Breast Cancer Research and Treatment

, Volume 131, Issue 2, pp 607–617 | Cite as

Racial/ethnic differences in initiation of adjuvant hormonal therapy among women with hormone receptor-positive breast cancer

  • Jennifer C. Livaudais
  • Dawn L. Hershman
  • Laurel Habel
  • Lawrence Kushi
  • Scarlett Lin Gomez
  • Christopher I. Li
  • Alfred I. Neugut
  • Louis Fehrenbacher
  • Beti Thompson
  • Gloria D. Coronado


Mortality after breast cancer diagnosis is known to vary by race/ethnicity even after adjustment for differences in tumor characteristics. As adjuvant hormonal therapy decreases risk of recurrence and increases overall survival among women with hormone receptor-positive tumors, treatment disparities may play a role. We explored racial/ethnic differences in initiation of adjuvant hormonal therapy, defined as two or more prescriptions for tamoxifen or aromatase inhibitor filled within the first year after diagnosis of hormone receptor-positive localized or regional-stage breast cancer. The sample included women diagnosed with breast cancer enrolled in Kaiser Permanente Northern California (KPNC). Odds ratios [OR] and 95% confidence intervals [CI] compared initiation by race/ethnicity (Hispanic, African American, Chinese, Japanese, Filipino, and South Asian vs. non-Hispanic White [NHW]) using logistic regression. Covariates included age and year of diagnosis, area-level socioeconomic status, co-morbidities, tumor stage, histology, grade, breast cancer surgery, radiation and chemotherapy use. Our sample included 13,753 women aged 20–79 years, diagnosed between 1996 and 2007, and 70% initiated adjuvant hormonal therapy. In multivariable analysis, Hispanic and Chinese women were less likely than NHW women to initiate adjuvant hormonal therapy ([OR] = 0.82; [CI] 0.71–0.96 and [OR] = 0.78; [CI] 0.63–0.98, respectively). Within an equal access, insured population, lower levels of initiation of adjuvant hormonal therapy were found for Hispanic and Chinese women. Findings need to be confirmed in other insured populations and the reasons for under-initiation among these groups need to be explored.


Breast cancer Adjuvant hormonal therapy Tamoxifen Aromatase inhibitors Racial/ethnic disparities 



Dr. Livaudais was supported by NCRR Grant TL1 RR025016 and NCI Grant R25 CA092408. Dr. Hershman is the recipient of a grant from the American Cancer Society (RSGT-08-009-01-CPHPS). Dr. Kushi is the recipient of a grant from the National Cancer Institute (R01 CA105274). Dr. Gomez is the recipient of a grant from the Surveillance Epidemiology and End Results Rapid Response Surveillance Study under contracts from N01-PC-35136. Dr. Neugut is the recipient of a grant from the Department of Defense (BC043120). Dr. Habel is the recipient of a grant from the National Cancer Institute (R01 CA98838).

Conflict of interest

The authors have no financial conflicts of interest to disclose.


  1. 1.
    Jemal A et al (2004) Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer 101(1):3–27PubMedCrossRefGoogle Scholar
  2. 2.
    Lin SS et al (2002) Survival differences among Asian subpopulations in the United States after prostate, colorectal, breast, and cervical carcinomas. Cancer 94(4):1175–1182PubMedCrossRefGoogle Scholar
  3. 3.
    Ooi SL, Martinez ME, Li CI (2011) Disparities in breast cancer characteristics and outcomes by race/ethnicity. Breast Cancer Res Treat 127(3):729–738PubMedCrossRefGoogle Scholar
  4. 4.
    Banerjee M et al (2007) Disentangling the effects of race on breast cancer treatment. Cancer 110(10):2169–2177PubMedCrossRefGoogle Scholar
  5. 5.
    Hershman D et al (2005) Racial disparities in treatment and survival among women with early-stage breast cancer. J Clin Oncol 23(27):6639–6646PubMedCrossRefGoogle Scholar
  6. 6.
    Clarke MJ (2008) Tamoxifen for early breast cancer. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD000486Google Scholar
  7. 7.
    Alkner S et al (2009) Tamoxifen reduces the risk of contralateral breast cancer in premenopausal women: results from a controlled randomised trial. Eur J Cancer 45(14):2496–2502PubMedCrossRefGoogle Scholar
  8. 8.
    Hershman DL, Shao T, Kushi LH, Buono D, Tsai WY, Fehrenbacher L, Kwan M, Gomez SL, Neugut AI (2011) Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat 126(2):529–537PubMedCrossRefGoogle Scholar
  9. 9.
    Prehn AW et al (2002) Differences in treatment patterns for localized breast carcinoma among Asian/Pacific islander women. Cancer 95(11):2268–2275PubMedCrossRefGoogle Scholar
  10. 10.
    Freedman RA et al (2011) The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care. Cancer 117(1):180–189PubMedCrossRefGoogle Scholar
  11. 11.
    Short LJ et al (2010) Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention. Cancer 116(1):193–202PubMedGoogle Scholar
  12. 12.
    Early Breast Cancer Trialists’ Collaborative Group (2005) Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 365(9472):1687–1717CrossRefGoogle Scholar
  13. 13.
    NCCN Guidelines Version 2.2011:Breast Cancer 2011. Accessed 16 May 2011
  14. 14.
    Fink AK et al (2004) Patient beliefs and tamoxifen discontinuance in older women with estrogen receptor-positive breast cancer. J Clin Oncol 22(16):3309–3315PubMedCrossRefGoogle Scholar
  15. 15.
    Demissie S, Silliman RA, Lash TL (2001) Adjuvant tamoxifen: predictors of use, side effects, and discontinuation in older women. J Clin Oncol 19(2):322–328PubMedGoogle Scholar
  16. 16.
    Kahn KL et al (2007) Patient centered experiences in breast cancer: predicting long-term adherence to tamoxifen use. Med Care 45(5):431–439PubMedCrossRefGoogle Scholar
  17. 17.
    Lash TL et al (2006) Adherence to tamoxifen over the five-year course. Breast Cancer Res Treat 99(2):215–220PubMedCrossRefGoogle Scholar
  18. 18.
    Owusu C et al (2008) Predictors of tamoxifen discontinuation among older women with estrogen receptor-positive breast cancer. J Clin Oncol 26(4):549–555PubMedCrossRefGoogle Scholar
  19. 19.
    Kimmick G et al (2009) Adjuvant hormonal therapy use among insured, low-income women with breast cancer. J Clin Oncol 27(21):3445–3451PubMedCrossRefGoogle Scholar
  20. 20.
    Pellegrini I, Sarradon-Eck A, Soussan PB, Lacour AC, Largillier R, Tallet A, Tarpin C, Julian-Reynier C (2010) Women’s perceptions and experience of adjuvant tamoxifen therapy account for their adherence: breast cancer patients’ point of view. Psychooncology 19(5):472–479PubMedCrossRefGoogle Scholar
  21. 21.
    Hershman DL et al (2010) Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early-stage breast cancer patients. J Clin Oncol 28(27):4120–4128PubMedCrossRefGoogle Scholar
  22. 22.
    Early Breast Cancer Trialists’ Collaborative Group (1998) Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 351(9114): 1451–1467Google Scholar
  23. 23.
    Yost K et al (2001) Socioeconomic status and breast cancer incidence in California for different race/ethnic groups. Cancer Causes Control 12(8):703–711PubMedCrossRefGoogle Scholar
  24. 24.
    Charlson ME et al (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383PubMedCrossRefGoogle Scholar
  25. 25.
    Klabunde CN et al (2000) Development of a comorbidity index using physician claims data. J Clin Epidemiol 53(12):1258–1267PubMedCrossRefGoogle Scholar
  26. 26.
    Bickell NA et al (2006) Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol 24(9):1357–1362PubMedCrossRefGoogle Scholar
  27. 27.
    Ashing-Giwa KT et al (2006) Understanding the breast cancer experience of Latina women. J Psychosoc Oncol 24(3):19–52PubMedCrossRefGoogle Scholar
  28. 28.
    Buki LP et al (2008) Latina breast cancer survivors’ lived experiences: diagnosis, treatment, and beyond. Cultur Divers Ethnic Minor Psychol 14(2):163–167PubMedCrossRefGoogle Scholar
  29. 29.
    Napoles-Springer AM et al (2007) Information exchange and decision making in the treatment of Latina and white women with ductal carcinoma in situ. J Psychosoc Oncol 25(4):19–36PubMedCrossRefGoogle Scholar
  30. 30.
    Medline Plus Drug Information: Anastrozole (2008) Accessed 1 July 2008
  31. 31.
    Medline Plus Drug Information: Tamoxifen (2008) Accessed 1 July 2008
  32. 32.
    Ashing-Giwa KT et al (2004) Understanding the breast cancer experience of women: a qualitative study of African American, Asian American, Latina and Caucasian cancer survivors. Psychooncology 13(6):408–428PubMedCrossRefGoogle Scholar
  33. 33.
    Oates DJ, Silliman RA (2009) Health literacy: improving patient understanding. Oncology (Williston Park) 23(4):376–379Google Scholar
  34. 34.
    Maunsell E et al (2005) Breast cancer survivors accurately reported key treatment and prognostic characteristics. J Clin Epidemiol 58(4):364–369PubMedCrossRefGoogle Scholar
  35. 35.
    Phillips KA et al (2005) Agreement between self-reported breast cancer treatment and medical records in a population-based Breast Cancer Family Registry. J Clin Oncol 23(21):4679–4686PubMedCrossRefGoogle Scholar
  36. 36.
    Du XL et al (2006) Information on chemotherapy and hormone therapy from tumor registry had moderate agreement with chart reviews. J Clin Epidemiol 59(1):53–60PubMedCrossRefGoogle Scholar
  37. 37.
    Clegg LX et al (2007) Quality of race, Hispanic ethnicity, and immigrant status in population-based cancer registry data: implications for health disparity studies. Cancer Causes Control 18(2):177–187PubMedCrossRefGoogle Scholar
  38. 38.
    Gomez SL, Glaser SL (2006) Misclassification of race/ethnicity in a population-based cancer registry (United States). Cancer Causes Control 17(6):771–781PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2011

Authors and Affiliations

  • Jennifer C. Livaudais
    • 1
  • Dawn L. Hershman
    • 2
  • Laurel Habel
    • 3
  • Lawrence Kushi
    • 3
  • Scarlett Lin Gomez
    • 4
  • Christopher I. Li
    • 5
    • 6
  • Alfred I. Neugut
    • 2
  • Louis Fehrenbacher
    • 3
  • Beti Thompson
    • 5
    • 6
  • Gloria D. Coronado
    • 7
  1. 1.Department of Health Evidence and PolicyMount Sinai School of MedicineNew YorkUSA
  2. 2.Department of Medicine and the Herbert Irving Comprehensive Cancer CenterColumbia University Medical CenterNew YorkUSA
  3. 3.Kaiser Division of ResearchOaklandUSA
  4. 4.Cancer Prevention Institute of CaliforniaFremontUSA
  5. 5.Fred Hutchinson Cancer Research CenterSeattleUSA
  6. 6.University of Washington School of Public HealthSeattleUSA
  7. 7.The Center for Health Research, Kaiser Permanente NorthwestPortlandUSA

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