Breast cancer incidence and mortality decreased over the period 1995–2006 among all women in Wisconsin, similar to declines observed nationally. In Wisconsin, incidence was consistently higher among white women than among African American women, while the opposite was observed for mortality. This pattern was similar to national trends. Wisconsin also paralleled national stage distribution data, revealing that a higher percentage of BC was detected at a later stage for African Americans than for whites. The relative disparity in cancer incidence and mortality between African Americans and whites in Wisconsin and nationally persisted over the period. Other Wisconsin reports have found that African Americans have a lower risk of receiving a diagnosis of BC but higher risk of dying from it.2,11–13
These reports aggregated data over several years, but did not present trends. The comprehensive analysis by Foote12
from 2003 is the only Wisconsin report to measure relative disparities, but the author did not report change over time. By measuring trends in rate ratios, the present study provides evidence that while BC incidence and mortality have declined in general, Wisconsin has not made sufficient progress reducing BC mortality to eliminate racial disparities in survival.
A number of limitations should be considered when interpreting the results of this study. First, the scope is limited to differences in BC incidence and mortality rates between African Americans and whites. The decision to focus on these 2 groups was determined by the demographic composition of Wisconsin and the rarity of cancer events. Wisconsin has relatively small non-white populations, making the comparisons in this report difficult to replicate between other racial or ethnic groups in the state. Second, WCRS, as a central state cancer registry participating in the National Program of Cancer Registries, maintains a passive system of data collection, and therefore, the various reporting facilities are largely responsible for the quality and timeliness of the data submissions to WCRS. The reliability of WCRS data has been detailed in previous reports.2,12
In short, reporting variability may impact the relatively small numbers used in this analysis. In addition, there was an unknown degree of misclassification or under-reporting of race.
Nevertheless, our results demonstrate that the “unacceptable reality”19
of BC disparity persists not only nationally, but within Wisconsin. The higher mortality rates observed in Wisconsin and nationally can be partially explained by the more advanced-stage distribution at diagnosis observed among African American women.14
Others have attributed the disparity to evidence that African American women are at greater risk for early onset of breast cancer and are often diagnosed with biologically more aggressive forms of disease.16,17
Social, economic, and cultural factors may impact African American women disproportionately and may mediate the biological expression of disease.17, 20–21
As many of these factors—such as poverty, inadequate health insurance, poor access to prevention, screening, treatment, fear of testing, and provider bias—are potentially modifiable, future efforts to reduce BC disparities should address them.
Many organizations in Wisconsin have focused on reducing disparities in breast cancer survival. The Wisconsin Well Woman Program, funded by the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program, provides breast and cervical cancer screening each year to approximately 10,000 low income, uninsured, and underinsured women, of whom approximately 10% are African American (compared to 6% of the general population). Various organizations, such as Susan G. Komen for the Cure, the American Cancer Society, the Wisconsin Women’s Health Foundation, and the Kohl’s Corporation, support programs that provide BC outreach and education, and facilitate access to BC clinical and treatment services for African American and other underserved populations. The state’s Minority Health Program by the Wisconsin Cancer Council and the Wisconsin Breast Cancer Coalition, among others, succeeded in passing the Breast and Cervical Cancer Prevention and Treatment Act in 2000 and further ensured that the state of Wisconsin exercised its option to provide medical assistance through Medicaid to eligible women who are screened through the Well Woman program and who require treatment for breast or cervical cancer. More recent advocacy activity resulted in legislation that established an income tax check off box, creating the Wisconsin Breast Cancer Research Fund.
The Wisconsin Comprehensive Cancer Control Program, in collaboration with the Milwaukee Regional Cancer Care Network and the Center for Urban Population Health, created a publication titled “Expanding Pathways to Care: Assessment of Cancer Care Capacity for Milwaukee and Waukesha Counties.”
This publication is a reference with online access for providers to review recommendations for implementing Wisconsin’s Comprehensive Cancer Control Plan and Healthiest Wisconsin 2010. This resource is important because a large portion of Wisconsin’s African American population lives in Milwaukee County.16
Finally, implementation of the 2010 Patient Protection and Affordable Care Act will expand access to BC prevention and screening services, particularly among Medicaid recipients.
However, these efforts also fail to address important new revelations about BC in African Americans. Recently presented data suggest that even when all suspected sources of disparity are controlled for (including socioeconomic status, stage, and hormone and human epidermal growth factor [HER2] receptor status), disparities in recurrence and survival still persist between African Americans and whites.22,23
This suggests an underlying and probably biologic difference. This can be further elucidated only by evaluating these differences in a controlled clinical trial setting. However, a review of 197 trials found only 17% reported accrual by race and only 2% analyzed by race.22
Inclusion of diverse groups, including African Americans, in clinical trials will be crucial to interpret and extrapolate results to a diverse population. Increasing accrual of minority populations and improving reporting should be a priority in Wisconsin to reduce health disparities and achieve cancer control.