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RESEARCH AND PRACTICE |
Department of Health and Social Behavior and the Harvard Center for Society and Health, Harvard School of Public Health, Boston, Mass.
Correspondence: Requests for reprints should be sent to Nancy Krieger, PhD, Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115
(e-mail:nkrieger{at}hsph.harvard.edu).
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INTRODUCTION |
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 TOP INTRODUCTION References |
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Notably, no routinely available data exist on US population rates of breast cancer incidence (or rates for any other cancer site) stratified by socioeconomic position.4–6 One consequence is that, during the past 50 years, only 10 US population-based studies have quantified socioeconomic gradients in breast cancer incidence rates.7–16
Partly on the basis of results of US7–16 and European17–25 incidence studies and additional case–control investigations, breast cancer typically has been portrayed as a "disease of affluence."19,26,27 For example, supporting the view that population distributions of breast cancer are linked to level of economic development, breast cancer incidence is currently estimated to be 2.7 times higher in more industrialized than in less industrialized countries (63 vs 23 per 100 000, age standardized to the 2000 world standard population; Table 1
).1 A closer look at the evidence, however, reveals a more complex picture: although breast cancer historically has been more common in industrialized, affluent countries and among more affluent women in any given country (i.e., a positive socioeconomic gradient), incidence rates in poorer countries and among poorer women in more affluent countries are "catching up."1,6,12,14–16,22,24
Within the United States, mortality data from the past 2 decades likewise reveal a declining positive class gradient in breast cancer mortality, probably reflecting changing class patterns in terms of both incidence and survival.28,29 A consistent finding is that once women are diagnosed with breast cancer, survival rates are much lower among those from poorer countries and, within any given country, among those who are poor or who face discrimination or both.28–30
The case of African American women is illustrative. Data from the US Surveillance, Epidemiology, and End Results (SEER) cancer registry show that, during 1996 to 1998, the lifetime risk of breast cancer for Black women (10.1%) was 73% that of White women (13.8%), but their lifetime risk of dying of the disease was 7% higher (3.4% vs 3.2%).3 Moreover, among women aged 20 years, Black women were at higher risk than White women of developing breast cancer over the subsequent 20 years,3 thereby creating more of a burden at younger ages.
Related data indicate that breast cancer is typically diagnosed at a younger age among Black and Hispanic women than among White women; likewise, it is typically diagnosed at a younger age in low-incidence than high-incidence countries.31,32 In addition, in terms of survival within each stage of cancer (localized, regional, or distant), data indicate that between 1992 and 1997, Black women were 17% less likely than White women to survive 5 years past diagnosis and 1.8 times more likely to be diagnosed at the most advanced stage (distant).3
Analogous population-based SEER data on US breast cancer incidence and survival rates stratified by socioeconomic position are not available,4,5 limiting population-based analyses of the extent to which observed Black–White disparities reflect inequalities in socioeconomic position. In the period from 1997 to 1999, the median household income among White Americans was $41 591, as compared with $26 608 among Black Americans,33 while 1999 poverty rates were 9.8% and 23.6% for White and Black Americans, respectively.34
In summary, in the case of women residing in the United States, White women are more likely than Black women to be diagnosed with breast cancer, but Black women are more likely to die of the disease. Of note, this excess breast cancer risk in White women has been declining over time, and rates among Black women have been "catching up." For example, the breast cancer incidence rate among Black women was 80% of that among White women in 1973 (68.9 and 94.6 per 100 000, respectively, age standardized to the 1970 US standard million) but had climbed to 88% as of the period 1994 to 1998 (Table 1).3
Moreover, Black mortality rates worsened during the same time period: Black and White women had almost identical breast cancer mortality rates in 1973 (26.3 and 27.1 per 100 000, respectively, age standardized to the 1970 US standard million), but during 1994 to 1998 rates were 30% higher among Black women (Table 1).3 Combine relatively high incidence and relatively high mortality, and the net result is that US Black women have among the highest breast cancer mortality rates in the world.
In conclusion, the conventional view that breast cancer is a "disease of affluence" is increasingly at odds with the empirical evidence and lived experiences of poorer women and women of color diagnosed with breast cancer.6,31,35 Misperceptions of the population burdens imposed by breast cancer can hinder efforts to understand, prevent, treat, and control this disease.6,35,36 It is time to move to a more accurate and complex assessment of social disparities in risks of being diagnosed with and dying from breast cancer.
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Footnotes |
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Accepted for publication November 12, 2001.
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References |
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TOPINTRODUCTIONReferences |
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2. American Cancer Society. Statistics: 2001. Available at: http://www.cancer.org. Accessed July 19, 2001.
3. National Cancer Institute. SEER cancer statistics review, 1973–1998. Available at: http://www.seer.cancer.gov/Publications/CSR1973–1998/. Accessed July 19, 2001.
4. Krieger N, Chen JT, Ebel G. Can we monitor socioeconomic inequalities in health? A survey of US health departments' data collection and reporting practices. Public Health Rep.1997;112:481–491.[Medline]
5. Krieger N. Socioeconomic data in cancer registries [letter]. Am J Public Health.2001;91:156–157.[Medline]
6. Kogevinas M, Pearce N, Susser M, Bofetta P, eds. Social Inequalities in Cancer. Lyon, France: International Agency for Research on Cancer; 1997. IARC scientific publication 138.
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Heck KE, Pamuk ER. Explaining the relation between education and postmenopausal breast cancer. Am J Epidemiol.1997;145:366–372.
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Bacquet CR, Horm JW, Gibbs T, Greenwald P. Socioeconomic factors and cancer incidence among blacks and whites. J Natl Cancer Inst.1991;83:551–557.
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Krieger N. Social class and the black/white crossover in age-specific incidence of breast cancer: a study linking census-derived data to population-based registry records. Am J Epidemiol.1990;131:804–814.
16. Krieger N, Quesenberry C Jr, Peng T, et al. Social class, race/ethnicity, and incidence of breast, cervix, colon, lung, and prostate cancer among Asian, black, Hispanic, and white residents of the San Francisco Bay Area, 1988–1992 (USA). Cancer Causes Control.1999;10:525–537.[Medline]
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20. Lynge E, Thygesen L. Occupational cancer in Denmark: cancer incidence in the 1970 census population. Scand J Work Environ Health.1990;16(suppl 2):3–35.
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Rix BA, Skov T, Lynge E. Socioeconomic group, occupation, and incidence of breast cancer and genital cancer among women in Denmark. Eur J Public Health.1997;7:177–181.
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23. Leon DA. Social Distribution of Cancer, 1971–1975. London, England: Her Majesty's Stationery Office; 1980. OCSP Series LS 3.
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Van Loon AJM, Goldbohm RA, Van den Brandt PA. Socioeconomic status and breast cancer incidence: a prospective cohort study. Int J Epidemiol.1994;23:899–905.
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McPherson K, Steel CM, Dixon JM. Breast cancer—epidemiology, risk factors, and genetics. BMJ.2000;321:624–628.
28.
Heck KE, Wagener DK, Schatzkin A, Devesa SS, Breen N. Socioeconomic status and breast cancer mortality, 1989 through 1993: an analysis of education data from death certificates. Am J Public Health.1997;87:1218–1222.
29.
Wagener DK, Schatzkin A. Temporal trends in the socioeconomic gradient for breast cancer mortality among US women. Am J Public Health.1994;84:1003–1006.
30. Kogevinas M, Porta M. Socioeconomic differences in cancer survival: a review of the evidence. In: Kogevinas M, Pearce N, Susser M, Boffetta P, eds. Social Inequalities and Cancer. Lyon, France: International Agency for Research on Cancer; 1997:177–206. IARC scientific publication 138.
31. Rose DP, Royak-Schaler R. Tumor biology and prognosis in black breast cancer patients: a review. Cancer Detect Prev.2001;25:16–31.[Medline]
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33. US Bureau of the Census. Income 1999. Available at: http://www.census.gov/hhes/income/income99/99tableb.html. Accessed July 19, 2001.
34. US Bureau of the Census. Poverty 1999—poverty estimates by selected characteristics. Available at: http://www.census.gov/hhes/poverty/poverty99/pv99est1.html. Accessed July 19, 2001.
35. Anglin MK. Working from the inside out: implications of breast cancer activism for biomedical policies and practices. Soc Sci Med.1997;44:1403–1415.
36. Krieger N. Exposure, susceptibility, and breast cancer risk: a hypothesis regarding exogenous carcinogens, breast tissue development, and social gradients, including black/white differences, in breast cancer incidence. Breast Cancer Res Treat.1989;13:205–223.[Medline]
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