NEWSWEEK: What were the major results of the study?
Sherri Gorin: The major result was that African-American women experienced a greater diagnostic, treatment and “total clinical delay” than women of any other race. Diagnosis delay began from the time the woman first saw her doctor about any sort of breast problem, or from the time of her annual breast examination, to the completion of the biopsy. Then we measured the time between definitive diagnosis from biopsy and the start of treatment. After that, we simply added the times together for the total clinical delay in both diagnosis and treatment.
Dr. Sherri Sheinfeld Gorin
What questions were you primarily interested in answering?
We were interested in looking at a simple question. We know that black women are more likely to die of breast cancer than women of other races or ethnicities. We don’t know why. But we know that delay of treatment can increase the risk of death. We were interested in how long it really takes to make this diagnosis—and to begin treatment. Was there really a time delay for different races and ethnic groups? We looked and found an astounding difference. African-American women were 40 percent more likely to have a diagnostic delay beyond two months and 64 percent more likely to have a treatment delay beyond one month. Overall, they had more than twice the clinical delay in the diagnosis and treatment of breast cancer by comparison to white, Hispanic or women of any other race or ethnicity.
What are the ramifications of a one- or two-month wait for treatment?
The implications are that African-American women could have higher-staged tumors—those that may be larger, may have spread to one or more lymph nodes or to other parts of the body. You have a greater chance of dying from the cancer at later stages.
Do black women wait longer to seek out diagnoses and treatment, or are their doctors just slower to treat them?
We don’t really know from this study whether it’s due to patient delay or physician delay. But we know from other studies that black women are more likely to detect their own lumps than other women. And, we know that poor, black women are more likely to be treated in public clinics that often have long waiting times for appointments, leading to delays in seeing a [care] provider. Black women have lower [rates] of breast cancer than white women, but higher incidences than women of other races or ethnicities. But, black women of all ages are more likely to die of breast cancer than are white or any other women.
Is racism a factor?
It seems to be on its face—but it’s really a complicated concern. If a black woman is very distrustful of medical professionals, then she may delay treatment. There are groups of black women who are fatalistic [they believe that disease is God’s will] and so they may not move on to treatment from the biopsy. And at the physician level, there may be fewer or less-qualified doctors to do the procedures in certain communities that are both black and poor. You can say that, in a sense, it’s racism, but it’s not a matter of overt discrimination against black women. All these factors we talked about lead to a delay in seeking and receiving treatment, but it’s still not institutional discrimination.
What are some of the other factors that account for a delay?
We took into account the age of the women when they were diagnosed, as this may increase their risk for breast cancer. We looked at where the women resided, if they were members of a Medicaid HMO during the seven years of our study, the number of physician visits a woman had per year and whether breast cancer was detected with a screening or a mammogram. And we took into account some characteristics of the cancer itself because those, too, can determine the rapidity of treatment. We tried to consider everything that was reasonable and was also scientifically defensible. I want to also say that, on the plus side, investments made at the national level have led to a huge increase in breast-cancer screening. Nonetheless, there are these differences in what happens after screening.
How many women were in the study?
A total of 49,865 female Medicare recipients [65 and older] participated. Black, white, Hispanic, Asian-American, Pacific Islander and other women were compared to each other , not to an ideal of how long breast-cancer diagnosis and treatment should take. The women were not enrolled in any sort of clinical study. We obtained this information from Medicare records linked to the Surveillance Epidemiology and End Results (SEER) database, which records cancer incidence and mortality across the U.S. The SEER database is the most widely used source of data on cancer, and Medicare covers 97 percent of Americans over 65. So we had a really extraordinary database to work with.
What recommendations could you see coming out of your findings?
Policy recommendations include holding health plans and medical centers accountable for the time between screening and diagnosis—and diagnosis and treatment. I would encourage national policy groups to look carefully at the issue of timing. We also need more trained radiologists and technicians and better distribution of these skilled professionals in poor communities. I would suggest that doctors develop in-office systems to track what happens after the mammogram. Finally, I would encourage informed patient decision making. Patients should be given educational materials for each step—from screening to biopsy to treatment. It’s a much more hopeful time for breast cancer now than many women may think. Treatment has really advanced. Many more women are being saved. Women also need support from their communities, their families and their doctor, so they can become activated patients who feel they have choices. And the sooner you take action, the more choices you have.
