Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer

JAMA. 1998 Jun 10;279(22):1801-7. doi: 10.1001/jama.279.22.1801.


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.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • African Americans* / psychology
  • African Americans* / statistics & numerical data
  • Aged
  • Breast Neoplasms / diagnosis
  • Breast Neoplasms / ethnology*
  • Breast Neoplasms / psychology
  • Case-Control Studies
  • Culture
  • European Continental Ancestry Group* / psychology
  • European Continental Ancestry Group* / statistics & numerical data
  • Female
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Logistic Models
  • Middle Aged
  • Multivariate Analysis
  • Neoplasm Staging
  • Socioeconomic Factors
  • United States / epidemiology