Presentation of study findings at the annual meeting of the American Public Health Association, Washington, DC, 2004 (Gorey et al., Breast Cancer Research and Treatment, 2009)

1. Increased Breast Cancer SurvivalIncreased Breast Cancer Survival
Differentials by Race in AmericaDifferentials by Race in America
Historic Observational Evidence
Consistent With a Health Insurance
Hypothesis, 1975 to 2000

2. Research ObjectiveResearch Objective
To learn from our experiences of the past
generation whether or not health care
outcomes (resources) have become
more or less equitably distributed
- African American vs. white people
- In metropolitan Detroit
- With breast cancer (sentinel outcome)

3. Historical Context: 1975 to 2000Historical Context: 1975 to 2000
- US health care system is multi-tiered:
Uninsured, underinsured, Medicaid,
Medicare, and array of private coverages
- Time of great systemic changes
- Managed care & for-profit proliferation
- Uninsured population nearly doubled
(increased from 24 to 44 million among
those < 65 years of age)

4. Theoretical Context: SystematicTheoretical Context: Systematic
Literature ReviewLiterature Review
- Race and socioeconomic status (SES)
are strongly associated with health
insurance statuses (ORs 2.0 to 15.0).
- Race, SES and health insurance statuses
are all strongly associated with cancer
screens, stages at diagnosis and access
to treatments (ORs 2.0 to 5.0).

5. Research QuestionsResearch Questions
Given the near 20% improvement in breast
cancer survival during the study period:
1. Has this medical advance been enjoyed
equitably by African American and white
women?
2. Is there a particular African American
disadvantage among those not yet
eligible for Medicare?

6. MethodsMethods
Using Historical Cohorts and
Focusing on Interactions, Rather
Than Mere Main Effects

7. Sample DesignSample Design
- Detroit Cancer Registry, SEER
- Detroit metro: 3 counties, 4 million+ pop
- Primary invasive breast cancer cases
- Women, 25 years of age and older
- Entire most valid cohort
1975 to 2000 inclusive followed until
December 31, 2001
- N = 57,668
10,237 African American and
47,431 White people

8. Analytic PlanAnalytic Plan
- 1970s & 1990s cohorts compared, e.g.,
1975-80 followed until 1986 vs. 1990-95
until 2001 for 5-year survival analyses
- Analyses of survival used proportional
hazards models.
- Analyses of stages of disease at the time
of diagnosis and treatments (1st
year
post-diagnosis) used logistic regression
models.
- All models were adjusted for age and
year of diagnosis.

9. Results
Significantly Increased Racial Group
Breast Cancer Survival, Stage and
Treatment Differentials

10. Race By Cohort InteractionsRace By Cohort Interactionsaa
onon
Survival: Odds Ratios (95% CIs)Survival: Odds Ratios (95% CIs)
Main Effects of Race Within CohortMain Effects of Race Within Cohort
1970s1970s 1990s1990s
1-yr 1.83 (1.60,2.09) 2.07 (1.86,2.31)
3-yr 1.67 (1.51,1.86) 2.09 (1.93,2.26)
5-yr 1.64 (1.46,1.84) 1.94 (1.79,2.16)
10-yr 1.64 (1.40,1.91) 1.88 (1.66,2.13)
a
All minimally significant at p < .05).

11. Race By Age By Cohort InteractionRace By Age By Cohort Interaction
on 5-Year Survival: ORs (95% CIs)on 5-Year Survival: ORs (95% CIs)
Race By Age Within CohortRace By Age Within Cohort
AgeAge 1970s1970s 1990s1990s
< 65 1.60 (1.39,1.84) 2.06 (1.85,2.30)
65 + 1.74 (1.41,2.16) 1.79 (1.58,2.04)
The 3-way interaction was significant at p < .05).

12. Race By Age By Cohort InteractionRace By Age By Cohort Interaction
on Local Disease: ORs (95% CIs)on Local Disease: ORs (95% CIs)
Race By Age Within CohortRace By Age Within Cohort
AgeAge 1970s1970s 1990s1990s
< 65 1.24 (1.12,1.37) 1.46 (1.35,1.58)
65 + 1.58 (1.36,1.84) 1.56 (1.41,1.72)
The 3-way interaction was significant at p < .05).

13. Race By Age By Cohort InteractionsRace By Age By Cohort Interactions
on Treatmentson Treatments
Similar interactions were observed on
receipt of surgery (localized disease), radiation
therapy (local & regional), chemotherapy and
hormone therapy (regional disease).
All were indicative of particularly increased
African American disadvantages among those
not yet eligible for Medicare.

14. Interactions Seem to ReflectInteractions Seem to Reflect
Sociologic, Not Biologic PhenomenaSociologic, Not Biologic Phenomena
When four socioeconomic variables were entered
into the analytic models each of the previously
significant interaction terms did not enter
(at p < .05).
The four measures were census tract- based
compositional (prevalence of poor and near poor
[200% poverty criterion] people) and contextual
(median home and rental values) measures of
social position.

15. DiscussionDiscussion
The Evidence Supports
Race as a Social Construction
&
The Implementation of Policies That Would Ensure
All Americans Access to
Timely Diagnosis & the Best Available Treatments

16. SummarySummary
African American women with breast cancer
have not fully enjoyed contemporary
survival advances. Relative to white
patients they are more disadvantaged
today than they were 25 years ago.
Alternative Explanations:
- Social policies and structures affecting
health insurance access have changed
drastically during this time frame.
- Gene-based, biologically-mediated
(tumor) characteristics have not.

17. Policy ImplicationsPolicy Implications
- Race and income (type of insurance one
has) still matter very much in American
health care.
- Racial and socioeconomic inequities
could probably be eliminated in large
measure by providing universal access
to all:
- The young and the old
- The poor and the rich
- People of color and white people.