Letters

Corresponding Author: Matthew L. Maciejewski, PhD, Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 411 W Chapel Hill St, Durham, NC 27705 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Arterburn reported receiving grants from the Health Services Research and Development, Department of Veterans Affairs (IIR 10-159), the National Institutes of Health, the Patient-Centered Outcomes Research Institute, and the Informed Medical Decisions Foundation; and receiving payment for travel expenses from the Informed Medical Decisions Foundation. Dr Eid reported receiving personal fees from Apollo Endosurgery, Bariatric Fusion, Cooper Surgical, and Covidien. Dr Maciejewski reported receiving institutional grants from the Health Services Research and Development, Department of Veterans Affairs (IIR 10-159), the Agency for Healthcare Research and Quality, and the Robert Wood Johnson Foundation’s Health Care Financing and Organization Initiative; receiving an institutional contract from the Centers for Medicare & Medicaid Services; receiving consulting fees from Daichi Sankyo; and owning stock in Amgen.

social conditions in this study was income, which is a weak marker of social class.5 The key claim in this study, that intrinsic factors accounted for the observed patterns of breast cancer in black women, is unconvincing. By emphasizing intrinsic (genetic) differences in black women in their conclusion, the authors provided an explanatory model that fails to elucidate the recent and sharp increases in racial disparities and underestimates the role and complexity of the natural history of breast cancer. Lundy Braun, PhD Jennifer Tsai, BA Laura Ucik, BA

1. Ambwani S, Boeka AG, Brown JD, et al. Socially desirable responding by bariatric surgery candidates during psychological assessment. Surg Obes Relat Dis. 2013;9(2):300-305.

Author Affiliations: Department of Pathology and Laboratory Medicine, Brown University, Providence, Rhode Island (Braun); Warren Alpert Medical School of Brown University, Providence, Rhode Island (Tsai, Ucik).

2. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761.

Corresponding Author: Lundy Braun, PhD, Department of Pathology and Laboratory Medicine, Brown University, Box G, Providence, RI 02912 ([email protected]).

3. Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741-752. 4. Maciejewski ML, Livingston EH, Smith VA, et al. Survival among high-risk patients after bariatric surgery. JAMA. 2011;305(23):2419-2426.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

5. Courcoulas AP, Yanovski SZ, Bonds D, et al. Long-term outcomes of bariatric surgery: a National Institutes of Health symposium. JAMA Surg. 2014;149(12): 1323-1329.

1. Iqbal J, Ginsburg O, Rochon PA, Sun P, Narod SA. Differences in breast cancer stage at diagnosis and cancer-specific survival by race and ethnicity in the United States. JAMA. 2015;313(2):165-173.

Racial and Ethnic Differences in Breast Cancer Diagnosis and Survival To the Editor Dr Iqbal and colleagues1 reported that black women with breast cancer had worse outcomes compared with other groups. The authors concluded that “much of the difference could be statistically accounted for by intrinsic biological differences such as lymph node metastasis, distant metastasis, and triple-negative behavior of tumors.”1 We question the emphasis the authors placed on intrinsic factors to explain biological differences in black women with breast cancer for several reasons. First, while racial/ethnic categories are important for monitoring disease incidence and mortality, these categories are genetically heterogeneous, change over time, and vary throughout the world. The US Census categories used in this study have changed every 10 years since 1790.2 It is thus problematic to draw conclusions about inherent differences among groups using fluctuating sociopolitical categories. Second, racial disparities in breast cancer are a recent phenomenon, emerging in the late 1980s,3 and the extent to which these disparities are related to social, environmental, or genetic factors (or a combination) is a matter of intense scholarly debate.4 Underestimating the many other systematic factors known to affect breast cancer in black women, such as differential exposure to carcinogens, quality of mammograms, high-quality care, social conditions, and diet, does not reflect the current state of knowledge. However, the authors did point to potential environmental influences on breast cancer incidence among Japanese women. Third, there is limited discussion of how social class might influence breast cancer in black women. The only measure of jama.com

2. Nobles M. History counts: a comparative analysis of racial/color categorization in US and Brazilian censuses. Am J Public Health. 2000;90(11): 1738-1745. 3. Mandelblatt JS, Sheppard VB, Neugut AI. Black-white differences in breast cancer outcomes among older Medicare beneficiaries: does systemic treatment matter? JAMA. 2013;310(4):376-377. 4. Roberts D. Debating the cause of health disparities—implications for bioethics and racial equality. Camb Q Healthc Ethics. 2012;21(3):332-341. 5. Braveman PA, Cubbin C, Egerter S, et al. Socioeconomic status in health research: one size does not fit all. JAMA. 2005;294(22):2879-2888.

In Reply Dr Braun and colleagues raise several important points. In our study, we did not wish to imply that the natural history of breast cancer is simple or easily understood. Many studies remain to be done. We recognize the challenge in distinguishing the relative importance of intrinsic factors and social factors vis à vis their contribution to disparities in health care outcomes (in this case, mortality among women with early-stage breast cancer). We entered into this inquiry with no prior hypothesis, and we included whites, blacks, Asians, and Hispanics as comparison groups. The categorization of race/ethnicity was assigned within the Surveillance, Epidemiology, and End Results (SEER) registries, and decisions regarding this assignment were not under our control. It is striking that the group with the poorest outcome was black women, who were not preselected for study. We accept that social conditions, quality of care, diet, frequency and quality of mammograms might have contributed to the disparity, but unfortunately we were limited in analyses to those variables that are routinely collected by SEER. Even though we might not have included some important factors, we maintain that the study of racial/ethnic differences is worthwhile, despite changes in categorization over time. (Reprinted) JAMA April 14, 2015 Volume 313, Number 14

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Letters

Our conclusion that the disparity in outcome from stage I breast cancer can be explained in large part by intrinsic factors is based on the observation that the propensity of small cancers to spread to the lymph nodes and other organs differs between different racial/ethnic groups, including blacks, whites, and Asians. Javaid Iqbal, MD Paula Rochon, MD, MPH, FRCPC Ophira Ginsburg, MD, FRCPC Author Affiliations: Women’s College Research Institute, Toronto, Ontario, Canada. Corresponding Author: Javaid Iqbal, MD, Women’s College Research Institute, Women’s College Hospital, Familial Breast Cancer Research Unit, 790 Bay St, Toronto, ON M5G 1N8, Canada ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

CORRECTION Incorrect Data in Text and Table: In the JAMA Clinical Evidence Synopsis entitled “Antibiotics for Acute Bronchitis,” published in the December 24/31, 2014, issue of JAMA (2014;312[24]:2678-2679. doi:10.1001/jama.2014.12839), the adverse effects should be 24 for the number needed to treat in the Summary of Findings and in the Table. This article was corrected online.

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JAMA April 14, 2015 Volume 313, Number 14 (Reprinted)

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Racial and ethnic differences in breast cancer diagnosis and survival.

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