Ahmedin Jemal, Anthony S. Robbins, Chun Chieh Lin, Carol E. DeSantis, and Elizabeth M. Ward, American Cancer Society; W. Dana Flanders, Emory University, Atlanta, GA; and Rachel A. Freedman, Dana-Farber Cancer Institute, Boston, MA.
J Clin Oncol. 2018 Jan 1;36(1):14-24. doi: 10.1200/JCO.2017.73.7932. Epub 2017 Oct 16.
Purpose To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer. Patients and Methods Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs). Results We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor-positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor-negative disease, although the HRs were substantially smaller. Conclusion Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.
评估人口统计学差异、合并症、保险、肿瘤特征和治疗对非老年黑人和白人女性早期乳腺癌整体死亡率差异的贡献。
在激素受体状态分层的情况下，使用多变量风险比（HR），在按顺序、倾向评分、最佳匹配的患者中，计算黑人与白人女性（诊断为 I 期至 III 期乳腺癌）每一个变量（人口统计学、合并症、保险、肿瘤特征和治疗）的全因死亡超额相对风险，以百分比表示。
我们从 2004 年至 2013 年在国家癌症数据库中确定了 563497 名年龄在 18 至 64 岁之间诊断为 I 期至 III 期乳腺癌的白人和黑人女性。在所有患者中占 78.5%的激素受体阳性疾病的女性中，黑人与白人女性在人口统计学匹配模型中的死亡 HR 为 2.05（95%CI，1.94 至 2.17）。当按顺序匹配合并症、保险、肿瘤特征和治疗时，HR 分别降至 1.93（95%CI，1.83 至 2.04）、1.54（95%CI，1.47 至 1.62）、1.30（95%CI，1.24 至 1.36）和 1.25（95%CI，1.19 至 1.31）。这些因素共同解释了黑人患者死亡总超额风险的 76.3%；保险占总超额的 37.0%，其次是肿瘤特征（23.2%）、合并症（11.3%）和治疗（4.8%）。结果在激素受体阴性疾病的女性中基本相似，尽管 HR 要小得多。
在非老年黑人与白人女性早期乳腺癌诊断中，按保险匹配解释了死亡超额风险的三分之一；按肿瘤特征匹配解释了大约五分之一的超额风险。关注医疗保健可及性均等化的努力可以大大减少非老年乳腺癌患者总体生存的种族/民族差异。
