SAN DIEGO—Black women with cancer have generally worse outcomes than white cancer patients, and some cancer experts suspect underlying differ-ences in cancer susceptibility or progression. US military medical researchers suggest that, at least for cervical cancer, they are looking in the wrong place.
With equal access to medical care, cervical cancer outcomes are virtually the same in black and white patients, Major John H. Farley, MD, reported at the 31st Annual Meeting of the Society of Gynecologic Oncologists (SGO).
“This review shows that cervical cancer survival for blacks can approach that of their nonminority counterparts, 75%. We have shown, in a nonracial, equal-access-to-health-care environment, that race, in and of itself, is not an independent predictor of survival for cervical cancer patients. Physician-patient interaction and impediments to care, not race, should be considered when evaluating cervical cancer survival,” Dr. Farley, of the Tripler Army Medical Center, Tripler, Hawaii, told ONI in an interview.
The investigators analyzed data for patients with the diagnosis of invasive cervical cancer recorded in the Automated Central Tumor Registry for the US Military Health Care System from 1988 to 1998. The analysis included race, age at diagnosis, histology, grade, stage, treatment modality, and survival.
“The purpose of this study was to investigate whether race is an independent prognostic factor in the survival of cervical cancer in a health care system with minimal racial bias and modest impediments to access to care,” Dr. Farley said.
The study included 1,553 patients (see Table ). Mean age at diagnosis was 44 years for black women and 42 years for white women. The investigators reported that 72% of cases were stage I; 15% stage II; 11% stage III; and 2% stage IV. Histology distribution was 75% squamous, 12% adenocarcinoma, and 6% adenosqua-mous. Nine percent of patients had grade 1 tumors, 31% grade 2, and 25% grade 3.
The researchers found no significant difference in distribution of stage, grade, histology, or age between whites and nonwhites, and specifically between whites and blacks. Dr. Farley said that socioeconomic status (mean income) was greater for whites than for blacks (P = .006). There was no difference in the percentage of patients among each group who received surgery (46%) or radiation therapy (56%).
Five-year survival was 76% for blacks vs 75% for whites. Ten-year survival was 65% for blacks vs 64% for whites (P = .59). The investigators concluded that race per se has no significant impact on cervical cancer outcome.
“Our study clearly lends credence to the possibility that racially related impediments to care may be the real variables that adversely affect cervical cancer survival in minority patients,” Dr. Farley said.
Physician bias to care based on ethnicity would be expected to be less in the military, he said, given the military’s diverse population and long history of integration. Equally important, he said, is the “unique, nonmonetary, equal-access-to-care environment of the military health care system. This distinctive system provides direct access not only to primary care physicians but also to subspecialists, including gynecologic oncologists.”
Finally, he said, the long history, since the 1970s, of military participation in NIH/NCI-sponsored studies has not only allowed women in the military access to state-of-the-art care but also provided an additional level of standardization and regulation in the treatment of women with gynecologic malignancies.
“These factors must undoubtedly play a role in the equivalent survival found in our population,” Dr. Farley said.
He emphasized that the report is the first demonstration that survival for cervical cancer among black women can be comparable to that of their white counterparts. “This difference in survival of 16% to 18% is of paramount importance not only for black women but also for their health care providers. A comparable survival rate for blacks would mean that every day, one black woman diagnosed with cervical cancer would have a chance at life rather than succumbing to her disease,” Dr. Farley said.
He noted that the data do not affect the basic understanding of the mechanisms of cervical cancer. “It is basically a sexually transmitted disease,” he said. “What should change is our understanding of the treatment of this disease among the minority population once it is diagnosed.”
Racial bias and impediments to standard care can have a pronounced effect on survival, Dr. Farley said. When these barriers are removed, survival can be and is equal. “The decreased survival of minorities in the community is not an absolute fact that cannot be influenced by screening and treatment,” he con-cluded.
