固有的生物变量。很明显，与白人女性相比，黑人女性出现晚期疾病的比例要高得多，而且在任何一个阶段，具有较差预后标志的黑人比例都高于白人，例如较高的病理分级和雌激素受体阴性疾病 (3,9)。 Gordon 及其同事 (10,11) 表明，低教育水平和低收入与雌激素受体阴性肿瘤的诊断相关，这表明与社会经济地位相关的因素可能会影响乳腺癌的生物学行为。事实上，这些研究 (10,11) 和布拉德利研究 (2) 相结合，在很大程度上解释了黑人和白人之间在分期、病理学和乳腺癌结果方面的人群差异，并帮助我们了解影响乳腺癌结果的因素对所有种族和民族的美国人都很重要。有充分的数据支持这一概念，即固有或遗传差异并不是黑人乳腺癌死亡率高于白人的原因。最明显的证据是 1980 年之前美国黑人和白人之间的死亡率没有差异。令人痛苦的是 Bradley 及其同事 (2) 发现，在调整了年龄、社会经济地位和保险覆盖范围后，被诊断患有乳腺癌的黑人女性接受肿瘤手术切除的可能性低于白人女性。然而，令人欣慰的是，医疗补助是乳腺癌护理模式中的一股均衡力量。这项研究表明，虽然种族在生物学上并不重要，但在美国社会中仍然非常重要。种族影响一个人获得充分医疗护理的机会，这是一个令人悲伤的说法。在美国，得癌症是不好的；在美国，得癌症是不好的。贫穷又得癌症更糟糕；贫穷、黑人和患有癌症就更糟糕了。事实上，后勤问题（即提供足够的护理）是黑人和白人之间乳腺癌差异的主要原因，这应该有助于引起社会和研究界的关注。所接受护理差异的原因可能包括缺乏方便的护理、患者拒绝、因合并症而导致护理不当，以及不幸的是种族主义和社会经济歧视 (12,13)。更好地界定差异的原因对于国家研究议程非常重要：社会需要致力于为所有人提供足够的护理。多项乳腺癌临床试验的结果表明，同等治疗在同等患者中产生同等结果 (14-16)。其他机构特定的治疗系列表明，当待遇平等时，不同种族之间的结果相似 (17-19)。这些发现与死亡率的种族差异始于 1981 年这一事实相结合，与这样一种假设相一致：当我们了解如何治疗乳腺癌时，某一群体（中上层阶级，主要是白人）中较大比例的人比其他群体接受了更好（或更有效）的治疗。
Over the past 20 years, there has been an increasing racial disparity in breast cancer mortality (1) (Fig. 1). Although the mortality rates for African-American women have recently begun to fall, the rates for white women have fallen at a greater pace, meaning that the disparity between black and white women has continued to increase every year since 1981. Finding the true reasons for the disparity is important if we are to effectively reduce it. So often, our ability to see the truth in racial matters is obscured by our fear of dealing with the issue of race. Bradley et al. (2) take a giant step toward finding the truth in their study entitled “Race, Socioeconomic Status, and Breast Cancer Treatment and Survival.” Their study demonstrates that socioeconomic factors that act largely through and are associated with race are responsible for much of the disparity between black and white women. Many factors that determine socioeconomic status are intimately related to race. However, in previous studies of cancer outcomes, it has been difficult to distinguish the effects of poverty from the effects of race (3,4).Most case–control studies have not enrolled enough wealthy blacks or poor whites to show that poverty is a poor prognostic factor independent of race. Socioeconomic status not only reflects income but also one’s age at bearing children, one’s diet, and other extrinsic influences on cancer etiology and behavior. Better definitions of these factors are still needed. In the population-based study reported by Bradley et al. (2), low-income women of all races, but especially black women who were uninsured or under insured, were more likely to receive less-than-adequate care after receiving a cancer diagnosis. These women had access to medical care such that they were diagnosed with cancer, so lack of access to health care is not a reason for receiving care that is less than adequate. Clearly, the national research agenda should include studies to determine why this less-than-adequate care is rendered to the poor and how to render them optimal care. The results of this study discredit the hypothesis that race is an inherent determinant of the biologic behavior of breast disease. In the past decade, some well-meaning individuals have suggested that the racial disparity exists because breast cancer is a more aggressive disease in blacks than it is in whites. Some have even suggested that breast cancer is a different disease in blacks than it is in whites (5,6). Some have gone so far as to suggest that the drugs used to treat breast cancer have not been tested as adequately in blacks as they have in whites (7). The National Institutes of Health Revitalization Act of 1993 is legislation that even contains language that says that clinical trials must be designed to determine the effects of test interventions in the various races (8). Race is a social variable, not an inherent biologic variable. It is clear that, compared with white women, a disproportionately higher proportion of black women present with later-stage disease and that, within any one stage, a higher proportion of blacks than whites have poor prognostic markers, such as higher pathologic grade and estrogen receptor-negative disease (3,9). Gordon and colleagues (10,11) have shown that low education level and low income are associated with the diagnosis of estrogen receptor-negative tumors, which suggests that factors associated with socioeconomic status may influence the biologic behavior of breast cancer. Indeed, those studies (10,11) and the Bradley study (2) combined do much to explain the population differences in stage, pathology, and breast cancer outcomes between blacks and whites and help us understand that factors that affect breast cancer outcomes are important to Americans of all races and ethnicities. There are good data supporting the concept that inherent or genetic differences are not the reasons that blacks have higher breast cancer mortality rates than whites. The most obvious evidence is the fact that there was no disparity in mortality between blacks and whites in the United States before 1980. It is distressing that Bradley and colleagues (2) found that, after adjusting for age, socioeconomic status, and insurance coverage, black women diagnosed with breast cancer were less likely to receive surgical removal of their tumors than white women. However, it is gratifying that Medicaid was an equalizing force in breast cancer patterns of care. This study shows that whereas race is not important biologically, it is still very important in American society. It is a sad statement that race influences one’s chances of obtaining adequate medical care. In the United States, it is bad to have cancer; it is worse to be poor and have cancer; and it is even worse to be poor, black, and have cancer. The fact that a logistical issue, the provision of adequate care, lies behind much of the breast cancer disparity between blacks and whites should help focus society and the research community. Reasons for the differences in care received could include the lack of convenient accessible care, refusal by the patient, inappropriateness of care because of comorbid conditions, and unfortunately, racism and socioeconomic discrimination (12,13). Better defining the reasons for the disparities is important to the national research agenda: Society needs to commit itself to the provision of adequate care for all. Results of several breast cancer clinical trials demonstrate that equal treatment yields equal outcomes among equal patients (14–16). Other institution-specific treatment series demonstrate that outcomes are similar among the races when there is equal treatment (17–19). These findings, taken together with the fact that the racial disparity in mortality began in 1981, are consistent with the hypothesis that as we have learned how to treat breast cancer, a larger proportion of one segment of the population (the middle and upper class, which is primarily white) is receiving better (or more effective) treatment than are other segments of
DOI：
10.1093/jnci/94.7.490
发表时间：
2002-04
期刊：
Journal of the National Cancer Institute
影响因子：
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作者：
C. Bradley;C. Given;Caralee Roberts
通讯作者：
C. Bradley;C. Given;Caralee Roberts
乳腺癌的种族和生存率：基于癌症和白血病 B 组试验 8541。
DOI：
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发表时间：
1997
期刊：
The cancer journal from Scientific American.
影响因子：
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作者：
Roach3rd,M;Cirrincione,C;Budman,D;Hayes,D;Berry,D;Younger,J;Hart,R;Henderson,IC
通讯作者：
Henderson,IC