Why Poor Women Are More Likely To Die From Breast Cancer

An exhaustive review of national breast cancer cases [2] released this week in the journal BMC Cancer found that the poorer you are, the better chance you have of dying from the disease. Epidemiologist Xue Qin Yu, formerly of the American Cancer Society, examined the records of more than 112,500 women diagnosed with breast cancer in the United States between 1998 and 2002 and tracked them until 2005. He found that women in the lowest socioeconomic areas were more inclined to have advanced-stage cancers at the time of diagnosis and to receive inadequate treatment. Black poor women fared the worst, and another statistic from 2006 found that death rates of black women were 38 percent higher [3] than for their white peers. Not only were black women genetically predisposed to develop deadly tumors and contract the disease at a younger age, but they were four times more likely to live in the most impoverished neighborhoods.

Why the disparity? Poor women sought out fewer mammograms—cancer-screening tools that could have helped doctors locate the disease when it was easier to treat. That’s because many did not have health insurance and couldn’t afford them otherwise. Even for middle-class women, the bad economy and a slew of other factors make it difficult for women over 40 to adhere to the American Cancer Society’s recommendation [4] that they get their boobs squished between panes of plastic once a year.

How much a mammogram actually costs is a medical mystery, requiring decoding the differential between self-pay and secretly negotiated insurance rates. To complicate matters, many facilities will give you a discount if you pay cash and spare staffers the task of filing insurance claims. On the low end, Medicare reimburses $89 for a film mammography. On the high end, a digital screening can run hundreds of dollars in New York City. Some quotes don’t include radiologist fees, which can add hundreds more. The website CostHelper.com includes cautionary postings from patients [5] who received unexpected big bills.

But whatever the cost of mammograms, experts predict more women will find it harder to afford them. And it’s not just a lament of the estimated 7 million uninsured women between 40 and 64, of whom only four in 10 get regular mammograms, compared with eight in 10 women with private insurance. Although most states require private health insurance companies to cover mammograms (the National Women’s Law Center recently published a state-by-state online “report card” [6]), the insurance industry has undergone such major changes in the last few years that many consumers are being asked to pay a larger percentage of the cost via rising co-pays or higher deductibles. The rapid growth of plans with deductibles of thousands of dollars means some women will have to pay for the whole thing out of pocket. Some insurance plans provide a small “preventative care” budget, but a pricey mammogram can quickly use it up, leaving little for other needs such as a general physical or annual OB/GYN exams. Is it really progress if every year you have to choose between a mammogram and a Pap smear?

Even before the cost of mammograms increased, several studies showed that nominal fees can deter low-income women from seeking out mammograms. One analysis from 2001 to 2004 on the effect of cost-sharing in Medicare health plans [7] found that the number of women who underwent screenings dropped significantly when they were asked to pay more than $10 or 10 percent of the cost. (The current co-pay is 20 percent [8].) Another study of nearly 900 low-income women in North Carolina found that more than half said cost prevented them from being screened [9], and 40 percent didn’t even know how much of the procedure their insurance policies would cover. Although many programs offer free or low-cost mammograms, such as the CDC’s National Breast and Cervical Cancer Early Detection Program [10], poor women often assume they can’t afford one, explains Ann Scheck McAlearney, an associate professor of health services management and policy at Ohio State University.

It doesn’t help that sourcing mammograms may become less convenient, since the number of imaging facilities [11] has dropped 12 percent since 2000, due to hospital consolidation and low reimbursement rates, which make the mammogram business unprofitable. And it’s hard to convince time- and resource-starved women to travel long distances when their ta-tas feel and look just fine. But mammograms matter. Some 40,000 women in the United States die annually from breast cancer, and epidemiologists estimate that early detection lowers the mortality rate anywhere from 17 percent to 32 percent. It also gives women a better chance of keeping their breasts and enduring less-toxic treatments.

Despite this disappointing news for poorer women, the overall fight against breast cancer has seen some bright spots [12]. Survival rates overall have steadily improved for the last two decades, especially among women younger than 50, thanks to earlier detection of the disease and better treatment. And though the poor are more likely to skip screenings, nearly 77 percent of women over 40 have received a mammogram within the last two years [13], according to the Kaiser Family Foundation’s analysis of Centers for Disease Control statistics.

The mammogram technology for that 77 percent keeps getting better. More than half of the 8,700 imaging facilities in the United States have switched over from film X-rays to the fancier digital machines [14], which are believed to be better for women under 50 and those with dense breasts. But improved technology comes at a cost. Digital mammograms are one-third more expensive, making it even more likely that the gap between the poorest and wealthiest patients will widen. As the barriers to these crucial tests increase, many women will seek medical help only after they find a lump.