Having breast cancer placed a significantly greater financial strain on black women than white women, according to study by researchers at the University of North Carolina Lineberger Comprehensive Cancer Center.

The researchers, who published their findings in the Journal of Clinical Oncology, surveyed women who were diagnosed with breast cancer in North Carolina between 2008 and 2013. They found that two years after a diagnosis with breast cancer, 58 percent of black women reported a negative financial impact of cancer, compared with 39 percent of white women.

“Financial hardship plays a role in delays, discontinuation and omission of treatment, and thus may correlate with racial disparities in breast cancer death,” said UNC Lineberger’s Stephanie Wheeler, the study’s lead author and an associate professor in the UNC Gillings School of Global Public Health. “With cancer care costs rapidly increasing, culturally appropriate strategies are urgently needed to address this problem.”

The researchers analyzed survey data from the Carolina Breast Cancer Study, the largest population-based study of breast cancer in North Carolina. Launched in 1993, the Carolina Breast Cancer Study aims to improve the understanding of breast cancer, and particularly why the disease’s fatality rate is higher in African-American women. The study is in its third phase, and is focused on how treatment decisions, access to care and financial or geographic barriers impact breast cancer outcomes.

The new study, led by Wheeler, included 1,265 white women, and 1,229 black women. On average, black women in the analysis were slightly younger, and they presented with higher-stage disease at the time of diagnosis. They more often received chemotherapy and radiation therapy, and were more likely to present with comorbid conditions such as obesity, hypertension and diabetes. They were also more socioeconomically disadvantaged, with lower average household incomes, education, and higher rates of Medicaid and no insurance.

Nearly half of the women – 48 percent – experienced negative financial impact from breast cancer, but the researchers said it was strikingly higher among black women. Even after they controlled for differences in clinical variables such as age, stage at diagnosis, comorbidities and cancer treatments received, they found that black women were significantly more likely to experience higher cancer-related financial burden.

Black women more often reported having a barrier to their care that caused them to delay or refuse recommended treatment because of cost (24 percent of black women compared to 11 percent of white women). Black women also had a greater likelihood of losing a job (14 percent compared to 6 percent of white women). While it was a small share overall, black women more often lost private health insurance (5 percent versus 1 percent of white women).

Wheeler said that although the study didn’t evaluate why the women may have lost private health insurance, it could have occurred as a result of a job loss or because of reduced hours at work that would put them below the threshold of qualifying for employer-sponsored health insurance.

“Employer-sponsored health insurance and paid sick leave are often reserved for employees with higher earnings, full-time status, and more generous benefits, which may correlate also with race,” she said.

Wheeler said work is ongoing to understand how patients communicate about cancer costs, and seek financial support, as well as to explore efforts to better connect patients with resources, and to try to reduce the financial burden of care.

“Wealth in our society is a complex construct, including not only how much money a person earns, but also the generosity of their health insurance benefits, the savings and assets that they can pull from in a time of crisis, and the flexibility of their commitments at work and at home,” said UNC Lineberger’s Katherine Reeder-Hayes, MD, MBA, MSc, an assistant professor in the UNC School of Medicine Division of Hematology/Oncology and the study’s senior author. “We need to do more work to understand why black women, even at similar income and education levels, seem to be more vulnerable to financial toxicity of breast cancer.”