By Linda Carroll

(Reuters Health) – Lack of insurance may be a major cause of delayed breast cancer detection in racial and ethnic minority women in the U.S., a new study suggests.

In an analysis of data from nearly 200,000 women, researchers found that racial and ethnic minority women are more often diagnosed at a later stage of the disease than white women, and that lack of insurance was a major contributing factor, according to the study published in JAMA Oncology.

“We’re seeing up to half of the disparity mediated by insurance,” said Dr. Naomi Ko, the study’s lead author. “That may not be surprising, but it’s nice to have the data and the evidence so we can have a thoughtful discussion,” said Ko, an assistant professor of medicine at the Boston University School of Medicine of the Boston Medical Center.

“People say they care about minority women dying from cancer,” Ko said. “We’re saying if you have insurance, you’re going to get your cancer caught at an earlier stage. This is something that really might help move the needle.”

Ko and her colleagues analyzed data collected from 2010 through 2016 by the National Cancer Institute. The researchers focused on women aged 40 to 64 diagnosed with a first, stage I to III primary invasive breast cancer.

Among the 177,075 women in the analysis, 148,124 had adequate health insurance coverage, while 28,951 either had no insurance at all or had some coverage through Medicaid, the government insurance program for the poor.

The majority of women, 113,079, were white, while 20,822 were black; 1,098, American Indian or Alaskan Native; 18,231, Asian or Pacific Islander; and 23,845, Hispanic.

When the researchers analyzed how advanced tumors were at diagnosis, they found a higher proportion of women who were uninsured or covered by Medicaid received a diagnosis of stage III breast cancer compared to those with health insurance (20% versus 11%).

Compared to non-Hispanic white women, non-Hispanic black women were 46% more likely to be diagnosed with more advanced cancer. Similarly, American Indian or Alaskan Natives were 31% more likely and Hispanic women were 35% were more likely to be diagnosed with an advanced cancer compared with white women.

When the researchers accounted for insurance status, those differences shrank. For example, black women, when insurance status was included in the analysis, went from being 46% more likely to be diagnosed with a late-stage cancer to 29% more likely.

The study team calculated that insurance status explained 45%-47% of the racial and ethnic disparities in stage at diagnosis.

While insurance status doesn’t explain all the disparities, “it’s huge,” Ko said. “It would make an enormous difference if all had insurance.”

Dr. Stephanie Bernik agreed that the solution would be more complex than just improving insurance coverage. Still, “better access to adequate screening and treatment needs to be addressed,” said Bernik, chief of breast surgery at Mount Sinai West in New York City.

“But we must continue to look for the cause for poorer prognosis in women of color diagnosed with breast cancer,” Bernik said in an email. “Genetics probably play a large role as well.”

It’s also important to reach out to minority communities to discover other factors that might make women reticent to come in to be screened, said Lajuana Fuller, director of women’s imaging at the UPMC Magee-Womens Hospital in Pittsburgh, and a member of the Disparity in Cancer Committee at UPMC.

“Education can play a big role,” Fuller said. “Sometimes women in the community are not as comfortable in a medical setting. They feel intimidated and don’t know what questions to ask.”

Part of the problem is fear, Fuller said. Women worry that the screening will be painful and they don’t understand why it has to be, she added.

That’s where community outreach can help, Fuller said. Healthcare providers can explain the process, including why there needs to be compression during a mammogram, she added.

SOURCE: JAMA Network Open, online January 9, 2020.