According to numerous studies, disparities in breast cancer diagnosis and survival rates between black and white women have not improved in the past two decades. However, the use of sentinel lymph node biopsy or SLNB to stage early breast cancer increased in both black and white women from 2002 to 2007. These increased rates, remained lower in black than white patients, a disparity that contributed to disparities in the risk for lymphedema, a common swelling of the arm after breast cancer treatment caused by damage to the lymphatic system.
Data from from a retrospective review of the Surveillance, Epidemiology, and End Results (SEER) and Medicare?linked database that performance of sentinel node biopsy in women with pathologically node-negative breast cancer has been 12% lower for black women compared with white women. And compared with white women, black women have more aggressive tumors, and worse outcomes.
These findings emphasize that not all newly developed techniques in breast cancer care are made available in a timely fashion to all eligible patients…
A sentinel lymph node is the first lymph node to which cancer cells are most likely to spread from a primary tumor. To help determine the extend or stage of cancer, a sentinel lymph node biopsy or SLNB was developed to replace axillary node dissection or ALND, can be used. This procedure involve less extensive surgery. Furthermore, the removal of fewer lymph nodes than standard lymph node surgery, results in a reduction of adverse effects and complications.
Racial disparities
Racial disparities exist in many aspects of breast cancer care but their existence in the use of SLNB had been uncharacterized. Now, for the first time, researchers at University of Texas MD Anderson Cancer Center, Houston, Texas, identified cases of nonmetastatic, node-negative breast cancer in women 66 years of age or older from 2002 through 2007. Of the 31,274 women identified, 1,767 (5.6%) were black, 27,856 (89.1%) were white and 1,651 (5.3%) were of other or unknown race.[1]
Sentinel lymph node biopsies were performed in 73.7% of white patients and 62.4% of black patients. While the use of SLNB increased by year for both black and white patients, blacks were 12% less likely than whites throughout the study period to undergo SLNB. The authors suggest that adoption of SLNB in blacks patients lagged two to three years behind its adoption in white patients. The 5-year cumulative lymphedema risk was 8.2% in whites and 12.3% in blacks. The authors note socioeconomic and geographic factors were associated with lower SLNB use including insurance coverage through Medicaid, living in areas with lower education or income levels, and living in areas with fewer surgeons.
“These findings emphasize that not all newly developed techniques in breast cancer care are made available in a timely fashion to all eligible patients,” explained Dalliah M. Black, M.D., of the University of Texas MD Anderson Cancer Center, Houston, Texas. “As new techniques continue to be developed, focused educational interventions must be developed to ensure that these techniques reach historically disadvantaged patients to avoid disparities in care. More contemporary data will be needed to determine whether this disparity still exists in black patients and other at-risk minorities.”
More Bad News
In a related commentary, Colleen D. Murphy, M.D., and Richard D. Schulick, M.D., M.B.A., of the University of Colorado, Aurora, noted: “One key and uncertain issue in the study of lymphedema is its very diagnosis.” [2]
“In the study by Black and colleagues, it seems likely that patients undergoing axillary lymph node dissection, when sentinel node biopsy may have been indicated, were cared for at institutions without lymphedema screening protocols. In black women, lymphedema screening may be especially relevant. In this study, the authors demonstrated that this population is at highest risk,” Murphy and Schulick continued.
“Black and colleagues have highlighted another disparity in breast cancer care and its associated morbidity. With this information in hand, we should seek to eliminate these differences as much as possible,” they said.
For more information:
[1] Black DM, Jiang J, Kuerer HM, Buchholz TA, Smith BD. Racial Disparities in Adoption of Axillary Sentinel Lymph Node Biopsy and Lymphedema Risk in Women With Breast Cancer. JAMA Surg. Published online June 18, 2014. doi:10.1001/jamasurg.2014.23 [Article]
[2] Murphy CD and Schulick RD. Racial Disparities in Breast Cancer: More Bad News JAMA Surg. Published online June 18, 2014.;():. doi:10.1001/jamasurg.2014.44.
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