1. Ethnic Disparities in Early Breast Cancer Management among Asian Americans and Pacific Islanders Rebecca P. Gelber, MD, MPH Department of Medicine, University of Hawaii; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Harvard Medical School

2. Background Standard treatment options for early breast cancer: – Breast-conserving surgery (BCS) – Radiation therapy following BCS – Chemotherapy for node-positive disease

3. Background Many women with early breast cancer do not receive standard treatment –Advanced age –Higher comorbidity –Rural residence –Lower socioeconomic status –Lack of health insurance –Non-white ethnicity

4. Background Few studies have addressed breast cancer management in Asian Americans and Pacific Islanders (AAPI) Results are conflicting Differences in presentation, survival for some ethnic groups

5. Objective To examine association between patient ethnicity and treatment of early breast cancer in a cohort of AAPI women.

6. Methods – Data Sources Linked data from: (1) Hawaii Tumor Registry –SEER (2) Healthcare claims –Largest health insurer in Hawaii –FFS, HMO, Medicare FFS –Treatment, comorbidity (3) 1990 Census tract data –Median household income

7. Study Population 2030 women Stages I, II, IIIA breast cancer Diagnosed 1995-2001 Insured by BC/BS and had healthcare claims White, Japanese, Chinese, Filipino, Hawaiian women

8. Treatment Outcomes BCS for primary resection Radiation therapy following BCS Adjuvant chemotherapy for node- positive disease

9. Statistical Analysis Logistic regression –Age –Tumor size, grade, nodal and receptor status –Income –Rural residence –Health plan type –Prior cancer history –Charlson comorbidity index –Year of diagnosis

10. Patient characteristics by ethnicity (n=2030) White (21%) Japanese (46%) Chinese (7%) Filipino (12%) Hawaiian (14%) * Mean age+ SD (y) 58+1362+1361+1453+1155+12 *Charlson >2 23638 * Income <$35,000 22212628 *P<0.001

11. Stage at diagnosis by ethnicity (n=2030) P<0.001

12. Tumor characteristics by ethnicity (n=2030) *P<0.001

13. Unadjusted treatment rates by ethnicity (n=2030) *P<0.05

14. Adjusted odds ratios for treatment by ethnicity Ref = white

15. Adjusted odds ratios for treatment by ethnicity Ref = white

16. Adjusted odds ratios for treatment by ethnicity Ref = white

17. Summary All AAPI women, particularly Japanese and Filipinos, less likely to receive BCS Filipinos may be less likely to receive radiation after BCS Similar use of adjuvant chemotherapy

18. Limitations Residual confounding Lack of information on patient preferences Case selection Power Generalizability

19. Strengths Large number of AAPIs Women <65 years Linked registry and claims – More complete treatment estimates – Ability to examine chemotherapy – Assess comorbidity

20. Conclusions Ethnic disparities in the management of early breast cancer among AAPIs Further study needed to determine reasons for these disparities and their impact on health outcomes

21. Ellen P. McCarthy, PhD, MPH Dept. of Medicine, Beth Israel Deaconess Medical Center James W. Davis, PhD University of Hawaii; Blue Cross/Blue Shield of Hawaii Todd B. Seto, MD, MPH Dept. of Medicine, University of Hawaii

22. BCS use by ethnicity (n=2030) EthnicityN (%)OR (95% CI) White263 (62)1.00 Japanese516 (55)0.62 (0.48-0.80) Chinese84 (58)0.74 (0.49-1.13) Filipino108 (46)0.47 (0.33-0.66) Hawaiian158 (54)0.81 (0.58-1.12) All1129 (56)

23. Use of XRT after BCS, by ethnicity (n=1129) EthnicityN with BCSXRT use (%)OR (95% CI) White263821.00 Japanese516881.38 (0.86-2.23) Chinese84892.33 (0.96-5.64) Filipino108770.80 (0.42-1.49) Hawaiian221831.23 (0.68-2.23) All112985

24. Use of CTX if LN+, by ethnicity (n=521) EthnicityN with LN+CTX use (%)OR (95% CI) White118811.00 Japanese187852.10 (0.98-4.50) Chinese36721.05 (0.35-3.18) Filipino78820.93 (0.40-2.18) Hawaiian102841.04 (0.46-2.35) All52183

25. Odds ratios for BCS, according to ethnicity and income level EthnicityBCS Low income (N=952)High income (N=1078) N (%)OR (95% CI)N (%)OR (95% CI) White144 (64)1.00119 (60)1.00 Japanese208 (53)0.65 (0.46-0.92)308 (57)0.90 (0.62-1.30) Chinese35 (59)0.84 (0.47-1.52)49 (57)0.89 (0.52-1.55) Filipino47 (40)0.37 (0.23-0.58)61 (52)0.78 (0.47-1.29) Hawaiian77 (48)0.52 (0.34-0.79)81 (60)1.10 (0.66-1.82) All511 (54)618 (57) LRT, P=0.34

26. Characteristics of women linked to claims CharacteristicLinkedUnlinkedP Age + SD (y)59 + 1361 + 13<0.001 Ethnicity (%)<0.001 Caucasian4159 Japanese6931 Chinese5941 Filipino5446 Hawaiian4555 Income >median (%)58420.001 Tumor <1cm (%)5941<0.001

27. BCS use: registry (n=3716) vs claims- supplemented (n=2030) data EthnicityAll Women in the RegistryWomen in the Registry with Linked Claims NBCSN %*Age-adjusted OR (95% CI) %*Age-adjusted OR (95% CI) White1038631.00423621.00 Japanese1351560.75 (0.64-0.89)935550.76 (0.60-0.97) Chinese242570.78 (0.58-1.03)144580.87 (0.59-1.28) Filipino436460.49 (0.39-0.62)235460.50 (0.36-0.70) Hawaiian649590.82 (0.67-1.00)293540.70 (0.52-0.95) All371657203056 P-value<0.0010.002

28. XRT after BCS: registry (n=3716) vs claims-supplemented (n=2030) data EthnicityAll Women in the RegistryWomen in the Registry with Linked Claims NXRT after BCSN %*Age-adjusted OR (95% CI) %*Age-adjusted OR (95% CI) White1038751.00423791.00 Japanese1351851.93 (1.47-2.54)935871.84 (1.24-2.75) Chinese242862.20 (1.30-3.72)144882.20 (1.05-4.59) Filipino436791.21 (0.82-1.78)235760.84 (0.49-1.44) Hawaiian649811.40 (1.02-1.92)293811.12 (0.68-1.86) All371681203083 P-value<0.0010.004

29. Patient characteristics (%) by ethnicity (n=2030) White (n=423) Japanese (n=935) Chinese (n=144) Filipino (n=235) Hawaiian (n=293) *Health plan FFS6673777276 HMO199102017 Medicare14171377 *P<0.05

30. Patient characteristics by ethnicity (n=2030) White (21%) Japanese (46%) Chinese (7%) Filipino (12%) Hawaiian (14%) * Stage I (%)6066575349 II3632414345 IIIA42246 * Tumor >2 cm (%) 2622302938 * +Node (%)2820253335 *P<0.001

31. Study Population Exclusions –>1 prior non-breast cancer (n=52) –>1 breast tumor diagnosed on the same date (n=34) –‘referred elsewhere, contraindicated, autopsy’ (n=26) –Missing tumor size (n=14) –Medicare-eligible in 1995-1996 (n=377)

32. Study Population 3339 eligible in tumor registry 2030 (61%) successfully linked to claims –Younger –Higher income –Smaller tumors –Japanese more likely linked