a doctor in a darkened room examines xrays of breast tissue to look for cancer.
Photo credit: U.S. Air Force photo/Airman 1st Class Andrew Lee

By Rose Hoban

Amid growing evidence that patients are under increased financial stress, new research from UNC Chapel Hill finds that black women with breast cancer end up under worse financial strain during treatment than whites.

Stephanie Wheeler, an associate professor at the Gillings School of Global Public Health, examined data collected as part of the long-running Carolina Breast Cancer Study and found that African-American women, in addition to being more likely to die from breast cancer, are more likely suffer financial harm as a result of treatment.

This financial toxicity could play a role in these women’s survival and their quality of life.

two images of breast tissue taken via mammogram
Two images of breast tissue obtained by two different imaging processes: using an xray in the left and after enhanced processing on the right. Photo credit: NASA Goddard Space Flight Center

Wheeler looked at data from the Carolina Breast Cancer Study, started in 1993, which initially looked at tumor tissue samples and other biological factors in breast cancer.

She explained that early research produced as part of that study consistently found that black women got sicker and died more often than their white counterparts, even when women of both races had the same type of cancer, with the same tumor characteristics.

“The investigators said that clearly there is something going on here other than biology, access factors, treatment factors, that must be influencing mortality,” Wheeler said. “It just didn’t make sense that black women would be dying more than white women given that historically they were at lower risk [for breast cancer] than white women.”

So, in a subsequent phase of research, the scientists leading the CBCS recruited about 1,500 black women and 1,500 white women from all over North Carolina. In addition to biobanking blood and tissue samples, they asked questions about the women’s access to care, the treatments they received, their quality of life, and the financial impact of all their treatment.

Unstable safety net

Earlier research had shown that black women are more likely to be diagnosed with breast cancer later, experience delays in getting started with treatment. They also are more likely not to be treated according to guidelines and frequently don’t complete therapy.

Wheeler and her colleagues wondered if some of those phenomena could be explained by finances, so they looked at five indicators of what they called “negative financial impact” that were a result of treatment:

  •    decreased income
  •    financial barriers to care
  •    transportation barriers
  •    losing a job as a result of the cancer diagnosis and treatment
  •    losing insurance as a result of losing a job after the cancer diagnosis

“What this doesn’t measure are things like the stress from financial impact or the actual dollar amount that women were being asked to pay for copayments, things like that,” Wheeler said.

The differences were striking.

“Overall 59 percent of black women reported any financial impact, compared to 40 percent of white women. So, right off the bat, this is a very high level of financial burden, as measured across all five of these indicators,” she said.

And when considering individual barriers to treatment, black women had a harder time.

Financial Impact of Breast Cancer in Black Versus White Women
The data showed that black women took more hits to their financial lives than comparable white women. The asterisks indicate that each of these findings were not the result of chance, but were “statistically significant.”

“One in four black women expressed that they had a cost related to care that forced them to forego, delay or skip or discontinue their medical care compared to 11 percent of white women,” Wheeler said.

“Across most of these indicators, black women were two to four times more likely to report every single one of these,” she said.

She posited that the different employment opportunities for black women could play a part in how financially toxic getting sick can be. [sponsor]

“What it suggests is that black women are in positions that less often have paid leave and less often have employment protection in the case of a medical shock,” Wheeler said. “So the fact that they’re losing more income, losing their jobs, losing private insurance, could be an indicator of the kind of employment and protections that these women have.”

Underlying disease plays a part

Wheeler said she spent time interrogating her data, trying to find other ways to explain the disparities in financial outcomes. One way she did that was to look at the tumors black women often have, so-called triple negative cancers, which can be more aggressive.

“The underlying biology is going to determine their treatment,” she said. “Black women are more often diagnosed with more advanced stages of disease so they’re more often getting aggressive treatment,” such as chemotherapy and radiation, on top of surgery.

That could add more cost.

She also noted that black women diagnosed with cancer often arrive with other problems, too, such as diabetes, high blood pressure and obesity, all of which occur at higher rates in the African American population. Those could also complicate treatment.

But Wheeler said that those clinical differences only explained part of the variation in financial impact.

“This is maybe the first evidence that definitely shows that black women are experiencing greater financial burden from their breast cancer in the context of the larger literature that shows that cancer cost is increasing,” she said. “At a policy level, we have to be attentive to the fact that there are subgroups within the general population who are just at much higher risk for these particularly bad outcomes.”

She added that there are many programs and not-for-profit organizations that help women with breast cancer manage everything from rent and hotel costs to the cost of medications.

“What we’re thinking about in the next stage of our research is looking at financial navigation, trying to help people get through this incredibly complex and stressful experience and providing some guidance and… some tailored resources to help people make sense of the financial complexity of care,” she said.

The original research paper is published in the Journal of Clinical Oncology’s April edition, which had several articles about the cost of breast cancer care and how those costs affect treatment.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...