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Impact of Toxicity Assumptions on Socioeconomic Analysis of Breast Cancer Chemotherapy

Oncology Care Medical Associates, Montebello, CA

To the Editor:

I am pleased to see the analysis of socioeconomic status and outcomes in the recent study by Griggs et al.¹ However, they assume that community physicians' biases may be the major reason for lower first chemotherapy dosing for patients of lower socioeconomic status. The authors state that first chemotherapy dose differences may be due to "providers' anticipation of a different response to the same adverse effects rather than a different adverse effect profile."

However, there is a higher toxicity from adjuvant therapy for patients from lower socioeconomic strata. Hassett et al² reported more frequent adverse effects in a community-based population compared with patients in clinical trials. They note that some of the differences may be due to the gradient of socioeconomic status and health. Gross et al³ confirm that participation in clinical trials is a surrogate for higher socioeconomic status in breast cancer patients. Like most other cooperative studies, the classic Bonnadonna and Valagussa trial⁴ documenting a dose/primary end point relationship was not stratified by socioeconomic status. I suspect at least some of their differences in dose-intensity may correlate with toxicity. In other words, excess toxicity may negate the benefits of high-quality chemotherapy in patients of lower socioeconomic status.

It seems logical that oncologists would prescribe lower first chemotherapy doses based on a realistic concern over higher toxicity in this population. Further prospective studies will solve these and other socioeconomic conundrums.

The gradient of socioeconomic status and health is based on complex interactions between health care, environment, and patient behavioral patterns.⁵ Griggs' study¹ should stimulate further research in this rapidly evolving discipline.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author indicated no potential conflicts of interest.

REFERENCES

1. Griggs JJ, Culacova E, Sorbero MES, et al: Effect of patient socioeconomic status and body mass index on the quality of breast cancer adjuvant chemotherapy. J Clin Oncol 25:277-284, 2007[Abstract/Free Full Text]

2. Hassett MJ, O'Malley J, Pakes JR, et al: Frequency and cost of chemotherapy-related serious adverse efffects in a population sample of women with breast cancer. J Natl Cancer Inst 98:1108-1117, 2006[Abstract/Free Full Text]

3. Gross CP, Filardo G, Mayne ST, et al: The impact of socioeconomic status and race on trial participation for older women with breast cancer. Cancer 103:483-491, 2005[CrossRef][Medline]

4. Bonnadonna G, Valagussa P: Dose-response effect of adjuvant chemotherapy in breast cancer. N Engl J Med 304:10-15, 1981[Abstract]

5. Deaton A: Policy implications of the gradient of health and wealth. Health Affairs 21:13-30, 2002[Abstract/Free Full Text]

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Related Reply

• In Reply
  Jennifer J. Griggs, Eva Culakova, Melony E.S. Sorbero, and Gary H. Lyman
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