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Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study

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Abstract

Purpose

Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations.

Methods

This analysis included 2,058 women age 45–74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to “During the past ten years, who did you usually see when you were sick or needed advice about your health?”) were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified.

Results

Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8–13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2–6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76–3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15–4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina.

Conclusions

Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.

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Data availability

To preserve patient confidentiality, Carolina Breast Cancer Study data are not publicly available but may be accessed after submission of a letter of intent and approval from the CBCS steering committee.

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Acknowledgements

We thank CBCS participants for their generous participation, as well as study staff. This work and the CBCS was supported by a grant from UNC Lineberger Comprehensive Cancer Center (Chapel Hill, NC), which is funded by the University Cancer Research Fund of North Carolina; the Susan G. Komen Foundation (OGUNC1202 and TREND21686258 to M.A. Troester); and the NCI of the NIH (P01CA151135, to M.A. Troester), including the NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (P50CA058223, M.A. Troester). This work was also supported by the UNC Lineberger Cancer Outcomes Research Program (M.R. Dunn). This research recruited participants and/or obtained data with the assistance of Rapid Case Ascertainment, a collaboration between the North Carolina Central Cancer Registry and UNC Lineberger Comprehensive Cancer Center. Rapid Case Ascertainment is supported by a grant from the NCI of the NIH (grant no. P30CA016086). The Pathology Services Core is supported in part by NCI of the NIH Center Core Support Grant (P30CA016080) and the UNC-CH University Cancer Research Fund. The authors would like to acknowledge the UNC-CH BioSpecimen Processing Facility for sample processing, storage, and sample disbursements (http://bsp.web.unc.edu/).

Funding

This work and the CBCS was supported by a grant from UNC Lineberger Comprehensive Cancer Center (Chapel Hill, NC), which is funded by the University Cancer Research Fund of North Carolina; the Susan G. Komen Foundation (OGUNC1202 and TREND21686258 to M.A. Troester); and the NCI of the NIH (P01CA151135, to M.A. Troester), including the NCI Specialized Program of Research Excellence (SPORE) in Breast Cancer (P50CA058223, M.A. Troester). This work was also supported by the UNC Lineberger Cancer Outcomes Research Program (M.R. Dunn). This research recruited participants and/or obtained data with the assistance of Rapid Case Ascertainment, a collaboration between the North Carolina Central Cancer Registry and UNC Lineberger Comprehensive Cancer Center. Rapid Case Ascertainment is supported by a grant from the NCI of the NIH (grant no. P30CA016086). The Pathology Services Core is supported in part by NCI of the NIH Center Core Support Grant (P30CA016080) and the UNC-CH University Cancer Research Fund.

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Author notes

  1. Melissa A. Troester and Eboneé N. Butler are co-senior authors.

Authors and Affiliations

  1. Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599, USA

    Matthew R. Dunn, Eman M. Metwally, Caroline A. Thompson, Melissa A. Troester & Eboneé N. Butler

  2. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA

    Matthew R. Dunn, Eman M. Metwally, Sanah Vohra, Louise M. Henderson, Katherine Reeder-Hayes, Caroline A. Thompson, Jennifer Elston Lafata, Melissa A. Troester & Eboneé N. Butler

  3. Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA

    Terry Hyslop

  4. Division of Pulmonary Disease and Critical Care Medicine, Department of Radiology, University of North Carolina, Chapel Hill, NC, USA

    Louise M. Henderson

  5. Division of Oncology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA

    Katherine Reeder-Hayes

  6. Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA

    Jennifer Elston Lafata

  7. Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA

    Melissa A. Troester

  8. David Geffen School of Medicine, University of California, Los Angeles, USA

    Sanah Vohra

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Contributions

The study was conceived by MD, EM, MT, and EB. All authors contributed to study methodology. Data analysis and figure preparation were performed by MD. Analysis was supervised by MT and EB. The first draft of the manuscript was written by MD. All authors contributed revisions for subsequent drafts. Funding for the Carolina Breast Cancer Study was acquired by MT. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Matthew R. Dunn or Melissa A. Troester.

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The authors declare no competing interests.

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The authors have no relevant financial or non-financial interests to disclose.

Ethical approval

All study protocols were adherent to ethical standards of the institutional review board of the University of North Carolina at Chapel Hill, which approved the study.

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Informed consent was obtained from all individual participants included in the Carolina Breast Cancer Study.

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Dunn, M.R., Metwally, E.M., Vohra, S. et al. Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study. Cancer Causes Control 35, 825–837 (2024). https://doi.org/10.1007/s10552-023-01833-5

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  • DOI: https://doi.org/10.1007/s10552-023-01833-5

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