Breast cancer among women in Mississippi: a preliminary report of excess mortality in African Americans.

Breast cancer, a major contributor to morbidity and mortality among women, occurs more frequently in the United States than any other type of cancer Breast cancer incidence and mortality rates vary among racial and ethnic groups in the United States. Increased mortality is associated with many factors including lack of access to health care services, lack of screening, advanced stage at diagnosis, socioeconomic conditions, poorer treatment, and limited preventive services. The purpose of this paper is to examine data on breast cancer in Mississippi women. Data sources include the Surveillance, Epidemiology and End Results Program, the American Cancer Society, and the Mississippi Central Cancer Registry. African American women in Mississippi have an excess breast cancer mortality rate and data from a recent publication, Cancer in Mississippi: An Annual Report 1996, suggest that it may be higher than previously recognized. These observations signal a need for more diligent surveillance of the trends in breast cancer as well as public health programs directed toward cancer prevention, treatment and control. Therefore, it is imperative that research be done to determine the relationships among socioeconomic and cultural factors, access to health care and preventive services, and attitudes about seeking treatment for breast cancer. Additionally, to effectively implement legislation for breast health, there must be increased education of consumers and health care providers of resources available.

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Breast cancer, a major contributor to morbidity and mortality among women, occurs more frequently in women in the United States than does any other type of cancer. During 2001 the American Cancer Society (ACS) estimates that 192,000 women in the United States will be diagnosed with breast cancer and 40,200 women will die from the disease (Greenlee et al., 2001). Within the state of Mississippi, however, it is estimated that in the year 2001 there will be 2000 new cases of breast cancer diagnosed among women and 400 women will die from the disease (American Cancer Society, 2001a).

BREAST CANCER STATISTICS

Breast cancer incidence and mortality rates vary among racial and ethnic groups in the United States. Nationally, data from the National Cancer Institute's (NCI) Surveillance, Epidemiology and End Results (SEER) Program for 1992-1996 show the age-adjusted incidence rate of breast cancer in women was 110.6/100,000 for all races, 113.9/100,000 for whites, and 101.5/100,000 for African Americans (Ries et al., 1999). The age-adjusted mortality rate of breast cancer in women for 1992-1996 was 25.4/100,000 for all races, 25.1/100,000 for whites, and 31.3/100,000 for African Americans-the highest breast cancer mortality rate among United States racial and ethnic groups. During 1992-1996, the average annual age-adjusted cancer mortality rate of breast cancer for all women in Mississippi was 23.8/100,000 (Reis et al., 1999). The state of Mississippi ranked 39th among the 50 states and the District of Columbia in breast cancer mortality and is one of the states with a lower rate (Ries et al., 1999). Few studies, howev er, have examined breast cancer among African American women in Mississippi. In this report data on breast cancer in Mississippi women are examined. Underlying factors that may contribute to differences in the mortality rate between blacks and whites and policy issues related to breast cancer are discussed.

Data from the SEER, the ACS, and the Mississippi Central Cancer Registry were reviewed. Incidence data are from the SEER program. The ACS and SEER mortality data are from the National Center of Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). Death rates were calculated using data on cancer deaths compiled by NCHS and population data collected by the U.S. Bureau of the Census. All SEER incidence and mortality rates are age-adjusted to the 1970 United States standard population. The Mississippi Central Cancer Registry (CCR), a population-based cancer registry within the Mississippi State Department of Health and established by the 1993 Legislature, began collecting data in 1996. Data sources include: (a) population data from the Surveillance, Epidemiology, and End Results Program (SEER) population files (December, 1998); (b) incidence data from the Mississippi State Department of Health Central Cancer Registry; and (c) mortality data from the Mississippi State Department of He alth Division of Vital Statistics (Mississippi State Department of Health, 1996). Mammography and clinical breast examination data are from the Behavioral Risk Factor Surveillance System, NCHS (American Cancer Society, 1996).

Table 1 shows a summary of data from SEER, the ACS, and the Mississippi CCR on breast cancer incidence and mortality rates for women in the United States and in Mississippi. Nationally, breast cancer incidence rate in whites is higher than in blacks. Incidence data for the Mississippi CCR for 1996 (its first year of operation) is estimated to be only 80% complete, and is therefore not shown (Mississippi State Department of Health, 1996). National and state data show the age-adjusted mortality rate of breast cancer to be higher in blacks than in whites. Black/white mortality rate ratios were calculated and the percentages of excess mortality for blacks were determined. During 1990-1996, SEER data show that blacks had a 22% greater risk of dying from breast cancer than whites. Data for Mississippi during a similar time period (1991-1995) show a slightly higher percentage of excess mortality at 29%. Data for the year 1996 show a higher rate of excess mortality nationally (28%) than seen for the 1990-1996 period. Preliminary data from the Mississippi CCR for 1996 suggest that the excess breast cancer mortality among blacks may be even greater than previously recognized, up to 55% (Mississippi State Department of Health, 1996). However, there are limitations to these data: (1) only data for 1996 are presented and (2) age-adjustment and standardization were made to the U.S. 2000 population in Mississippi, and not to the 1970 United States standard population used in SEER. Accordingly, these data are preliminary and must be interpreted with caution. Increased breast cancer mortality is associated with many factors including a lack of access to health care services, lack of screening, advanced stage at diagnosis, socioeconomic conditions, poorer treatment, and limited preventive services. In order to determine the behavioral pattern of women in Mississippi related to mammography screening, state-specific data on screening practices were reviewed using state survey data from the Behavioral Risk Factor Surveillance System. As shown in Table 2, women in Mississippi are involved less often in breast cancer screening prevention practices than women nationally. Only 76.3% of women age 40 and older in Mississippi reported they ever had a mammogram compared to 84.1% of women nationally. Only three other states had a lower percentage of women who had ever had a mammogram. Between ages 40--49 years, the percentages of women who had a recent mammogram are similar at nearly 65%. However, fewer women in Mississippi age 50 years and older report having had a recent mammogram (approximately 40%) compared to mammogram use by women nationally, nearly 55% (American Cancer Society, 1996).

UNDERLYING FACTORS

Differences in race-specific and state-specific incidence and death rates for breast cancer may be attributed to differences in factors such as socioeconomic status, access to delivery of medical care, lifestyle, and specific biological risk factors for disease (Centers for Disease Control, 1 992b; Miller et al., 1995). A major factor contributing to higher breast cancer mortality among black women is that they often do not seek prevention and treatment services until the disease has advanced. They are less likely than white women to be screened for breast cancer through such measures as clinical breast examination and mammography because of a lack of knowledge about prevention services and less access to health care (Blendon et al., 1989; Fletcher et al., 1993). Consequently, a diagnosis of breast cancer in black women occurs when the disease is in a less treatable stage.

Underlying reasons that may explain why black women do not seek treatment until the disease is advanced are also related to socioeconomic factors coupled with beliefs and attitudes regarding breast cancer's disease process, treatment, and the impact of treatment on a woman's relationship with the significant other. In a study by Lannin et al. (1998) of the economic factors and cultural beliefs influencing the reporting of breast cancer, they found that: (a) African American women had a more advanced-stage disease at diagnosis, (b) socioeconomic factors and cultural beliefs strongly influence the stage at which the patient seeks treatment after a diagnosis of a breast lump, and (c) the combination of the two factors provide an explanation of the racial difference (Lannin et al., 1998). Specific demographic and socioeconomic factors, which are listed as they were presented in the survey forms, that were identified as significant predictors of advanced-stage breast cancer include: (a) being an African American, (b) low income, (c) never having been married, (d) no private health insurance, and (e) delay in seeing a physician due to lack of money or lack of transportation. Cultural beliefs were also identified as significant predictors of women presenting with advanced-stage breast cancer. Medically invalid cultural beliefs that were reported include: (a) air causes a cancer to spread, (b) the devil can cause a person to get cancer, (c) women who have breast surgery are no longer attractive to men, and (d) chiropractic is an effective treatment for breast cancer. Most recent research indicates that socioeconomic variables alone do not account for observed differences in breast cancer between African American and white women. Cultural factors such as beliefs, attitudes and knowledge about cancer vary among races and could be underlying contributors to the disparities in breast cancer incidence and mortality between African American women and white women (Lannin et al., 1998).

Mississippi is one of many states with large rural populations. Compared to other states, its economic base is depressed. Pockets of poverty and lack of access to quality health care in largely poor and rural areas contribute to its low ranking as the unhealthiest state in the Nation (Kanengiser, 2000). In a study by Amey et al. (1997), the role of race and residence in determining stage at the diagnosis of breast cancer was examined in 79,946 women from the state of Florida between 1981-1989. With the exception of age, race was the most influential individual characteristic. When race and residence were entered into the logistic regression equation, rural black women from remote areas of the state were diagnosed with breast cancer much later than other women (Amey et al., 1997). However, rural white women demonstrated no significant disadvantage from residence. An unanswered question is why the most rural of white women suffered no significant disadvantage from residence (Amey et al., 1997). Further researc h is needed to better understand the relationship between socioeconomic and cultural factors, and geographic barriers to screening and healthcare services.

POLICY ISSUES

Recognizing the value of screening and early detection for breast cancer, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Centers for Disease Control and Prevention, 2000). This act is responsible for the establishing the CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The program targets underserved women, including those who are older, have low incomes or are members of racial and ethnic minority groups and provides breast and cervical cancer screening exams. It provides grants to states for program implementation and includes education and outreach programs for women and health care providers, improving quality assurance measures for screening and improving access to screening and follow-up services (Centers for Disease Control and Prevention, 2000). By 1992, 12 states had received funding and technical assistance in program implementation (Centers for Disease Control, 1992a). In 1996 the program was implemented nation-wide.

As a result of NBCCEDP, the state of Mississippi offers breast screening and mammograms for women 50 years of age or older who have no Medicaid, private insurance, Medicare or other third-party payment. In addition to screening, the program provides diagnostic services, public information and educational programs, and training to improve the skills of health professionals in detection and control of breast cancer (Centers for Disease Control and Prevention, 2000). The NBCCEDP, however, did not provide free treatment for women too poor to afford insurance but not poor enough to qualify for Medicaid. Consequently, in October 2000 the Breast and Cervical Cancer Prevention and Treatment Act of 2000 was signed into law This law authorizes states to provide Medicaid coverage for women who are diagnosed with breast or cervical cancer, but have no way to pay for treatment (Pear, 2000). Prior to this law, women with an abnormal screening result, received diagnostic evaluation and treatment referral, but no resources were made available to pay for the treatment.

African American women in Mississippi have excess breast cancer mortality. Recent data from the Mississippi Central Cancer Registry suggest that it may be higher than previously recognized. These observations signal a need for more diligent surveillance of the trends in breast cancer as well as public health programs directed towards cancer prevention, treatment and control. Comparatively, Mississippi women participate in breast cancer screening services less frequently than women in most other states, and nationally. Therefore, it is imperative that research be done to determine the relationships among socioeconomic and cultural factors, access to health care and preventive services, and attitudes about seeking treatment for breast cancer. Additionally, to effectively implement policies legislated for breast health, there must be increased education of consumers and health care providers of resources available to improve breast cancer screening and thereby decrease mortality.

Table 1

Age-adjusted Breast Cancer Incidence and Mortality Rates * in Females.

                    Incidence  Mortality  % Excess
                    Rate       Rate       Black/White
                                          Mortality

1990-1996: United
States, SEER
All races           109.1      25.9
  White             113.2      25.7
  Black             113.2      31.4        22%

1991-1995:
Mississippi **
All races           n/a        23.6
  Whites            n/a        21.9
  Blacks            n/a        28.2        29%

Year 1996: United
States, SEER
All races           110.7      24.3
  Whites            113.3      24.0
  Blacks            100.3      30.8        28%

Mississippi Cancer
Registry ***
All races           n/a        30.1
  Whites            n/a        26.1
  Blacks            n/a        40.4        55%

* Age-adjusted per 100,000 to the 1970 U.S. standard population.

** Source: American Cancer Society (2001b). Based on data from the
National Center for Health Statistics.

*** Cancer in Mississippi: Annual Report, 1996, Mississippi State
Department of Health.
Table 2

Mammography and Clinical Breast Examination for Women 40 and Older,
1996.

                          % Ever
                            Had
                         Mammogram
              % Ever    & Clinical
                Had       Breast
             Mammogram  Examination        % Had Recent Mammogram

Years:         40 &        40 &        40-49         50 %     65 &
               Older       Older                     Over     Over

United         84.1        79.5         65.4         56.9     54.1
States

Mississippi    76.3        71.9         66.1         41.8     38.3

Recent mammograms: Women 40-49 within the last two years; women 50 and
older within the last year. Behavioral Risk Factor Surveillance System
CD-ROM, National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention

Source: 1996.

LITERATURE CITED

American Cancer Society. 2001a. Cancer Facts and Figures 2001. Atlanta; American Cancer Society, 2001.

American Cancer Society. 2001 b. 1991-1995 Cancer Mortality Statistics for All Races, Whites, and Blacks: Mississippi. Source: National Center for Health Statistics. {On-line}. Available: http://www.cancer.org/asp/statistics/stt_global.asp

American Cancer Society. 1996. Behavioral Risk Factor Surveillance System CD-ROM, National Center for Chronic Disease Prevention and Health Promotion. Centers for Disease Control and Prevention.

Amey, C., M. Miller, and S. Albrecht. 1997. The role of residence in determining stage at diagnosis of breast cancer. The Journal of Rural Health, 13:99-108.

Blendon, R.J., L.H. Aiken, H.E. Freeman, and R.C. Christopher. 1989. Access to medical care for black and white Americans. Journal of the American Medical Association, 261, 278-281.

Centers for Disease Control and Prevention. 2000. The national breast and cervical cancer early detection program; At-a-glance 2000. National Center for Chronic Disease Prevention and Health Promotion.

Centers for Disease Control. 1992a. CDC's progress in building a national program 1990-1999. The National Breast and Cervical Early Detection Program. National Center for Prevention and Health Promotion.

Centers for Disease Control. 1992b. Breast and cervical cancer surveillance, United States, 1973-1987, In CDC Surveillance Summaries (April). MMWR 41, (no. SS-2), 1-15.

Fletcher, S.W., R.P. Harris, J.J. Gonzalez, D. Degan, D. Lannin, V. Strecher, C. Pilgrim, D. Quade, J. Earp, and R. Clark. 1993. Increasing mammography utilization: a controlled study. Journal of National Cancer Institute, 85, 112-120.

Greenlee, R., M. Hill-Harmon, T. Murray, and M. Thon. 2001. Cancer statistics, 2001. CA: Cancer Journal for Clinicians, 51, 15-36.

Kanengiser, A. 2000, November 15. Mississippi ranked unhealthiest state in nation. The Clarion Ledger, pp. A1 A5.

Lannin, D., H. Mathew, J. Mitchell, S. Swanson, F. Swanson, and M. Edwards. 1998. Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. Journal of the American Medical Association, 279, 1801-1807.

Miller, B.B.A., L.N. Kolonel, L. Berstein, et al. 1995. Racial/ethnic patterns of cancer in the United States, 1988-92. Bethesda, MD: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute.

Mississippi State Department of Health. 1996. Cancer in Mississippi: An annual report 1996. Jackson, MS: Mississippi State Department of Health.

Pear, R. 2000. New breast and cervical cancer prevention and treatment act. The New York Times. (October 24, 2000).

Ries, L.A., C.L. Kosary, B.F. Hankey, B.A. Miller, L. Clegg, and B.K. Edwards (eds). 1999. SEER cancer statistics review, 1973-1996. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute.