Differences Between Black and White Women With Breast Cancer in Time From Symptom Recognition to Medical Consultation Ralph J. Coates,* Diana D. Bransfield, Margaret Wesley, Benjamin Hankey, J. William Eley, Raymond S. Greenberg, Dana Flanders, Carrie P. Hunter, Brenda K. Edwards, Michele Forman, Vivien W. Chen, Peggy Reynolds, Peggy Boyd, Don Austin, Hyman Muss, Robert S. Blacklow, Black/White Cancer Survival Study Group

938

In the United States, White women have a lower fatality rate than Black women following a diagnosis of breast cancer (i-5). From 1981 through 1986, the 5-year relative survival rate was 64% among Black women and 78% among White women (6). Black women are much more likely than White women to be diagnosed with later stage disease (5), but racial differences in survival remain even after controlling for stage of disease at diagnosis {5,7,8). The reasons for racial differences in survival are not well understood. Some researchers have found that adjustment for socioeconomic status eliminates survival differences (4,9), while others have found that differences remain (3,7). Some tumor characteristics associated with poor prognosis are more prevalent among Black patients; these characteristics include less differentiated tumors (2,10), more severe clinical symptoms (2,10), estrogen receptor-negative tumors (10,11), and

Received May 17. 1991; revised March 24, 1992, accepted March 24, 1992. Supported in part by Public Health Service contracts N01CN-45I74, NOICN-05227. N0ICNM5I75, and NOICN-45176 from the Division of Cancer Prevention and Control. National Cancer Institute, National Institutes of Health. Department of Health and Human Services. R. J. Coates, J. W. Eley, R. S. Greenberg, D. Flanders, Epidemiology Division. Emory University School of Public Health, Atlanta, Ga. D. D. Bransfield. VA Medical Center and Vanderbilt University, Nashville. Tenn. M Wesley, Information Management Services. Inc.. Silver Spring, Md B. Hankey, C. P. Hunter, B. K. Edwards, M. Forman. Division of Cancer Prevention and Control. National Cancer Institute. Bethesda, Md. V. W. Chen, Department of Pathology. Louisiana Stale University Medical School, New Orleans. P. Reynolds. P. Boyd. D. Austin, California Department of Health, Emeryville. H. Muss, Section of Hematology and Oncology. Bowman Gray School of Medicine. Winston-Salem. N.C. R S. Blacklow, Department of Medicine. Jefferson Medical College. Philadelphia. Pa. Black/White Cancer Survival Study Group, c/o Surveillance Program, Division of Cancer Prevention and Control, National Cancer Institute, Bethesda. Md. 'Correspondence to: Ralph J. Coates. Ph.D.. Epidemiology Division. School of Public Health, Emory University, 1599 Clifton Rd.. N.E., Atlanta. GA 30329.

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Background: Studies in the United States have reported that Black women have higher fatality rates than White women following a diagnosis of breast cancer and are more likely to be diagnosed with late-stage cancers. Purpose: To evaluate reasons for these racial differences, we explored the difference between Black and White women in the length of time from symptom recognition to initial medical consultation. We also evaluated the extent to which other factors related to the length of this interval might contribute to any observed racial difference. Methods: As part of a collaborative study of differences in the survival rates of Black patients and White patients with cancer, we interviewed a sample of 410 Black women and 325 White women from Atlanta, New Orleans, and San Francisco/ Oakland who were newly diagnosed in 1985 or 1986 with invasive breast cancer. Retrospective data were collected on symptoms, dates of symptom recognition and initial medical consultation, and several other factors which may affect the interval between symptom recognition and medical consultation. Data were analyzed as if from a follow-up study, using product limit procedures and proportional hazards regression. Results: At diagnosis, Black women with breast cancer were two times more likely to have stage IV breast cancer and one and one-half times more likely to have stage III breast cancer than White women with breast cancer and were only approximately one-half as likely to have stage I breast cancer. Similarly, Black women were almost twice as likely as White women to have tumors that were larger than 5 cm or tumors that had extensions to the chest wall or skin at presentation. However, the average rate at which Black women with breast cancer obtained an initial medical consultation lagged behind that for White women by only a slight but statistically significant difference (15%). The median time between symptom recognition and medical consultation was slightly longer for Black women (16 days) than for White women (14 days) (P = .06). Adjustment for other characteristics predictive of the length of this interval had little effect on racial differences. The racial differences tended to vary somewhat by age and metropolitan area, suggesting that the results may not apply equally to all demographic subgroups and regions in the United States. Conclusion: This small difference in the time from symp-

tom recognition to medical consultation is unlikely to account for the large racial differences in survival rates and in stage of disease at the time of diagnosis. [J Natl Cancer Inst 84:938-950, 1992]

Subjects and Methods Study Population Black and White women aged 20-79 years who were residents of the metropolitan areas of Atlanta, New Orleans, or San Francisco/Oakland were eligible if they had newly diagnosed invasive breast cancers of any histologic type, excluding lymphomas, diagnosed between January 1, 1985, and December 31, 1986, and had no history of cancer, except nonmelanoma skin cancer. To ensure that patients would be interviewed soon after diagnosis, we rapidly identified respondents through review of hospital pathology and other medical records. Approximately 70% of eligible Black patients were randomly selected for inclusion. To ensure that ages, residence

Vol. 84, No. 12, June 17, 1992

areas, and dates of diagnosis and of interview for Black women were similar to those for White women, we matched the sample of White patients by stratum to the expected age distribution (20-49, 50-64, and 65-79 years) and metropolitan area of residence of the Black patients, with the use of tumor registry data from previous years. For this analysis, the study population consisted of eligible women from whom information on symptom recognition and the time between symptom recognition and medical consultation had been obtained in the interview. Of the 1222 women with breast cancer who were identified and selected for this study, informed consent and interviews were obtained from 1013 (82.9%). The 209 persons who could not be interviewed included women who 1) had died, 2) were too ill to be interviewed, 3) refused to be interviewed, 4) had physicians who declined the opportunity for an interview, or 5) were lost to follow-up. In-person interviews were conducted for the majority (65%) of the subjects within 3 months of diagnosis and for 87% of the subjects within 6 months. There were no significant differences between Black women and White women in the time from diagnosis to interview. The median times between diagnosis and interview were 80 days for White women and 76 days for Black women. Of the 1013 women interviewed, we excluded all 68 patients with in situ carcinoma and 210 patients with invasive cancer, including 1) 90 patients who were asymptomatic at diagnosis, 2) 109 patients who reported no symptoms at interview but whose medical records noted potentially recognizable signs, 3) six symptomatic patients who did not recall the date of symptom recognition, and 4) five patients who did not recall the date of initial medical consultation. However, we included 166 women who recognized their symptoms prior to seeing a physician but who were diagnosed with breast cancer during a medical visit for another illness or for a routine checkup. The final study population consisted of 735 women, 410 Black and 325 White. Data Collection In-person interviews were conducted to obtain information on race, whether respondents had any of a number of different symptoms prior to their diagnosis, the date on which they first noticed the symptoms, and the date on which the symptom was brought to the attention of a physician. For all patients, we compared the data from the medical record on the symptoms reported by the patient to medical personnel prior to hospital admission with the data collected in the interview. Whenever discrepancies between the medical record and the interview data were noted, we reviewed in detail the conflicting reports of symptoms, the sequence of consultations, and the dates of symptom recognition and medical consultation for those patients. For seven women, we substituted information on symptom status taken from the medical record for interview information. For 21 women, we substituted symptom recognition dates obtained from the medical record for dates obtained from the interview. For two women, we substituted information on both symptoms and dates from the medical record for that obtained from the interview. From the dates of symptom recognition and of medical consultation, we calculated the "symptom duration," the interval between the recognition of breast cancer symptoms and the ini-

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cancers of histologic types associated with an unfavorable prognosis (10,12). Additional explanations include more limited access to health care by Black women, diagnostic understaging of tumors by physicians examining Black women, and less appropriate or less aggressive therapeutic management for Black women (12-14). Other reasons that have been proposed—racial differences in the proportion of women screened for cancer, in the recognition of symptoms, and in the time between symptom recognition and medical consultation—need further evaluation (12). To evaluate one factor possibly contributing to these racial differences in survival and in stage of disease at diagnosis, we studied the difference between Black and White women in the interval of time from the recognition of breast cancer symptoms to the initial medical consultation. Our presumption was that, if racial differences exist in the length of this interval, they may provide a partial explanation for racial differences in survival. However, there has been little research on this issue. A longer interval may result in a later stage of disease at diagnosis and, hence, poorer survival after diagnosis (15-17). We found only five studies which have addressed this issue (7,15,18-21). Two of the studies (15,18) combined the interval between symptom recognition with the interval between consultation and treatment, and one study (21) had too few women with breast cancer to make a Black/White comparison. Vernon et al. (7) found that Black women had a longer time period between symptom recognition and initial medical consultation. In contrast, Dennis et al. (19) and Gardner (20) found no Black/White differences in the interval between symptom recognition and the first medical consultation. A collaborative study of differences in the survival rates of Black patients and White patients with cancer (12) compared the survival of Black cancer patients with that of White cancer patients and evaluated factors that might explain these differences. Although data on survival are not yet available from this study, baseline data have been collected on symptom recognition and medical consultation. In the current analysis, we used data from this study 1) to estimate differences between Black women and White women with breast cancer in the length of time between symptom recognition and medical consultation and 2) to evaluate the extent to which other factors associated with length of time between symptom recognition and medical consultation might explain any observed racial differences.

940

We collected information in the interview on the patients' reactions to and interpretations of the breast cancer symptoms. This information was coded in the form of three variables: 1] the patient's concern about breast symptoms (not worried, worried but thought condition was not serious, worried and though! symptom was serious, or worried and thought the symptom was cancer); 2) a determination of whether the first medical consultation was because of symptoms or for another reason; and 3) patient's belief that cancer can be cured. In addition, the respondent was asked if she had discussed the symptoms with a friend or a family member prior to seeing a physician and if she had a friend or family member who had been diagnosed with cancer. Information on socioeconomic status and on social support and responsibilities was obtained from several questions concerning education and usual occupational status (housewives; service, craft, operators, farmers; technical, sales, administrative; and managerial, professional). A poverty index was created by combining information on household income and the number of people supported by the income. For a given number of people supported, the household income was divided by the national 1986 poverty level income for a family of that size (34). In addition, information on marital status, participation in community organizations, and parity was available. Several questions pertained to health and health practices, including breast self-examination, alcohol consumption during the 5 years prior to symptoms, and cigarette smoking status prior to symptom recognition. Self-reported height and weight were used to create a body mass index (weight [kg]/height [m]1-5). Respondents were classified into four categories: 1) less than the 25th percentile, 2) the 25th through the 50th percentile, 3) the 51st through the 85th percentile, and 4) above the 85th percentile for women aged 20-29. The 85th percentile for women aged 20-29 is commonly used in defining overweight for women of all ages (55). Access to the health care system and health care utilization were indicated by several variables: (a) usual care source (none or hospital emergency room; hospital outpatient clinic, public health center, or community clinic; or private clinic, physician office, or Health Maintenance Organization); (b) whether the respondent usually saw the same individual medical care provider; (c) whether during the year before symptom occurrence the respondent received a reminder notice for a routine checkup; and (d) insurance coverage (none, public only, private insurance). The respondent's health care utilization practices were indicated by the number of each of the following examinations she had had during the 6 years prior to the occurrence of the breast cancer symptoms: general physical examination, routine dental examination, Pap smears, clinical breast examination, and mammograms. In addition, a variable representing the readiness to seek medical care was created by determining if, during the year prior to the occurrence of breast cancer symptoms, the respondent experienced any of 12 common health problems or symptoms, such as "sore throat," "backache," or "stopped-up nose," and whether medical care was sought for any of the problems. The number of conditions for which care was sought was divided by the number of conditions that were experienced to yield the percentage of symptoms for which care was sought.

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tial medical consultation. Although other researchers have used the same term to mean the interval between symptom recognition and the date on which surgery was performed (75), we preferred to use this term rather than the term "patient delay." The latter term seems pejorative, and the amount of time between symptom recognition and consultation may be affected by many factors that lie outside the control of the patient, such as access to health care. From the questions on symptoms, variables were created for the analysis that indicated the presence or absence of the following: lump in breast or under arm, pain in the breast or under the arm, and other breast cancer symptoms (edema, nipple retraction or discharge, ulceration, discoloration, and other definitive breast cancer symptoms). Since researchers have examined the relationship between this "symptom-duration" interval and a wide variety of factors, information on these and related variables was used in these analyses. These variables included tumor characteristics (15,17,22-24), types of symptoms (15,16,25-28), patient reactions to cancer symptoms (16,21,24,26-28), body size (26), socioeconomic and demographic characteristics of the patient (15,16,20,21,26,29), social support and responsibilities (21,24,29), personal and family history of cancer (21,26), health habits and practices (21,23,24), health system characteristics (16,21,26,29,30), and health care access (26,29) and utilization (21). Information on prediagnostic perceptions of the health care system (16,24,26,27,29) and methods for coping with symptoms prior to diagnosis (21,24,27,29-32) were not collected. Information on tumor characteristics, treatment, and comorbidity was abstracted from hospital medical records. When hospital records were unavailable or incomplete, information was abstracted from the office records of the patient's physician. In addition, a centralized pathology review of representative biopsy and surgical specimens was conducted. For these analyses, the following variables were selected from medical record abstracts and coded: 1) stage of disease (TNM classification system); 2) tumor size, as determined by the pathologist after excision; 3) histopathologic tumor grade; 4) age of the patient at diagnosis; and 5) comorbid conditions (including heart disease, hypertension, diabetes mellitus, and other chronic conditions). The breast cancer of each patient was assigned to a TNM stage category, according to the 1983 edition of the American Joint Committee on Cancer's "Manual for Staging of Cancer" (33) as follows: stage I—Tl, NO, MO; stage II (NO)—T2, NO, MO; stage II (Nl)—Tl,2, Nl, MO; stage III—Tl,2, N2, MO or T3,4, NO, 1,2, MO or any T, N3, MO; stage IV—any T, any N, Ml, since our data were collected prior to the 1988 reclassification. In the 1983 classification system, the stage III, N3 designation was assigned to cancers noted in the ipsilateral supraclavicular or infraclavicular lymph nodes. Under the current staging recommendations adopted in 1988, such cancers would be categorized as stage IV, Ml. We assigned to stage II (NO) the tumors of eight women whose tumors were stage II, but whose nodal status was unknown. Tumor grade was classified as low, moderate, or high, corresponding to the 1983 American Joint Committee on Cancer's classes of well differentiated (Gl), moderately well differentiated (G2), and poorly to very poorly differentiated (G3 or G4), respectively.

Statistical Analysis

We used the Cox proportional hazards regression analysis (39) to estimate a medical consultation rate ratio, i.e., the rate at which women in one category of a predictor variable obtained medical consultation divided by the rate at which women in the baseline category obtained consultation (37). For example, the rate ratio for race compared the rate of initial medical consultations per unit time among Black women with the rate among White women. Approximate 95% confidence intervals were calculated. In each of these analyses, predictor variables were classified as described above or in the tables. An indicator variable (coded 0 or 1) was created for each category or level of the predictor variable, indicating whether the person was a member of that category. Using these indicator variables in Cox regression analysis, we calculated rate ratios for each category or level of each predictor variable relative to the rate in the baseline category or level. A time-dependent covariate was created to test whether racial differences in symptom duration varied over time (40). To examine the association between race and other predictors of symptom duration, odds ratios were calculated using logistic regression analysis (37,41). These ratios represented the odds that Black women with invasive breast cancer in our study had a given characteristic relative to their having the baseline characteristic, compared with the corresponding odds for White women. The odds ratios were used to estimate the direction and strength of the association between race and the other predictors of symptom duration. An odds ratio above 1.0 indicated a positive association between a given characteristic and being Black, an odds ratio of 1.0 indicated no association, and an odds ratio below 1.0 indicated a negative association. The higher the odds ratio was above 1.0, the stronger the association. All odds ratios were adjusted for age and metropolitan area. Since the percentages of women in each category were large, the odds ratio could not be used to estimate the likelihood that a Black woman had a given characteristic relative to the likelihood that a White woman had the given characteristic; instead, the odds ratio tended to overestimate this ratio. The proportional hazards model was used to evaluate the effect of simultaneous adjustment for several predictors of symptom duration. Age and metropolitan area were included in all analyses, regardless of whether they were associated with symptom duration, because sampling was based on age and area. Education, poverty index, and the symptom variable Vol. 84, No. 12, June 17, 1992

Results The women in this study with invasive breast cancer were younger and had somewhat less advanced disease than did those who were not included because they could not be interviewed (Table 1). Nevertheless, the two groups were similar with regard to race, metropolitan area, grade, size of tumor, and comorbid conditions. However, the women included in our analysis were quite different from the women who were asymptomatic at diagnosis for breast cancer (Table 1). The women whose breast cancer was diagnosed prior to symptom occurrence were much more likely to have been White and older, to have lived in San Francisco/Oakland, and to have had smaller, earlier stage, and lower grade tumors. On each day after the first 3 days following symptom recognition, White women were slightly more likely than Black women to have obtained an initial medical consultation following the recognition of symptoms (Fig. 1). By the 7th day after symptom recognition, 32.0% of Black women and 40.3% of White women had obtained an initial medical consultation. These percentages were 60.0% and 64.9% at 1 month, 73.2% and 77.5% at 2 months, and 88.0% and 92.6% at 6 months after symptom recognition for Black women and for White women, respectively. Adjusted for age and metropolitan area, the average rate at which Black women obtained initial medical consultations after symptom recognition was 85% of the rate at which White women obtained such consultations (95% confidence interval, 73%-99%) (Table 2). Although during the first 3 days after symptom recognition Black women appeared to be slightly more likely than White women to have obtained a consultation, ARTICLES 941

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To assess the relationship between these predicting factors and the length of time between symptom recognition and initial medical consultation, we analyzed the information obtained by recall as though it were from a follow-up study without censoring or truncation. We conducted survival analyses (36-39) on these data, with the interval consisting not of survival duration but of the time from the recognition of breast cancer symptoms to the initial medical consultation. Thus, the outcome in these analyses was the initial medical consultation, not death. Product limit procedures (36,37) were used to estimate, by the category or level of each predictor variable, the median days of symptom duration. The Mantel-Cox test (38) was used to assess the statistical significance of the differences, adjusted for age and metropolitan area, in symptom duration by category or level of the predictor variable. Trend tests were used with ordered variables.

"lump in the breast or under the arm" were tested to see whether they were potentially important confounding variables, since socioeconomic status and the symptom variable "lump" have been consistently reported to be associated with symptom duration (15,16,21,25,26,29). In patients who were diagnosed with breast cancer during a medical visit for another illness, a routine checkup, or screening, the reason for the medical visit was considered a confounding variable rather than a censoring variable. We used a simple procedure to screen the other predicting factors to determine whether they were potentially confounding variables (42), since (a) the number of other potential confounders was large, (b) the literature on the relationship between many of these variables and symptom duration was sparse, and (c) certain variables had not been previously evaluated in published literature. We excluded variables that were not associated with symptom duration at a significance level of P^.20 and that were not associated with symptom duration as we had expected, given the literature on that relationship. We then adjusted for those predictor variables in the Cox regression model to determine if they affected the relationship between race and symptom duration. To determine if racial differences in symptom duration varied among different subgroups of patients defined by the predictor variables other than race that were identified in our screening analysis above, we introduced interaction terms between race and each of the predictor variables into the Cox models, along with race, the predictor variable, age, and metropolitan area.

Table 1. Comparison of characteristics, taken from medical records, of eligible patients included in the analysis with those of eligible patients not included,* a collaborative study of differences in the survival rates of Black patients and White patients with cancer {12) Patients not included Eligible patients for whom insufficient data were obtained on symptoms or duration!

Patients included in symptom duration analytic study

Eligible patients known to be asymptomatic at diagnosis^

Characteristic

Level or category

No.

%

No.

%

Race

Black White

410 325

55.8 44.2

175 130

57.4 42.6

27 63

30.05 70.0

Age at diagnosis, y

20-49 50-64 65-79

328 249 158

44.6 33.9 21 5

95 99 111

31.2§ 32.5 36.4

20 43 27

22.21 47.8 30.0

Metropolitan area

Atlanta San Francisco/Oakland New Orleans

288 247 200

39.2 33.6 27.2

109 107 89

35.7 35.1 29.2

34 46 10

37.8 51.1 11.1

Stage of cancerfl

I II (NO) II (Nl)

21.5 20.8 307 17.8

IV No information

158 153 226 131 37 30

4.1

72 56 67 61 35 14

23.6§ 18.9 22.0 20.0 11.5 4.6

58 8 12 1 1 10

64.4§ 8.9 13.3 1.1 1.1 II.1

Tumor grade H

Low Moderate High No information

149 399 140 47

20.3 54.3 19.0 6.4

73 157 51 24

23.9 51.5 16.7 7.8

30 47 6 7

33.3§ 52.2 6.7 7.8

Tumor size, cm

0.0-2.0 2.1-5.0 >5.0 or extension No information

254 329 140 14

34.6 44.8 19.0 1.6

105 108 78 4

34.4 38.7 25.6 1.3

68 13 1 8

75.6§ 14.9 1.1 8.9

Comorbid conditions

None Present No information

275 315 145

37.4 42.9 19.7

101 154 50

33.1 50.5 16.4

34 44 12

37.8 48 9 13.3

735

100.0

305

100.0

90

100.0

Total

5.0

* Not included either because data were insufficient or because patients were diagnosed with asymptomatic cancer. tThis category included both patients who could not be interviewed and patients who were interviewed but for whom insufficient data were obtained for inclusion in symptom duration analytic study. tThese patients were interviewed and did not have recognizable symptoms prior to diagnosis. § Distribution is significantly different from that of the analytic study population; chi-square / > =£.20 (Table 2): 1) Age—On a given day following symptom recognition, women aged 50-64 years were 82% as likely and women aged 65-79 were 79% as likely to have had an initial medical consultation for their symptoms as were women aged 20-49. 2) Metropolitan area/region—Women in New Orleans and San Francisco/Oakland were somewhat 942

more likely to have consulted a medical practitioner earlier than women in Atlanta. 3) Tumor characteristics—Later stage disease and larger tumors were associated with lower medical consultation rates, whereas high-grade tumors were associated with higher rates. 4) Type of symptoms—Women who saw a physician because they experienced symptoms that they thought might be related to breast cancer had higher consultation rates than women who sought consultations for other reasons, but the consultation rates varied according to the type of symptom. Women with lumps obtained consultations more quickly than those who did not recognize a lump. Women who experienced either pain or symptoms other than a lump or pain obtained consultations less rapidly. 5) Socioeconomic status, organizational membership, and access to and utilization of health care services—Women of higher socioeconomic status, church participants, women with greater access to Journal of the National Cancer Institute

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III

%

No.

care, and women who had utilized health services to a greater extent over the prior 6 years generally had higher rates of medical consultation. 6) Health status and health behavior—Women with chronic illnesses and women who smoked obtained consultations less rapidly than women without these characteristics. 7) Reactions to symptoms and perceptions regarding outcome—Women who recalled greater concern about symptoms and those who had discussed symptoms with a friend or a relative obtained earlier consultations than women who thought cancer was curable.

' WIDTH OF INTERVAL IS NOT PROPORTIONAL TO TIME

Fig. 1. Cumulative percentage of women who had consulted with a physician for breast cancer symptoms by a given time after symptom recognition, by race, a collaborative study of differences in the survival rates of Black patients and White patients with cancer (12).

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TIME AFTER SYMPTOM RECOGNITION

• BLACK a WHITE

Black women were more likely than White women to have many of the tumor characteristics listed above that were associated with longer symptom duration. At diagnosis, compared with White women with breast cancer, Black women with breast cancer were two times more likely to have stage IV breast cancer (6.6% compared with 3.1%) and one and onehalf times more likely to have stage III breast cancer (21.2% compared with 13.5%). Furthermore, Black women were only approximately one half as likely to have stage I breast cancer as White women (15.4% compared with 29.2%) (Table 3).

Table 2. Symptom duration and relative rates of initial medical consultation after breast cancer symptom recognition, by characteristics predictive of symptom duration, a collaborative study of differences in the survival rates of Black patients and White patients with cancer (12)

Predictor

Level or category

Race

White Black 20-49 50-64 65-79

Age at diagnosis, y

Metropolitan area

Stage of cancerS

Tumor graded

Atlanta San Francisco/Oakland New Orleans I II (NO) II (Nl) III IV No information Low Moderate High

No information Tumor size, cm

Lump symptom

0.0-2.0 2.1-5.0 >5.0 or extension No information None Present No information

Pain symptom

Other breast cancer symptom(s)

None Present No information

None Present No information

No of respondents

325 410 328 249 158 288 247 200 158 153 226 131 37

Median symptom duration* Days

14 16 14 21 13 16 15 14 10 14 14 31 42

P% .06

.01

Medical consultation ratest Rate ratio 95% confidence interval

1.00 0.85 1.00 0.82 0.79 I.QO 1.10 1.15 1.00 0.76 0.80 0.56 0.53

0.61-0.95 0.65-0.98 0.45-0.71 0.37-0.76

1,00 1.27 1.22

1.05-1.53 0.97-1.54

1.00 0.83 0.60

0.71-0.98 0.48-0.73

0.73-0.99 0.69-0.96 0.65-0.96 0.93-1.31 0.96-1.38

30 149 399 140 47 254 329 140 12 34 701

25 14 15

.09

II 15 32 30 15

.18

1.00 1.23

0.87-1.74

13 18

.04

1.00 0.87

0.75-1.01

1.00 0.79

0.68-0.92

O 404 331 0 384 351 0

12 21

*Time between the date of symptom recognition and the date at which a symptom is brought to the attention of a physician, unadjusted. tRate of physician visits among women in the given category divided by the rate in the referent category, adjusted for age and city. Rate ratios by city are adjusted for age, and rate ratios by age are adjusted for city. tP value from Mantel-Cox test of differences in symptom duration by category or level of the predictor variable, adjusted for age and city. If variable is rankorder, trend test P value is reported. §TNM classification. See Table 1 footnote and "Subjects and Methods" section. \\See Table I footnote and "Subjects and Methods" section. (Table 2 continued on next page.)

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Table 2 (continued). Symptom duration and relative rates of initial medical consultation after breast cancer symptom recognition, by characteristics predictive of symptom duration, a collaborative study of differences in the survival rates of Black patients and White patients with cancer (12) r

N

Predictor

Level or category

Comorbid conditions

Body mass index

Poverty index. %

Participation in organizations

Usual source of care

Usually sees same care provider

Days

None Present No information

275 315 145

13 16 20

19.7-25.99 26.0-27.99 28.0-34.99 2=35.00 No information

93 97 329 211 5

14 13 15 15

»SI25 126-200 201-300 301-400 >400 No information

175 73 107 86 221 73

16 18 13 12 14

0-8 9-11 12 >12 No information Name Church/other Other/not church No information

106 98 234 295 2 213 392 129 1

16 26 13 15

None/hospital emergency room Community clinic Private/Health Maintenance Organization No information

101 92 543 9 175 540

25 20 14

No Yes No information

16 14 20

P%

.03

1.00 0.80 0.86

0.67-0.% 0.70-1.06

.04

1.00 0.99 0.86 0.80

0.74-1.32 0.68-1.08 0.62-1.03

.04

1.00 1.09 1.34 1.28 1.24

0.82-1.43 1.05-1.72 0.97-1.68 1.00-1.54

.04

1.00 1.13 1.43 1.43

0.85-1.51 1.11-1.85 1.11-1.86

.12

1.00 1.17 1 01

0.99-1.38 0 81-1.26

.06

1 00 1.05 1.29

0.78-1.40 1.03-1.62

.01

1.00 1.23

1.03-1.46

04

1.00 1.02 1.26

0.74-1.40 0.96-1.04

.03

1.00 1.13 1.21 1.34

0.92-1.39 0.97-1.52 1.09-1.64

00

1.00 1.23 1.35 1.43

0.98-1.54 1.08-1.69 1.11-1.85

22 14

Medical consultation ratest Rate ratio 95% confidence interval

20 21 16 14

None Public only Some private No information Routine dental examinations, No./6 y 0 1-5 6 >6 No information

66 129 540 0 207 175 145 205 3

Routine breast examinations, N0./6 y 0 1-5 6 >6 No information

134 219 251 128 3

15 19 15 11

Never Former Current No information

378 165 188 4 179 111 99 332 14 166 563 6 221 97 413 4

13 20 18

1.00 0.92 0.86

0.76-1.11 0.72-1.03

28 21 10 13

.00

1.00 1.13 1.40 1.49

0.89-1.44 1.09-1.80 1.23-1.79

51 13

.00

1.00 1.93

1.60-2.23

14 17 15

1.00 0.84 0.78

0.66-1.07 0.66-0.92

234 495

21 13

1.00 1.35

1.15-1.59

Health insurance

Cigarette smoking status

Concern about breast symptoms

Reason for first medical visit

Thought cancer curable

Discussed symptoms with friend

Not worried Worried Thought serious Thought cancer No information Not for symptoms For symptoms No information Disagree Do not know Agree No information No Yes No information

21 18 12 12

6

•Time between the date of symptom recognition and the date at which a symptom is brought to the attention of a physician, unadjusted. tRate of physician visits among women in the given category divided by the rate in the referent category, adjusted for age and city. Rate ratios by city are adjusted for age. and rate ratios by age are adjusted for city. %P value from Mantel-Cox test of differences in symptom duration by category or level of the predictor variable, adjusted for age and city. If variable is rankorder, trend test P value is reported.

944

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Education, y

Median symptom duration*

respondents

Table 3. Relationship between race and other characteristics predictive of symptom duration and numbers and percentages of Black and White women with invasive breast cancer who had given characteristics and the corresponding odds ratios, a collaborative study of differences in the survival rates of Black patients and White patients with cancer (12) Black Predictor characteristic Age at diagnosis, y

Metropolitan area

Stage of cancert

Tumor size, cm

Lump symptom

Pain sympton

No.

20-49 50-64 65-79

176 141 93 174 139 97 63 89 130 87 27 14 73 221 86 30 113 195 96 6 16 394 0 220 190 0 203 207 0 117 219 74 33 30 174 169 4 148 52 57 41 65 47 87 73 126 123 1 100 264 46 0 54 82 267 7

Atlanta San Francisco/Oakland New Orleans I II (NO) II (Nl) III IV No information Low Moderate High No information 0.0-2.0 2.1-5.0 >5.0 or extension No information None Present No information None Present No information

Other breast cancer symptom(s)

None Present No information

Comorbid conditions

None Present No information

Body mass index

19.7-25.99 26.0-27.99 28.0-34.99 5=35.00 No information

Poverty index, % 126-200 201-300 301-400 >400 No information Education, y

Participation in organizations

Usual source of care

0-8 9-11 12 >I2 No information None Church/other Other/not church No information None/hospital emergency room Community clinic Private/Health Maintenance Organization No information

White

No.

%

42.9 34.4 22.7 42.4 33.9 23.7 15.4 21.7 31.7 21.2 6.6 3.4 17.8 53.9 21.0 7.3 27.6 47.6 23.4 1.5 3.9 96 1 0.0 53.7 46.3 0.0 49.5 50.5 0.0 28.5 53.4 18.0 8.0 7.3 42.4 41.2 1.0 36.1 12.7 13.9 10.0 15.9 11.5 21.2 17.8 30.7 30.0 0.2

152 108 65 114 108 103 95 64 96 44 10 16 76 178 54 17 141 132 44 8 18 307 0 198 127 0 181 144 0 158 96 71 60 67 155 42 1 27 21 50 45 156 26 19 25 108 172 1

46.8 33.2 20.0 35.1 33.2 31.7 29.2 19.7 29.5 13.5 3.1 4.9 23.4 54.8 16.6 5.2 43.4 40.6 13.5 2.5 5.5 94.5 0.0 60.9 39.1 0.0 55.7 44.3 0.0 48.6 29.5 21.8 18.5 20.6 47.7 12.9 0.3 8.3 6.5 15.4 13.8 48.0 8.0 5.8 7.7 33.2 52.9 0.3

24.4 64.4 11.2 0.0 13.2 20.0 65.1 1.7

113 128 83 1 37 10 276 2

34.8 39.4 25.5 0.3 11.4 3.1 84.9 0.6

%

Odds ratio* 9 5 % confidence i 1.00 1.22 1.41 1.00 0.82 0.62 1.00 2.22 2.16 3.23 3.96

0.58-1.17 0.43-0.89

1.00 1.35 1.73

0.92-1.98 1.07-2.78

1.00 1.91 2.90

1.37-2.68 1.87-4.51

1.00 1 61

0.80-3.22

1.00 1.38

1.02-1.89

1.00 1.26

0.93-1.69

0.83-1.80 1.07-1.86

1.40-3.51 1.42-3.28 1.98-5.28 1.78-8.82

1.00 3.45 1.28 1.00 0.82 2.07 7.55

0.45-1.51 1.28-3.35 4 35-13.10

1 00 0.41 0.16 0.10 0.05

0.21-0.81 0.09-0.29 0.05-0.19 0.03-0.08

1.00 0.53 0.18 0.10

0.27-1.06 0.10-0.33 0.05-0.18

1.00 2.47 0.62

1.70-3.60 0.39-0.98

1.00 5.70 0.66

2.61-12.47 0.42-1.05

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Tumor gradei

Level or category

2.39-4.99 0.84-1.94

*Odds ratios were calculated using logistic regression analysis (37,41) and were adjusted for metropolitan area and/or for age of the patient at diagnosis. These odds ratios estimated the odds that a Black woman with invasive breast cancer had a given characteristic relative to her having the baseline characteristic, divided by the corresponding odds for a White woman. For example, the odds ratio for stage IV disease equals (P4 x P,V(P2 x P3), where P4 = number of Black women with stage IV disease, P, = the number of White women with stage I disease, P2 = the number of White women with stage IV disease, and P3 = number of Black women with stage I disease. That odds ratio (3.96) represents the odds that a Black woman had stage IV disease as opposed to stage I disease relative to the corresponding odds for a White woman. Because the odds ratios were adjusted for age of the patient and metropolitan area, they cannot be calculated directly from the numbers in the table. The odds ratios for age were adjusted for metropolitan area, and the odds ratios for metropolitan area were adjusted for age. All other odds ratios were adjusted for age and for metropolitan area. tTNM classification. See Table 1 footnote and "Subjects and Methods" section. tSee Table 1 footnote and "Subjects and Methods" section. (Table 3 continued on next page.)

Vol. 84, No. 12, June 17, 1992

ARTICLES

945

Table 3 (continued). Relationship between race and other charactenstics predictive of symptom duration and numbers and percentages of Black and White women with invasive breast cancer who had given characteristics and the corresponding odds ratios, a collaborative study of differences in the survivaJ rates of Black patients and White patients with cancer (12) Black Level or category

No.

Usually sees same care provider

No Yes No information

120 278 12 59 114 237 0 157 114 70 66 3 93 108 127 79 3 213 78 115 4 99 67 66 169 9 107 300 3 102 51 256 1 135 272 3

Health insurance

Routine dental examinations, No./6 y

Routine breast examinations, N0./6 y

None Public only Some private No information 0 1-5 6 >6 No information 0 1-5

6 >6 No information Cigarette smoking status

Concern about breast symptoms

Reason for first medical visit

Thought cancer curable

Never Former Current No information Not worried Worried Thought serious Thought cancer No information Not for symptoms For symptoms No information Disagree

Did not know Agree No information Discussed symptoms with friend

No Yes No information

White

% 29.3 67.8 2.9 14.4 27.8 57.8 0.0 38.3 27.8 17.1 16.1 0.7 22.7 26.3 31.0 19.3 0.7 52.0 19.0 28.0 1.0 24.2 16.3 16.1 41.2 2.2 26.1 73.2 0.7 24.9 12.4 62.4 0.2 32.9 66.3 0.7

No. 55 262 8 7 15 303 0 50 61 75 139 0 41 111 124 49 0 165 87 73 0 80 43 33 163 6 59 263 3 119 46 157 3 99 223 3

% 16.9 80.6 2.5 2.2 4.6 93.2 0.0 15.4 18.8 23.1 42.8 0.0 12.6 34.2 38.2 15.1 0.0 50.8 26.8 22.5 0.0 24.6 13.2 13.5 50.2 1.9 18.2 80.9 0.9 36.6 14.2 48.3 0.9 30.5 68.6 0.9

Odds ratio

95% confidence interval

1.00 0.48

0.33-0.69

1.00 1.06 0.09

0.40-2.82 0.04-0.21

1.00 0.54 0.27 0.13

0.34-0.80 0.17-0.43 0.08-0.20

1.00 0.39 0.41 0.68

0.24-0.62 0.26-0.65 0.40-1.15

1.00 0.67 1.18

0.46-0.98 0 82-1.70

1.00 1 24 1.67 0.85

0 76-2.02 0.99-2.80 0.58-1.23

1.00 0.64

0.45-0 93

1.00 1.28 1.93

0.79-2 07 1.38-2 69

1.00 0.94

0.68-1.30

•Odds ratios were calculated using logistic regression analysis (37,41) and were adjusted for metropolitan area and/or for age of the patient at diagnosis. These odds ratios estimated the odds that a Black woman with invasive breast cancer had a given characteristic relative to her having the baseline characteristic, divided by the corresponding odds for a White woman. For example, the odds ratio for stage IV disease equals (P,, x P|(/(P2 x Pj). where P4 = number of Black women with stage IV disease, P, = the number of White women with stage I disease, P2 = the number of White women with stage IV disease, and P, = number of Black women with stage I disease. That odds ratio (3.96) represents the odds that a Black woman had stage IV disease as opposed to stage I disease relative to the corresponding odds for a White woman. Because the odds ratios were adjusted for age of the patient and metropolitan area, they cannot be calculated directly from the numbers in the table. The odds ratios for age were adjusted for metropolitan area, and the odds ratios for metropolitan area were adjusted for age. All other odds ratios were adjusted for age and for metropolitan area.

Similarly, Black women were almost twice as likely as White women (23.4% compared with 13.5%) to have a tumor that was larger than 5 cm or that had an extension to the chest wall or skin. Other symptoms associated with longer symptom duration were also more common in Black women, including pain and symptoms other than a lump or pain. In addition, more Black than White women were of lower socioeconomic status and had less access to, and lower rates of utilization of, health care services. For example, 36.1% of the Black women in our study had a poverty index of less than or equal to 125%, while only 8.3% of White women were thus classified. Black women were also more likely to have thought that cancer was curable and less likely to have discussed their symptoms with a friend. Conversely, Black women were more likely than White women to have a few of the characteristics associated with 946

shorter symptom duration: a higher grade tumor, a lump in the breast or under the arm, and participation in church organizations (Table 3). Since many of the predictor variables that were associated with symptom duration were also associated with race, we evaluated the extent to which adjustment for these variables reduced or increased racial differences in symptom duration. Analytic adjustment for predictor variables other than race, either singly or in various combinations, had little effect on the small racial difference in medical consultation rates that were observed (Table 4). The first column of rate ratios in the table indicates that medical consultation rate ratios varied little, ranging from 0.84 to 0.87, when women with missing information pertaining to each of the listed variables were excluded from the analysis. The second column of rate ratios presents the Black-to-White medical consultation rate ratios after adjustJournal of the National Cancer Institute

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Predictor characteristic

Table 4. Rates of initial medical consultation for breast cancer symptoms among Black women divided by rates among White women, adjusted for age, metropolitan area, and other factors predictive of symptom duration, a collaborative study of differences in the survival rates of Black patients and White patients with cancer (12) Black/White medical consultation rate; Adjusted for Adjusted for age, metropolitan area, and the listed predictive characteristics metropolitan area and age Predictor characteristic

Rate ratios

95% confidence interval

Rate ratios

95% confidence interval

735 705 688 723 735 735 735 735 730 662 733 734 726 715 735

0.85 0.86 0.85 0.87 0.85 0.85 0.85 0.85 0.85 0.84 0.84 0.84 0.86 0.86 0.85

0.73-0.99 0.74-1.01 0.73-0.99 0.75-1.00 0.73-0.99 0.73-0.99 0.73-0.99 0.73-0.99 0.74-0.99 0.72-0.98 0.73-0.98 0.72-0.97 0.74-0.99 0.74-1.00 0.73-0.99

0.85 0.93 0.83 0.92 0.84 0.86 0.85 0.87 0.89 0.89 0.90 0.78 0.89 0 88 0.90

0.73-0.99 0.79-1.08 0.71-0.97 0.79-1.07 0.73-0.98 0.74-1.00 0.74-0.99 0.75-1.02 0.76-1.04 0.74-1.06 0.77-1.05 0.66-0.91 0.76-1.03 0.75-1.02 0.77-1.06

732 732 731 721 729 731 729 662

0.85 0.85 0.85 0.85 0.85 0.85 0.85 0.84

0.73-0.98 0.73-0 98 0.73-O.99 0.74-0.99 0.73-0.98 0.73-0.98 0.73-0.98 0.72-0 98

0.90 0.87 0.85 0.85 0.89 0.87 0.86 0.90

0.77-1.06 0.74-1.01 0.73-0.99 0.73-0.99 0.77-1.03 0.75-1 01 0.74-1.01 0.75-1.08

661 563

0.84 0.84

0.72-0.98 0.71-O.99

0.92 0.82

0.77-1.11 0.65-1.03

'Number varies, depending on missing data for variables included in the analysis

merit for the listed predictor variable or set of variables. The variables that resulted in the greatest reduction in the racial difference, when adjusted for singly, included two tumor characteristics (stage of disease and tumor size) and three other variables (education, health insurance, and routine dental examinations). Since we believed stage of disease was more likely to be an outcome than a cause of symptom duration, we adjusted for all of the variables listed in Table 4 except stage of disease. The result was that the Black-to-White medical consultation rate ratio changed very little, from 0.84 to 0.82. We found no consistent statistically significant interaction effects between race and any other predictor variable. This indicated that Black/White differences in consultation rates did not vary in a statistically significant manner according to the category or level of the other predictor variables. For example, the Black-to-White rate ratio among women with stage I disease was similar to that among women with stage III disease, and the ratio among smokers was similar to that among nonsmokers. The method by which we interpreted and analyzed answers to the following question affected our results. During the interview, symptomatic study participants were asked: "Did you go to see a doctor or medical person because of (this/these) symptom(s), or was your problem first discovered during a medical visit for some other reason?" Women whose breast cancer was discovered during a visit for some other reason (n = 166, 22.6% of the sample) saw the physician for another illness or condition n = 72), for a routine checkup (n = 89) or screening (n = 3), when taking someone else to the physician (n = Vol. 84, No. 12, June 17, 1992

1), or for an unknown reason (n = 1). In such cases, we assumed that the woman initiated a conversation about symptoms, and, therefore, we treated the reason for the visit as a confounding variable, i.e., a factor which affected symptom duration and which was differentially distributed by race. However, if the woman never consulted the provider about the symptom but instead waited for the provider to examine her breasts to discover the sign, the reason for first visit would be treated as a censoring variable. The result of the second assumption was a reduction in the Black-to-White medical consultation rate ratio from 0.85 to 0.80 (95% confidence interval, 0.68-0.95). However, we thought that the first interpretation was more probable. The variations in rate ratios by age, by metropolitan area, and by age and metropolitan area combined were not statistically significant (P = .61, .11, and .14, respectively) (Table 5). However, the racial differences in symptom duration and in the medical consultation rate tended to be greater in Atlanta and New Orleans than in San Francisco/Oakland. In addition, among those aged 50 or older, Black women from San Francisco/Oakland had somewhat higher consultation rates than did White women, while in the two southern cities the reverse was true.

Discussion In this study of 735 women, all of whom obtained a medical consultation for symptoms, we found that, on the average, Black women obtained a consultation somewhat later than did ARTICLES 947

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None Stage of cancer Tumor grade Tumor size Lump symptom Pain sympton Other breast cancer symptoms Comorbid conditions Body mass index Poverty index Education Participation in organizations Usual source of care Usually sees same care provider Health insurance Routine examinations Dental Breast Cigarette smoking Concern about breast symptoms Reason for first medical visit Thought cancer curable Discussed symptoms with friend Lump, poverty, and education Poverty, education, health insurance, and routine dental examinations All of the predictive characteristics except stage

No. of subjects*

948

differences may have been reduced. In addition, Black/Whit< differences may vary somewhat by region. Although w< detected a small difference between the races in symptom dura tion, while Dennis et al. (79) and Gardner (20) did not detec any difference, regional variation was observed in the presen study that could explain this apparent discrepancy. Compared with these earlier studies, the current study ha; several strengths. The purpose of the larger study, of which this analysis was a part, was to evaluate possible reasons foi Black/White differences in cancer patient survival. Data wert collected to allow a comparison of differences in symptorr duration and an examination of possible reasons for those differences. We were able, therefore, to use multivariable modeling to examine the potential role of several factors ir explaining racial differences. Controlling for a large number ol predictors of symptom duration had little effect on the Blacky White medical consultation rate ratio, suggesting that the results were not confounded by variables other than race. In addition, the present study did not rely on information from patients admitted to a single hospital or from a breast cancel treatment protocol; it was population based. The study also drew upon experience in three different U.S. cities rather than in a single location. For these reasons, the findings of our analysis may be more generalizable than the findings of other studies. While the strengths of the current analysis are apparent, several limitations must be recognized as well. The most important limitation is that these results rely on the accuracy of information on symptom duration that was recalled by patients after medical consultation or after treatment. Random error in recalled data may have biased the observed medical consultation rate ratios toward the null (i.e., 1). However, we believe that this potential source of error should not have greatly influenced our results. Most symptom-duration intervals were short, providing a limited range for reporting error, and we observed strong associations with factors other than race. In addition, we evaluated the reliability of interview data on symptom duration by comparing them with medical record data whenever such data were available. It is also possible that patients of both races may recall later dates of symptom recognition than were actually experienced. A woman diagnosed with breast cancer, like any cancer patient, may find it difficult to tell anyone that she has experienced symptoms for a long period without obtaining a medical consultation. Without a source of information on dates of symptom recognition independent of patient recall, we were unable to verify the existence or extent of this source of bias. The effect of such a bias would be to reduce the number of days of symptom duration for both Black women and White women and to reduce the actual racial difference. However, given the substantial differences between the races in stage of disease at diagnosis and the amount of time required for a tumor to progress from one stage to another (weeks or months), both the frequency and the degree of underreporting would have had to have been very great to obscure actual racial differences in symptom duration that were large enough to account for differences in stage of disease at diagnosis. Therefore, we believe that this source of bias was unlikely to affect our conclusion that differences in symptom duration cannot account for the racial differences in stage of disease at diagnosis. Journal of the National Cancer Institute

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White women. The racial difference in medical consultation rates was small, but this difference persisted over time. Analytic adjustments for a few single predictors of symptom duration other than race reduced this differential somewhat, but no single factor or combination of factors could completely account for this racial difference, and adjustment for all the other predictor variables combined resulted in a marginally greater racial difference in rates of medical consultation. The small racial difference in symptom duration appeared somewhat more evident in Atlanta and New Orleans than in San Francisco/Oakland and tended to be greater in older women than in younger women, but these variations by age and metropolitan area were not statistically significant. We had anticipated that racial differences in several variables, including symptom duration, might be greater in the South than in San Francisco/Oakland and might be greater in older women than in younger women. Racial differences in socioeconomic status and access to care may be less in San Francisco/Oakland than in the South and may be less in younger than in older women. Changes in racial discrimination affecting the access of Black women to medical care, improvements in education, or increases in health awareness over time may have contributed to reduced racial differences in younger women. An important finding of this study is that Black women were twice as likely as White women to have stage IV breast cancer and to have tumors larger than 5 cm or tumors with extensions than White women. Yet the small racial difference in time between symptom recognition and medical consultation could not explain the large racial differences in breast cancer stage or tumor size at diagnosis. Following symptom recognition, Black women were only 15% slower on the average than White women to obtain a medical consultation, and the differences in the times between symptom recognition and medical consultation were small: 2 days between the medians and 14 days between the 75th percentiles of each group. The available literature (7,15,18-20) on racial differences in time between symptom recognition and medical consultation is limited and inconsistent. In only two studies (18-20) was information collected on Black/White differences in the time between symptom recognition and initial medical consultation, and the results varied. In a study of 1983 women treated for breast cancer in a Houston, Texas, hospital from 1949 through 1968, Vernon et al. (7) found that 63.8% of Black women and 44.6% of White women obtained an initial medical consultation 3 or more months after symptom recognition. In contrast, in a group of 237 women treated for breast cancer in a New York City hospital from 1965 through 1970, Dennis et al. (19) and Gardner (20) found no racial differences in the time between symptom recognition and the first medical visit. The results of the current study are generally consistent with this literature. Like Vernon et al. (7), we found that the time between symptom recognition and medical consultation was greater for Black women than for White women. However, we found smaller racial differences in symptom duration in the present study: By the end of the 2nd month, 73.2% of Black women and 77.5% of White women had consulted with a physician, whereas in the study by Vemon et al. these figures were 36.2% and 55.4%, respectively. It may be that, from 1949 through 1968 to 1985 through 1986, the time between symptom recognition and medical consultation has declined in the United States, and Blade/White

disease at diagnosis. Our results suggest that two symptomrelated factors may contribute somewhat to the racial difference in stage of disease at diagnosis. One is the large disparity between the percentages of Black women and White women diagnosed with asymptomatic breast cancer. Of the women diagnosed with asymptomatic breast cancer, 70% were White compared with 30% who were Black (Table 1). In women with invasive breast cancer, White women were much more likely than Black women to have had their cancers discovered prior to the occurrence of symptoms. Also, Black women were less likely than White women to have had routine breast examinations (Table 3). Thus, differential access to health care services and differential participation in screening may account for some of the difference in stage of disease at diagnosis. The other possibility is that Black women might have been slower than White women to recognize equivalent symptoms, i.e., lumps of a given size, pain of a given level, or other manifestations of equivalently staged cancer. This possibility is consistent with studies (43,44) in which Blacks were found to be less knowledgeable than Whites about cancer symptoms. The stage of the breast cancer at diagnosis is dependent on the interval between the onset of the tumor and the recognition of symptoms as well as on the interval between symptom recognition and the initial medical consultation. Since the first interval may be longer than the second, the effect of this racial difference in symptom recognition might be large.

References (/) YOUNG JL JR, RIES LG, POLLACK ES' Cancer patient survival among ethnic groups in the United States. JNCI 73:341-352. 1984 (2) OWNBY HE. FREDERICK J. RUSSO J. ET AL: Racial differences in breast

cancer patients JNCI 75:55-60, 1985 (3) BAIN RP, GREENBERG RS, WHITAKER JP: Racial differences in survival of

women with breast cancer. J Chronic Dis 39:631-642. 1986 (4) BASSETT MT, KRIEGER N: Social class and black-white differences in breast cancer survival. Am J Public Health 76:1400-1403. 1986

Table 5. Symptom duration and rates of physician visits after breast cancer symptom recognition among Black and White women, a collaborative study of differences in the survival rates of Black patients and White patients with cancer (12) Metropolitan area

Age, y

Race

No. of respondents

Symptom duration,* d

Rate ratiot

95% confidence interval

Atlanta

20-49

White Black

62 81

15 15

0.90

0.65-1.26

50-64

White Black

29 57

II 34

0.73

0.46-1.15

65-79

White Black

23 36

10 16

0.54

0.31-0.94

20-49

White Black

38 51

7 15

0.83

0.54-1.27

50-64

White Black

40 52

31 14

1.09

0.72-1.65

65-79

White Black

30 36

13 10

1.19

0.73-1 95

20-49

White Black

52 44

10 14

0.90

0.60-1.36

50-64

White Black

39 32

II 16

0.85

0.53-1.37

White Black

12 21

7 22

0.57

0.27-1.21

San Francisco/Oakland

New Orleans

65-79

*Time between the date of symptom recognition and the date at which a symptom was brought to the attention of a physician. tRale of physician visits in Black women divided by that in White women.

Vol. 84, No. 12, June 17, 1992

ARTICLES 949

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Although White women might have reported dates of symptom recognition that were earlier than the actual dates and Black women might have reported dates of symptom recognition that were later than the actual dates, no literature exists suggesting that such a systematic reporting bias might occur. While recall might be affected by racial differences in time between diagnosis and interview, the average interval between diagnosis and interview was similar for both races. Another possible source of bias was our inability to collect interview information on symptom duration from all of the women identified as eligible for the study, particularly older women and those with later stage disease. A greater racial difference may have existed in women who could not be interviewed than in women who were interviewed. We did observe a small, inconsistent, and statistically insignificant variation in the Black/White rate ratio by age (P = .61) (Table 5). In addition, we detected a small difference in Black/White medical consultation rates by stage, 0.96 for women with stage I disease compared with 0.82 for women with stage IV disease; these differences, however, were not statistically significant (P = .99) (data not shown). Thus, we believe this source of bias was unlikely to affect our results. Another limitation of this study was the size and geographic distribution of the population sampled. Despite the fact that the current analysis is one of the larger studies to address racial differences in symptom duration, the power of our analysis to determine whether real variation existed by age and/or by metropolitan area was limited by the small numbers in each ageregion stratum. Although the variations we noted were not statistically significant, a real variation may have existed that we were unable to detect. Thus, the advisability of generalizing our results to populations in rural areas, in the midwest, or in the northeast region of the United States is uncertain, given the possible regional variation in findings. The small observed racial differences in symptom duration leave unexplained the substantial racial differences in stage of

(5) National Cancer Institute: 1987 Annual Cancer Statistics Review, Including Cancer Trends: 1950-1985. DHHS Publ No. (NIH)88-2789. Washington, DC: US Govt Print Off, 1988 (6) National Cancer Institute: Cancer Statistics Review, 1973-1987. DHHS Publ No. (NIH)9O-2789. Washington, DC: US Govt Print Off, 1990 (7) VERNON SW. TILLEY BC, NEALE AV, ET AL: Ethnicity, survival, and

delay in seeking treatment for symptoms of breast cancer. Cancer 55:1563-1571, 1985 (8) SONDIK EJ, YOUNG JL, HORM JW, ET AL: Annual Cancer Statistics

Review. Washington, DC: US Govt Print Off, 1987 (9) DAYAL HH, POWER RN, CHIU C: Race and socio-economic status in sur-

vival from breast cancer. J Chronic Dis 35:675-683, 1982 (/0) VALANIS B, WIRMAN J, HERTZBERG VS: Social and biological factors in

relation to survival among black vs. white women with breast cancer. Breast Cancer Res Treat 9:135-143, 1987 ( / / ) STANFORD JL, SZKLO M, BORING CC, ET AL: A case-control study of

breast cancer stratified by estrogen receptor status. Am J Epidemiol 125:184-194, 1987 (12) HOWARD J, HANKEY BF, GREENBERG RS, ET AL: A collaborative study of

differences in the survival rates of Black patients and White patients with cancer. Cancer 69:2349-2360, 1992 (13) NATARAJAN N, NEMOTO T, METTUN C, ET AL: Race-related differences in

(15) FISHER ER, GREGORIO RM, FISHER B, ET AL: The pathology of invasive

breast cancer A syllabus derived from findings of the National Surgical Adjuvant Breast Project (Protocol No. 4). Cancer 36:1-85, 1975 (16) WILKINSON GS, EDGERTON F, WALLACE HJ JR, ET AL: Delay, stage of dis-

ease and survival from breast cancer. J Chronic Dis 32:365-373, 1979 (17) ROBINSON E, MOHILEVER J, BOROVIK R: Factors affecting the delay in

(26) GOULD-MARTIN K, PAGANINI-HILL A, CASAGRANDE C, ET AL: Behavioral

and biological determinants of surgical stage of breast cancer. Prev Med 11:429-440, 1982 (27) SAFER MA, THARPS QJ, JACKSON TC, ET AL: Determinants of three stages

of delay in seeking care at a medical clinic. Med Care 17:11-29, 1979 (28) GREEN LW: Site- and symptom-related factors in secondary prevention of cancer. In Cancer: The Behavioral Dimension (Cullen JW, Fox BH, Martin CR, eds). New York: Raven Press, 1976 (29) BATTTSTELLA RM: Factors associated with delay in the initiation of physician's care among late adulthood persons Am J Public Health 61:1348— 1361, 1971 (JO) GREENWALD HP: HMO membership, copayment, and initiation of care for cancer: A study of working adults. Am J Public Health 77:461^*66, 1987 (31) WATSON M, GREER S, BLAKE S, ET AL: Reaction to a diagnosis of breast

cancer: Relationship between denial, delay and rates of psychological morbidity: Cancer 53:2008-2012, 1984 (32) OWENS RG, ASHCROFT JJ: Breast cancer screening—the way ahead. J Psychosoc Oncol 4:15-26, 1986 (33) AMERICAN JOINT COMMITTEE FOR CANCER STAGING AND END RESULTS

REPORTING: Manual for Staging of Cancer, 2nd ed. Philadelphia: Lippincott, 1983 (34) U.S. Department of Health and Human Services: Poverty income guidelines: Annual revision. Fed Reg 51:5105-5106, 1986 (35) NATIONAL CENTER FOR HEALTH STATISTICS: Obese and overweight adults

in the United States. Vital and Health Statistics Series 11, No. 230. DHHS Publ No (PHS)83-l680. Washington, DC: US Govt Print Off, 1987 (36) KAPLAN EL, MEIER P: Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457-481, 1958 (37) DLXON WJ, BROWN MD, ENGELMAN L, ET AL: BMDP Statistical Software

diagnosis of breast cancer Relationship of delay to stage of disease. Isrl J Med Sci 22:333-338, 1986

(18)

(19) (20) (21)

(22)

(23)

Manual. Berkeley, CA: Univ Calif Press, 1985 (38) MANTEL N: Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep 50:163-170, 1966 GREGORIO DI, CUMMINGS KM, MICHALEK A: Delay, stage of disease, and survival among white and black women with breast cancer. Am J Public (39) Cox DR: Regression models and life tables. J Stat Soc [B] 34:187-220, Health 73:590-593, 1983 1972 DENNIS CR, GARDNER B, LIM B: Analysis of survival andrecurrencevs. (40) KALBFLEISCH JD, PRENTICE RL: The Statistical Analysis of Failure Time patient and doctor delay in treatment of breast cancer. Cancer 35:714Data. New York: Wiley, 1980 720, 1975 (41) BRESLOW NE, DAY NE: Statistical methods in cancer research, vol. 1 The Analysis of Case-Control Studies. Lyon: International Agency for GARDNER B: The relationship of delay in treatment to prognosis in human Research on Cancer, 1980 cancer Prog Clin Cancer 7:123-133, 1978 SAMET JM, HUNT WC, LERCHEN ML, ET AL: Delay in seeking care for (42) MICKEY RM, GREENLAND S: The impact of cofounder selection criteria on cancer symptoms: A population-based study of elderly New Mexicans. J effect estimation. Am J Epidemiol 129:125-137, 1989 Natl Cancer Inst 80:432^t38, 1988 (43) AMERICAN CANCER SOCIETY: Black Americans' attitudes towards cancer SHERIDAN B, FLEMING J, ATKINSON L, ET AL: The effects of delay in treatand cancer tests: Highlights of a study. CA Cancer J Clin 31:212-218. ment on survival rates in carcinoma of the breast. Med J Aust 1:262-267, 1981 1971 (44) PRICE JH, DESMOND SM, WALLACE M, ET AL: Differences in black and GIVIO (Interdisciplinary Group for Cancer Care Evaluation) Italy: white adolescents' perceptions about cancer J Sch Health 58:66-70, Reducing diagnostic delay in breast cancer. Cancer 58:1756-1761, 1986 1988

IZuropean Organization for Research and IVcMtment of