John P. Murtha Cancer Center, Uniformed Services University and Walter Reed National Military Medical Center, Bethesda, Maryland.
Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland.
JAMA Surg. 2019 Mar 1;154(3):e185113. doi: 10.1001/jamasurg.2018.5113. Epub 2019 Mar 20.
Racial disparities in time to surgery (TTS) after a breast cancer diagnosis and whether these differences account for disparities in overall survival have been understudied in the US population.
To compare TTS in non-Hispanic black (NHB) and non-Hispanic white (NHW) women with breast cancer and to examine whether racial differences in TTS may explain possible racial disparities in overall survival in a universal health care system.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort identified from the Department of Defense Central Cancer Registry and Military Health System Data Repository linked databases containing records between January 1, 1998, and December 31, 2008, of 998 NHB women and 3899 NHW women who received a diagnosis of stages I to III breast cancer and underwent breast-conserving surgery (BCS) or mastectomy in the US Military Health System during the study period. Data analyses were conducted from July 5, 2017, to December 29, 2017.
The main outcome was time to breast cancer surgery. Non-Hispanic black and NHW women were compared at the 25th, 50th (median), 75th, and 90th percentiles of TTS by using multivariable quantile regression. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs for all-cause death in NHB compared with NHW women after controlling for potential confounders first without and then with TTS.
Among the 4887 NHB and NHW women in the cohort, the mean (SD) age was 50.0 (9.4) years. The median TTS was 21 days (95% CI, 20.6-21.4 days) among NHW women and 22 days (95% CI, 20.6-23.4 days) among NHB women. Non-Hispanic black women had a significantly greater estimated TTS at the 75th (3.6 days; 95% CI, 1.6-5.5 days) and 90th (8.9 days; 95% CI, 5.1-12.6 days) percentiles than NHW women in multivariable models. The estimated differences were similar by surgery type. Non-Hispanic black women had a higher adjusted risk for death (HR, 1.45; 95% CI, 1.06-2.01) compared with NHW women among patients receiving breast-conserving surgery. The risks were similar between races among those receiving mastectomy (HR, 1.06; 95% CI, 0.76-1.48). The HRs remained similar after adding TTS to the Cox proportional hazards regression models.
This study's results indicate that time to breast cancer surgery was delayed for NHB compared with NHW women in the Military Health System. However, the racial differences in TTS did not explain the observed racial differences in overall survival among women who received breast-conserving surgery.
在美国人群中，关于乳腺癌诊断后手术时间（TTS）的种族差异，以及这些差异是否导致总生存的差异，研究还不够充分。
比较非西班牙裔黑人（NHB）和非西班牙裔白人（NHW）女性的 TTS，并检查在全民健康保险制度中，TTS 方面的种族差异是否可以解释总生存方面可能存在的种族差异。
设计、地点和参与者：这是一项从国防部中央癌症登记处和军事健康系统数据存储库中确定的回顾性队列研究，纳入了 1998 年 1 月 1 日至 2008 年 12 月 31 日期间在美军健康系统中接受 I 期至 III 期乳腺癌诊断，并接受保乳手术（BCS）或乳房切除术的 998 名 NHB 女性和 3899 名 NHW 女性的记录，该研究期间在该系统中进行。数据分析于 2017 年 7 月 5 日至 2017 年 12 月 29 日进行。
主要结局是乳腺癌手术时间。通过多变量分位数回归比较 TTS 第 25、50（中位数）、75 和 90 百分位的 NHB 和 NHW 女性。使用 Cox 比例风险回归模型，在控制了潜在混杂因素后，首先不包括 TTS，然后包括 TTS，估计 NHB 与 NHW 女性所有原因死亡的风险比（HR）和 95%CI。
在队列中的 4887 名 NHB 和 NHW 女性中，平均（SD）年龄为 50.0（9.4）岁。NHW 女性的中位 TTS 为 21 天（95%CI，20.6-21.4 天），而 NHB 女性的中位 TTS 为 22 天（95%CI，20.6-23.4 天）。在多变量模型中，NHB 女性在第 75（3.6 天；95%CI，1.6-5.5 天）和第 90（8.9 天；95%CI，5.1-12.6 天）百分位的 TTS 估计值显著高于 NHW 女性。按手术类型估计的差异相似。与接受保乳手术的 NHW 女性相比，接受保乳手术的 NHB 女性死亡风险更高（HR，1.45；95%CI，1.06-2.01）。在接受乳房切除术的患者中，种族间的风险相似（HR，1.06；95%CI，0.76-1.48）。在 Cox 比例风险回归模型中加入 TTS 后，HR 仍相似。
本研究结果表明，与接受保乳手术的 NHW 女性相比，美军健康系统中 NHB 女性的乳腺癌手术时间延迟。然而，TTS 方面的种族差异并不能解释接受保乳手术的女性中观察到的总生存种族差异。
