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Donald R. Lannin, MD; Holly F. Mathews, PhD; Jim Mitchell, PhD; Melvin S. Swanson, PhD; Frances H. Swanson, MS; Maxine S. Edwards, RN

JAMA. 1998;279:1801-1807.

Context.— Breast cancer mortality is higher among African American women than among white women in the United States, but the reasons for the racial difference are not known.

Objective.— To evaluate the influence of socioeconomic and cultural factors on the racial difference in breast cancer stage at diagnosis.

Design.— Case-control study of patients diagnosed as having breast cancer at the University Medical Center of Eastern Carolina from 1985 through 1992.

Setting.— The major health care facility for 2 rural counties in eastern North Carolina.

Subjects.— Five hundred forty of 743 patients with newly diagnosed breast cancer and 414 control women from the community matched by age, race, and area of residence.

Main Outcome Measures.— Breast cancer stage at diagnosis.

Results.— Of the 540 patients, 94 (17.4%) presented with TNM stage III or IV disease. The following demographic and socioeconomic factors were significant predictors of advanced stage: being African American (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.7); having low income (OR, 3.7; 95% CI, 2.1-6.5); never having been married (OR, 2.9; 95% CI, 1.4-5.9); having no private health insurance (OR, 2.5; 95% CI, 1.6-4.0); delaying seeing a physician because of money (OR, 1.6; 95% CI, 1.1-2.5); or lacking transportation (OR, 2.0; 95% CI, 1.2-3.6). Univariate analysis also revealed a large number of cultural beliefs to be significant predictors. Examples include the following beliefs: air causes a cancer to spread (OR, 2.8; 95% CI, 1.8-4.3); the devil can cause a person to get cancer (OR, 2.1; 95% CI, 1.2-3.5); women who have breast surgery are no longer attractive to men (OR, 1.9; 95% CI, 1.1-3.5); and chiropractic is an effective treatment for breast cancer (OR, 2.4; 95% CI, 1.4-4.4). When the demographic and socioeconomic variables were included in a multivariate logistic regression model, the OR for late stage among African Americans decreased to 1.8 (95% CI, 1.1-3.2) compared with 3.0 (95% CI, 1.9-4.7) for race alone. However, when the belief measures were included with the demographic and socioeconomic variables, the OR for late stage among African Americans decreased further to 1.2 (95% CI, 0.6-2.5).

Conclusions.— Socioeconomic factors alone were not sufficient to explain the dramatic effect of race on breast cancer stage; however, socioeconomic variables in conjunction with cultural beliefs and attitudes could largely account for the observed effect.

From the Departments of Surgery (Drs Lannin and Swanson and Mss Swanson and Edwards), Family Medicine (Dr Mitchell), Sociology (Dr Mitchell), and Anthropology (Dr Mathews), and the Leo W. Jenkins Cancer Center, East Carolina University, Greenville, NC.

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