Response

Extract

Schwartz et al. suggest that our observation (1) of the well-reported black–white crossover in age-specific breast cancer incidence disappearing after stratification by molecular subtype is an example of a Simpson’s Paradox. A Simpson’s Paradox can lead observers to incorrectly conclude that effects seen within subgroups reflect the true effect in the overall group. In such a situation, the observer must then carefully consider causality, confounding, and other knowledge about the subject matter to decide whether the subgroup or the overall population provides better information for answering the question under study (2).

We approached our analysis from a different perspective—namely, to ask whether the black–white crossover in overall breast cancer rates is also observed for breast cancer subtypes that are based on well-studied molecular subtypes defined jointly by hormone receptor and HER2 status. We concluded that the joint distributions of race/ethnicity and molecular subtype are more useful than race/ethnicity alone in understanding racial and ethnic differences in breast cancer occurrence. We further identified triple-negative (ie, hormone receptor–negative and HER2-negative) breast cancer as having very different age-specific incidence patterns compared with other subtypes, inferring etiologic heterogeneity. Schwartz and colleagues provide a graph of age-specific incidence rate ratios for estrogen receptor (ER)–positive vs ER-negative breast cancer among whites and blacks, which shows that the ratios are relatively consistent among races and suggests “similar effects within similar populations.” Using our own data, we extended that analysis by stratifying ratios further by HER2 status (Figure 1). The rate ratios for black and white women with HER2-positive cancers are similar across age groups, but for HER2-negative cancers the rate ratios increase slightly with age among black women and increase markedly with age among white women. This additional stratification by HER2 status shows that HER2-negative cancers may have differential occurrence among white women, especially at older ages.