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

High-grade tumor differentiation is an indicator of poor prognosis in African Americans with colonic adenocarcinomas

BACKGROUND

To identify the factors that contribute to poorer colon carcinoma survival rates for African Americans compared with Caucasians, the authors evaluated survival differences based on the histologic grade (differentiation) of the tumor.

METHODS

All 169 African Americans and 229 randomly selected non-Hispanic Caucasians who underwent surgery during 1981-1993 for first primary sporadic colon carcinoma at the University of Alabama at Birmingham or its affiliated Veterans Affairs hospital were included in the current study. None of these patients received presurgery or postsurgery therapies. Recently, the authors reported an increased risk of colon carcinoma death for African Americans in this patient population, after adjustment for stage and other clinicodemographic features. The authors generated Kaplan-Meier survival probabilities according to race and tumor differentiation and multivariate Cox proportional hazards models to estimate hazard ratios (HR) with 95% confidence intervals (95% CI).

RESULTS

There were no differences in the distribution of pathologic tumor stage between racial groups after stratifying by histologic tumor grade. Among patients with high-grade tumors, 54% of African Americans and 21% of Caucasians died within the first year after surgery (P = 0.007). African Americans with high-grade tumors were 3 times (HR = 3.05; 95% CI, 1.32-7.05) more likely to die of colon carcinoma within 5 years postsurgery, compared with Caucasians with high-grade tumors. There were no survival differences by race among patients with low-grade tumors.

CONCLUSIONS

These findings suggested that poorer survival among African-American patients with adenocarcinomas of the colon may not be attributable to an advanced pathologic stage of disease at diagnosis, but instead may be due to aggressive biologic features like high tumor grades.

A population-based study of racial and ethnic differences in survival among women with invasive cervical cancer: analysis of Surveillance, Epidemiology, and End Results data

OBJECTIVE

The incidence of cervical cancer is higher in Hispanic than in non-Hispanic or African American women in the United States, but few studies have examined differences in survival between these groups. The objective of this study was to examine racial/ethnic differences in survival after diagnosis with invasive cervical cancer in a population-based sample of patients while adjusting for patient and tumor characteristics and treatment types.

METHODS

We identified 7267 women (4431 non-Hispanic Caucasians, 1830 Hispanic Caucasians, and 1006 non-Hispanic African Americans) diagnosed with primary invasive cervical cancer from 1992 to 1996 (with follow-up through 2000) from the Surveillance, Epidemiology and End Results (SEER) Program. Kaplan-Meier and Cox proportional hazards survival methods were used to assess differences in survival by race/ethnicity.

RESULTS

After adjusting for age at diagnosis, histology, stage, first course of cancer-directed treatment (surgery and radiation therapy), and SEER registry, Hispanic Caucasian women were at 26% decreased risk of death from any cause (hazard ratio (HR) = 0.74, 95% confidence interval (CI): 0.66-0.83) and non-Hispanic African American women were at 19% increased risk of death (HR = 1.19, 95% CI: 1.06-1.33) compared to non-Hispanic Caucasian women over the follow-up period.

CONCLUSION

Analysis of population-based SEER data indicates significant survival differences by race/ethnicity for women with invasive cervical cancer. Hispanic Caucasian women in SEER had improved survival compared to non-Hispanic Caucasian or non-Hispanic African American women.

Disparities across the breast cancer continuum

OBJECTIVE

We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality.

METHODS

We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum.

RESULTS

Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact.

CONCLUSION

A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.

Colorectal cancer and race: understanding the differences in outcomes between African Americans and whites

Understanding the differences in the incidence and mortality rate between African Americans and whites with CRC remains a perplexing problem. There is clearly not any one factor that explains the observed differences. Clinicians are just beginning to understand the importance of tumor biology, genetics, and lifestyle risk factors in explaining differences in how CRCs present and how they behave. This holds true regardless of a patient's race, sex, or age. Whether these factors will add disproportionately to the understanding of racial differences in presentation and outcome remains to be seen. Certainly, issues surrounding screening for CRC remain important in understanding the advanced stage of presentation for African Americans. In particular, a better understanding is needed of who is being screened and who is not and why. For example, are higher-risk African Americans being screened and if not what are the reasons for this? Importantly, even if one were able to eliminate the differences in stage at presentation between African Americans and whites, a survival disadvantage, albeit a much smaller one, would likely persist. Clearly, there is a need to understand better why African Americans are not receiving recommended therapy at the same rate as whites. This becomes even more important as the life-prolonging options for treating both localized and metastatic colon cancer continue to multiply. Finally, the apparent greater disparity in outcome for African Americans who have stage II disease should be explored in more detail, because this could have an immediate impact on treatment recommendations. For example, a 23-gene signature was recently found to be predictive of recurrence among patients with Dukes B colon cancer [66]. If this model is validated in further studies, one could look at whether African-American patients are more likely to have this predictive signature. The problem has been clearly defined: a higher incidence of and a higher mortality from CRC for African Americans than whites. The task now becomes to continue to understand the reasons for the disparities and ultimately to come up with workable solutions so that the amazing progress in CRC treatment benefits all groups in this country.

Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting

BACKGROUND

Colorectal carcinoma ranks as the second most common cancer and the second leading cause of cancer death in the United States. Hispanics are less likely than their non-Hispanic white counterparts to have ever received a fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy. Little is known about the barriers to screening in the Hispanic population.

METHODS

The authors used baseline data from a community randomized trial of cancer prevention to compare screening prevalence and the associations between reported barriers and screening participation between Hispanics (n = 137) and non-Hispanic whites (n = 491) age > or = 50 years.

RESULTS

Hispanics were less likely than non-Hispanic whites to have ever received an FOBT (P = 0.003) or sigmoidoscopy/colonoscopy (P = 0.001). No significant difference across ethnic groups was observed in the prevalence of recent screening using FOBT (29.8% for Hispanics vs. 34.5% for non-Hispanic whites; P = 0.41), but recent use of sigmoidoscopy/colonoscopy was lower for Hispanics (24.1% for Hispanics vs. 33.7% for non-Hispanic whites; P 0.06). Lacking health care coverage or having few years of education were directly associated with failure to ever receive an FOBT or sigmoidoscopy/colonoscopy.

CONCLUSIONS

Interventions to improve adherence to colorectal carcinoma screening recommendations among Hispanics should target initial screening examinations, particularly among those lacking health care coverage or having low levels of education.

Racial disparities in treatment and survival of women with stage I-III breast cancer at a large academic medical center in metropolitan Detroit

African-American (AA) women with breast cancer have higher mortality rates than Caucasian woman, and some studies have suggested that this disparity may be partly explained by unequal access to medical care. The purpose of this study was to analyze racial differences in patterns and costs of care and survival among women treated for invasive breast cancer at a large academic medical center. Subjects included 331 AA and 257 Caucasian women diagnosed with stage I-III breast cancer between 1994 and 1997. Clinical, socio-demographic, and cost data were obtained from the medical record, cancer registry, and hospital financial database. Data were collected on the use of cancer directed treatments (surgery, radiation, chemo and hormonal therapy) up to 1-year post-diagnosis. Survival analyses compared disease-free and overall survival by race adjusting for age, stage, nodal involvement, ER/PR status and a diagnosis of hypertension, diabetes, heart disease and cerebral vascular accident. There were no significant racial differences in treatment utilization and costs. The mean total 1-year treatment costs were US 16,348 dollars for AAs and US 15,120 dollars for Caucasians. While AAs had a significantly higher unadjusted relative risk (RR) of recurrence 2.09 (95% CI: 1.41-3.10) and death 1.56 (95% CI: 1.09-2.25), the multivariate adjusted analyses resulted in no significant differences in recurrence 1.38 (95% CI: 0.85-2.26) or death 1.06 (95% CI: 0.64-1.75). There was no obvious racial disparity in treatment and costs noted. Our findings support the theory that equal treatments produce equal outcomes. Improvement in screening may have an important impact on survival among minority women with breast cancer.

Digital rectal examination is barrier to population-based prostate cancer screening

OBJECTIVES

To determine whether use of the digital rectal examination (DRE) results in decreased participation in prostate cancer (PCa) screening, which, in turn, would result in lower detection. Population-based PCa screening includes prostate-specific antigen (PSA) measurement with or without a DRE. PSA and DRE screening provide greater sensitivity than PSA alone; however, the increased participation rate resulting from PSA-alone screening may result in a greater detection rate.

METHODS

We performed a survey of 13,580 healthy men undergoing PSA-only population-based screening. In addition to the basic demographic information, the survey asked whether the participant would still be willing to participate in the screening if it included a DRE. We modeled the willingness to participate to assess the effect of PSA screening versus PSA and DRE screening on the basis of previously published data and our results.

RESULTS

The results of our study indicated that only 78% of men would participate in screening that included both DRE and PSA. Thus, 7800 men of a theoretical population of 10,000 would participate in a screening that included both DRE and PSA. The positive screen rate (PSA > or = 4.0 ng/mL and/or abnormal DRE) would then have been 2013, with 472 PCa cases and 1540 negative biopsies. In the PSA-alone arm, all 10,000 men would have agreed to participate, and the positive screen rate (PSA > or = 4.0 ng/mL) would have been 1480, with 499 PCa cases and 980 negative biopsies. The PSA-alone arm would thus have detected 27 more cancers and performed 560 fewer negative biopsies.

CONCLUSIONS

The results of our study have demonstrated that DRE is a significant barrier to participation in PCa screening. PSA plus DRE-based programs result in fewer cases of PCa detected, with a significant increase in negative biopsies. We, therefore, suggest that future mass screening efforts include only PSA determination and omit the DRE.

Cancer, Medicaid enrollment, and survival disparities

BACKGROUND

The current article examined survival for adults < 65 years old diagnosed with breast, colorectal, or lung carcinoma who were either Medicaid insured at the time of diagnosis, Medicaid insured after diagnosis, or non-Medicaid insured.

METHODS

The authors hypothesized that subjects enrolling in Medicaid after they were diagnosed with cancer would explain disparate survival outcomes between Medicaid and non-Medicaid-insured subjects. The authors used the Michigan Tumor Registry, a population-based cancer registry covering the State of Michigan, to identify subjects who were diagnosed with the cancer sites of interest (n = 13,740). The primary outcome was all cause mortality over an 8-year time period.

RESULTS

Subjects who enrolled in Medicaid after diagnosis with cancer had much lower 8-year survival rates relative to Medicaid-enrolled and non-Medicaid subjects. These reductions in survival were partly due to a high proportion of lung carcinoma and late-stage cancers within the sample of subjects who enrolled in Medicaid after diagnosis. The likelihood of death was two to three times greater for subjects enrolled in Medicaid relative to subjects who were not enrolled in Medicaid once the analysis was stratified by cancer site and stage.

CONCLUSIONS

Disparities in cancer survival were apparent between subjects enrolled in Medicaid and subjects not enrolled in Medicaid. From a policy perspective, cancer survival in the Medicaid population cannot be improved as long as 40% of the population enrolls in Medicaid after diagnosis with late-stage disease.

Regional patterns and trends in cancer mortality among American Indians and Alaska Natives, 1990-2001

BACKGROUND

National estimates of cancer mortality indicate relatively low rates for American Indians (AIs) and Alaska Natives (ANs). However, these rates are derived from state vital records in which racial misclassification is known to exist.

METHODS

In this cross-sectional study of cancer mortality among AIs and ANs living in counties on or near reservations, the authors used death records and census population estimates to calculate annualized, age-adjusted mortality rates for key cancer types for the period 1996-2001 for 5 geographic regions: East (E), Northern Plains (NP), Southwest (SW), Pacific Coast (PC), and Alaska (AK). Mortality rate ratios (MRRs) and 95% confidence intervals (95% CIs) also were calculated to compare rates with those in the general United States population (USG) for the same period. To examine temporal trends, MRRs for 1996-2001 were compared with MMRs for 1990-1995.

RESULTS

The overall cancer mortality rate was lower in AIs and ANs (165.6 per 100,000 population; 95% CI, 161.7-169.5) than in the USG (200.9 per 100,000 population; 95% CI, 200.7-201.2). In the regional analysis, however, cancer mortality was higher in AK (MRR=1.26; 95% CI, 1.17-1.36) and in the NP (MMR=1.37; 95% CI, 1.31-1.44) than in the USG. In both regions, the excess mortality was attributed to cancer of the lung, colorectum, liver, stomach, and kidney. In the SW, the mortality rate for cancer of the liver and stomach was higher than the rate in the USG, in contrast with that region's nearly 4-fold lower mortality rate for lung cancer (MRR=0.23; 95% CI, 0.19-0.27). Rates of cervical cancer mortality were higher among AIs and ANs (MRR=1.35; 95% CI, 1.13-1.62), notably in the NP and SW. Rates of breast cancer mortality generally were lower (MRR=0.60; 95% CI, 0.55-0.66), notably in the PC, SW, and E. Cancer mortality increased by 5% in AIs and ANs (MRR for 1996-2001 compared with 1990-1995: 1.05; 95% CI, 1.01-1.08), whereas it decreased by 6% in the USG (MMR=0.94; 95% CI, 0.94-0.94).

CONCLUSIONS

Regional data should guide local cancer prevention and control activities in AIs and ANs. The disparity in temporal trends in cancer mortality between AIs and ANs and the USG gives urgency to improving cancer control in this population.

A national framework for cancer surveillance in the United States

Enhancements to cancer surveillance systems are needed for meeting increased demands for data and for developing effective program planning, evaluation, and research on cancer prevention and control. Representatives from the American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, National Cancer Registrars Association, and North American Association of Central Cancer Registries have worked together on the National Coordinating Council for Cancer Surveillance to develop a national framework for cancer surveillance in the United States. The framework addresses a continuum of disease progression from a healthy state to the end of life and includes primary prevention (factors that increase or decrease cancer occurrence in healthy populations), secondary prevention (screening and diagnosis), and tertiary prevention (factors that affect treatment, survival, quality of life, and palliative care). The framework also addresses cross-cutting information needs, including better data to monitor disparities by measures of socioeconomic status, to assess economic costs and benefits of specific interventions for individuals and for society, and to study the relationship between disease and individual biologic factors, social policies, and the environment. Implementation of the framework will require long-term, extensive coordination and cooperation among these major cancer surveillance organizations.

Colorectal cancer in African Americans

Colorectal cancer in African Americans has an increased incidence and mortality relative to Whites. The mean age of CRC development in African Americans is younger than that of Whites. There is also evidence for a more proximal colonic distribution of cancers and adenomas in African Americans. African Americans are less likely to have undergone diagnostic testing and screening for colorectal cancer. Special efforts are needed to improve colorectal cancer screening participation rates in African Americans. Clinical gastroenterologists should play an active role in educating the public and primary care physicians about special issues surrounding colorectal cancer in African Americans. Community healthcare groups and gastrointestinal specialists should develop culturally sensitive health education programs for African Americans regarding colorectal cancer. The high incidence and younger age at presentation of colorectal cancer in African Americans warrant initiation of colorectal cancer screening at the age 45 yr rather than 50 yr.

Ethnic disparities in the treatment of stage I non-small cell lung cancer

RATIONALE

Important variations exist in the treatment of non-small cell lung cancer. Because resection is the most effective treatment for patients with early disease, disparities in surgical rates can generate considerable differences in outcomes.

OBJECTIVE

We analyzed data from a national population-based registry to evaluate disparities in the treatment of Hispanic and white patients with stage I lung cancer and to assess the extent to which these inequalities explain survival differences.

METHODS

This study included 16,036 Hispanic and white patients with stage I lung cancer diagnosed between 1991 and 2000. Cases were identified from the Surveillance, Epidemiology, and End Results registry. Survival was compared among white and Hispanics using Kaplan-Meier curves. Stratified survival curves and Cox regression were used to evaluate whether inequalities in stage (IA vs. IB) and resection could explain survival differences.

RESULTS

Hispanics had worse overall and lung cancer-specific survival compared with whites (p = 0.04 and 0.008, respectively). Five-year lung cancer survival was 54% for Hispanics versus 62% for whites. Hispanics were more frequently diagnosed with stage IB disease (p = 0.0002) and less likely to undergo resection (p = 0.03). Among resected patients, survival was similar for the two groups, as it was among those who did not undergo unresection. After adjusting for surgery and stage, there was no difference in survival between groups.

CONCLUSIONS

Hispanics with stage I lung cancer had worse survival as compared with whites. These disparities are largely explained by lower rates of resection and higher probability of diagnosis at stage IB. Future work must delineate why Hispanics are receiving less surgery.

Explaining racial differences in prostate cancer in the United States: sociology or biology?

Black men in the United States have the highest incidence and mortality from prostate cancer in the world. Even after adjusting for stage at diagnosis, black men have higher mortality rates than white men. Multiple reasons have been postulated to explain these findings including access to care, attitudes about care, socioeconomic and education differences, differences in type and aggressiveness of treatment, dietary, and genetic differences. While each reason may contribute to the higher incidence or higher mortality, likely combinations of reasons will best explain all the findings. Racial differences in socioeconomic status have been well established and we review the significance of these findings in relationship to prostate cancer. Also, with recent advances in the understanding of genetic variation in the human genome, in general, and in the genes involved in pathways relevant to prostate cancer biology, in particular, a number of genes with alleles which differ in frequency between black and white men have been proposed as a genetic cause or contributor to the increased prostate cancer risk in black men. However, the clinical significance of these genetic differences is not fully known. Finally, we conclude with some thoughts as to how to integrate the findings from sociological as well as biological studies and touch upon methods to reduce the disparate burden of prostate cancer among blacks in the United States.

Effect of Race on Long-Term Survival of Breast Cancer Patients: Transinstitutional Analysis from an Inner City Hospital and University Medical Center

Black women have the highest mortality for breast cancer. Our hypothesis is that racial disparities in breast cancer survival persist after controlling for stage of disease and treatment at both a city hospital as well as at a university hospital. Data from tumor registries of breast cancer patients at a city hospital and a university center were analyzed for overall and disease-specific survival, controlling for stage and treatment. Black patients presented with more advanced stages and had significantly worse survival compared with whites. After controlling for stage of disease and treatment, a difference in survival persisted for stage II patients, with blacks doing worse than whites at both institutions. Although there were socioeconomic differences, race was an independent prognostic factor, with black patients having the worse prognosis. The lower survival of black women with breast cancer is only partially explained by their advanced stage at diagnosis. Black women with potentially curable stage II cancer had a lower survival that is not explained by the variables measured.

Transperineal in vivo fluence-rate dosimetry in the canine prostate during SnET2-mediated PDT

Advances in photodynamic therapy (PDT) treatment for prostate cancer can be achieved either by improving selectivity of the photosensitizer towards prostate gland tissue or improving the dosimetry by means of individualized treatment planning using currently available photosensitizers. The latter approach requires the ability to measure, among other parameters, the fluence rate at different positions within the prostate and the ability to derive the tissue optical properties. Here fibre optic probes are presented capable of measuring the fluence rate throughout large tissue volumes and a method to derive the tissue optical properties for different volumes of the prostate. The responsivity of the sensors is sufficient to detect a fluence rate of 0.1 mW cm(-2). The effective attenuation coefficient in the canine prostate at 660 nm is higher at the capsule (2.15+/-0.19 cm(-1)) than in proximity of the urethra (1.84+/-0.36 cm(-1)). Significant spatial and temporal intra- and inter-canine variability in the tissue optical properties was noted, highlighting the need for individualized monitoring of the fluence rate for improved dosimetry.

Colorectal cancer among Asians and Pacific Islanders in the U.S.: Survival disadvantage for the foreign-born

BACKGROUND

Asian Americans and Pacific Islanders (AAPI) have better colorectal cancer survival than other racial populations. However, immigrants face challenges that may place them at higher risk for late diagnosis and death.

METHODS

To compare survival between the foreign- and U.S.-born, we identified 17,302 AAPI colorectal cancer patients between 1973 and 1998 from the Surveillance, Epidemiology, and End-Results (SEER) Program. Patients were categorized as foreign-born or U.S.-born using multiple imputation methods.

RESULTS

Foreign birth was associated with higher risk for death from any cause (hazard ratio [HR] 1.29; 95% CI 1.23-1.36) and with modestly higher risk after adjustment for selected demographic characteristics (HR 1.13; 95% CI 1.05-1.21) and registry site (HR 1.05; 95% CI 0.98-1.14). Although foreign-born AAPI were more likely to present later, additional adjustment for cancer stage reduced but did not eliminate their higher risk of death (HR 1.09; 95% CI 1.01-1.18)

CONCLUSIONS

Compared to the U.S.-born, foreign-born AAPI have poorer survival following colorectal cancer diagnosis. Future investigation of the care processes after diagnosis may be important in understanding these differences.

Quality-of-life concerns of African American breast cancer survivors within rural North Carolina: blending the techniques of photovoice and grounded theory

Social norms imposing a prevailing silence around breast cancer in rural African American communities have made it difficult for survivors to express their quality-of-life (QOL) concerns. In this article, the authors describe how they blended the photovoice method (providing participants with cameras so they can record, discuss, and relate the realities of their lives) with grounded theory techniques to assist 13 African American breast cancer survivors from rural eastern North Carolina in (a) exploring how they perceive and address their QOL within their own social context and (b) developing a conceptual framework of survivorship QOL. The framework that emerged reveals that three social forces (racism, stigmas regarding cancer, and cultural expectations of African American women) drive four QOL concerns (seeking safe sources of support, adjusting to the role of cancer survivor, feeling comfortable about the future, and serving as role models) and that survivors address these concerns by relying on spiritual faith and devising strategies to maintain social standing.

Breast Cancer in African‐American Women

African-American women face a lower risk of being diagnosed with breast cancer as compared to Caucasian-American women, yet they paradoxically face an increased breast cancer mortality hazard. An increased incidence rate for early-onset disease has also been documented. This manuscript review summarizes the socioeconomic, environmental, genetic, and possible primary tumor biologic factors that may explain these disparities.

Barriers to planning and conducting a screening: prostate cancer

African American men participated in a screening initiative and completed the 22-item Barriers to Prostate Cancer Screening Checklist. Forty-three men received a digital rectal exam (DRE) and prostate specific antigen (PSA) laboratory test. The age of the males was M = 56.4 (range = 45-76) years; 47% were compliant with the American Cancer Society annual screening guidelines for high-risk individuals. Nineteen men from the screened group completed a 22-item Response to Barriers Checklist. The barrier ranked a "big problem" for not getting a prostate exam, and the highest by 32% (n = 6) of the sample was "Too many things going on in their lives." The lowest ranked problem by 100% of the participants was "Takes too long to get an appointment." Two individuals reported taking the over-the-counter supplement, saw palmetto. It is important that when planning a health screening in the community, both barriers and advantages be evaluated during the planning and before the implementation phase of the project.

Postsurgical disparity in survival between African Americans and Caucasians with colonic adenocarcinoma

BACKGROUND

Studies of colorectal adenocarcinoma (CRC) indicate a higher mortality rate for African Americans compared with Caucasians in the United States. In the current study, the authors evaluated the racial differences in survival based on tumor location and pathologic stage between African-American patients and Caucasian patients who underwent surgery alone for CRC.

METHODS

All 199 African American patients and 292 randomly selected, non-Hispanic Caucasian patients who underwent surgery between 1981 and 1993 for first primary sporadic CRC at the University of Alabama-Birmingham (Birmingham, AL) or an affiliated Veterans Affairs hospital were assessed for differences in survival. None of these patients received preoperative or postoperative neoadjuvant or adjuvant therapy. Survival curves were generated using the Kaplan-Meier method, and hazard ratios with 95% confidence intervals (95% CI) were estimated from Cox proportional hazards models, adjusting for demographic and tumor characteristics.

RESULTS

African Americans were 1.67 (95% CI, 1.21-2.33) and 1.52 (95% CI, 1.12-2.07) times more likely to die of colonic adenocarcinoma (CAC) within 5 years and 10 years of surgery, respectively, compared with Caucasians. Racial differences in survival were observed among patients with Stage II, III, and IV CAC; however, the strongest and statistically significant association was observed among patients with Stage II CAC. There were no significant racial differences in survival in patients with rectal adenocarcinomas.

CONCLUSIONS

The current findings suggest that the decreased overall survival at 5 years and 10 years postsurgery observed in African-American patients with CAC may not be attributable to tumor stage at diagnosis or treatment but may be due to differences in other biologic or genetic characteristics between African-American patients and Caucasian patients.

Annual report to the nation on the status of cancer, 1975-2001, with a special feature regarding survival

BACKGROUND

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information regarding cancer occurrence and trends in the U.S. This year's report features a special section on cancer survival.

METHODS

Information concerning cancer cases was obtained from the NCI, CDC, and NAACCR and information concerning recorded cancer deaths was obtained from the CDC. The authors evaluated trends in age-adjusted cancer incidence and death rates by regression models and described and compared survival rates over time and across racial/ethnic populations.

RESULTS

Incidence rates for all cancers combined decreased from 1991 through 2001, but stabilized from 1995 through 2001 when adjusted for delay in reporting. The incidence rates for female lung cancer decreased (although not statistically significant for delay adjusted) and mortality leveled off for the first time after increasing for many decades. Colorectal cancer incidence rates also decreased. Death rates decreased for all cancers combined (1.1% per year since 1993) and for many of the top 15 cancers occurring in men and women. The 5-year relative survival rates improved for all cancers combined and for most, but not all, cancers over 2 diagnostic periods (1975-1979 and 1995-2000). However, cancer-specific survival rates were lower and the risk of dying from cancer, once diagnosed, was higher in most minority populations compared with the white population. The relative risk of death from all cancers combined in each racial and ethnic population compared with non-Hispanic white men and women ranged from 1.16 in Hispanic white men to 1.69 in American Indian/Alaska Native men, with the exception of Asian/Pacific Islander women, whose risk of 1.01 was similar to that of non-Hispanic white women.

CONCLUSIONS

The continued measurable declines for overall cancer death rates and for many of the top 15 cancers, along with improved survival rates, reflect progress in the prevention, early detection, and treatment of cancer. However, racial and ethnic disparities in survival and the risk of death from cancer, and geographic variation in stage distributions suggest that not all segments of the U.S. population have benefited equally from such advances.

Where's Maria? A video to increase awareness about breast cancer and mammography screening among low-literacy Latinas

BACKGROUND

The need exists to educate and motivate medically disadvantaged Latinas to engage in regular mammography screening to reduce their high breast cancer (BC) mortality risk due to the illness' late detection.

METHODS

Qualitative research methods [e.g., focus groups, key informants] were primarily used during the basic and formative research phases in preproducing and producing a breast cancer educational video for low-literacy Latinas.

RESULTS

An 8-min video was created in an Entertainment-Education soap opera format. The purpose of the video is to create awareness about breast cancer and to motivate low-literacy Latinas who are at the precontemplation stage of behavior change to consider engaging in mammography screening. Thus, the video presents a compelling story of a Latina with whom the target audience can identify and become involved with the unfolding events of her story as she realizes her risk for breast cancer and struggles with the decision to engage in mammography. The content and format of the video include culturally relevant clues and modeling to influence Latinas' cognitive and subjective processes involved in making the decision to change.

CONCLUSIONS

Complex attitudinal and behavioral issues can be effectively targeted to decrease the influence that psychological barriers exert in Latinas low breast cancer screening rates.

Identification and analysis of single-nucleotide polymorphisms in the gemcitabine pharmacologic pathway

Significant variability in the antitumor efficacy and systemic toxicity of gemcitabine has been observed in cancer patients. However, there are currently no tools for prospective identification of patients at risk for untoward events. This study has identified and validated single-nucleotide polymorphisms (SNP) in genes involved in gemcitabine metabolism and transport. Database mining was conducted to identify SNPs in 14 genes involved in gemcitabine metabolism. Pyrosequencing was utilized to determine the SNP allele frequencies in genomic DNA from European and African populations (n=190). A total of 14 genetic variants (including 12 SNPs) were identified in eight of the gemcitabine metabolic pathway genes. The majority of the database variants were observed in population samples. Nine of the 14 (64%) polymorphisms analyzed have allele frequencies that were found to be significantly different between the European and African populations (P<0.05). This study provides the first step to identify markers for predicting variability in gemcitabine response and toxicity.

Breast cancer outcomes in South Asian population of West Yorkshire

Objective: To examine tumour stage at diagnosis, treatment, patient and provider delays to diagnosis/treatment and survival of South Asian patients with breast cancer in Yorkshire in comparison with the general population. Design: Retrospective study, using Yorkshire Cancer Registry population-based data on breast cancer. Data on 16 879 women with breast cancer diagnosed between 1986 and 1994 was available, of which 120 patients were South Asian. All-cause survival, controlling for age, socio-economic profile, tumour stage and treatment was examined. Effects of ethnicity on tumour stage at diagnosis, treatment, patient and provider delays to diagnosis and treatment were described. Over the period 1986–1994, an increase in the number of registered South Asian patients with breast cancer was observed. South Asian patients were significantly younger at the time of diagnosis and presented with larger primary tumours. They received similar treatment to non-Asian patients, but a higher mastectomy rate was noted. South Asian patients' survival, after controlling for age differences was similar to non-South Asian patients. South Asian patients had a significantly longer patient-related delay between initial symptoms and presentation to GP and a slightly longer provider-related delay in time to diagnosis and treatment. In conclusion, outcomes of breast cancer treatment in South Asian patients were similar to non-Asian patients. Asian patients presented later to their GPs, with larger primary tumours and more frequently had mastectomy.

Clinical characteristics of African-American men with hereditary prostate cancer: the AAHPC study

INTRODUCTION

The African-American Hereditary Prostate Cancer (AAHPC) Study was designed to recruit African-American families fulfilling very stringent criteria of four or more members diagnosed with prostate cancer at a combined age at diagnosis of 65 years or less. This report describes the clinical characteristics of a sample of affected AAHPC family members.

METHODS

In all, 92 African-American families were recruited into the study between 1998 and 2002. Complete clinical data including age and PSA at diagnosis, number of affected per family, stage, grade, and primary treatment were available on 154 affected males. Nonparametric Wilcoxon two-sample tests and Fisher's exact test (two-tailed), were performed to compare families with 4-6 and >6 affected males with respect to clinical characteristics.

RESULTS

The mean number of affected men per family was 5.5, with a mean age at diagnosis of 61.0 (+/-8.4) years. Age at diagnosis, PSA and Gleason score did not show significant differences between the two groups of families. Based on the Gleason score, 77.2% of affected males had favorable histology. Significantly, there were marked differences between the two groups in the frequency of node-positive disease (P=0.01) and distant metastases (P=0.0001). Radical prostatectomy was the preferred primary therapy for 66.2% of all affected men followed by 20.8% who chose radiation therapy.

CONCLUSIONS

Our findings suggest that affected males who carry the highest load of genetic factors are at the highest risk for early dissemination of disease, thus efforts at early diagnosis and aggressive therapeutic approaches may be warranted in these families. Since the primary therapy choices in our study favored definitive treatment (87.0%) when compared to the 1983 and 1995 SEER data in which 28 and 64% received definitive treatment, respectively, it appears that affected African-American men in multiplex families may be demonstrating the reported psycho-social impact of family history on screening practices and treatment decisions for prostate cancer.

Computer simulation of prostate cryoablation--fast and accurate approximation of the exact solution

OBJECTIVE

Cryosurgery is a minimally invasive cancer treatment that uses liquid nitrogen or supercooled argon to freeze and destroy tumors. To achieve complete ablation of the prostate, we have developed a computer program that can determine treatment effects by calculating iceball formation. This is based on a three-dimensional (3D) model of the patient's prostate constructed from ultrasound images. The program predicts the best set of cryoablation parameters and cryoprobe spatial positions, then displays these parameters in graphical or numerical form. The objective of this work was to improve our prostate cryoablation modeling software by making its partial differential equation (PDE) solver more accurate and faster.

MATERIALS AND METHODS

CryoSim, our software package, accepts a set of acquired and processed 3D ultrasound images of the prostate, then models heat diffusion using numerical approximations of the heat equation.

RESULTS

We describe the latest version of the CryoSim software, which models cryoablation therapy. Solving the problems of low spatial resolution (now down to a fraction of a millimeter, as compared to 5 mm in the old version) and modeling cryosurgery in a short time (down to few minutes versus hours) provides a platform for proper planning of cryosurgery and a tool for the training of surgeons.

CONCLUSION

Changes in the PDE solver algorithm produce more accurate results, leading to an improved visualization of the iceball, with a precision of a few mm and a significant decrease in computation time.

Chemoprevention of prostate cancer with selenium: an update on current clinical trials and preclinical findings

Prostate cancer is the most common cancer diagnosed and the second leading cause of cancer-related deaths in men in the United States. The etiological factors that give rise to prostate cancer are not known. Therefore, it is not possible to develop primary intervention strategies to remove the causative agents from the environment. However, secondary intervention strategies with selenium (Se) compounds and other agents represent a viable option to reduce the morbidity and mortality of prostate cancer. In this review, we discuss ongoing clinical trials. In addition, we discuss preclinical mechanistic studies that provide insights into the biochemical and molecular basis for the anti-carcinogenic activity of both inorganic and organic forms of Se.

Cancer survival and incidence from the Surveillance, Epidemiology, and End Results (SEER) program

An overview of data on cancer at all sites combined and on selected, frequently occurring cancers is presented. Descriptive cancer statistics include average annual Surveillance, Epidemiology, and End Results (SEER) Program incidence, U.S. mortality and median age at diagnosis, and death for the period 1996-2000. Changes during the time period 1992-2000 are summarized by the annual percent change in SEER incidence and U.S. mortality data for this period. Five-year relative survival for selected cancers is examined by stage at diagnosis, based on data from 1990-1999. In addition, 5-year conditional survival for patients already surviving for 1-3 years after diagnosis is discussed as well as relative survival for other time periods. These measures may be more meaningful for clinical management and prognosis than 5-year relative survival from time of diagnosis. The likelihood of developing cancer during one's lifetime is 1 in 2 for males and 1 in 3 for females, based on 1998-2000 data. It is estimated that approximately 9.6 million people in the U.S. who have had a diagnosis of cancer are alive. Five-year relative survival varies greatly by cancer site and stage at diagnosis, and tends to increase with time since diagnosis. The median age at cancer diagnosis is 68 for men and 65 for women. The 5-year relative survival rate for persons diagnosed with cancer is 62.7%, with variation by cancer site and stage at diagnosis. For patients diagnosed with cancers of the prostate, female breast, corpus uteri, and urinary bladder, the relative survival rate at 8 years is over 75%.

Disparities in screening mammography. Current status, interventions and implications

OBJECTIVE

This paper describes trends in screening mammography utilization over the past decade and assesses the remaining disparities in mammography use among medically underserved women. We also describe the barriers to mammography and report effective interventions to enhance utilization.

DESIGN

We reviewed medline and other databases as well as relevant bibliographies.

MAIN RESULTS

The United States has dramatically improved its use of screening mammography over the past decade, with increased rates observed in every demographic group. Disparities in screening mammography are decreasing among medically underserved populations but still persist among racial/ethnic minorities and low-income women. Additionally, uninsured women and those with no usual care have the lowest rates of reported mammogram use. However, despite apparent increases in mammogram utilization, there is growing evidence that limitations in the national survey databases lead to overestimations of mammogram use, particularly among low-income racial and ethnic minorities.

CONCLUSIONS

The United States may be farther from its national goals of screening mammography, particularly among underserved women, than current data suggests. We should continue to support those interventions that increase mammography use among the medically underserved by addressing the barriers such as cost, language and acculturation limitations, deficits in knowledge and cultural beliefs, literacy and health system barriers such as insurance and having a source regular of medical care. Addressing disparities in the diagnostic and cancer treatment process should also be a priority in order to affect significant change in health outcomes among the underserved.

Epidemiology of prostate cancer

Prostate cancer incidence and mortality rates vary worldwide. In the United States, prostate cancer is the most common malignancy affecting men and is the second-leading cause of cancer death. Risk of developing prostate cancer is associated with advancing age, African American ethnicity, and a positive family history, and may be influenced by diet and other factors. The incidence of prostate cancer increased sharply after the introduction of widespread screening for prostate-specific antigen (PSA), although rates have now returned to levels seen before that time. PSA screening has been associated with a shift toward diagnosis of earlier-stage disease, but this has not been accompanied by a shift toward a lower histologic grade. Although overall prostate cancer mortality rates decreased during the 1990s, it was largely because of reductions in deaths among men diagnosed with distant disease. In contrast, mortality rates for men diagnosed with localized or regional disease increased gradually during most of the 1990s before decreasing slightly among white men and reaching plateaus among African Americans.

Flow cytometric enrichment for respiratory epithelial cells in sputum

BACKGROUND

Induced sputum, in contrast to bronchoscopic biopsies and lavages, is an easily obtained source of biological specimens. However, obtaining abnormal exfoliated cells for detailed molecular studies is limited because respiratory epithelial cells comprise only about 1% of sputum cell populations.

METHODS

We developed a multiparameter flow sorting strategy to purify epithelial cells from nonepithelial sputum cells, using anti-cytokeratin antibody AE1/AE3 to recognize human epithelial cells and DAPI to stain DNA. We excluded cells with a high degree of side-scatter, which were composed predominantly of squamous cells and contaminating macrophages. The remaining cytokeratin-positive respiratory epithelial cells were then sorted based on anti-cytokeratin (PE) vs DNA (DAPI) parameters.

RESULTS

In this proof of principle study, the AE1AE3 cytokeratin/DNA flow sorting strategy enriched rare diploid respiratory epithelial cells from an average of 1.1% of cells in unsorted induced sputum samples to average purities of 42%. Thus, AE1AE3 flow-sorting results in a 38-fold enrichment of these cells.

CONCLUSIONS

We report a multiparameter flow cytometric assay to detect and enrich rare respiratory epithelial cells from induced sputum samples to average purities of 42%. With further development, this methodology may be useful as part of a molecular screening approach of populations at high risk for lung cancer.

The effect of ethnicity on immediate reconstruction rates after mastectomy for breast cancer

BACKGROUND

Multiple factors may influence whether patients undergo immediate breast reconstruction along with mastectomy for breast cancer. The authors investigated whether ethnicity was an independent predictor of immediate breast reconstruction.

METHODS

The authors identified 1004 patients who underwent mastectomy for breast cancer during the period 2001-2002. The rates of immediate reconstruction among different ethnicities were evaluated using the chi-square test. Logistic regression was used to adjust for covariates, including age and disease stage. Medical records were analyzed to identify factors that influenced each patient's decision for or against immediate breast reconstruction.

RESULTS

Three hundred seventy-six women (37.5%) underwent immediate breast reconstruction: This included 20.2% of African-American women, compared with 40.0% of white women, 42.0% of Hispanic women, 42.2% of Asian women, and 10.0% of Middle Eastern women (P < 0.001). The unadjusted odds ratio (OR) for immediate reconstruction for African-Americans versus whites was 0.38 (95% confidence interval [95% CI], 0.23-0.63; P < 0.001). After multivariate analysis, this disparity persisted, with an adjusted OR of 0.34 (95% CI, 0.18-0.62; P = 0.001). Asian women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.50; 95% CI, 0.24-1.04; P = 0.06). Hispanic women did not have immediate reconstruction rates that differed significantly from white women. Middle Eastern women had lower rates of immediate reconstruction compared with white women (adjusted OR, 0.08; 95% CI, 0.02-0.38; P = 0.002), but they had a corresponding increase in the rate of delayed reconstruction. In a stepwise analysis of the decision pathway to immediate reconstruction, it was found that African-American women were less likely to be offered referrals for reconstruction, were less likely to accept offered referrals, were less likely to be offered reconstruction, and were less likely to elect reconstruction if it was offered.

CONCLUSIONS

African-American women underwent immediate breast reconstruction at significantly lower rates compared with white women, Hispanic women, and Asian women. After adjusting for covariates, including age and disease stage, African-American women and Asian women had lower rates of reconstruction compared with white women. The factors that contribute to these differences warrant further study.

Ethnic Neutropenia and Treatment Delay in African American Women Undergoing Chemotherapy for Early-Stage Breast Cancer

Disparities in breast cancer survival have been observed between African American and white women. There are also known differences in mean baseline white blood cell (WBC) count among racial and ethnic groups. If the WBC count falls below conventionally defined treatment thresholds for patients undergoing adjuvant chemotherapy, reduced doses or treatment delays may occur, which could lead to race-based differences in treatment duration. We used the tumor registry at Columbia-Presbyterian Medical Center to identify 1178 women with newly diagnosed stage I and II breast cancer from whom we collected base-line information for 73 African American women and 126 age- and tumor stage-matched white women. Of these women, 43 African American and 93 white women underwent adjuvant chemotherapy. African American women had statistically significantly lower WBC counts than white women at diagnosis (6.2 x 10(9)/L for African American women versus 7.4 x 10(9)/L for white women, difference = 1.2, 95% confidence interval [CI] = 0.2 to 1.2; P =.02) and after treatment (5.3 x 10(9)/L for African American women versus 6.4 x 10(9)/L for white women, difference = 1.1, 95% CI = 0.2 to 2.5; P =.03). Overall, African American women required a statistically significantly longer duration of treatment than white women (19 weeks versus 15 weeks, respectively, difference = 4 weeks, 95% CI = 0.5 to 7.2 weeks; P =.03). The lower baseline WBC counts and longer duration of treatment for early-stage breast cancer in African American women compared with those in white women result in lower dose intensity of treatment for African American women, possibly contributing to observed racial differences in breast cancer survival.

Is patient travel distance associated with survival on phase II clinical trials in oncology?

BACKGROUND

Prior research has suggested that patients who travel out of their neighborhood for elective care from specialized medical centers may have better outcomes than local patients with the same illnesses who are treated at the same centers. We hypothesized that this phenomenon, often called "referral bias" or "distance bias," may also be evident in curative-intent cancer trials at specialized cancer centers.

METHODS

We evaluated associations between overall survival and progression-free survival and the distance from the patient residence to the treating institution for 110 patients treated on one of four phase II curative-intent chemoradiotherapy protocols for locoregionally advanced squamous cell cancer of the head and neck conducted at the University of Chicago over 7 years.

RESULTS

Using Cox regression that adjusted for standard patient-level disease and demographic factors and neighborhood-level economic factors, we found a positive association between the distance patients traveled from their residence to the treatment center and survival. Patients who lived more than 15 miles from the treating institution had only one-third the hazard of death of those living closer (hazard ratio [HR] = 0.32, 95% confidence interval [CI] = 0.12 to 0.84). Moreover, with every 10 miles that a patient traveled for care, the hazard of death decreased by 3.2% (HR = 0.97, 95% CI = 0.94 to 0.99). Similar results were obtained for progression-free survival.

CONCLUSION

Results of phase II curative-intent clinical trials in oncology that are conducted at specialized cancer centers may be confounded by patient travel distance, which captures prognostic significance beyond cancer stage, performance status, and wealth. More work is needed to determine what unmeasured factors travel distance is mediating.

Cancer rates among American Indians and Alaska Natives: is there a national perspective

BACKGROUND

Two important goals of cancer surveillance are to provide milestones in the effort to reduce the cancer burden and to generate observations that form the basis for cancer research and intervention for cancer prevention and control. Determination of the cancer burden among American Indians and Alaska Natives (AIAN) has been difficult largely due to lack of data collection efforts in many areas of the country and misclassification of racial data that results in undercounting of Native Americans. There is a revitalized commitment to improve data collection among the national agencies and organizations.

METHODS

Data on cancer trends from 12 areas covered by the Surveillance, Epidemiology and End Results (SEER) Program were reviewed for incidence and death rates for 1992-2000. AIAN trends were examined and compared with trends among other racial/ethnic population groups. Reference was made to studies of disease-specific survival for nine of the SEER areas for 1988-1997.

RESULTS

In SEER areas, cancer incidence rates for AIAN populations appeared to be decreasing significantly for lung and breast cancers among women and for prostate cancer among men. However, death rates rose, although not significantly, over the same period, except for a significant decrease in prostate cancer. Among the cancers with rising death rates were lung cancer (AIAN women) and colorectal cancer (AIAN men). In addition, survival often was lower for AIAN populations.

CONCLUSIONS

Although the incidence was stable or decreased among AIAN populations, increased death rates and lower survival rates indicate the need for intensified application of cancer prevention and control measures, including screening and treatment. Difficulties in interpretation of data include small population size and substantial interregional differences in rates.

Racial differences in survival after diagnosis with primary malignant brain tumor

BACKGROUND

Previous studies have shown that the overall incidence of primary malignant brain tumor is greatest in Caucasians, although survival is better in African Americans. The objective of this study was to examine racial differences in survival after diagnosis with primary malignant brain tumor in a population-based sample of patients while adjusting for prognostic variables that differ by race.

METHODS

The authors analyzed 21,493 patients (20,493 Caucasians and 1000 African Americans) who were diagnosed with primary malignant brain tumors from 1973 to 1997 (with follow-up through 1999) from the population-based Surveillance, Epidemiology, and End Results (SEER) Program. Chi-square tests were used to determine statistical significance of prognostic variables and race (using two-sided P values). Kaplan-Meier and Cox proportional hazards models were used to assess survival differences by race.

RESULTS

The univariable model for race showed no survival difference by race. The multivariable model demonstrated that African American patients were at a 13% increased risk of death from any cause compared with Caucasian patients. The racial difference was explained further by an interaction between race and surgery type in which there was an increased risk of death for African American patients who underwent subtotal resections or surgery not otherwise specified compared with Caucasian patients who underwent the same procedures.

CONCLUSIONS

There was a significant difference in the risk of death due to any cause for Caucasian patients and African American patients who were diagnosed with first primary brain tumors.