Breast-Conserving Surgery Underused in Asian and Pacific Island Women

Behind the Cancer Headlines®

July 15, 2005

Asian American and Pacific Island women, particularly those born abroad, are less likely to receive breast-conserving surgery for early-stage breast cancer than non-Hispanic white women, according to a study published in the Journal of General Internal Medicine.

"Differences in use of breast-saving surgery among foreign-born Asian American and Pacific Island women and non-Hispanic white women have persisted, despite the fact that in 1990 the National Cancer Institute recommended breast-conserving surgery as first-line treatment for early-stage breast cancer," said Mita Sanghavi Goel, M.D., a researcher in general internal medicine at Northwestern University Feinberg School of Medicine, who led the study.

Breast cancer incidence and death appear to be rising among Asian American and Pacific Island women, the fastest growing minority group in the United States, underscoring the importance of studying patterns of breast cancer care in this population, Goel said.

Asian Americans and Pacific Islanders are disproportionately foreign-born compared to non-Hispanic white Americans. Moreover, foreign-born individuals are at risk for receiving poorer quality of care due to lower use of preventive services, lack of a regular source of health care, lower rates of insurance coverage and cultural factors such as low English proficiency and lack of acculturation, Goel said.

Previous studies have found that Asian Americans and Pacific Islanders who are foreign-born are less likely to receive cancer screening and hospice care than Asian Americans and Pacific Islanders who were born in the United States.

Goel and colleagues from Harvard Medical School and the University of California Irvine College of Medicine believe that foreign birthplace may explain previously described disparities in breast-conserving surgery use between white and Asian American and Pacific Island women as well as among various Asian American and Pacific Island ethnic groups.

Using data from the NCI's 1992 to 2000 Surveillance, Epidemiology and End Results (SEER) Program, Goel and co-researchers analyzed demographic and tumor characteristics of over 66,000 women who were diagnosed with early-stage, biopsy-proved breast cancer, 10,360 of whom were Asian American or Pacific Islander. Approximately 30 percent of the latter group were foreign-born; about 40 percent were U.S.-born; and 27 percent had an unknown birthplace.

Foreign-born Asian American and Pacific Islander women were more often diagnosed with stage II (later-stage) breast cancer, with lymph node involvement, larger tumors and poorly differentiated or undifferentiated tumors than either non-Hispanic white or U.S.-born Asian American and Pacific Island women.

Overall, foreign-born Asian American and Pacific Island women were significantly less likely to receive breast-conserving surgery than non-Hispanic white women (43 percent and 56 percent versus 59 percent, respectively).

For most demographic and tumor characteristics, Asian American and Pacific Island women, particularly those who were foreign-born, were less likely to receive breast-conserving surgery than non-Hispanic white women. Notably, foreign-born Asian American or Pacific Island women had substantially lower use of breast-conserving surgery even when diagnosed in the earliest stage or with tumors less than 1 centimeter in size.

The researchers also found that while use of breast-conserving surgery increased over time, foreign-born Asian American and Pacific Island women had breast-conserving surgery substantially less often than white and U.S.-born Asian American and Pacific Island women in any given year. Korean, Hawaiian, Indian and Pakistani women were less likely to receive breast-conserving surgery than white women.

"Clinical factors, such as a history of connective tissue disease or undesirable cosmetic result, alone are unlikely to explain the observed differences," Goel said.

In contrast, language barriers may contribute to observed differences in use of breast-saving surgery. Foreign-born Asian American and Pacific Islanders generally have lower English proficiency and thereby may have greater difficulty communicating with their physicians, possibly adversely affecting treatment outcomes.

Another explanation for the differences is that foreign-born Asian American women may be less likely to choose breast-conserving surgery. Despite conflicting evidence of the impact of mastectomy on the self-image of Asian American or Pacific Island women, some, especially immigrants, may prefer immediate treatment (mastectomy, which does not require additional radiation therapy).

Thus, the choice of mastectomy may be less disruptive to the care-taking roles many women hold in their families and may explain why Asian American and Pacific Island ethnic groups that are largely foreign-born, or generally less acculturated, may choose mastectomy.

Foreign-born individuals are less likely to have insurance; however, it was unclear whether insurance would account for the observed treatment disparities because the focused only on women receiving some form of cancer treatment. More research on the insurance issue is required, Goel said.

SOURCES:

Journal of General Internal Medicine, April, 2005

Northwestern University (http://www.northwestern.edu)