An ounce of prevention or a pound of cure? Investing to improve breast cancer outcomes for African American women.

Abstract

Recent improvements in breast cancer care have failed to improve outcomes equally for all cancer patients in the United States. Notably, African American women have a lower incidence of breast cancer than white women but are more likely to present with advanced disease and have greater breast cancer mortality than ageand stage-matched white women. These findings parallel disparities noted across the spectrum of medicine and reflect persistent unequal treatment. Although effective interventions to improve adherence to breast cancer screening recommendations have been developed and evaluated, less effort has been devoted to enhancing the care of African American women following the diagnosis of breast cancer. Given limited health care resources and available data showing that many African American women are not optimally treated, it is important to ask whether it is more efficient for society to fund interventions that improve outcomes in African American women with breast cancer or interventions aimed at further increasing the rate of breast cancer screening. In this context, we are intrigued by the findings reported by Mandelblatt et al in this issue of the Journal of Clinical Oncology suggesting that the most cost-effective method to improve breast cancer outcomes for African Americans is to use interventions which target women with a cancer diagnosis, rather than women who may potentially develop a cancer. Using simulation modeling, the authors compare the costs and benefits of increased biennial mammography screening to those associated with improved compliance with National Comprehensive Cancer Network and the St Gallen consensus recommendations for treatment. They found that at investments of up to $6,000 per breast cancer patient, the cost of an intervention designed to enhance treatment is less than $75,000/yr of life saved. In contrast, the cost-effectiveness of using reminder letters or outreach workers to improve rates of mammography among African American women is poor (cost exceeding $120,000/yr of life saved), unless these interventions are specifically targeted toward pockets of very underscreened or high-risk women. Patients with advanced stage breast cancer have the most to gain with treatment, and our treatments have improved significantly; as such, the relative lack of improvement in outcomes for African American women is disturbing. Mandelblatt et al’s simulation analysis suggests we redirect research and health care funding toward improving our understanding of why African American women with breast cancer receive less standard of care treatment than white women and then toward developing interventions that enhance care. Although it seems logical that modest investments could significantly improve outcomes, we suspect that the devil truly is in the details for eliminating disparities in cancer care within vulnerable populations. The question of what investment per patient is sufficient to eliminate disparities begs empirical testing. A theoretical model never adequately describes clinical practice, which continues to evolve and is dynamically shaped by diverse medical, logistic, and social forces. Mandelblatt et al assume their interventions will be effective and efficient and compare interventions between dissimilar groups. Substantial investments can still have only modest impacts on adherence. As we develop and test interventions designed to improve outcomes for African American women with breast cancer, evaluating the costs of these interventions, as well as their effectiveness, is essential to inform policy decisions. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 22 NUMBER 13 JULY 1 2004