BETA
This is a BETA experience. You may opt-out by clicking here

More From Forbes

Edit Story

Lack Of Insurance Plays A Key Role In Why Black Women Are More Likely To Die Of Breast Cancer

This article is more than 6 years old.

Before the early 1980s, women weren't screened for breast cancer, and treatments weren't very effective. White women diagnosed with the disease were just as likely to die as black women diagnosed with the disease.

Thanks to improvements in screening and treatment, the U.S. breast cancer death rate dropped 39% between 1989 to 2015, according to the American Cancer Society. But the gap in the breast cancer death rate for white and black women widened during that time, and in 2015, the most recent year for which data are available, it was 42% higher in black women.

What happened? A 2013 study attributed most of the excess breast cancer deaths in black women to more aggressive tumors and accompanying illnesses than in white women diagnosed with the disease.

But that didn't make sense to Dr. Ahmedin Jemal. There couldn't have been a change in the biology of the disease or the women it affects in only 35 years, a fraction of a blip in the grand scheme of evolution. In a study published Monday in the Journal of Clinical Oncology, Jemal and his coauthors concluded that insurance, or rather the lack of it, explains more than a third of the black-white gap in deaths from breast cancer.

Their findings, along with those of other recently published research, suggest that President Donald Trump's dismantling of the Affordable Care Act, a.k.a. Obamacare, would increase the disparity in breast cancer deaths between black women and white women by raising the number of uninsured Americans, Jemal, vice president of the Surveillance and Health Services Research Program at the cancer society, told me.

Watch on Forbes: 6 Tips For This Year's Health Insurance Open Enrollment

"We know that blacks are disproportionately present in low-income populations and are more likely to be uninsured," Jemal said. Dismantling the Affordable Care Act, he said, will "widen disparities in mortality, not only for breast but for other cancers and other causes of death."

Jemal and his coauthors analyzed data from the National Cancer Database, which is sponsored by the cancer society and the American College of Surgeons. The hospital-based registry captures about 70% of all U.S. cancer cases.

Besides skin cancers, breast cancer is the most commonly diagnosed malignancy among U.S. women, with about 253,000 new cases expected this year, according to the cancer society. About 41,000, women are expected to die from breast cancer this year, the cancer society says, making it the second leading cause of cancer death in women after lung cancer, which is expected to kill about 71,000 women in 2017.

Jemal and his coauthors identified approximately 560,000 black and white women 18 to 64 years of age who were diagnosed with stage I, II or III breast cancer from 2004 to 2013. They found that insurance status explained more than a third of the black-white gap in breast cancer deaths among the patients in their analyses. Tumor characteristics accounted for about 23% of the gap, while the presence of other illnesses accounted for 11%.

"Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer," the researchers concluded.

Insurance status didn't stand out as a major factor in the 2013 study because it focused on breast cancer patients 65 and older, Jemal said. Their age made them eligible for Medicare, so black women and white women had relatively uniform health-care coverage, he said. But breast cancer is most frequently diagnosed among women not yet eligible for Medicare, those ages 55 to 64, according to the National Cancer Institute; the average age at diagnosis is 62.

Screening mammography is a preventive benefit under the Affordable Care Act, so women whose insurance plans are governed by the law pay nothing out-of-pocket for it. And many states require Medicaid and public employee health plans to cover screening mammograms.

In their new study, Jemal and his coauthors analyzed data up to the point the Affordable Care Act allowed states to expand Medicaid eligibility to cover more low-income residents. As of Jan. 1, 2014, 24 states and the District of Columbia had opted to do so.

The researchers have collected data about women diagnosed with breast cancer in 2014, but they have to wait a little longer to accumulate and analyze death data for those women to see if Medicaid expansion--the future of which is uncertain under the Trump administration--has helped narrow the black-white death gap for the disease, Jemal said.

Two recent reports coauthored by Jemal suggest that is the case.

Using National Cancer Database data, the researchers looked at coverage changes among more than 1.7 million patients, ages 18 to 64, who were diagnosed with a first primary cancer (as opposed to a cancer that had spread from another part of the body) in 2011-2014.

They reported in September that the proportion of uninsured, low-income, newly diagnosed cancer patients dropped from 9.6% in 2011-2013 to 3.6% in 2014 in Medicaid expansion states. In states that did not expand Medicaid, the percentage of such patients who were uninsured declined only from 14.7% to 13.3%. The study also found a small but significant shift toward earlier diagnosis of a handful of different types of cancer, including breast cancer, in patients who lived in Medicaid expansion states.

"Coverage status at the time of diagnosis is an important determinant of the initial trajectory of cancer treatment," the report's authors wrote. "The small shift toward early-stage diagnosis for select common cancers, particularly in Medicaid expansion states, also corroborates the positive effects of ACA (Affordable Care Act) provisions on health outcomes."

And a study published early this month found wide variation across the states in the black-white gap in deaths from breast cancer, adding more evidence to the notion that factors besides biology play a role.

In 2011-2015, the breast cancer death rates in black women and white women were not statistically different in seven states. In four of those states, that finding could have reflected a lack of statistical power due to low numbers of deaths, Jemal and his coauthors wrote.

But in Massachusetts, Connecticut and, possibly Delaware, similar death rates among black and white breast cancer patients "likely reflect achievements in equitable access to health care in these states," the authors wrote.

All three of those states had expanded Medicaid in 2014 under the Affordable Care Act.