Introduction
Breast cancer is the most commonly diagnosed cancer in women and the second leading cause of cancer deaths in Texas women (BreastCancer.org, 2010). From 2002 to 2006, urban counties had much higher female breast cancer incidence and mortality rates compared to rural counties. Breast cancer was the second leading cause of cancer deaths among black females in Texas. This paper I examine the geographic distribution of breast cancer in Texas counties from 1980 to1998 and the reasons for this pattern. In addition, I examine the relationships between breast cancer mortality and race/ethnicity, socioeconomic status, genes, and environment. Using ArcGIS and statistical analysis in a human ecology framework, I will show who gets breast cancer where in Texas and why.
Breast cancer is a malignant tumor that has developed from cells in the breast. It is considered a heterogeneous disease, differing by individual, age group, and even the kinds of cells within the tumors themselves. Usually breast cancer either begins in the cells of the lobules, which are the milk-producing glands, or the ducts, the passages that drain milk from the lobules to the nipple. Less commonly, breast cancer can begin in the stromal tissues, which include the fatty and fibrous connective tissues of the breast (Breastcancer.org, 2010). Over time, cancer cells can invade nearby healthy breast tissue and make their way into the underarm lymph nodes, small organs that filter out foreign substances in the body. If cancer cells get into the lymph nodes, they then have a pathway into other parts of the body.
Breast cancer is always caused by a genetic abnormality, a mistake in the genetic material. However, only 5 to10% of cancers are due to an abnormality inherited from your mother or father. About 90% of breast cancers are due to genetic abnormalities that happen as a result of the aging process and “wear and tear” of life in general (Breastcancer.org, 2010). Even though Breast cancer is always a genetic abnormality, if diagnosed early it will not lead to death.
Breast cancer has been attributed to many factors including race/ethnicity, socio-economic status, genes and environment, either in a rural or urban community. Race/ethnicity appears to be a major factor in breast cancer. Black women are more prone to breast cancer than White women. The disparity in mortality rates between White and Black women increased between 1980 and 2000, so that by 2000 the age-standardized death rate was 32% higher in African Americans (Ghafor et al., 2003). While the rate of breast cancer diagnosed among black women has decreased the mortality rate has increased. This difference in breast cancer death rates between Black women and White women in Texas may be explained by the differences in the time of diagnoses. Use of mammography in the 1980’s and early 1990’s was lower in Black than in White women. Black women are less likely to receive radiation therapy after breast conserving surgery (Ghafor, et al., 2003). Because they generally have lower incomes, Black women may not have the money to cover these costs, so they never go back for follow ups or therapy.
Generally speaking survival in White women from breast cancer is greater than for Black women, but the disparity is less in situations where equality of treatment is the same across racial and ethnic groups. An analysis of the survival experience of women with breast cancer treated in U.S. military health care facilities suggests that the disparity in breast cancer survival between Black and White women could be reduced by 70% by providing equal treatment to all women (Ghafor, et al., 2003). It appears that this survival gap can be decreased by eliminating disparities in access to health care services and improving access for lower socioeconomic status people.
Disparities exist between rural and urban populations in the stage of disease at first diagnosis. Early staging is considered an indicator of quality medical care and improves outcomes for many cancer types. Conversely, delayed diagnosis (unstated or late stage) can result in poorer outcomes (Gosschalk & Carozza, 2003). For environmental or geographic reasons, it may be harder for Black women to access mammogram facilities or equal mammographic quality compared to White women.
Genetics may also be a factor in who gets breast cancer. Recent studies have shown that the Ashkenazi, a population of Eastern European Jews, may have a higher chance of breast cancer because they have a higher proportion of BRCA1 and BRCA2 mutations than the general U.S. population. However this alone may not make a significant difference in the disparity of breast cancer between White and Black women. These groups of women may still have faster and easier access to health and treatment than Black women do. Researchers indicate that because of these new findings more women will benefit from closer monitoring for breast cancers. Nonetheless this may only benefit the specific groups of women that carry the gene. I think it will take attention away from the groups of women that do not have access to early detection, due to their economic status and or environment.
Insurance and socioeconomic status may play a role in cancer screening, diagnosis, staging, and treatment. A statewide Michigan study found that low income groups, defined as receiving Medicaid, had a disproportionately large share of cancer. Many Black people that live in urban areas are there because they do not have other choices. An average mammogram costs $200 for uninsured women in Texas. This does not include the diagnoses fee or the treatment fees if cancer is found. A Florida study found that those insured by Medicaid and the uninsured were at a greater risk of late-stage diagnosis than the insured (Gosschalk & Carozza, 2003). It seems that a person’s economic status affects the kind of service they get. The quality of a person’s insurance may define her prognosis.
Differences in breast cancer mortality rates between Black and White women have been observed in previous studies. Many of the results seem to reveal that Black women with breast cancer have a much higher mortality rate than White women (Ghafor et al., 2003). There are several explanations for this, which I have touched on, ranging from poor socioeconomic status to genetics. Indeed these are factors that should be examined further.
Hypotheses
I will be focusing on 3 primary hypotheses. They are as follows:
1. Race/ethnicity is a predictor of breast cancer mortality. Counties with higher number of Black people will have a higher rate of breast cancer mortality.
2. Counties with a higher number of uninsured people and low income areas will have higher rates of breast cancer mortality.
3. Population density will also be an indicator in breast cancer mortality in Texas counties; urban counties, with a larger population density, will have higher breast cancer mortality rates.