Cancer survival among US whites and minorities: a SEER (Surveillance, Epidemiology, and End Results) Program population-based study

International comparisons of survival from lung cancer: pitfalls and warnings

Population-based survival data can provide valuable comparative data on outcome but should be interpreted with caution. Differences in data collection and analysis, patient and tumor characteristics and treatment options can have an impact on reported results. Ideally, data from the whole population, including clinical-only diagnoses, should be reported and the methods of case identification described. The relative survival rates should preferably be given. Data on patient characteristics such as age, sex, ethnicity and socioeconomic deprivation should be described, together with tumor details such as pathology and clinical stage. Whenever possible, details on the use of treatments should be reported.

Associations of physical activity, sedentary time, and insulin with percent breast density in Hispanic women

BACKGROUND

In a previous study of Hispanic women, we reported a positive association between sedentary time and percent breast density, a marker of breast cancer risk. It is unclear whether associations between sedentary time or physical activity and percent breast density are mediated through serum insulin levels or insulin resistance, factors also associated with physical activity and breast cancer risk.

METHODS

In the Chicago Breast Health Project phase II pilot study, detailed information on health and lifestyle factors, including sitting time and total physical activity over the previous 7 days, was collected from 95 Hispanic women aged 40-77 years. We also assessed percent breast density and measured fasting serum insulin and glucose to calculate the Homeostasis Model Assessment (HOMA) index, a measure of insulin resistance. Multivariable linear regression was used to assess associations of total physical activity, time spent sitting, serum insulin, and HOMA index with percent breast density.

RESULTS

There was no association between total physical activity and percent breast density (p = 0.98), whereas there was a positive association between sedentary time and percent density (beta = 0.25% per 100 metabolic equivalent (MET)-minutes/week, p = 0.06). Percent breast density was not associated with insulin or with HOMA index. The strength of the association between time spent sitting and percent density was unchanged after inclusion of insulin or the HOMA index in the model.

CONCLUSIONS

These results are consistent with our previous finding of an association between sedentary time and percent breast density and suggest that insulin or insulin resistance is unlikely to mediate this relation.

Parity and disparity in first course treatment of invasive breast cancer

BACKGROUND

Adherence to first course treatment guidelines for breast cancer may not be uniform across racial/ethnic groups and could be a major contributing factor to disparities in outcome. In this population-based study, we assessed racial differences in initial treatment of breast cancer.

METHODS

Surveillance, Epidemiology, and End Results (SEER) program data were used to study all primary invasive breast cancers diagnosed during 2000-2001 among Black (n = 877) and White (n = 2437) female residents of the five Atlanta SEER counties, counties with several large teaching hospitals. Differences in treatment delay, cancer directed surgery, and receipt of chemotherapy, radiotherapy, or hormonal therapy were analyzed according to guidelines for treatment. Analyses utilized frequency distributions, chi(2) tests of independence and statistics in and across strata.

RESULTS

Black women experienced longer treatment delays, regardless of stage at diagnosis, and were 4-5 fold more likely to experience delays greater than 60 days (P < 0.001). For local-regional disease, more Black women did not receive cancer directed surgery (7.5% vs. 1.5% of white women, P < 0.001), but did receive breast conserving surgery (BCS) equivalently. Only 61% of Black vs. 72% of White women received radiation with BCS (P < 0.001). Black women eligible for hormonal therapy were less likely to receive it (P < 0.001).

CONCLUSION

Our findings suggest treatment standards are not adequately or equivalently met among Black and White women, even in an area where teaching hospitals provide a substantial portion of breast cancer care. Treatment differences can adversely affect outcome and reasons for the differences need to be addressed.

Meta-analysis of racial disparities in survival in association with socioeconomic status among men and women with colon cancer

BACKGROUND

Few studies have addressed racial disparities in survival for colon cancer by adequately incorporating both treatment and socioeconomic factors, and the findings from those studies have been inconsistent. The objectives of the current study were to systematically review the existing literature and provide a more stable estimate of the measures of association between socioeconomic status and racial disparities in survival for colon cancer by undertaking a meta-analysis.

METHODS

For this meta-analysis, the authors searched the MEDLINE database to identify articles published in English from 1966 to August 2006 that met the following inclusion criteria: original research articles that addressed the association between race/ethnicity and survival in patients with colon or colorectal cancer after adjusting for socioeconomic status. In total, 66 full articles were reviewed, and 56 of those articles were excluded, which left 10 studies for the final analysis.

RESULTS

The pooled hazard ratio (HR) for African Americans compared with Caucasians was 1.14 (95% confidence interval [95% CI], 1.00-1.29) for all-cause mortality and 1.13 (95% CI, 1.01-1.28) for colon cancer-specific mortality. The test for homogeneity of the HR was statistically significant across the studies for all-cause mortality (Q=31.69; P<.001) but was not significant across the studies for colon cancer-specific mortality (Q=7.45; P=.114).

CONCLUSIONS

Racial disparities in survival for colon cancer between African Americans and Caucasians were only marginally significant after adjusting for socioeconomic factors and treatment. Attempts to modify treatment and socioeconomic factors with the objective of reducing racial disparities in health outcomes may have important clinical and public health implications.

Community readiness to promote Latinas' participation in breast cancer prevention clinical trials

The high breast cancer (BC) mortality rates that exist among Hispanic women (Latinas) are a health disparity burden that needs to be addressed. Prevention clinical trials are a burgeoning area of cancer prevention efforts and may serve to promote parity. Unfortunately, Latinas, along with other ethnic minority women, continue to be under-represented in this form of research. Previous studies have examined individual barriers to ethnic minorities' participation, but none have assessed community factors contributing to Latinas' under-representation in these studies. The present study addressed these limitations from a community perspective by exploring which factors might inhibit Latinas' participation in clinical trials, specifically BC prevention trials. Using the Community Readiness Model (CRM), 19 key informants were interviewed in four communities, two rural and two urban, in Colorado, USA. The key informant assessment involved a semistructured interview that measured the level of community readiness to encourage participation in BC prevention activities. The results reflected a community climate that did not recognise BC as a health problem that affected Latinas in participating communities. Compared to other healthcare priorities, participation in BC prevention clinical trials was considered a low priority in these communities. Overall, leadership and community resources were not identified or allocated to encourage the participation of Latinas. The results highlight the lack of awareness regarding clinical trials among both community members and leaders. According to the CRM, strategies to enhance awareness at multiple levels in the community are necessary. This study demonstrates how the CRM can be used to better understand a community's perspective on BC, and specifically, the under-representation of Latinas in clinical trials.

Ethnic disparities in conditional survival of patients with non-small cell lung cancer

PURPOSE

Conditional survival (CS) is an accurate estimate of survival probability for patients who have already survived at least 1 year after diagnosis. The purpose of this study was to determine whether ethnicity plays a role in 5-year CS rates for patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results database, we analyzed 96,480 patients with NSCLC diagnosed between 1988 and 1995. Patients were divided into five ethnic groups: White (non-Hispanic), Hispanic, African American, Asian/Pacific Islander, and Native American/Alaskan. Using the life table method, we computed observed 5-year CS rates for patients who had already survived up to 5 years after diagnosis. Results were analyzed by stage, age, sex, and histology.

RESULTS

In general, 5-year CS rates increase for all ethnicities as time from diagnosis increases, but African Americans continued to have lower CS rates compared with other ethnic groups, even up to 5 years from diagnosis. When analyzed by stage, Hispanics with stage IV disease showed the greatest improvement in CS rate, increasing to 73% at 5 years from diagnosis. Among patients older than 70 years, African Americans had the lowest CS at 5 years--only 28%, compared with 40% to 47% for other groups. When analyzed by histology, Hispanics with large cell carcinoma had the worst CS rate (35% at 5 years).

CONCLUSION

For patients with NSCLC surviving a period of time after diagnosis, 5-year CS rates vary by ethnicity. CS can provide accurate prognostic information for patients with NSCLC who have already survived several years after diagnosis.

Racial differences in tumor stage and survival for colorectal cancer in an insured population

BACKGROUND

Despite declining death rates from colorectal cancer (CRC), racial disparities have continued to increase. In this study, the authors examined disparities in a racially diverse group of insured patients.

METHODS

This study was conducted among patients who were diagnosed with CRC from 1993 to 1998, when they were enrolled in integrated healthcare systems. Patients were identified from tumor registries and were linked to information in administrative databases. The sample was restricted to non-Hispanic whites (n = 10,585), non-Hispanic blacks (n = 1479), Hispanics (n = 985), and Asians/Pacific Islanders (n = 909). Differences in tumor stage and survival were analyzed by using polytomous and Cox regression models, respectively.

RESULTS

In multivariable regression analyses, blacks were more likely than whites to have distant or unstaged tumors. In Cox models that were adjusted for nonmutable factors, blacks had a higher risk of death from CRC (hazard ratio [HR], 1.17; 95% confidence interval [95% CI], 1.06-1.30). Hispanics had a risk of death similar to whites (HR, 1.04; 95% CI, 0.92-1.18), whereas Asians/Pacific Islanders had a lower risk of death from CRC (HR, 0.89; 95% CI, 0.78-1.02). Adjustment for tumor stage decreased the HR to 1.11 for blacks, and the addition of receipt of surgical therapy to the model decreased the HR further to 1.06. The HR among Hispanics and Asians/Pacific Islanders was stable to adjustment for tumor stage and surgical therapy.

CONCLUSIONS

The relation between race and survival from CRC was complex and appeared to be related to differences in tumor stage and therapy received, even in insured populations. Targeted interventions to improve the use of effective screening and treatment among vulnerable populations may be needed to eliminate disparities in CRC.

Asian/Pacific Islander American Women: Age and Death Rates During Hospitalization for Breast Cancer

PURPOSE/OBJECTIVES

To investigate whether differences in age and death rates exist between hospitalized Asian/Pacific Islander American (APIA) women and women of other racial groups.

DESIGN

Secondary data analysis of a national data set.

SETTING

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample, Release 6, was used to obtain hospitalization data on women with breast cancer based on racial status. A total of 20,507 hospitalization records met the study criteria.

SAMPLE

All women who were hospitalized with a primary diagnosis of breast cancer, were older than 18, and did not die during hospitalization, plus all women who met the criteria stated above but died during hospitalization.

METHODS

Secondary data analysis. Post hoc analysis was used to identify significant differences among racial groups.

FINDINGS

Significant differences were found between APIA and Caucasian and Latino women. Significant differences based on race were found between subjects who had died during hospitalization. On average, APIA women were the youngest to die.

CONCLUSIONS

APIA women with breast cancer were among the youngest women being hospitalized and the youngest to die during hospitalization.

IMPLICATIONS FOR NURSING

Cultural awareness by nurses is critical when discussing methods for prevention and early detection of breast cancer with minority women. Targeting new immigrants is a priority for those who screen and educate women about detection and treatment of breast cancer.

Quality of race, Hispanic ethnicity, and immigrant status in population-based cancer registry data: implications for health disparity studies

Population-based cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute are based on medical records and administrative information. Although SEER data have been used extensively in health disparities research, the quality of information concerning race, Hispanic ethnicity, and immigrant status has not been systematically evaluated. The quality of this information was determined by comparing SEER data with self-reported data among 13,538 cancer patients diagnosed between 1973-2001 in the SEER--National Longitudinal Mortality Study linked database. The overall agreement was excellent on race (kappa = 0.90, 95% CI = 0.88-0.91), moderate to substantial on Hispanic ethnicity (kappa = 0.61, 95% CI = 0.58-0.64), and low on immigrant status (kappa = 0.21. 95% CI = 0.10, 0.23). The effect of these disagreements was that SEER data tended to under-classify patient numbers when compared to self-identifications, except for the non-Hispanic group which was slightly over-classified. These disagreements translated into varying racial-, ethnic-, and immigrant status-specific cancer statistics, depending on whether self-reported or SEER data were used. In particular, the 5-year Kaplan-Meier survival and the median survival time from all causes for American Indians/Alaska Natives were substantially higher when based on self-classification (59% and 140 months, respectively) than when based on SEER classification (44% and 53 months, respectively), although the number of patients is small. These results can serve as a useful guide to researchers contemplating the use of population-based registry data to ascertain disparities in cancer burden. In particular, the study results caution against evaluating health disparities by using birthplace as a measure of immigrant status and race information for American Indians/Alaska Natives.

African-American and Caucasian disparities in colorectal cancer mortality and survival by data source: an epidemiologic review

Over the past four decades in the United States, there has been a divergent trend in mortality rates between African-Americans and Caucasians with colorectal cancer (CRC). Rates among Caucasians have been steadily declining, whereas rates among African-Americans have only started a gradual decline in recent years. We reviewed epidemiologic studies of CRC racial disparities between African-Americans and Caucasians, including studies from SEER and population-based cancer registries, Veterans Affairs (VA) databases, healthcare coverage databases, and university and other medical center data sources. Elevated overall and stage-specific risks of CRC mortality and shorter survival for African-Americans compared with Caucasians were reported across all data sources. The magnitude of racial disparities varied across study groups, with the strongest associations observed in university and non-VA hospital-based medical center studies, while an attenuated discrepancy was found in VA database studies. An advanced stage of disease at the time of diagnosis among African-Americans is a major contributing factor to the racial disparity in survival. Several studies, however, have shown that an increased risk of CRC death among African-Americans remains even after controlling for tumor stage at diagnosis, socioeconomic factors, and co-morbidity. Despite advances in treatment, improvements in the standard of care, and increased screening options, racial differences persist in CRC mortality and survival. Therefore, continued research efforts are necessary to disentangle the clinical, social, biological, and environmental factors that constitute the racial disparity. In addition, results across data sources should be considered when evaluating racial differences in cancer outcomes.

Differences in health and cultural beliefs by stage of mammography screening adoption in African American women

Behavioral studies show that women's stage of readiness to adopt mammography screening affects their screening rates and that beliefs about breast cancer and screening affect stages of screening. The purposes of this study were to determine, first, the relationship between particular health and cultural beliefs and stage of mammography screening adoption in urban African American women, and second, whether demographic and experiential characteristics differed by stage. Data were analyzed from 344 low-income African American women nonadherent to mammography screening who participated in a 21-month trial to increase screening. At baseline, these women were randomized into 1 of 3 groups: tailored interactive computer instruction, targeted video, or usual care. Participants were categorized by stage of mammography screening adoption at 6 months as precontemplators (not planning to have a mammogram), contemplators (planning to have a mammogram), or actors (had received a mammogram). Although demographic and experiential variables did not differentiate stages of screening adoption at 6 months postintervention, some health and cultural beliefs were significantly different among groups. Actors were more preventive-health-oriented than precontemplators and had fewer barriers to screening than did contemplators. Precontemplators had more barriers, less self-efficacy, and greater discomfort with the mammography screening environment than did contemplators or actors. These results will be useful, not to change cultural beliefs, but to guide the design of health education messages appropriate to an individual's culture and health belief system. Cancer 2007. (c) 2006 American Cancer Society.

Early initiation of colorectal cancer screening in individuals with affected first-degree relatives

BACKGROUND

Several guidelines recommend initiating colorectal cancer screening at age 40 for individuals with affected first-degree relatives, yet little evidence exists describing how often these individuals receive screening procedures.

OBJECTIVES

To determine the proportion of individuals in whom early initiation of colorectal cancer screening might be indicated and whether screening disparities exist.

DESIGN

Population-based Supplemental Cancer Control Module to the 2000 National Health Interview Survey.

PARTICIPANTS

Respondents, 5,564, aged 40 to 49 years were included within the analysis.

MEASUREMENTS

Patient self-report of sigmoidoscopy, colonoscopy, or fecal occult blood test.

RESULTS

Overall, 279 respondents (5.4%: 95% C.I., 4.7, 6.2) reported having a first-degree relative affected with colorectal cancer. For individuals with a positive family history, 67 whites (27.9%: 95% C.I., 21.1, 34.5) and 3 African American (9.3%: 95% C.I., 1.7, 37.9) had undergone an endoscopic procedure within the previous 10 years (P-value = .03). After adjusting for age, family history, gender, educational level, insurance status, and usual source of care, whites were more likely to be current with early initiation endoscopic screening recommendations than African Americans (OR = 1.38: 95% C.I., 1.01, 1.87). Having an affected first-degree relative with colorectal cancer appeared to have a stronger impact on endoscopic screening for whites (OR = 3.21: 95% C.I., 2.31, 4.46) than for African Americans (OR = 1.05: 95% C.I., 0.15, 7.21).

CONCLUSIONS

White participants with a family history are more likely to have endoscopic procedures beginning before age 50 than African Americans.

Racial disparities and socioeconomic status in association with survival in a large population-based cohort of elderly patients with colon cancer

BACKGROUND

To the authors' knowledge, few studies have addressed racial disparities in the survival of patients with colon cancer by adequately incorporating treatment and socioeconomic factors in addition to patient and tumor characteristics.

METHODS

The authors studied a nationwide and population-based, retrospective cohort of 18,492 men and women who were diagnosed with stage II or III colon cancer at age >or=65 years between 1992 and 1999. This cohort was identified from the Surveillance, Epidemiology, and End Results (SEER) cancer registries-Medicare linked databases and included up to 11 years of follow-up.

RESULTS

A larger proportion (70%) of African-American patients with colon cancer fell into the poorest quartiles of socioeconomic status compared with Caucasians (21%). Patients who lived in communities with the lowest socioeconomic level had 19% higher all-cause mortality compared with patients who lived in communities with the highest socioeconomic status (hazards ratio [HR], 1.19; 95% confidence interval [95% CI], 1.13-1.26; P < .001 for trend). The risk of dying was reduced only slightly after controlling for race/ethnicity (HR, 1.17; 95% CI, 1.10-1.24). Compared with Caucasian patients with colon cancer, African-American patients were 21% more likely to die after controlling for age, sex, comorbidity scores, tumor stage, and grade (HR, 1.21; 95% CI, 1.12-1.30). After also adjusting for definitive therapy and socioeconomic status, the HR of mortality was only marginally significantly higher in African Americans compared with Caucasians for all-cause mortality (HR, 1.10; 95% CI, 1.02-1.19) and colon cancer-specific mortality (HR, 1.16; 95% CI, 1.01-1.33).

CONCLUSIONS

Lower socioeconomic status and lack of definitive treatment were associated strongly with decreased survival in both men and women with colon cancer. Racial disparities in survival were explained substantially by differences in socioeconomic status.

Research institute for nurse scientists responds to the challenge to expand and strengthen research focused on breast cancer in African American women

In an era where scientifically derived 'evidence' is used as a basis for nursing practice, it is imperative that nurses have a breadth of knowledge relative to the fundamentals of nursing science; knowledge of the current standards of nursing and medical practice; and knowledge of the characteristics, needs, concerns, and challenges of diverse consumer and patient population groups. Yet, while a significant body of 'evidence' that describes the experiences and needs of African American women across the breast care continuum has been generated, research suggests that there is a need to expand and strengthen this body of science. This report presents an overview of a decade of research focused on breast cancer among African American women and describes an initiative funded by the Susan G. Komen Breast Cancer Foundation to expand and strengthen nursing science that aims to reduce and/or eliminate excess breast cancer morbidity and mortality among African American women. Cancer 2007. (c) 2006 American Cancer Society.

Differences in predictors of cervical and breast cancer screening by screening need in uninsured Latina women

BACKGROUND

Latino women experience higher mortality for cervical cancer and lower 5-year survival for breast cancer than non-Latino White women. Adherence with screening recommendations can increase chances of survival, yet the factors that influence screening behaviors in uninsured women are not well documented.

METHODS

Uninsured Latino women (N = 467) recruited in four US cities participated in the study. Logistic regression was used to model adherence to recommendations by screening type (cervical or breast cancer) and screening need (needs to obtain initial screening, overdue for rescreening, up-to-date with rescreening).

RESULTS

Predictors differed by type of screening and screening need. Women who reported exposure to cancer education were more likely to have had a mammogram and to be up-to-date with Pap smear screening than women without such exposure. Women who were younger, had more than a sixth grade education, and/or had children were more likely to have had a Pap smear. Older women who had been in the US the longest were more likely to be overdue for a Pap smear. Women with incomes 5000 to 7000 were more likely to have obtained a mammogram. Regional differences were found with respect to mammography screening and maintenance behaviors.

CONCLUSIONS

Exposure to cancer education is an important predictor of screenings among uninsured urban Latino women. The potential of creating educational interventions that can increase screening rates among women who evidence health disparities is encouraging. Recruitment strategies to reach women in need of screenings are provided.

Changing Nature of High Risk Patients Undergoing Radical Prostatectomy

PURPOSE

We examined the outcomes of radical prostatectomy alone in high risk patients with prostate cancer and evaluated changes in high risk prostate cancer outcomes with time.

MATERIALS AND METHODS

From 1988 to 2003, 251 men with high risk prostate cancer (prostate specific antigen more than 20 ng/ml and/or biopsy Gleason greater than 7) were identified in a cohort of 1,796 (14%) enrolled in the Shared Equal Access Regional Cancer Hospital Database. Temporal changes in clinicopathological characteristics and prostate specific antigen recurrence rates were examined stratified by 4, 4-year periods.

RESULTS

With time significantly more men were considered at high risk due to a high biopsy Gleason score relative to prior years, when the most common reason for being considered at high risk was increased PSA (p <0.001). Only 3% of high risk men from 2000 to 2003 had increased prostate specific antigen and high biopsy Gleason score compared to 23% from 1988 to 1991. With time there were no differences in biochemical recurrence rates (p = 0.147). Men with a high biopsy Gleason score and increased prostate specific antigen had worse outcomes than men with only a high Gleason score or men with only high prostate specific antigen (p = 0.046 and 0.081, respectively). On multivariate analysis that only included preoperative clinical characteristics only prostate specific antigen was an independent predictor of prostate specific antigen failure following radical prostatectomy (p = 0.014). There was a trend, which did not attain statistical significance, for higher biopsy Gleason scores and higher clinical stage to be associated with higher failure rates (p = 0.060 and 0.081, respectively).

CONCLUSIONS

Patients are designated as high risk by Gleason grade more commonly now than early in the prostate specific antigen era. Outcomes in high risk patients undergoing radical prostatectomy alone have not significantly improved with time. New treatment strategies, such as multimodality therapy, are needed to improve outcomes in high risk patients with prostate cancer.

Genome-wide linkage of 77 families from the African American Hereditary Prostate Cancer study (AAHPC)

BACKGROUND

The African American Hereditary Prostate Cancer (AAHPC) Study was designed to recruit families with early-onset disease fulfilling criteria of >or=4 affected.

METHODS

We present a approximately 10 cM genome-wide linkage (GWL) analysis on 77 families including 254 affected and 274 unaffected genotyped.

RESULTS

Linkage analysis revealed three chromosomal regions with GENEHUNTER multipoint HLOD scores >or=1.3 for all 77 families at 11q22, 17p11, and Xq21. One family yielded genome-wide significant evidence of linkage (LOD = 3.5) to the 17p11 region with seven other families >or=2.3 in this region. Twenty-nine families with no-male-to-male (MM) transmission gave a peak HLOD of 1.62 (alpha = 0.33) at the Xq21 locus. Two novel peaks >or=0.91 for the 16 families with '>6 affected' occurred at 2p21 and 22q12.

CONCLUSIONS

These chromosomal regions in the genome warrant further follow-up based on the hypothesis of multiple susceptibility genes with modest effects, or several major genes segregating in small subsets of families.

A socioecological approach to improving mammography rates in a tribal community

This article highlights the processes and intermediate outcomes of a pilot project to increase mammography rates of women in an American Indian tribe in New Mexico. Using a socioecological framework and principles of community-based participatory research, a community coalition was able to (a) bolster local infrastructure to increase access to mammography services; (b) build public health knowledge and skills among tribal health providers; (c) identify community-specific knowledge, attitudes, and beliefs related to breast cancer; (d) establish interdependent partnerships among community health programs and between the tribe and outside organizations; and (e) adopt local policy initiatives to bolster tribal cancer control. These findings demonstrate the value of targeting a combination of individual, community, and environmental factors, which affect community breast cancer screening rates and incorporating cultural strengths and resources into all facets of a tribal health promotion intervention.

Obesity and prognosis of breast cancer

Obesity has a complicated relationship to both breast cancer risk and the clinical behaviour of the established disease. It is suggested that obesity is associated with both an increased risk of developing breast cancer risk and worse prognosis after disease onset. In post-menopausal women, various measures of obesity such as body mass index, weight, weight gain and waist : hip ratio have all been positively associated with risk of developing breast cancer. In most but not all case-control and prospective cohort studies, an inverse relationship has been found between weight and breast cancer among pre-menopausal women. Some data suggest that adult weight gain and central obesity increase the risk of pre-menopausal breast cancer. Obesity at the time of diagnosis is thought to be significant as a poor prognostic factor. Obesity is associated with adverse outcomes in both pre- and post-menopausal women with breast cancer. Many cancer survivors seek ways to minimize the risk of recurrence and death because of breast cancer. Despite complex and at times controversial data, enough evidence is available at present to suggest that weight management should be a part of the strategy to prevent the occurrence, recurrence and death because of breast cancer. In this review the effect of obesity on the prognosis of breast cancer is examined in detail.

Reducing racial/ethnic disparities in female breast cancer: screening rates and stage at diagnosis

OBJECTIVES

We assessed whether population rates of mammography screening, and their changes over time, were associated with improvements in breast cancer stage at diagnosis and whether the strength of this association varied by race/ethnicity.

METHODS

We analyzed state cancer registry data linked to socioeconomic characteristics of patients' areas of residence for 1990-1998 time trends in the likelihood of early stage diagnosis. We appended each cancer registry record with matching subgroup estimates of self-reported mammography screening.

RESULTS

Trends in screening and stage at diagnosis were consistent within groups, but African American women had a significantly lower proportion of early stage cancers despite an advantage in screening. Population screening rates were significantly associated with early diagnosis, with a weaker association in African American women than White women (odds ratio [OR] = 1.70; P<.0001 vs OR=2.02; P<.0001, respectively).

CONCLUSIONS

Improvements in screening rates during the 1990s across racial/ethnic groups appear to have contributed significantly to earlier diagnosis within each group, but a smaller effect in African American women should raise concerns. A key health policy challenge is to ensure that screening effectively translates into earlier diagnosis.

The influence of race, ethnicity, and individual socioeconomic factors on breast cancer stage at diagnosis

OBJECTIVES

Previous research has generally found that racial/ethnic differences in breast cancer stage at diagnosis attenuate when measures of socioeconomic status are included in the analysis, although most previous research measured socioeconomic status at the contextual level. This study investigated the relation between race/ethnicity, individual socioeconomic status, and breast cancer stage at diagnosis.

METHODS

Women with stage 0 to III breast cancer were identified from population-based data from the Surveillance, Epidemiology, and End Results tumor registries in the Detroit and Los Angeles metropolitan areas. These data were combined with data from a mailed survey in a sample of White, Black, and Hispanic women (n=1700). Logistic regression identified factors associated with early-stage diagnosis.

RESULTS

Black and Hispanic women were less likely to be diagnosed with early-stage breast cancer than were White women (P< .001). After control for study site, age, and individual socioeconomic factors, the odds of early detection were still significantly less for Hispanic women (odds ratio [OR]=0.45) and Black women (OR = 0.72) than for White women. After control for the method of disease detection, the White/Black disparity attenuated to insignificance; the decreased likelihood of early detection among Hispanic women remained significant (OR=0.59).

CONCLUSION

The way in which racial/ethnic minority status and socioeconomic characteristics produce disparities in women's experiences with breast cancer deserves further research and policy attention.

Obesity and survival after radical prostatectomy: A 10-year prospective cohort study

BACKGROUND

Obesity and prostate cancer are among the most common health problems affecting American men today. The authors' goal was to assess the impact of obesity on clinical and pathologic features of prostate cancer and long-term outcomes.

METHODS

The authors performed a prospective cohort study on 5313 men who underwent radical prostatectomy between 1990 and 1999. Patient height and weight were measured at the time of surgery to calculate the body mass index (BMI). The patients were separated into 3 BMI groups: BMI <25, 25-29.9, and > or =30 kg/m2. The associations between BMI and age, prostate-specific antigen (PSA) level, and Gleason score were assessed with the Spearman rank correlation test. The associations between BMI and pathologic features were assessed with the Mantel-Haenszel chi 2 test. Fifteen-year biochemical progression-free survival, systemic progression-free survival, cancer-specific survival, and overall survival were estimated using the Kaplan-Meier method and evaluated using Cox models. RESULTS.: The median length of follow-up for the entire cohort was 10.1 years. Clinical and pathologic features appear worse in patients with a higher BMI. On univariate and multivariate analyses, it was found that BMI had no impact on biochemical progression, systemic progression, prostate cancer survival, or overall survival.

CONCLUSIONS

Obese patients appear to have worse pathologic features at the time of prostatectomy. Despite these features, long-term oncologic outcomes, including cancer-specific survival, remain the same regardless of BMI. BMI appears to influence prostate cancer outcomes at the time of prostatectomy, as evidenced by more aggressive pathologic features. However, after prostatectomy, BMI does not appear to be an independent predictor of recurrence or survival.

Disparities in Lung Cancer: Focus on Asian Americans and Pacific Islanders, American Indians and Alaska Natives, and Hispanics and Latinos

Significant population changes in the United States are expected over the next few decades. The changing demographics inclusive of native and newly native individuals will significantly impact health care because racial and ethnic groups vary widely in their risks for disease and approach to medical care. For lung cancer specifically, racial and ethnic groups differ in smoking habits, metabolism of nicotine, presentation, stage at diagnosis, treatment received, and outcomes. This article summarizes current information on lung cancer for American and Pacific Islanders, American Indians and Alaska natives,and Hispanics and Latinos with an emphasis on tobacco use, epidemiologic issues sur-rounding acculturation and assimilation, genetic epidemiology, and disparities in treatment outcomes.

Effect of depression on all-cause mortality in adults with cancer and differential effects by cancer site

OBJECTIVE

The objective of this study was to compare the effect of depression on the risk of death in adults with and without cancer and by specific cancer site among those with cancer.

RESEARCH DESIGN AND METHODS

We analyzed data on 10,025 participants in the population-based National Health and Nutrition Examination Survey (NHANES) 1 Epidemiologic Follow-up Study. Four groups were created based on cancer and depression status in 1982: (a) no cancer, no depression (reference group; no CA, no DEP); (b) depression but no cancer (DEP, no CA); (c) cancer but no depression (CA, no DEP); and (d) cancer and depression (CA+DEP). Six CA sites were defined: lung, breast, gastrointestinal (GI), genitourinary (GU), skin and other. Cox proportional models were used to calculate adjusted hazard for death for each group compared with the reference group and by cancer site.

RESULTS

Over 8 years (78,433 person-years of follow-up), 1925 deaths were documented. The mortality rate per 1000 person-years of follow-up was highest in the CA+DEP group. Compared to the reference group, the hazard ratios (HRs) for all-cause mortality were as follows: CA, no DEP: 1.43 [95% confidence interval (95% CI)=1.23-1.67]; DEP, no CA: 1.44 (95% CI=1.28-1.63); CA+DEP: 1.87 (95% CI=1.49-2.34). HRs for depression by site were as follows: lung: 1.30 (95% CI=0.49-3.99); breast: 1.27 (95% CI=0.58-2.79); GI: 1.47 (95% CI=0.58-3.75); GU: 0.93 (95% CI=0.50-1.74); skin: 1.07 (95% CI=0.67-1.69); other: 2.13 (95% CI=0.55-8.25).

CONCLUSION

The coexistence of cancer and depression is associated with a significantly increased risk of death, and the effect of depression on the risk of death differs by cancer site.

The North Carolina-Louisiana Prostate Cancer Project (PCaP): methods and design of a multidisciplinary population-based cohort study of racial differences in prostate cancer outcomes

BACKGROUND

The North Carolina-Louisiana Prostate Cancer Project (PCaP) is a multidisciplinary study of social, individual, and tumor-level causes of racial differences in prostate cancer aggressiveness.

METHODS

A population-based sample of incident prostate cancer cases from North Carolina and Louisiana will include 1,000 African Americans and 1,000 Caucasian Americans. Study nurses administer structured questionnaires and collect blood, adipose tissue, urine, and toenail samples during an in-home visit. Clinical data are abstracted from medical records, diagnostic biopsies are reviewed and assayed, and tissue microarrays are constructed from prostatectomy samples. Prostate cancer aggressiveness is classified based on PSA, clinical stage, and Gleason grade.

RESULTS

Preliminary data demonstrate between- and within-group differences in patient characteristics, screening, and treatment by race and state. Participation exceeds 70% in all groups.

CONCLUSIONS

Preliminary data support the feasibility of this comprehensive study to help determine the focus of public health efforts to reduce racial disparities in prostate cancer mortality.

The epidemiology of pancreatic cancer in the United States: changes below the surface

BACKGROUND

Pancreatic cancer is the fourth leading cause of cancer death in the United States.

AIM

To examine temporal changes in the incidence and survival of patients with pancreatic adenocarcinoma.

METHODS

Using data from nine registries of the Surveillance, Epidemiology and End Results programme, age-adjusted incidence rates per 100 000 and survival rates were calculated for pancreatic cancer between 1977 and 2001.

RESULTS

We identified 58 655 cases of pancreatic cancer. The age-adjusted incidence rate remained stable during the study period (11.3 in 1977-1981 and 10.9 in 1997-2001). Overall, men were 30% more affected than women (age-adjusted incidence rate of 13.0 in men and 9.8 in women). The age-adjusted incidence rates were almost 50% higher among Blacks (16.4) than Whites (10.8) and people of other races (9.8). Over time the proportions of patients with localized disease decreased from 12.3% to 7.4% and those with regional disease increased from 18.6% to 25.8%, while metastatic disease remained stable (52.5% vs. 49.8%). The 1-year relative survival increased from 15.2% in 1977-1981 to 21.6% in 1997-2001.

CONCLUSIONS

The incidence of pancreatic cancer is stable. A shift from localized to regional disease was observed over time. The overall survival remains poor despite important improvements among patients with early stage disease.

Ethnicity and survival in childhood acute myeloid leukemia: a report from the Children's Oncology Group

We evaluated differences in outcome by ethnicity among children with acute myeloid leukemia (AML). We analyzed 791 children in the CCG 2891 trial and confirmed positive findings in 850 children in the CCG 2961 trial. Hispanic and black children treated with chemotherapy in CCG 2891 had significantly inferior overall survival (OS) from study entry compared with white children (37%+/- 9% vs 48%+/- 4% [P = .016] and 34% +/- 10% vs 48% +/- 4%, [P = .007], respectively). Significantly fewer black children had related donors. Analyses of CCG 2961 confirmed that black children had significantly decreased OS rates compared with white children (45% +/- 12% vs 60% +/- 4%; P = .007) The difference in OS rates between Hispanic and white children approached statistical significance (51% +/- 8% vs 60% +/- 4%; P = .065) Only 7.5% of black children on CCG 2961 had an available family donor. In conclusion, Hispanic and black children with AML have worse survival than white children. Access to chemotherapy, differences in supportive care or leukemia phenotype, and reduced compliance are unlikely explanations for this difference because therapy was given intravenously according to CCG protocols. Fewer black children than expected had an available family marrow donor.

Colorectal cancer model of health disparities: understanding mortality differences in minority populations

African Americans are more likely to be diagnosed with and die as a result of colorectal cancer than white patients. This review briefly documents these differences and explores the factors that may contribute to advanced stage at diagnosis and reduced survival once African Americans are diagnosed with colorectal cancer. Attention is focused on what is known about the role of socioeconomic status, cancer screening, comorbidities and lifestyle factors, tumor biology and genetics, and the differences in the receipt of and benefit of appropriate therapy. Finally, areas of ongoing and future research and policy initiatives aimed at reducing disparities are discussed.

Genetics, epidemiology, and cancer disparities: is it black and white?

Epidemiologic studies attempt to understand the distribution and determinants of human disease. Epidemiologic research often incorporates information about race, ethnicity, or ancestry, usually as a self-identified race or ethnicity (SIRE) variable. Differences in the distribution and determinants of disease on the basis of SIRE may be identified in these studies. In addition, genetic and other biologic differences according to SIRE are frequently reported. If these differences are real and meaningful, they may have value in identifying disease-causative or -preventive factors, and thus may be beneficial to human health. However, the concepts of race, ethnicity, or ancestry are often poorly considered or crudely applied, particularly in genetic studies of disease etiology or outcome. Consequently, results suggesting genetic differences with respect to disease etiology or outcome across SIRE groups may not be meaningful; in fact, these differences may prove harmful if they propagate stereotypes or spurious differences. Therefore, it is critical to properly consider the meaning, definitions, and use of race, ethnicity, or ancestry in molecular epidemiologic studies.

Racial differences in breast cancer survival in the Detroit Metropolitan area

African American (AA) women have poorer breast cancer survival compared to Caucasian American (CA) women. The purpose of this analysis was to determine whether socioeconomic status (SES) and treatment differences influence racial differences in breast cancer survival. The study population included 9,321 women (82% CA, 18% AA) diagnosed with local (63%) or regional (37%) stage disease between 1988 and 1992, identified through the Metropolitan Detroit SEER registry. Data on SES were obtained through linkage with the 1990 Census of Population and Housing Summary Tape and cases were geocoded to census block groups. Pathology, treatment and survival data were obtained through SEER. Cox proportional hazards models were used to compare survival for AA versus CA women after adjusting for age, SES, tumor size, number of involved lymph nodes, and treatment. AA women were more likely to live in a geographic area classified as working poor than were CA women (p<0.001). AA women were less likely to have lumpectomy and radiation and more likely to have mastectomy with radiation (p<0.001). After multivariable adjusted analysis, there were no significant racial differences in survival among women with local stage disease, although AA women with regional stage disease had persistent but attenuated poorer survival compared to CA women. After adjusting for known clinical and SES predictors of survival, AA and CA women who are diagnosed with local disease demonstrate similar overall and breast cancer-specific survival, while race continues to have an independent effect among women presenting at a later stage of disease.

Prostate cancer screening in high-risk men: African American Hereditary Prostate Cancer Study Network

BACKGROUND

There are scant data available on prostate cancer screening among high-risk African American men with positive family histories. It is important to determine whether or not their screening rates differ from those in the general population.

METHODS

This study computed rates of previous digital rectal examination (DRE) and prostate-specific antigen (PSA) screening for prostate cancer in cancer-free (unaffected) relatives age 40-69 years from African American families that had four or more men with prostate cancer. The rates for these 134 high-risk African American men from the African American Hereditary Prostate Cancer Study (AAHPC) were compared with nationwide estimates obtained from participants in the 1998 and 2000 National Health Interview Survey (NHIS), for which the numbers of demographically comparable subjects were 5583 (4900 Caucasians, plus 683 African Americans) and 3359 (2948 Caucasians, 411 African Americans), respectively.

RESULTS

Men in the AAHPC cohort (with a strong positive family history) had significantly less screening than both African Americans and Caucasians in the NHIS cohorts. Only about one-third (35%) of the men in the AAHPC unaffected cohort had ever had a DRE, and only about 45% of them had ever received a PSA test. These rates were much lower than those obtained for African American men in the NHIS: 45% for DRE and 65% for PSA. These discrepancies increased with age.

CONCLUSIONS

Older African American men with positive family histories report surprisingly low rates of DRE and PSA screening compared with their counterparts in the NHIS surveys. At-risk men need to be informed of the benefits and limitations of prostate cancer screening and actively involved in decision-making for or against prostate cancer screening.

Racial comparison of outcomes and costs for inpatient neutropenic patients: a multicenter evaluation

PURPOSE

Racial disparities have been reported in the care and outcome of cancer patients. We evaluated whether race would influence the cost and outcomes of inpatient neutropenic cancer patients in a multicenter study from a large health care system in the southern United States.

METHODS

Data was collected on all cancer inpatients with a diagnosis code for neutropenia in a 16-hospital system between October 1, 2002, and September 30, 2003. Demographics, treatment outcomes, and costs were compared between white and minority patients. A P value less than .05 was considered statistically significant.

RESULTS

Two hundred seventy-nine cancer patients (0.29% of all admits) had a diagnosis of neutropenia. Demographics were similar between white and minority patients. However, minorities were more likely to be younger than whites (P = .002). With regards to outcomes, length of stay (LOS), LOS in the intensive care unit, and discharge status were not statistically different. Total hospital, medication, laboratory, radiation, surgery, and respiratory costs were also similar (P > .05), although minorities were less likely to receive myeloid colony-stimulating factors (P = .032) and more likely to have higher nursing care costs (P = .048).

CONCLUSION

In light of the escalating reports of racial disparities in cancer care, these minimal differences are encouraging.

Racial disparity and socioeconomic status in association with survival in older men with local/regional stage prostate carcinoma

BACKGROUND

Few studies have examined the outcomes for Hispanic men with prostate carcinoma and incorporated socioeconomic factors in association with race/ethnicity in affecting survival, adjusting for factors on cancer stage, grade, comorbidity, and treatment.

METHODS

We studied a population-based cohort of 61,228 men diagnosed with local or regional stage prostate carcinoma at age 65 years or older between 1992 and 1999 in the 11 SEER (Surveillance, Epidemiology, and End Results) areas, identified from the SEER-Medicare linked data with up to 11 years of followup.

RESULTS

Low socioeconomic status was significantly associated with decreasing survival in all men with prostate carcinoma. Those living in the community with the lowest quartile of socioeconomic status were 31% more likely to die than those living in the highest quartile (hazard ratio [HR] of all-cause mortality: 1.31; 95% confidence interval [CI]: 1.25-1.36) after adjustment for patient age, comorbidity, Gleason score, and treatment. The HR remained almost unchanged after controlling for race/ethnicity (HR: 1.32; 95% CI: 1.26-1.38). Compared with Caucasians, the risk of mortality in African American men was marginally significantly higher (HR: 1.06; 95% CI: 1.01-1.11) after controlling for education, and no longer significant after adjusting for poverty, income, or composite socioeconomic variable; the HR was lower for Hispanic men (HR: 0.80; 95% CI: 0.72-0.89) after adjustment for education and other socioeconomic variables.

CONCLUSION

Racial disparity in survival among men with local or regional prostate carcinoma was largely explained by socioeconomic status and other factors. Lower socioeconomic status appeared to be one of the major barriers to achieving comparable outcomes for men with prostate carcinoma.

Epidemiology of cancer in the United States

OBJECTIVES

To describe the epidemiology of cancer in the United States-risk factors, trends, and recent patterns of disparities in cancer incidence, mortality, and survival.

DATA SOURCES

Published articles, research reports and monographs, book chapters, government publications, and machine-readable public-use data files.

CONCLUSION

The discipline of cancer epidemiology has greatly increased our understanding of cancer risk, morbidity and mortality, survival, trends over time, and disparities in cancer treatment and outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Nursing can use epidemiologic tools to reduce the suffering and death caused by cancer and improve the quality of life for cancer survivors.

Cancer prevention among racial ethnic minorities

OBJECTIVES

To provide an overview of the cancer disparities among racial and ethnically diverse populations and to describe primary and secondary prevention among them.

DATA SOURCES

Published articles, reports, book chapters, and government documents.

CONCLUSION

Despite the advances in cancer diagnosis, treatment, and survival, racial and ethnic minorities suffer disproportionately from cancer. Poverty has emerged as a significant factor influencing poor cancer outcomes for all races, but especially among racial and ethnic minorities.

IMPLICATIONS FOR NURSING PRACTICE

Continued and sustained efforts are needed on all fronts (education, practice, and research, policy) to improve the poor cancer-related outcomes for minorities.

Association of overweight with breast cancer survival

The authors investigated the association between overweight at the time of or soon after cancer diagnosis and survival in a cohort of 1,455 breast cancer patients aged 25-64 years. The patients were recruited into the Shanghai Breast Cancer Study (Shanghai, China), a population-based case-control study, between August 1996 and March 1998. The median follow-up time for this cohort was 5.1 years (1996-2002) after breast cancer diagnosis, and 240 deaths were identified. Being overweight at cancer diagnosis or soon afterward, as measured by body mass index (BMI; weight (kg)/height (m)(2)), was associated with poorer overall survival and disease-free survival. Five-year survival rates were 86.5%, 83.8%, and 80.1% for subjects whose BMIs were <23.0, 23.0-24.9, and >or=25.0, respectively (p = 0.02); the corresponding 5-year disease-free survival rates were 81.9%, 78.1%, and 76.6% (p = 0.05). The inverse association between BMI and survival persisted after adjustment for age at diagnosis and other known prognostic factors for breast cancer, including disease stage. The authors found neither waist:hip ratio nor waist circumference to be independently associated with overall survival or disease-free survival. These results suggest that excess weight may be an independent predictor of breast cancer survival among Chinese women.

Multiple imputation methods for modelling relative survival data

In population-based cancer survival studies, the cause-specific survival measures the net survival (excess mortality) due to cancer when the cause of death information is available and reliable. In contrast, when the cause of death is uncertain or unavailable, relative survival, the ratio of the survival rate due to all causes to the expected survival rate, is more appropriate. There is a large body of work on the modelling and hypothesis testing of cause-specific survival, but many of these methods are not directly applicable to relative survival. In this paper, we extend the multiple imputation (MI) methods (Stat. Methods Med. Res. 1999; 8:3-15) to the case of relative survival data. The MI methodology is combined with relative survival to estimate the net survival by changing relative survival data to cause-specific data. This facilitates the direct application to statistical methods developed for the cause-specific survival to the special situation of relative survival. The parameter estimates and the log-rank statistics are obtained by combining the results from multiple imputed cause-specific data. The likelihood-based methods for modelling relative survival data have been implemented by a Windows application called CANSURV (Comput. Meth. Prog. Biomed 2005). Although these methods produce accurate parameter estimates, the choice for models and diagnostic tools is limited. The MI method is presented as a simpler alternative. The relative survival data for the colorectal cancer patients from Surveillance, Epidemiology, and End Results (SEER) program (SEER Cancer Statistics Review, 1973-1999. National Cancer Institute: Bethesda, 2002) is used as an illustration. The results are compared with those obtained from the likelihood-based relative survival analysis methods. A sample SAS macro for the MI method is provided.

Ethnic or Racial Differences Revisited

Ethnic or racial differences in pharmacokinetics and pharmacodynamics have been attributed to the distinctions in the genetic, physiological and pathological factors between ethnic/racial groups. These pharmacokinetic/pharmacodynamic differences are also known to be influenced by several extrinsic factors such as socioeconomic background, culture, diet and environment. However, it is noted that other factors related to dosage regimen and dosage form have largely been ignored or overlooked when conducting or analysing pharmacokinetic/pharmacodynamic studies in relation to ethnicity/race. Potential interactions can arise between the characteristics of ethnicity/race and a unique feature of dosage regimen or dosage form used in the study, which may partly account for the observed pharmacokinetic/pharmacodynamic differences between ethnic/racial groups. Ethnic/racial differences in pharmacokinetics/pharmacodynamics can occur from drug administration through a specific route that imparts distinct pattern of absorption, distribution, transport, metabolism or excretion. For example, racial differences in the first-pass metabolism of a drug following oral administration may not be relevant when the drug is applied to the skin. On the other hand, ethnic/racial difference in pharmacokinetics/pharmacodynamics can also happen via two different routes of drug delivery, with varying levels of dissimilarity between routes. For example, greater ethnic/racial differences were observed in oral clearance than in systemic clearance of some drugs, which might be explained by the pre-systemic factors involved in the oral administration as opposed to the intravenous administration. Similarly, changes in the dose frequency and/or duration may have profound impact on the ethnic/racial differences in pharmacokinetic/pharmacodynamic outcome. Saturation of enzymes, transporters or receptors at high drug concentrations is a possible reason for many observed ethnic/racial discrepancies between single- and multiple-dose regimens, or between low- and high-dose administrations. The presence of genetic polymorphism of enzymes and/or transporters can further complicate the analysis of pharmacokinetic/pharmacodynamic data in ethnic/racial populations. Even within the same dosage regimen, the use of different dosage forms may trigger significantly different pharmacokinetic/pharmacodynamic responses in various ethnic/racial groups, given that different dosage forms may exhibit different rates of drug release, may release the drug at different sites, and/or have different retention times at specific sites of the body. It is thus cautioned that the pharmacokinetic/pharmacodynamic data obtained from different ethnic/racial groups cannot be indiscriminately compared or combined for analysis if there is a lack of homogeneity in the apparent 'extrinsic' factors, including dosage regimen and dosage form.

African-American race is associated with a poorer overall survival rate for breast cancer patients treated with mastectomy and doxorubicin-based chemotherapy

BACKGROUND

African-American (AA) race has been associated with a worse outcome in breast cancer. It is unclear whether this is due to biological factors, socioeconomic factors, or both.

METHODS

The records from 2 independent cohorts of breast cancer patients treated on institutional protocols with mastectomy and adjuvant (n = 1456) or neoadjuvant (n = 684) doxorubicin-based chemotherapy were retrospectively reviewed.

RESULTS

The adjuvant (Adj) chemotherapy cohort included 1142 Caucasian (CA), 186 Hispanic (HI), and 128 (AA) patients. The neoadjuvant (Neo) chemotherapy protocols included 448 CA, 114 HI, and 122 AA patients. In both groups, AA patients had later-stage tumors (Adj P = .017; Neo P = .051), a higher rate of estrogen receptor (ER)-negative disease (Adj P = .054; Neo P = .039), and a worse 10-year actuarial overall survival rate than CA or HI patients (Adj, 52%, 62%, and 62%, respectively, P = .009; Neo, 40%, 50%, and 56%, respectively, P = .015). In multivariate analyses, AA race remained independently associated with a poorer overall survival rate in both cohorts (Adj, hazard ratio = 1.39, P = .018; Neo, hazard ratio = 1.37, P = .02).

CONCLUSIONS

The data suggest that AA race is associated with less favorable biological tumor features, such as an increased likelihood of ER-negative disease, than those found in CA and HI patients. Such differences in tumor biology, as well as previously described socioeconomic factors, likely contribute to the lower rate of survival in the AA breast cancer population.

The role of vitamin D in cancer prevention

Vitamin D status differs by latitude and race, with residents of the northeastern United States and individuals with more skin pigmentation being at increased risk of deficiency. A PubMed database search yielded 63 observational studies of vitamin D status in relation to cancer risk, including 30 of colon, 13 of breast, 26 of prostate, and 7 of ovarian cancer, and several that assessed the association of vitamin D receptor genotype with cancer risk. The majority of studies found a protective relationship between sufficient vitamin D status and lower risk of cancer. The evidence suggests that efforts to improve vitamin D status, for example by vitamin D supplementation, could reduce cancer incidence and mortality at low cost, with few or no adverse effects.

Disability and preventive cancer screening: results from the 2001 California Health Interview Survey

OBJECTIVE

We sought to evaluate preventive cancer screening compliance among adults with disability in California.

METHODS

We used data from the 2001 California Health Interview Survey to compare disabled and nondisabled adults for differences in preventive cancer screening behaviors. Compliance rates for cancer screening tests (mammography, Papanicolaou test, prostate-specific antigen, sigmoidoscopy/colonoscopy, and fecal occult blood test) between the 2 subpopulations were evaluated.

RESULTS

Women with disabilities were 17% (Papanicolaou tests) and 13% (mammograms) more likely than women without disabilities to report noncompliance with cancer screening guidelines. Interactions between disability and reports of a doctor recommendation on cervical cancer screening were significant; women with disabilities had a lower likelihood of receiving a recommendation. Men with disabilities were 19% less likely than men without disabilities to report a prostate-specific antigen test within the last 3 years.

CONCLUSIONS

secondary to structural and/or clinical factors underpinning the differences found.

Outcome of Ethnic Minorities With Acute or Chronic Leukemia Treated With Hematopoietic Stem-Cell Transplantation in the United States

Purpose

We previously reported a higher risk of mortality among Hispanics after allogeneic hematopoietic stem-cell transplantation (HSCT). However, it is not known how specific post-transplantation events (acute or chronic graft-versus-host disease [GVHD], treatment-related mortality [TRM], and relapse) may explain mortality differences. The purpose of this study was to examine the relationship between ethnicity and post-transplantation events and determine their net effect on survival.

Patients and Methods

We identified 3,028 patients with acute myeloid leukemia, acute lymphoblastic leukemia, or chronic myeloid leukemia reported to the International Bone Marrow Transplant Registry between 1990 and 2000 who received an HLA-identical sibling HSCT after a myeloablative conditioning regimen in the United States. There were 2,418 white patients (80%) and 610 ethnic minority patients (20%), of whom 251 were black (8%), 122 were Asian (4%), and 237 were Hispanic (8%). Cox proportional hazards regression was used to compare outcomes between whites and ethnic minorities while adjusting for other significant clinical factors.

Results

No statistically significant differences in the risk of acute or chronic GVHD, TRM, or relapse were found between whites and any ethnic minority group. However, Hispanics had higher risks of treatment failure (death or relapse; relative risk [RR] = 1.30; 95% CI, 1.08 to 1.54; P = .004) and overall mortality (RR = 1.23; 95% CI, 1.03 to 1.47; P = .02).

Conclusion

The higher risks of treatment failure and mortality among Hispanics may be the net result of modest but not statistically significant increases in both relapse and TRM and cannot be accounted for by any single transplantation-related complication. Further studies should examine the role of social, economic, and cultural factors.

Screening for Prostate Cancer: Opportunities and Challenges

Prostate cancer screening with PSA and with digital rectal examination isa reality in the United States. Regardless of recent observations regarding the complexities of PSA interpretation, millions of U.S. men expect an annual PSA test and physicians have come to rely on the test, in combination with digital rectal examination, to assess for prostate cancer risk. What has become evident is that PSA can no longer be interpreted dichotomously as a simple yes or no. The test reflects a range of risk and PSA value must be merged with other risk factors of an individual man including ethnicity, family history, as well as the individual's risk aversion to complications from prostate cancer. The future of prostate cancer screening will be built upon incorporation of new biomarkers to the prediction of risk of disease. As these markers move forward in testing, it will no longer be acceptable to move these into clinical usage without formal validation studies and, because of the high frequency of prostate cancer in the general male population, these validation studies will almost certainly have to include measures of prognosis. It is the holy grail of cancer biomarker development to acquire a test that is positive in the man with clinically-aggressive prostate cancer but is negative in both the patient without disease and in the man with disease that will be of no clinical consequence over his lifetime.

Differences in colorectal carcinoma stage and survival by race and ethnicity

BACKGROUND

In the United States, blacks with colorectal carcinoma (CRC) presented with more advanced-stage disease and had higher mortality rates compared with non-Hispanic whites. Data regarding other races/ethnicities were limited, especially for Asian/Pacific Islander and Hispanic white subgroups.

METHODS

Using data from 11 population-based cancer registries that participate in the Surveillance, Epidemiology and End Results program, the authors evaluated the relation among 18 different races/ethnicities and disease stage and mortality rates among 154,103 subjects diagnosed with CRC from 1988 to 2000.

RESULTS

Compared with non-Hispanic whites, blacks, American Indians, Chinese, Filipinos, Koreans, Hawaiians, Mexicans, South/Central Americans, and Puerto Ricans were 10-60% more likely to be diagnosed with Stage III or IV CRC. Alternatively, Japanese had a 20% lower risk of advanced-stage CRC. With respect to mortality rates, blacks, American Indians, Hawaiians, and Mexicans had a 20-30% greater risk of mortality, whereas Chinese, Japanese, and Indians/Pakistanis had a 10-40 % lower risk.

CONCLUSIONS

The authors observed numerous racial/ethnic disparities in the risks of advanced-stage cancer and mortality among patients with CRC, and there was considerable variation in these risks across Asian/Pacific Islander and Hispanic white subgroups. Although the etiology of these disparities was multifactorial, developing screening and treatment programs that target racial/ethnic populations with elevated risks of poor CRC outcomes may be an important means of reducing these disparities.

Racial Disparities in Treatment and Survival Among Women With Early-Stage Breast Cancer

Purpose

Black women with breast cancer are known to have poorer survival than white women. Suboptimal treatment may compromise the survival benefits of adjuvant chemotherapy. We analyzed the association of race and survival with duration of treatment and number of treatment cycles among women receiving chemotherapy for early-stage breast cancer.

Patients and Methods

Patients were women in the Henry Ford Health System tumor registry who were diagnosed with stage I/II breast cancer between January 1, 1996, and December 31, 2001, who received adjuvant chemotherapy. We calculated an observed/expected ratio of treatment duration and of completed chemotherapy cycles for each patient. Using Cox proportional hazards models, we analyzed the association of early treatment termination and treatment duration with all-cause mortality, controlling for age, race, stage, hormone receptor status, grade, comorbidity score, and doxorubicin use.

Results

Of 472 eligible patients, 28% (31% black, 23% white; P = .03) received fewer cycles of treatment than expected. Black race, receipt of ≤ 75% of the expected number of cycles, increasing age, hormone receptor negativity, and a comorbidity score of more than 1 were associated with poorer survival. Among the 344 patients receiving the expected number of cycles, 60% experienced delays. These delays did not reduce survival.

Conclusion

This study is the first to find that a substantial fraction of women with early-stage breast cancer terminated their chemotherapy prematurely and that early termination was associated with both black race and poorer survival. A better understanding of the determinants of suboptimal treatment may lead to interventions that can reduce racial disparities and improve breast cancer outcomes for all women.

Breast cancer survival in South Asian women in England and Wales

STUDY OBJECTIVES

To estimate ethnic and socioeconomic differences in breast cancer incidence and survival between South Asians and non-South Asians in England and Wales, and to provide a baseline for surveillance of cancer survival in South Asians, the largest ethnic minority.

SETTING

115 712 women diagnosed with first primary invasive breast cancer in England and Wales during 1986-90 and followed up to 1995.

METHODS/DESIGN

Ethnic group was ascribed by a computer algorithm on the basis of the name. Incidence rates were derived from 1991 census population denominators for each ethnic group. One and five year relative survival rates were estimated by age, quintile of material deprivation, and ethnic group, using national mortality rates to estimate expected survival.

MAIN RESULTS

Age standardised incidence was 29% lower among South Asian women (40.5 per 100 000 per year) than among all other women (57.4 per 100 000). Five year age standardised relative survival was 70.3% (95%CI 65.2 to 75.4) for South Asian women and 66.7% (66.4 to 67.0) for other women. For both ethnic groups, survival was 8%-9% higher for women in the most affluent group than those in the most deprived group. In each deprivation category, however, survival was 3%-8% higher for South Asian women than other women.

CONCLUSIONS

This national study confirms that breast cancer incidence is substantially lower in South Asians than other women in England and Wales. It also provides some evidence that South Asian women diagnosed up to 1990 had higher breast cancer survival than other women in England and Wales, both overall and in each category of deprivation.