Differences in Breast Cancer Stage at Diagnosis and Cancer-Specific Survival by Race and Ethnicity in the United States

Abstract

IMPORTANCE: Women with early-stage breast cancers are expected to have excellent survival rates. It is important to identify factors that predict diagnosis of early-stage breast cancers. OBJECTIVE: To determine the proportion of breast cancers that were identified at an early stage (stage I) in different racial/ethnic groups and whether ethnic differences may be better explained by early detection or by intrinsic biological differences in tumor aggressiveness. DESIGN, SETTING, AND PARTICIPANTS: Observational study of women diagnosed with invasive breast cancer from 2004 to 2011 who were identified in the Surveillance, Epidemiology, and End Results (SEER) 18 registries database (N = 452,215). For each of 8 racial/ethnic groups, biological aggressiveness (triple-negative cancers, lymph node metastases, and distant metastases) of small-sized tumors of 2.0 cm or less was estimated. The odds ratio (OR) for being diagnosed at stage I compared with a later stage and the hazard ratio (HR) for death from stage I breast cancer by racial/ethnic group were determined. The date of final follow-up was December 31, 2011. MAIN OUTCOMES AND MEASURES: Breast cancer stage at diagnosis and 7-year breast cancer-specific survival, adjusted for age at diagnosis, income, and estrogen receptor status. RESULTS: Of 373,563 women with invasive breast cancer, 268,675 (71.9%) were non-Hispanic white; 34,928 (9.4%), Hispanic white; 38,751 (10.4%), black; 25,211 (6.7%), Asian; and 5998 (1.6%), other ethnicities. Mean follow-up time was 40.6 months (median, 38 months). Compared with non-Hispanic white women diagnosed with stage I breast cancer (50.8%), Japanese women (56.1%) were more likely to be diagnosed (OR, 1.23 [95% CI, 1.15-1.31], P < .001) and black women (37.0%) were less likely to be diagnosed (OR, 0.65 [95% CI, 0.64-0.67], P < .001). Actuarial risk of death from stage I breast cancer at 7 years was higher among black women (6.2%) than non-Hispanic white women (3.0%) (HR, 1.57 [95% CI, 1.40-1.75]; P < .001), and lower among South Asian women (1.7%) (HR, 0.48 [95% CI, 0.20-1.15]; P = .10). Black women were more likely to die of breast cancer with small-sized tumors (9.0%) than non-Hispanic white women (4.6%) (HR, 1.96 [95% CI, 1.82-2.12]; P < .001); the difference remained after adjustment for income and estrogen receptor status (HR, 1.56 [95% CI, 1.45-1.69]; P < .001). CONCLUSIONS AND RELEVANCE: Among US women diagnosed with invasive breast cancer, the likelihood of diagnosis at an early stage, and survival after stage I diagnosis, varied by race and ethnicity. Much of the difference could be statistically accounted for by intrinsic biological differences such as lymph node metastasis, distant metastasis, and triple-negative behavior of tumors.