Having breast cancer places a significantly greater financial strain on black women than on white women, according to a study led by Dr. Stephanie Wheeler, associate professor of health policy and management at the UNC Gillings School of Global Public Health.
[Photo: Dr. Stephanie Wheeler]
Dr. Wheeler and colleagues, whose findings were published online April 18 in the Journal of Clinical Oncology, surveyed women who were diagnosed with breast cancer in North Carolina between 2008 and 2013. They found that two years after a diagnosis with breast cancer, 58 percent of black women reported a negative financial impact of cancer, compared with 39 percent of white women.
“Financial hardship plays a role in delays, discontinuation and omission of treatment, and thus may correlate with racial disparities in breast cancer death,” said Dr. Wheeler, who also is a member of the UNC Lineberger Comprehensive Cancer Center. “With cancer care costs rapidly increasing, culturally appropriate strategies are urgently needed to address this problem.”
The researchers analyzed survey data from the Carolina Breast Cancer Study, the largest population-based study of breast cancer in North Carolina. Launched in 1993, the Carolina Breast Cancer Study aims to improve the understanding of breast cancer, and particularly, why the fatality rate for the disease is higher in African-American women. Now in its third phase, the study is focused on how treatment decisions, access to care and financial or geographic barriers impact breast cancer outcomes.
Dr. Wheeler’s new study included 1,265 white women and 1,229 black women. On average, black women in the analysis were slightly younger, and they presented with higher-stage disease at the time of diagnosis. They more often received chemotherapy and radiation therapy and were more likely to present with comorbid conditions such as obesity, hypertension and diabetes. They were also more socio-economically disadvantaged, had lower average household incomes, less education, and were more likely to be on Medicaid or have no insurance.
Nearly half of the women – 48 percent – experienced negative financial impact from breast cancer, but the researchers said it was strikingly higher among black women. Even after they controlled for differences in clinical variables such as age, stage at diagnosis, comorbidities and cancer treatments received, they found that black women were significantly more likely to experience higher cancer-related financial burden.
Black women more often reported having a barrier to care that caused them to delay or refuse recommended treatment because of cost (24 percent of black women compared to 11 percent of white women). Black women also had a greater likelihood of losing a job (14 percent compared to 6 percent of white women). While it was a small share overall, black women more often lost private health insurance (5 percent versus 1 percent of white women).
Dr. Wheeler said that although the study did not evaluate why the women may have lost private health insurance, it could have occurred as a result of a job loss or because of reduced hours at work that would put them below the threshold of qualifying for employer-sponsored health insurance.
“Employer-sponsored health insurance and paid sick leave are often reserved for employees with higher earnings, full-time status, and more generous benefits, which may correlate also with race,” she said.
Dr. Wheeler said work is ongoing to understand how patients communicate about cancer costs, and seek financial support, as well as to explore efforts to better connect patients with resources, and to try to reduce the financial burden of care.
“Wealth in our society is a complex construct, including not only how much money a person earns, but also the generosity of their health insurance benefits, the savings and assets they can pull from in a time of crisis, and the flexibility of their commitments at work and at home,” said senior author Dr. Katherine Reeder-Hayes, assistant professor in the UNC School of Medicine Division of Hematology/Oncology and UNC Lineberger member. “We need to do more work to understand why black women, even at similar income and education levels, seem to be more vulnerable to financial toxicity of breast cancer.”
Other study authors are Ms. Jennifer C. Spencer, doctoral student, and Ms. Laura Pinheiro, research collaborator, both in health policy and management at the Gillings School; Dr. Andrew Olshan, Barbara Sorenson Hulka Distinguished Professor in Cancer Epidemiology and former chair of the Gillings School’s epidemiology department; and Dr. Lisa A. Carey, the Richardson and Marilyn Jacobs Preyer Distinguished Professor in Breast Cancer Research and chief of the Division of Hematology and Oncology in the UNC School of Medicine.
The study was supported by an American Cancer Society Mentored Research Scholar grant, the University Cancer Research Fund, the National Cancer Institute Specialized Program of Research Excellence in Breast Cancer grant, the National Cancer Institute, and Susan G. Komen.