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Schneider BP, Zhao F, Ballinger TJ, Garcia SF, Shen F, Virani S, Cella D, Bales C, Jiang G, Hayes L, Miller N, Srinivasiah J, Stringer-Reasor EM, Chitalia A, Davis AA, Makower DF, Incorvati J, Simon MA, Mitchell EP, DeMichele A, Miller KD, Sparano JA, Wagner LI, Wolff AC. ECOG-ACRIN EAZ171: Prospective Validation Trial of Germline Predictors of Taxane-Induced Peripheral Neuropathy in Black Women With Early-Stage Breast Cancer. J Clin Oncol 2024; 42:2899-2907. [PMID: 38828938 DOI: 10.1200/jco.24.00526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/16/2024] [Accepted: 05/02/2024] [Indexed: 06/05/2024] Open
Abstract
PURPOSE Black women experience higher rates of taxane-induced peripheral neuropathy (TIPN) compared with White women when receiving adjuvant once weekly paclitaxel for early-stage breast cancer, leading to more dose reductions and higher recurrence rates. EAZ171 aimed to prospectively validate germline predictors of TIPN and compare rates of TIPN and dose reductions in Black women receiving (neo)adjuvant once weekly paclitaxel and once every 3 weeks docetaxel for early-stage breast cancer. METHODS Women with early-stage breast cancer who self-identified as Black and had intended to receive (neo)adjuvant once weekly paclitaxel or once every 3 weeks docetaxel were eligible, with planned accrual to 120 patients in each arm. Genotyping was performed to determine germline neuropathy risk. Grade 2-4 TIPN by Common Terminology Criteria for Adverse Events (CTCAE) v5.0 was compared between high- versus low-risk genotypes and between once weekly paclitaxel versus once every 3 weeks docetaxel within 1 year. Patient-rated TIPN and patient-reported outcomes were compared using patient-reported outcome (PRO)-CTCAE and Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity. RESULTS Two hundred and forty of 249 enrolled patients had genotype data, and 91 of 117 (77.8%) receiving once weekly paclitaxel and 87 of 118 (73.7%) receiving once every 3 weeks docetaxel were classified as high-risk. Physician-reported grade 2-4 TIPN was not significantly different in high- versus low-risk genotype groups with once weekly paclitaxel (47% v 35%; P = .27) or with once every 3 weeks docetaxel (28% v 19%; P = .47). Grade 2-4 TIPN was significantly higher in the once weekly paclitaxel versus once every 3 weeks docetaxel arm by both physician-rated CTCAE (45% v 29%; P = .02) and PRO-CTCAE (40% v 24%; P = .03). Patients receiving once weekly paclitaxel required more dose reductions because of TIPN (28% v 9%; P < .001) or any cause (39% v 25%; P = .02). CONCLUSION Germline variation did not predict risk of TIPN in Black women receiving (neo)adjuvant once weekly paclitaxel or once every 3 weeks docetaxel. Once weekly paclitaxel was associated with significantly more grade 2-4 TIPN and required more dose reductions than once every 3 weeks docetaxel.
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Affiliation(s)
- Bryan P Schneider
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Fengmin Zhao
- Dana Farber Cancer Institute-ECOG-ACRIN Biostatistics Center, Boston, MA
| | - Tarah J Ballinger
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Sofia F Garcia
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Fei Shen
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | | | - David Cella
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Casey Bales
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Guanglong Jiang
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Lisa Hayes
- Pink-4-Ever Ending Disparities, Indianapolis, IN
| | - Nadia Miller
- Pink-4-Ever Ending Disparities, Indianapolis, IN
| | | | | | - Ami Chitalia
- MedStar Washington Hospital Center, Washington, DC
| | | | | | | | - Melissa A Simon
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Edith P Mitchell
- Thomas Jefferson University Hospital, Philadelphia, PA
- Deceased, Baltimore, MD
| | | | - Kathy D Miller
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN
| | - Joseph A Sparano
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY
| | | | - Antonio C Wolff
- Johns Hopkins University/Sidney Kimmel Comprehensive Cancer Center
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Christensen EW, Rosenblatt RB, Patel AG, Rula EY, Carlos RC, Narayan AK, Patel BK. Differential Access to Breast Magnetic Resonance Imaging Compared with Mammography and Ultrasound. Am J Prev Med 2024:S0749-3797(24)00250-2. [PMID: 39140933 DOI: 10.1016/j.amepre.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION For high-risk women, breast magnetic resonance (MR) is the preferred supplemental imaging option, but spatial access differences may exacerbate disparities in breast care. METHODS This was a cross-sectional study examining distance between ZIP codes and the nearest breast imaging facility (MR, mammography, ultrasound) using 2023 data from the Food and Drug Administration and the American College of Radiology. Linear regression was used to assess distance differences controlling for Area Deprivation Index (ADI), urbanicity, and population size. Analyses were conducted in 2024. RESULTS Among the 29,629 ZIP codes with an ADI and known urbanicity, unadjusted mean distance to breast MR was 23.2±25.1 miles (SD) compared with 8.2±8.3 for mammography and 22.2±25.0 for ultrasound. Hence, the average distance to breast MR facilities was 2.8 times further than to mammography facilities. ADI and urbanicity were associated with increased distance to the nearest breast imaging facility. The additional miles associated with the least advantaged areas compared with most advantaged areas was 12.2 (95%CI: 11.3, 13.2) for MR, 11.5 miles (95%CI: 10.6, 12.3) for ultrasound, and 2.4 (95%CI: 2.1, 2.7) for mammography. Compared with metropolitan areas, the additional miles to breast MR facilities was 23.2 (95%CI: 22.5, 24.0) for small/rural areas. CONCLUSIONS Spatial access is substantially better for mammography sites compared with breast MR or ultrasound sites. Given these findings, consideration of options to mitigate the impact of differential access should be considered. For example, mammography sites could offer contrast-enhanced mammography. Future research should examine the feasibility and effectiveness of this and other options.
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Affiliation(s)
- Eric W Christensen
- Neiman Health Policy Institute, Reston, Virginia; Health Services Management, University of Minnesota, St. Paul, Minnesota.
| | - Robert B Rosenblatt
- Arizona College of Osteopathic Medicine, Midwestern University, Phoenix, Arizona
| | - Anika G Patel
- College of Liberal Arts, University of Texas at Austin, Austin, Texas
| | | | - Ruth C Carlos
- Division of Abdominal Radiology, University of Michigan, Ann Arbor, Michigan
| | - Anand K Narayan
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
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Daly GR, Naidoo S, Alabdulrahman M, McGrath J, Dowling GP, AlRawashdeh MM, Hill ADK, Varešlija D, Young L. Screening and Testing for Homologous Recombination Repair Deficiency (HRD) in Breast Cancer: an Overview of the Current Global Landscape. Curr Oncol Rep 2024; 26:890-903. [PMID: 38822929 PMCID: PMC11300621 DOI: 10.1007/s11912-024-01560-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE OF REVIEW Homologous recombination repair deficiency (HRD) increases breast cancer susceptibility and influences both prophylactic and active management of breast cancer. This review evaluates HRD testing and the therapeutic implications of HRD in a global context. RECENT FINDINGS Ongoing research efforts have highlighted the importance of HRD beyond BRCA1/2 as a potential therapeutic target in breast cancer. However, despite the improved affordability of next-generation sequencing (NGS) and the discovery of PARP inhibitors, economic and geographical barriers in access to HRD testing and breast cancer screening do not allow all patients to benefit from the personalized treatment approach they provide. Advancements in HRD testing modalities and targeted therapeutics enable tailored breast cancer management. However, inequalities in access to testing and optimized treatments are contributing to widening health disparities globally.
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Affiliation(s)
- Gordon R Daly
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland.
- The Department of Surgery, Beaumont Hospital, Dublin, Ireland.
| | - Sindhuja Naidoo
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Mohammad Alabdulrahman
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Jason McGrath
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Gavin P Dowling
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Maen M AlRawashdeh
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Arnold D K Hill
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- The Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Damir Varešlija
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Beaumont Hospital, Dublin, Ireland
| | - Leonie Young
- The Department of Surgery, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- Beaumont RCSI Cancer Centre, Beaumont Hospital, Dublin, Ireland
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Peckham ME, Shah LM, Meeks HD, Fraser A, Galvao C, Safazadeh G, Hutchins TA, Anzai Y, Fritz JM, Kean J, Carlos RC. Disparities in Provider Ordering Practices of Image-Guided Interventions and Surgery for Patients With Low Back Pain: A Cohort Study. J Am Coll Radiol 2024; 21:1010-1023. [PMID: 38369043 DOI: 10.1016/j.jacr.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/28/2024] [Accepted: 02/02/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To assess individual- and neighborhood-level sociodemographic factors associating with providers' ordering of nonpharmacologic treatments for patients with low back pain (LBP), specifically physical therapy, image-guided interventions, and lumbar surgery. METHODS Our cohort included all patients diagnosed with LBP from 2000 to 2017 in a statewide database of all hospitals and ambulatory surgical facilities within Utah. We compared sociodemographic and clinical characteristics of (1) patients with LBP who received any treatment with those who received none and (2) patients with LBP who received invasive LBP treatments with those who only received noninvasive LBP treatments using the Student's t test, Wilcoxon's rank-sum tests, and Pearson's χ2 tests, as applicable, and two separate multivariate logistic regression models: (1) to determine whether sociodemographic characteristics were risk factors for receiving any LBP treatments and (2) risk factors for receiving invasive LBP treatments. RESULTS Individuals in the most disadvantaged neighborhoods were less likely to receive any nonpharmacologic treatment orders (odds ratio [OR] 0.74 for most disadvantaged, P < .001) and received fewer invasive therapies (0.92, P = .018). Individual-level characteristics correlating with lower rates of treatment orders were female sex, Native Hawaiian or other Pacific Islander race (OR 0.50, P < .001), Hispanic ethnicity (OR 0.77, P < .001), single or unmarried status (OR 0.69, P < .001), and no insurance or self-pay (OR 0.07, P < .001). CONCLUSION Neighborhood and individual sociodemographic variables associated with treatment orders for LBP with Area Deprivation Index, sex, race or ethnicity, insurance, and marital status associating with receipt of any treatment, as well as more invasive image-guided interventions and surgery.
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Affiliation(s)
- Miriam E Peckham
- Assistant Professor, Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah.
| | - Lubdha M Shah
- Professor, Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Huong D Meeks
- Assistant Professor, Department of Pediatrics, Critical Care Division, University of Utah Spencer F. Eccles School of Medicine, Salt Lake City, Utah
| | - Alison Fraser
- Senior Database Manager, Utah Population Database, Pedigree and Population Resource, Salt Lake City, Utah
| | - Carlos Galvao
- Database Analyst, Utah Population Database, Salt Lake City, Utah
| | - Ghazaleh Safazadeh
- Research Associate, Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Troy A Hutchins
- Associate Professor, Vice Chair of Clinical Operations, Department of Radiology at University of Utah, Salt Lake City, Utah
| | - Yoshimi Anzai
- Professor, Vice Chair for Quality and Safety, Department of Radiology at University of Utah School of Medicine, Salt Lake City, Utah
| | - Julie M Fritz
- Professor, Department of Physical Therapy & Athletic Training, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Jacob Kean
- Associate Professor, Department of Population Health Sciences, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Ruth C Carlos
- Professor, Department of Radiology, University of Michigan, Ann Arbor, Michigan; and Editor-in-Chief of the JACR
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Chua AV, Sheng H, Liang E, Gandhi S, Kwan ML, Ergas IJ, Roh JM, Laurent CA, Yan L, Khoury T, Ambrosone CB, Kushi LH, Yao S. Epidemiology of early vs. Late recurrence among women with Early-Stage estrogen Receptor-Positive breast cancer in the pathways study. J Natl Cancer Inst 2024:djae128. [PMID: 38845078 DOI: 10.1093/jnci/djae128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/15/2024] [Accepted: 05/31/2024] [Indexed: 08/09/2024] Open
Abstract
BACKGROUND Relatively little is known about the differences in prognostic factors for early vs late recurrence among women with early-stage estrogen receptor-positive (ER+) breast cancer. METHODS We analyzed factors related to early (<5 years) vs late (≥5 years) recurrence in 2,992 women with stage I-IIB ER+ breast cancer in the Pathways Study, a prospective cohort of women with breast cancer enrolled between 2006 and 2013, with ascertainment of recurrence and death through December 2021. RESULTS After a median follow-up of 13.3 years, 341 (13.8%) women had recurrences, including 181 (53.7%) with late recurrence. Higher stage and grade were associated with recurrence regardless of timing, whereas progesterone receptor (PR) negativity was associated with early but not late recurrence. Receipt of endocrine therapy was associated with reduced risk of overall recurrence, but the length of endocrine therapy was not significant in multivariable models. Minoritized racial and ethnic groups, including Asian, Black, and Hispanic women, had higher risk of early but not late recurrence, compared with non-Hispanic White women. The trend of higher risk of early recurrence among these groups remained after adjustment for clinical, demographic, and socioeconomic factors, but was statistically significant only in Asian women. CONCLUSIONS Our study revealed potentially important distinctions for early vs late recurrence, including the associations with PR-negativity and self-identified race and ethnicity. Possible higher risk of early recurrence among Asian, Black, and Hispanic women provides novel evidence for the existence of disparities in cancer outcomes, even within the breast cancer subtype indicative of generally good prognosis.
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Affiliation(s)
- Alfredo V Chua
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Haiyang Sheng
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Emily Liang
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Shipra Gandhi
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Isaac J Ergas
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Janise M Roh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Cecile A Laurent
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Li Yan
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Thaer Khoury
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Christine B Ambrosone
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Song Yao
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Chen JC, Stover DG, Ballinger TJ, Bazan JG, Schneider BP, Andersen BL, Carson WE, Obeng-Gyasi S. Racial Disparities in Breast Cancer: from Detection to Treatment. Curr Oncol Rep 2024; 26:10-20. [PMID: 38100011 DOI: 10.1007/s11912-023-01472-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2023] [Indexed: 02/12/2024]
Abstract
PURPOSE OF REVIEW Update on current racial disparities in the detection and treatment of breast cancer. RECENT FINDINGS Breast cancer remains the leading cause of cancer death among Black and Hispanic women. Mammography rates among Black and Hispanic women have surpassed those among White women, with studies now advocating for earlier initiation of breast cancer screening in Black women. Black, Hispanic, Asian, and American Indian and Alaskan Native women continue to experience delays in diagnosis and time to treatment. Further, racial discrepancies in receipt of guideline-concordant care, access to genetic testing and surgical reconstruction persist. Disparities in the initiation, completion, toxicity, and efficacy of chemotherapy, endocrine therapy, and targeted drug therapy remain for racially marginalized women. Efforts to evaluate the impact of race and ethnicity across the breast cancer spectrum are increasing, but knowledge gaps remain and further research is necessary to reduce the disparity gap.
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Affiliation(s)
- J C Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Daniel G Stover
- Department of Internal Medicine, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Tarah J Ballinger
- Department of Internal Medicine, Indiana University, Indianapolis, IN, USA
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Bryan P Schneider
- Department of Internal Medicine, Indiana University, Indianapolis, IN, USA
| | | | - William E Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH, USA.
- The Ohio State University, N924 Doan Hall, 410 West 10th, Columbus, OH, 43210, USA.
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Kelly KM, Rai P, Studts JL, Dickinson S, Henschel B, Dignan M, Chambers M, Hazard-Jenkins H. Communication with physicians and family about breast Cancer recurrence. PEC INNOVATION 2023; 3:100237. [PMID: 38148854 PMCID: PMC10750108 DOI: 10.1016/j.pecinn.2023.100237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 11/09/2023] [Accepted: 11/25/2023] [Indexed: 12/28/2023]
Abstract
Objective Adequate physician-patient communication about cancer recurrence is vital to quality of life and to informed decision-making related to survivorship care. The current study was guided by a cognitive-affective framework to examine communication with family and physicians about breast cancer recurrence risk. Methods A survey of recently-diagnosed, early-stage breast cancer patients in Appalachia investigated physician-patient and familial communication about breast cancer recurrence risk. Results Over 30% of participants reported not talking to family or physicians about breast cancer recurrence risk. Younger patients reported more conversations, and speaking with physicians was associated with greater perception risk factors associated with recurrence risk. Greater worry about recurrence was associated with more communication with family and plans to talk to family, physicians, and friends about recurrence risk in the future. Conclusion Additional supports for patients and physicians are needed to improve understanding of breast cancer recurrence risk and risk factors for recurrence. Innovation Family communication about breast cancer recurrence risk is understudied. The combination of physician and family communication adds novelty to our analysis.
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Affiliation(s)
- Kimberly M. Kelly
- Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, 66 N. Pauline St, Memphis, TN, USA
- West Virginia University School of Pharmacy, HSC PO Box 9510, Morgantown, WV 26506, USA
| | - Pragya Rai
- Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, 66 N. Pauline St, Memphis, TN, USA
| | - Jamie L. Studts
- University of Colorado School of Medicine, Aurora, CO 80045, USA
| | | | | | - Mark Dignan
- University of Kentucky, Lexington, KY 40505, USA
| | | | - Hannah Hazard-Jenkins
- West Virginia University School of Pharmacy, HSC PO Box 9510, Morgantown, WV 26506, USA
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Glass CC, Pride RM, Freedman RA, Mayer EL, Ogayo ER, Chavez-MacGregor M, King TA, Mittendorf EA, Kantor O. Racial Disparities in Locoregional Recurrence in Postmenopausal Patients with Stage I-III, Hormone Receptor-Positive Breast Cancer Enrolled in the NSABP B-42 Clinical Trial. Ann Surg Oncol 2023; 30:8320-8326. [PMID: 37670122 DOI: 10.1245/s10434-023-14220-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/08/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND There are limited data examining racial disparities in locoregional recurrence (LRR) among women with access to high-quality care. We aimed to examine differences in late LRR by race in patients with stage I-IIIA, hormone receptor-positive (HR+) breast cancer enrolled in the National Surgical Adjuvant Breast and Bowel (NSABP) B-42 trial. METHODS From 2006 to 2010, 3966 postmenopausal women with stage I-IIIA HR+ breast cancer who were disease-free after 5 years of endocrine therapy were randomized to an additional 5 years of endocrine therapy or placebo. Patients were excluded if multi-racial or if race was unknown. Kaplan-Meier curves were used to estimate 6-year LRR from the time of trial registration and according to race. Cox proportional hazards models were used for adjusted survival analyses. RESULTS Overall, 3929 NSABP B-42 patients were included: 3688 (93.9%) White, 151 (3.8%) Black, and 90 (2.3%) Asian patients. Median follow-up was 75.2 months. Overall estimated 6-year LRR from trial registration was 1.8% and differed by race: LRR rates were 1.7% in White women, 4.9% in Black women, and 0% in Asian women (p = 0.046). Adjusted Cox proportional hazards analysis found Black race to be independently associated with LRR (hazard ratio [HzR] 2.36, 95% confidence interval [CI] 1.01-5.49; p = 0.047). Node-positivity was also associated with increased LRR (HzR 1.75, 95% CI 1.07-2.86; p = 0.025). Adjusted Cox analysis found LRR (HzR 2.32, 95% CI 1.33-4.06; p = 0.003) to be associated with increased overall mortality; however, race was not independently associated with mortality. CONCLUSION Among postmenopausal patients with stage I-IIIA HR+ breast cancer in the NSABP B-42 trial, racial differences in late LRR were present, with the highest LRR in Black women.
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Affiliation(s)
- Charity C Glass
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Robert M Pride
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | - Rachel A Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Erica L Mayer
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Esther R Ogayo
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
| | | | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Kyalwazi B, Yau C, Campbell MJ, Yoshimatsu TF, Chien AJ, Wallace AM, Forero-Torres A, Pusztai L, Ellis ED, Albain KS, Blaes AH, Haley BB, Boughey JC, Elias AD, Clark AS, Isaacs CJ, Nanda R, Han HS, Yung RL, Tripathy D, Edmiston KK, Viscusi RK, Northfelt DW, Khan QJ, Asare SM, Wilson A, Hirst GL, Lu R, Symmans WF, Yee D, DeMichele AM, van ’t Veer LJ, Esserman LJ, Olopade OI. Race, Gene Expression Signatures, and Clinical Outcomes of Patients With High-Risk Early Breast Cancer. JAMA Netw Open 2023; 6:e2349646. [PMID: 38153734 PMCID: PMC10755617 DOI: 10.1001/jamanetworkopen.2023.49646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/26/2023] [Indexed: 12/29/2023] Open
Abstract
Importance There has been little consideration of genomic risk of recurrence by breast cancer subtype despite evidence of racial disparities in breast cancer outcomes. Objective To evaluate associations between clinical trial end points, namely pathologic complete response (pCR) and distant recurrence-free survival (DRFS), and race and examine whether gene expression signatures are associated with outcomes by race. Design, Setting, and Participants This retrospective cohort study used data from the Investigation of Serial Studies to Predict Your Therapeutic Response With Imaging and Molecular Analysis 2 (I-SPY 2) multicenter clinical trial of neoadjuvant chemotherapy with novel agents and combinations for patients with previously untreated stage II/III breast cancer. Analyses were conducted of associations between race and short- and long-term outcomes, overall and by receptor subtypes, and their association with 28 expression biomarkers. The trial enrolled 990 female patients between March 30, 2010, and November 5, 2016, with a primary tumor size of 2.5 cm or greater and clinical or molecular high risk based on MammaPrint or hormone receptor (HR)-negative/ERBB2 (formerly HER2 or HER2/neu)-positive subtyping across 9 arms. This data analysis was performed between June 10, 2021, and October 20, 2022. Exposure Race, tumor receptor subtypes, and genomic biomarker expression of early breast cancer. Main Outcomes and Measures The primary outcomes were pCR and DRFS assessed by race, overall, and by tumor subtype using logistic regression and Cox proportional hazards regression models. The interaction between 28 expression biomarkers and race, considering pCR and DRFS overall and within subtypes, was also evaluated. Results The analytic sample included 974 participants (excluding 16 self-reporting as American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or multiple races due to small sample sizes), including 68 Asian (7%), 120 Black (12%), and 786 White (81%) patients. Median (range) age at diagnosis was 47 (25-71) years for Asian, 49 (25-77) for Black, and 49 (23-73) years for White patients. The pCR rates were 32% (n = 22) for Asian, 30% for Black (n = 36), and 32% for White (n = 255) patients (P = .87). Black patients with HR-positive/ERBB2-negative tumors not achieving pCR had significantly worse DRFS than their White counterparts (hazard ratio, 2.28; 95% CI, 1.24-4.21; P = .01), with 5-year DRFS rates of 55% (n = 32) and 77% (n = 247), respectively. Black patients with HR-positive/ERBB2-negative tumors, compared with White patients, had higher expression of an interferon signature (mean [SD], 0.39 [0.87] and -0.10 [0.99]; P = .007) and, compared with Asian patients, had a higher mitotic score (mean [SD], 0.07 [1.08] and -0.69 [1.06]; P = .01) and lower estrogen receptor/progesterone receptor signature (mean [SD], 0.31 [0.90] and 1.08 [0.95]; P = .008). A transforming growth factor β signature had a significant association with race relative to pCR and DRFS, with a higher signature associated with lower pCR and worse DRFS outcomes among Black patients only. Conclusions and Relevance The findings show that women with early high-risk breast cancer who achieve pCR have similarly good outcomes regardless of race, but Black women with HR-positive/ERBB2-negative tumors without pCR may have worse DRFS than White women, highlighting the need to develop and test novel biomarker-informed therapies in diverse populations.
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Affiliation(s)
- Beverly Kyalwazi
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Christina Yau
- Department of Surgery, University of California, San Francisco
| | | | - Toshio F. Yoshimatsu
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
| | - A. Jo Chien
- Department of Hematology Oncology and Surgery, University of California, San Francisco Helen Diller Comprehensive Cancer Center, San Francisco
| | - Anne M. Wallace
- Division of Breast Surgery and the Comprehensive Breast Health Center, University of California San Diego, La Jolla
| | | | - Lajos Pusztai
- Department of Medical Oncology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | | | - Kathy S. Albain
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Anne H. Blaes
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Barbara B. Haley
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas
| | | | | | - Amy S. Clark
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | | | - Rita Nanda
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
| | - Hyo S. Han
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Rachel L. Yung
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Debasish Tripathy
- Division of Cancer Medicine, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Rebecca K. Viscusi
- Department of Surgery, University of Arizona College of Medicine, Tucson
| | | | - Qamar J. Khan
- Division of Medical Oncology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City
| | - Smita M. Asare
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - Amy Wilson
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | | | - Ruixiao Lu
- Quantum Leap Healthcare Collaborative, San Francisco, California
| | - William Fraser Symmans
- Division of Pathology and Laboratory Medicine, Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston
| | - Douglas Yee
- Division of Hematology-Oncology, Department of Medicine, University of Minnesota, Minneapolis
| | - Angela M. DeMichele
- Division of Hematology and Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Laura J. van ’t Veer
- Department of Laboratory Medicine, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco
| | | | - Olufunmilayo I. Olopade
- Center for Clinical Cancer Genetics and Global Health, The University of Chicago, Chicago, Illinois
- Department of Medicine, Section of Hematology/Oncology, The University of Chicago, Chicago, Illinois
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10
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Liggett JR, Norris EA, Rush TM, Sicignano NM, Oxner C. The Military Health System: Minimizing Disparities in Breast Cancer Treatment. Mil Med 2023; 188:494-502. [PMID: 37948201 DOI: 10.1093/milmed/usad218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/16/2023] [Accepted: 05/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The Military Health System (MHS) is a universal health care system, in which health care disparities are theoretically minimized. This study aimed to identify disparities and assess their impact on the initiation of timely treatment for breast cancer within a universally insured population. METHODS A retrospective cohort study was performed to evaluate the treatment of female breast cancer patients ≥18 years of age within the MHS from January 1, 2014, to December 31, 2018. Incident breast cancer was defined as ≥2 breast cancer diagnoses without a prior diagnosis of breast cancer during the three continuous years before index diagnosis. Time from index diagnosis to initial treatment was calculated and dichotomized as receiving treatment within a clinically acceptable time course. Poisson regression was used to estimate relative risk (RR) with 95% CIs. RESULTS Among the 30,761 female breast cancer patients identified in the MHS, only 6% of patients had a prolonged time to initial treatment. Time to initial treatment decreased during the study period from a mean (SD) of 63.2 (152.0) days in 2014 to 37.1 (28.8) days in 2018 (P < 0.0001). Age, region, and military characteristics remained significantly associated with receiving timely treatment even after the adjustment of confounders. Patients 70-79 years old were twice as likely as 18-39 years olds to receive timely treatment (RR: 2.0100, 95% CI, 1.52-2.6563, P < 0.0001). Senior officers and their dependents were more likely to receive timely initial treatment compared to junior enlisted patients and their dependents (RR: 1.5956, 95% CI, 1.2119-2.1005, P = 0.004). CONCLUSIONS There have been significant improvements in the timely initiation of breast cancer treatment within the MHS. However, demographic and socioeconomic disparities can be identified that affect the timely initiation of therapy.
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Affiliation(s)
| | - Emily A Norris
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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11
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Mandelblatt J, Meza R, Trentham-Dietz A, Heckman-Stoddard B, Feuer E. Using simulation modeling to guide policy to reduce disparities and achieve equity in cancer outcomes: state of the science and a road map for the future. J Natl Cancer Inst Monogr 2023; 2023:159-166. [PMID: 37947330 PMCID: PMC11009490 DOI: 10.1093/jncimonographs/lgad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Jeanne Mandelblatt
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
- Georgetown Lombardi Comprehensive Cancer Center, Cancer Prevention and Control Program, Washington, DC, USA
- Georgetown Lombardi Institute for Cancer and Aging Research, Georgetown University Medical Center, Washington, DC, USA
| | - Rafael Meza
- Department of Integrative Oncology, British Columbia Cancer Research Centre, Vancouver, BC, Canada
| | - Amy Trentham-Dietz
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
- Carbone Cancer Center, University of Wisconsin–Madison, Madison, WI, USA
| | - Brandy Heckman-Stoddard
- Breast and Gynecologic Cancer Research Program, Division of Cancer Prevention, National Cancer Institute at the National Institutes of Health, Bethesda, MD, USA
| | - Eric Feuer
- Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute at the National Institutes of Health, Bethesda, MD, USA
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12
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Winn RA, Tossas KY, Doubeni C. Commentary: Some water in the data desert: the Cancer Intervention and Surveillance Modeling Network's capacity to guide mitigation of cancer health disparities. J Natl Cancer Inst Monogr 2023; 2023:167-172. [PMID: 37947328 DOI: 10.1093/jncimonographs/lgad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023] Open
Abstract
Despite significant progress in cancer research and treatment, a persistent knowledge gap exists in understanding and addressing cancer care disparities, particularly among populations that are marginalized. This knowledge deficit has led to a "data divide," where certain groups lack adequate representation in cancer-related data, hindering their access to personalized and data-driven cancer care. This divide disproportionately affects marginalized and minoritized communities such as the U.S. Black population. We explore the concept of "data deserts," wherein entire populations, often based on race, ethnicity, gender, disability, or geography, lack comprehensive and high-quality health data. Several factors contribute to data deserts, including underrepresentation in clinical trials, poor data quality, and limited access to digital technologies, particularly in rural and lower-socioeconomic communities.The consequences of data divides and data deserts are far-reaching, impeding equitable access to precision medicine and perpetuating health disparities. To bridge this divide, we highlight the role of the Cancer Intervention and Surveillance Modeling Network (CISNET), which employs population simulation modeling to quantify cancer care disparities, particularly among the U.S. Black population. We emphasize the importance of collecting quality data from various sources to improve model accuracy. CISNET's collaborative approach, utilizing multiple independent models, offers consistent results and identifies gaps in knowledge. It demonstrates the impact of systemic racism on cancer incidence and mortality, paving the way for evidence-based policies and interventions to eliminate health disparities. We suggest the potential use of voting districts/precincts as a unit of aggregation for future CISNET modeling, enabling targeted interventions and informed policy decisions.
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Affiliation(s)
- Robert A Winn
- Massey Comprehensive Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Katherine Y Tossas
- Department of Health Behavior & Policy, School of Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Chyke Doubeni
- Department of Family and Community Medicine, Wexner Medical Center, Arthur G. James Cancer Hospital, and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH, USA
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13
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Mandelblatt JS, Schechter CB, Stout NK, Huang H, Stein S, Hunter Chapman C, Trentham-Dietz A, Jayasekera J, Gangnon RE, Hampton JM, Abraham L, O’Meara ES, Sheppard VB, Lee SJ. Population simulation modeling of disparities in US breast cancer mortality. J Natl Cancer Inst Monogr 2023; 2023:178-187. [PMID: 37947337 PMCID: PMC10637022 DOI: 10.1093/jncimonographs/lgad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence. METHODS Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group-specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy. RESULTS Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness. CONCLUSION Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.
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Affiliation(s)
- Jeanne S Mandelblatt
- Department of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program at Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Clyde B Schechter
- Departments of Family and Social Medicine and of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Natasha K Stout
- Department of Population Sciences, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Hui Huang
- Department of Data Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Sarah Stein
- Department of Population Sciences, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Christina Hunter Chapman
- Department of Radiation Oncology, Section of Health Services Research, Baylor College of Medicine and Health Policy, Quality and Informatics Program at the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Lab, National Institute on Minority Health and Health Disparities, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Ronald E Gangnon
- Departments of Population Health Sciences and of Biostatistics and Medical Informatics and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - John M Hampton
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Linn Abraham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ellen S O’Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Sandra J Lee
- Department of Data Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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14
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Chapman C, Jayasekera J, Dash C, Sheppard V, Mandelblatt J. A health equity framework to support the next generation of cancer population simulation models. J Natl Cancer Inst Monogr 2023; 2023:255-264. [PMID: 37947339 PMCID: PMC10846912 DOI: 10.1093/jncimonographs/lgad017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/03/2023] [Accepted: 06/22/2023] [Indexed: 11/12/2023] Open
Abstract
Over the past 2 decades, population simulation modeling has evolved as an effective public health tool for surveillance of cancer trends and estimation of the impact of screening and treatment strategies on incidence and mortality, including documentation of persistent cancer inequities. The goal of this research was to provide a framework to support the next generation of cancer population simulation models to identify leverage points in the cancer control continuum to accelerate achievement of equity in cancer care for minoritized populations. In our framework, systemic racism is conceptualized as the root cause of inequity and an upstream influence acting on subsequent downstream events, which ultimately exert physiological effects on cancer incidence and mortality and competing comorbidities. To date, most simulation models investigating racial inequity have used individual-level race variables. Individual-level race is a proxy for exposure to systemic racism, not a biological construct. However, single-level race variables are suboptimal proxies for the multilevel systems, policies, and practices that perpetuate inequity. We recommend that future models designed to capture relationships between systemic racism and cancer outcomes replace or extend single-level race variables with multilevel measures that capture structural, interpersonal, and internalized racism. Models should investigate actionable levers, such as changes in health care, education, and economic structures and policies to increase equity and reductions in health-care-based interpersonal racism. This integrated approach could support novel research approaches, make explicit the effects of different structures and policies, highlight data gaps in interactions between model components mirroring how factors act in the real world, inform how we collect data to model cancer equity, and generate results that could inform policy.
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Affiliation(s)
- Christina Chapman
- Department of Radiation Oncology, Baylor College of Medicine, and the Center for Innovations in Quality, Effectiveness, and Safety in the Department of Medicine, Baylor College of Medicine and the Houston VA, Houston, TX, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities, Intramural Research Program, National Institutes of Health, Bethesda, MD, USA
| | - Chiranjeev Dash
- Office of Minority Health and Health Disparities Research and Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Vanessa Sheppard
- Department of Health Behavior and Policy and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jeanne Mandelblatt
- Departments of Oncology and Medicine, Georgetown University Medical Center, Cancer Prevention and Control Program at Georgetown Lombardi Comprehensive Cancer Center and the Georgetown Lombardi Institute for Cancer and Aging Research, Washington, DC, USA
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15
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Lipsyc-Sharf M, Ballman KV, Campbell JD, Muss HB, Perez EA, Shulman LN, Carey LA, Partridge AH, Warner ET. Age, Body Mass Index, Tumor Subtype, and Racial and Ethnic Disparities in Breast Cancer Survival. JAMA Netw Open 2023; 6:e2339584. [PMID: 37878313 PMCID: PMC10600583 DOI: 10.1001/jamanetworkopen.2023.39584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Importance Black women in the United States have higher breast cancer (BC) mortality rates than White women. The combined role of multiple factors, including body mass index (BMI), age, and tumor subtype, remains unclear. Objective To assess the association of race and ethnicity with survival among clinical trial participants with early-stage BC (eBC) according to tumor subtype, age, and BMI. Design, Setting, and Participants This cohort study analyzed survival data, as of November 12, 2021, from participants enrolled between 1997 and 2010 in 4 randomized adjuvant chemotherapy trials: Cancer and Leukemia Group B (CALGB) 9741, 49907, and 40101 as well as North Central Cancer Treatment Group (NCCTG) N9831, legacy groups of the Alliance of Clinical Trials in Oncology. Median follow-up was 9.8 years. Exposures Non-Hispanic Black and Hispanic participants were compared with non-Hispanic White participants within subgroups of subtype (hormone receptor positive [HR+]/ERBB2 [formerly HER2] negative [ERBB2-], ERBB2+, and HR-/ERBB2-), age (<50, 50 to <65, and ≥65 years), and BMI (<18.5, 18.5 to <25.0, 25.0 to <30.0, and ≥30.0). Main Outcomes and Measures Recurrence-free survival (RFS) and overall survival (OS). Results Of 9479 participants, 436 (4.4%) were Hispanic, 871 (8.8%) non-Hispanic Black, and 7889 (79.5%) non-Hispanic White. The median (range) age was 52 (19.0-89.7) years. Among participants with HR+/ERBB2- tumors, non-Hispanic Black individuals had worse RFS (hazard ratio [HR], 1.49; 95% CI, 1.04-2.12; 5-year RFS, 88.5% vs 93.2%) than non-Hispanic White individuals, although the global test for association of race and ethnicity with RFS was not significant within any tumor subtype. There were no OS differences by race and ethnicity in any subtype. Race and ethnicity were associated with OS in young participants (age <50 years; global P = .008); young non-Hispanic Black participants (HR, 1.34; 95% CI, 1.04-1.71; 5-year OS, 86.6% vs 92.0%) and Hispanic participants (HR, 1.62; 95% CI, 1.16-2.29; 5-year OS, 86.2% vs 92.0%) had worse OS than young non-Hispanic White participants. Race and ethnicity were associated with RFS in participants with BMIs of 25 to less than 30, with non-Hispanic Black participants having worse RFS (HR, 1.81; 95% CI, 1.23-2.68; 5-year RFS, 83.2% vs 87.3%) than non-Hispanic White participants. Conclusions and Relevance In this cohort study, racial and ethnic survival disparities were identified in patients with eBC receiving standardized initial care, and potentially at-risk subgroups, for whom focused interventions may improve outcomes, were found.
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Affiliation(s)
- Marla Lipsyc-Sharf
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- David Geffen School of Medicine at UCLA/Jonsson Comprehensive Cancer Center, Los Angeles, California
| | - Karla V. Ballman
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Jordan D. Campbell
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Hyman B. Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | | | | | - Lisa A. Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | - Ann H. Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Erica T. Warner
- Clinical Translational Epidemiology Unit, Mongan Institute, Massachusetts General Hospital, Boston
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16
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Kumar B, Khatpe AS, Guanglong J, Batic K, Bhat-Nakshatri P, Granatir MM, Addison RJ, Szymanski M, Baldridge LA, Temm CJ, Sandusky G, Althouse SK, Cote ML, Miller KD, Storniolo AM, Nakshatri H. Stromal heterogeneity may explain increased incidence of metaplastic breast cancer in women of African descent. Nat Commun 2023; 14:5683. [PMID: 37709737 PMCID: PMC10502140 DOI: 10.1038/s41467-023-41473-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/05/2023] [Indexed: 09/16/2023] Open
Abstract
The biologic basis of genetic ancestry-dependent variability in disease incidence and outcome is just beginning to be explored. We recently reported enrichment of a population of ZEB1-expressing cells located adjacent to ductal epithelial cells in normal breasts of women of African ancestry compared to those of European ancestry. In this study, we demonstrate that these cells have properties of fibroadipogenic/mesenchymal stromal cells that express PROCR and PDGFRα and transdifferentiate into adipogenic and osteogenic lineages. PROCR + /ZEB1 + /PDGFRα+ (PZP) cells are enriched in normal breast tissues of women of African compared to European ancestry. PZP: epithelial cell communication results in luminal epithelial cells acquiring basal cell characteristics and IL-6-dependent increase in STAT3 phosphorylation. Furthermore, level of phospho-STAT3 is higher in normal and cancerous breast tissues of women of African ancestry. PZP cells transformed with HRasG12V ± SV40-T/t antigens generate metaplastic carcinoma suggesting that these cells are one of the cells-of-origin of metaplastic breast cancers.
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Affiliation(s)
- Brijesh Kumar
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- School of Biomedical Engineering, Indian Institute of Technology (Banaras Hindu University), Varanasi, UP, 221005, India
| | - Aditi S Khatpe
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Jiang Guanglong
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Katie Batic
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | | | - Maggie M Granatir
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Rebekah Joann Addison
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Megan Szymanski
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Lee Ann Baldridge
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Constance J Temm
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - George Sandusky
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Sandra K Althouse
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Michele L Cote
- Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, IN, 46202, USA
| | - Kathy D Miller
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Anna Maria Storniolo
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Harikrishna Nakshatri
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
- VA Roudebush Medical Center, Indianapolis, IN, 46202, USA.
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17
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Canales B, Laud PW, Tarima S, Zhou Y, Bikomeye JC, McGinley EL, Yen TWF, Bemanian A, Beyer KMM. Isolation and survival: The impact of local and MSA isolation on survival among non-Hispanic Black women diagnosed with breast cancer in the United States using a SEER-Medicare cohort. Health Place 2023; 83:103090. [PMID: 37531804 PMCID: PMC10528833 DOI: 10.1016/j.healthplace.2023.103090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/11/2023] [Accepted: 07/16/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Residential segregation is an important factor that negatively impacts cancer disparities, yet studies yield mixed results and complicate clear recommendations for policy change and public health intervention. In this study, we examined the relationship between local and Metropolitan Statistical Area (MSA) measures of Black isolation (segregation) and survival among older non-Hispanic (NH) Black women with breast cancer (BC) in the United States. We hypothesized that the influence of local isolation on mortality varies based on MSA isolation-specifically, that high local isolation may be protective in the context of highly segregated MSAs, as ethnic density may offer opportunities for social support and buffer racialized groups from the harmful influences of racism. METHODS Local and MSA measures of isolation were linked by Census Tract (CT) with a SEER-Medicare cohort of 5,231 NH Black women aged 66-90 years with an initial diagnosis of stage I-IV BC in 2007-2013 with follow-up through 2018. Proportional and cause-specific hazards models and estimated marginal means were used to examine the relationship between local and MSA isolation and all-cause and BC-specific mortality, accounting for covariates (age, comorbidities, tumor stage, and hormone receptor status). FINDINGS Of 2,599 NH Black women who died, 40.0% died from BC. Women experienced increased risk for all-cause mortality when living in either high local (HR = 1.20; CI = 1.08-1.33; p < 0.001) or high MSA isolation (HR = 1.40; CI = 1.17-1.67; p < 0.001). A similar trend existed for BC-specific mortality. Pairwise comparisons for all-cause mortality models showed that high local isolation was hazardous in less isolated MSAs but was not significant in more isolated MSAs. INTERPRETATION Both local and MSA isolation are independently associated with poorer overall and BC-specific survival for older NH Black women. However, the impact of local isolation on survival appears to depend on the metropolitan area's level of segregation. Specifically, in highly segregated MSAs, living in an area with high local isolation is not significantly associated with poorer survival. While the reasons for this are not ascertained in this study, it is possible that the protective qualities of ethnic density (e.g., social support and buffering from experiences of racism) may have a greater role in more segregated MSAs, serving as a counterpart to the hazardous qualities of local isolation. More research is needed to fully understand these complex relationships. FUNDING National Cancer Institute.
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Affiliation(s)
- Bethany Canales
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA.
| | - Purushottam W Laud
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
| | - Sergey Tarima
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
| | - Yuhong Zhou
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
| | - Jean C Bikomeye
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
| | - Emily L McGinley
- Center for Advancing Population Science, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
| | - Tina W F Yen
- Center for Advancing Population Science, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA; Division of Surgical Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
| | - Amin Bemanian
- Department of Pediatrics, University of Washington Medicine, Seattle Children's Hospital, PO Box 5371, OC.7.830, Seattle, WA, 98145-5005, USA
| | - Kirsten M M Beyer
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226-3596, USA
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18
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Bhattacharyya O, Relation T, Fisher JL, Li Y, Oppong BA. County characteristics associated with refusing breast cancer surgery: Evidence from the Surveillance, Epidemiology, and End Results program. Surgery 2023; 174:457-463. [PMID: 37296055 DOI: 10.1016/j.surg.2023.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Individuals' communities impact cancer disparities and are intimately related to social determinants of health. Studies show that personal factors affect treatment refusals for a potentially curable cancer, but few studies have investigated whether community-based characteristics affect the receipt of surgery. METHODS We used Surveillance Epidemiology and End Results Program registries from 2010 to 2015 to examine differences in rates of surgery refusal among non-Hispanic White, non-Hispanic Black, and Hispanic women diagnosed with nonmetastatic breast cancer. The community factor measures were based on county-level factors. Sociodemographic and community differences were analyzed using Pearson's χ2 tests and analysis of variance. Multivariate logistic regression of predictors of surgery refusal and the Cox proportional hazard model of disease-specific mortality were performed. RESULTS Surgery refusers among non-Hispanic Black and Hispanic all races lived in counties with lower rates of educational attainment, median family and household income, and higher rates of poverty, unemployment, foreign-born, language isolation, urban population, and women more than 40 years old having mammography in last 2 years. Multivariate analysis shows surgery refusal rates increased in counties having a high percentage of urban population and declined in counties with an increased percentage of less than high school level education, unemployment, and median household income. Breast cancer-specific mortality increased significantly with surgery refusal. CONCLUSION Residence in counties with the lowest socioeconomic status and disproportionately populated by racial and ethnic minorities is associated with surgery refusal. Given the high mortality associated with refusing surgery, culturally sensitive education on the benefits of care may be appropriate.
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Affiliation(s)
- Oindrila Bhattacharyya
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH; The William Tierney Center for Health Services Research, Regenstrief Institute, Inc, Indianapolis, IN
| | - Theresa Relation
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH; MetroHealth Systems Case Western Reserve University, Cleveland, OH
| | - James L Fisher
- James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH
| | - Yaming Li
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Bridget A Oppong
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH; Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH.
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19
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King CB, Bychkovsky BL, Warner ET, King TA, Freedman RA, Mittendorf EA, Katlin F, Revette A, Crookes DM, Maniar N, Pace LE. Inequities in referrals to a breast cancer risk assessment and prevention clinic: a mixed methods study. BMC PRIMARY CARE 2023; 24:165. [PMID: 37626335 PMCID: PMC10464083 DOI: 10.1186/s12875-023-02126-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Inequitable access to personalized breast cancer screening and prevention may compound racial and ethnic disparities in outcomes. The Breast Cancer Personalized Risk Assessment, Education and Prevention (B-PREP) program, located within the Brigham and Women's Hospital (BWH) Comprehensive Breast Health Center (BHC), provides care to patients at high risk for developing breast cancer. We sought to characterize the differences between BWH primary care patients referred specifically to B-PREP for risk evaluation and those referred to the BHC for benign breast conditions. Through interviews with primary care clinicians, we sought to explore contributors to potentially inequitable B-PREP referral patterns. METHODS We used electronic health record data and the B-PREP clinical database to identify patients referred by primary care clinicians to the BHC or B-PREP between 2017 and 2020. We examined associations with likelihood of referral to B-PREP for risk assessment. Semi-structured interviews were conducted with nine primary care clinicians from six clinics to explore referral patterns. RESULTS Of 1789 patients, 78.0% were referred for benign breast conditions, and 21.5% for risk assessment. In multivariable analyses, Black individuals were less likely to be referred for risk than for benign conditions (OR 0.38, 95% CI:0.23-0.63) as were those with Medicaid/Medicare (OR 0.72, 95% CI:0.53-0.98; OR 0.52, 95% CI:0.27-0.99) and those whose preferred language was not English (OR 0.26, 95% CI:0.12-0.57). Interviewed clinicians described inconsistent approaches to risk assessment and variable B-PREP awareness. CONCLUSIONS In this single-site evaluation, among individuals referred by primary care clinicians for specialized breast care, Black, publicly-insured patients, and those whose preferred language was not English were less likely to be referred for risk assessment. Larger studies are needed to confirm these findings. Interventions to standardize breast cancer risk assessment in primary care may improve equity.
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Affiliation(s)
- Claire B King
- Comprehensive Breast Health Center, Brigham and Women's Hospital, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Brittany L Bychkovsky
- Comprehensive Breast Health Center, Brigham and Women's Hospital, Boston, MA, USA
- Division of Cancer Genetics and Prevention, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Erica T Warner
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | - Tari A King
- Comprehensive Breast Health Center, Brigham and Women's Hospital, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Comprehensive Breast Health Center, Brigham and Women's Hospital, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fisher Katlin
- Comprehensive Breast Health Center, Brigham and Women's Hospital, Boston, MA, USA
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Anna Revette
- Division of Population Science, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Danielle M Crookes
- Department of Health Sciences, Northeastern University, Boston, MA, USA
- Department of Sociology and Anthropology, Northeastern University, Boston, MA, USA
| | - Neil Maniar
- Department of Health Sciences, Northeastern University, Boston, MA, USA
| | - Lydia E Pace
- Comprehensive Breast Health Center, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA.
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20
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Odai-Afotey A, Lederman RI, Ko NY, Gagnon H, Fikre T, Gundersen DA, Revette AC, Hershman DL, Crew KD, Keating NL, Freedman RA. Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors. Breast Cancer Res Treat 2023; 200:127-137. [PMID: 37178432 PMCID: PMC10182756 DOI: 10.1007/s10549-023-06960-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors. METHODS During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity. RESULTS The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed. CONCLUSION In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.
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Affiliation(s)
- Ashley Odai-Afotey
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ruth I Lederman
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Naomi Y Ko
- Section of Hematology and Medical Oncology, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Tsion Fikre
- Section of Hematology and Medical Oncology, Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anna C Revette
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Dawn L Hershman
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
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21
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Mango VL, Stoeckl EM, Reid NJ, Miles RC, Flores EJ, Weissman IA, Wagner A, Morla A, Jose O, Narayan AK. Impact of High Neighborhood Socioeconomic Deprivation on Access to Accredited Breast Imaging Screening and Diagnostic Facilities. J Am Coll Radiol 2023; 20:634-639. [PMID: 37230233 PMCID: PMC10528477 DOI: 10.1016/j.jacr.2023.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE The aim of this study was to evaluate the presence or absence of accredited breast imaging facilities in ZIP codes with high or low neighborhood socioeconomic deprivation. METHODS A retrospective ecological study design was used. Neighborhood socioeconomic disadvantage rankings at the ZIP code level were defined by the University of Wisconsin Neighborhood Atlas Area Deprivation Index. Outcomes included the presence or absence of FDA- or ACR-accredited mammographic facilities, accredited stereotactic biopsy or breast ultrasound facilities, and ACR Breast Imaging Centers of Excellence. US Department of Agriculture rural-urban commuting area codes were used to define urban and rural status. Access to breast imaging facilities in high-disadvantage (≥97th percentile) and low-disadvantage (≤3rd percentile) ZIP codes was compared using χ2 tests, stratified by urban or rural status. RESULTS Among 41,683 ZIP codes, 2,796 were classified as high disadvantage (1,160 rural, 1,636 urban) and 1,028 as low disadvantage (39 rural, 989 urban). High-disadvantage ZIP codes were more likely rural (P < .001) and less likely to have FDA-certified mammographic facilities (28% versus 35%, P < .001), ACR-accredited stereotactic biopsy (7% versus 15%, P < .001), breast ultrasound (9% versus 23%, P < .001), or Breast Imaging Centers of Excellence (7% versus 16%, P < .001). Among urban areas, high-disadvantage ZIP codes were less likely to have FDA-certified mammographic facilities (30% versus 36%, P = .002), ACR-accredited stereotactic biopsy (10% versus 16%, P < .001), breast ultrasound (13% versus 23%, P < .001), and Breast Imaging Centers of Excellence (10% versus 16%, P < .001). CONCLUSIONS People living in ZIP codes with high socioeconomic disadvantage are less likely to have accredited breast imaging facilities within their ZIP codes, which may contribute to disparities in access to breast cancer care experienced by underserved groups living in these areas.
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Affiliation(s)
- Victoria L Mango
- Director of Radiology, Memorial Sloan Kettering Cancer Center Ralph Lauren Center, and Assistant Director, Global Cancer Disparities Initiatives, Memorial Sloan Kettering Cancer Center, New York, New York.
| | | | - Nicholas J Reid
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Randy C Miles
- Chief of Breast Imaging and Associate Director of Radiology for Research, Denver Health, Denver, Colorado
| | - Efren J Flores
- Associate Chair, Equity, Inclusion and Community Health, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ian A Weissman
- Milwaukee VA Medical Center, Milwaukee, Wisconsin; Chair, ACR Commission on Patient- and Family-Centered Care Outreach Committee, Chair, ACR Commission on General, Small, Emergency and/or Rural Practice, Veterans Affairs Committee, and President, Wisconsin Radiological Society
| | | | - Alexander Morla
- Department of Biology, University of Puerto Rico, Río Piedras Campus, San Juan, Puerto Rico
| | | | - Anand K Narayan
- Vice Chair of Equity, Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin; Vice Chair, ACR Commission on Patient- and Family-Centered Care Outreach Committee
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22
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Kantor O, King TA, Freedman RA, Mayer EL, Chavez-MacGregor M, Korde LA, Sparano JA, Mittendorf EA. Racial and Ethnic Disparities in Locoregional Recurrence Among Patients With Hormone Receptor-Positive, Node-Negative Breast Cancer: A Post Hoc Analysis of the TAILORx Randomized Clinical Trial. JAMA Surg 2023; 158:583-591. [PMID: 37043210 PMCID: PMC10099173 DOI: 10.1001/jamasurg.2023.0297] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/04/2022] [Indexed: 04/13/2023]
Abstract
Importance Whether racial and ethnic disparities in locoregional recurrence (LRR) exist among patients with similar access to care treated in randomized clinical trials is unknown. Objective To examine racial and ethnic differences in LRR among patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (ERBB2 [formerly HER2 or HER2/neu])-negative, node-negative breast cancer enrolled in the Trial Assigning Individualized Options for Treatment (TAILORx). Design, Setting, and Participants This unplanned retrospective post hoc analysis examined a prospective multicenter clinical trial population of women with breast cancer enrolled between 2006 and 2010, with 9 years of follow-up. The TAILORx investigators randomized patients to treatment based on their Oncotype DX recurrence score, including endocrine therapy alone (recurrence score <11), endocrine therapy alone vs chemotherapy followed by endocrine therapy (recurrence score 11-25), or chemotherapy followed by endocrine therapy (recurrence score >25). Patients with unknown race and ethnicity or lack of follow-up were excluded from this analysis. Data analysis was performed between December 2021 and March 2022. Main Outcome and Measures Locoregional recurrence was defined as ipsilateral in breast, skin, chest wall, or regional nodal recurrence without concurrent distant recurrence, and was stratified by racial and ethnic group. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards regression models were used for survival analyses. Results Of the 10 273 women enrolled in TAILORx, this analysis included 9369 with T1-2N0 HR-positive, ERBB2-negative breast cancer. Of these patients, 428 (4.6%) were Asian, 886 (9.4%) were Hispanic, 676 (7.2%) were non-Hispanic Black (hereinafter Black), and 7406 (78.8%) were non-Hispanic White (hereinafter White). Assigned treatment receipt was high, with a 9.3% (n = 870) crossover of treatment groups and a median endocrine therapy duration of longer than 60 months, ranging from 61.1 to 65.9 months, across racial and ethnic groups. A total of 6818 patients (72.6%) received radiation (6474 [96.1%] after breast-conserving surgery and 344 [13.0%] after mastectomy). At a median follow-up of 94.8 months (range, 1-138 months), 8-year LRR rates were 3.6% (95% CI, 1.6%-5.6%) in Asian patients, 3.9% (95% CI, 2.2%-5.4%) in Black patients, 3.1% in Hispanic patients (95% CI, 1.7%-4.5%), and 1.8% (95% CI, 1.5%-2.3%) in White patients (P < .001). In survival analyses adjusted for patient, tumor, and treatment factors, Asian race (hazard ratio, 1.91 [95% CI, 1.12-3.29]) and Black race (1.78 [1.15-2.77]) were independently associated with LRR. In adjusted survival analyses for breast cancer mortality, LRR was independently associated with increased breast cancer mortality (hazard ratio, 5.71 [95% CI, 3.50-9.31]). Conclusions and Relevance In this post hoc analysis, racial and ethnic differences in LRR were observed among patients with T1-2N0 HR-positive, ERBB2-negative breast cancer despite high rates of treatment receipt in this clinical trial population, with the highest LRR rates in Asian and Black patients. Further study is needed to understand whether failure to rescue after LRR may contribute to racial disparities in breast cancer mortality. Trial Registration ClinicalTrials.gov Identifier: NCT00310180.
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Affiliation(s)
- Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tari A. King
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rachel A. Freedman
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Erica L. Mayer
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mariana Chavez-MacGregor
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Joseph A. Sparano
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth A. Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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23
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Hoskins KF, Calip GS, Huang HC, Ibraheem A, Danciu OC, Rauscher GH. Association of Social Determinants and Tumor Biology With Racial Disparity in Survival From Early-Stage, Hormone-Dependent Breast Cancer. JAMA Oncol 2023; 9:536-545. [PMID: 36795405 PMCID: PMC9936381 DOI: 10.1001/jamaoncol.2022.7705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/29/2022] [Indexed: 02/17/2023]
Abstract
Importance Black women with hormone receptor-positive breast cancer experience the greatest racial disparity in survival of all breast cancer subtypes. The relative contributions of social determinants of health and tumor biology to this disparity are uncertain. Objective To determine the proportion of the Black-White disparity in breast cancer survival from estrogen receptor (ER)-positive, axillary node-negative breast cancer that is associated with adverse social determinants and high-risk tumor biology. Design, Setting, and Participants A retrospective mediation analysis of factors associated with the racial disparity in breast cancer death for cases diagnosed between 2004 and 2015 with follow-up through 2016 was carried out using the Surveillance, Epidemiology, and End Results (SEER) Oncotype registry. The study included women in the SEER-18 registry who were aged 18 years or older at diagnosis of a first primary invasive breast cancer tumor that was axillary node-negative and ER-positive, who were Black (Black), non-Hispanic White (White), and for whom the 21-gene breast recurrence score was available. Data analysis took place between March 4, 2021, and November 15, 2022. Exposures Census tract socioeconomic disadvantage, insurance status, tumor characteristics including the recurrence score, and treatment variables. Main Outcomes and Measures Death due to breast cancer. Results The analysis with 60 137 women (mean [IQR] age 58.1 [50-66] years) included 5648 (9.4%) Black women and 54 489 (90.6%) White women. With a median (IQR) follow-up time of 56 (32-86) months, the age-adjusted hazard ratio (HR) for breast cancer death among Black compared with White women was 1.82 (95% CI, 1.51-2.20). Neighborhood disadvantage and insurance status together mediated 19% of the disparity (mediated HR, 1.62; 95% CI, 1.31-2.00; P < .001) and tumor biological characteristics mediated 20% (mediated HR, 1.56; 95% CI, 1.28-1.90; P < .001). A fully adjusted model that included all covariates accounted for 44% of the racial disparity (mediated HR, 1.38; 95% CI, 1.11-1.71; P < .001). Neighborhood disadvantage mediated 8% of the racial difference in the probability of a high-risk recurrence score (P = .02). Conclusions and Relevance In this study, racial differences in social determinants of health and indicators of aggressive tumor biology including a genomic biomarker were equally associated with the survival disparity in early-stage, ER-positive breast cancer among US women. Future research should examine more comprehensive measures of socioecological disadvantage, molecular mechanisms underlying aggressive tumor biology among Black women, and the role of ancestry-related genetic variants.
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Affiliation(s)
- Kent F. Hoskins
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago
- University of Illinois Cancer Center, Chicago
| | - Gregory S. Calip
- University of Illinois Cancer Center, Chicago
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois College of Pharmacy, Chicago
- Flatiron Health, New York, New York
| | - Hsiao-Ching Huang
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois College of Pharmacy, Chicago
| | - Abiola Ibraheem
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago
- University of Illinois Cancer Center, Chicago
| | - Oana C. Danciu
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago
- University of Illinois Cancer Center, Chicago
| | - Garth H. Rauscher
- University of Illinois Cancer Center, Chicago
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago
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Lovejoy LA, Shriver CD, Haricharan S, Ellsworth RE. Survival Disparities in US Black Compared to White Women with Hormone Receptor Positive-HER2 Negative Breast Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2903. [PMID: 36833598 PMCID: PMC9956998 DOI: 10.3390/ijerph20042903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
Black women in the US have significantly higher breast cancer mortality than White women. Within biomarker-defined tumor subtypes, disparate outcomes seem to be limited to women with hormone receptor positive and HER2 negative (HR+/HER2-) breast cancer, a subtype usually associated with favorable prognosis. In this review, we present data from an array of studies that demonstrate significantly higher mortality in Black compared to White women with HR+/HER2-breast cancer and contrast these data to studies from integrated healthcare systems that failed to find survival differences. Then, we describe factors, both biological and non-biological, that may contribute to disparate survival in Black women.
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Affiliation(s)
- Leann A. Lovejoy
- Chan Soon-Shiong Institute of Molecular Medicine at Windber, Windber, PA 15963, USA
| | - Craig D. Shriver
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Svasti Haricharan
- Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Rachel E. Ellsworth
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
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Hu X, Kaplan CM, Martin MY, Walker MS, Stepanski E, Schwartzberg LS, Vidal GA, Graetz I. Race Differences in Patient-Reported Symptoms during Chemotherapy among Women with Early-Stage Hormone Receptor-Positive Breast Cancer. Cancer Epidemiol Biomarkers Prev 2023; 32:167-174. [PMID: 36166516 PMCID: PMC9905215 DOI: 10.1158/1055-9965.epi-22-0692] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Symptom burden differences may contribute to racial disparities in breast cancer survival. We compared symptom changes from before to during chemotherapy among women with breast cancer. METHODS This observational study followed a cohort of Black and White women diagnosed with Stage I-III, hormone receptor-positive breast cancer from a large cancer center in 2007 to 2015, and reported symptoms before and during chemotherapy. We identified patients who experienced a one-standard deviation (SD) increase in symptom burden after starting chemotherapy using four validated composite scores (General Physical Symptoms, Treatment Side Effects, Acute Distress, and Despair). Kitagawa-Blinder-Oaxaca decomposition was used to quantify race differences in symptom changes explained by baseline characteristics (sociodemographic, baseline scores, cancer stage) and first-line chemotherapy regimens. RESULTS Among 1,273 patients, Black women (n = 405, 31.8%) were more likely to report one-SD increase in General Physical Symptoms (55.6% vs. 48.2%, P = 0.015), Treatment Side Effects (74.0% vs. 63.4%, P < 0.001), and Acute Distress (27.4% vs. 20.0%, P = 0.010) than White women. Baseline characteristics and first-line chemotherapy regimens explained a large and significant proportion of the difference in Acute Distress changes (93.7%, P = 0.001), but not General Physical Symptoms (25.7%, P = 0.25) or Treatment Side Effects (16.4%, P = 0.28). CONCLUSIONS Black women with early-stage breast cancer were more likely to experience significant increases in physical and psychological symptom burden during chemotherapy. Most of the difference in physical symptom changes remained unexplained by baseline characteristics, which suggests inadequate symptom management among Black women. IMPACT Future studies should identify strategies to improve symptom management among Black women and reduce differences in symptom burden. See related commentary by Rosenzweig and Mazanec, p. 157.
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Affiliation(s)
- Xin Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Cameron M Kaplan
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine of USC, Los Angeles, California
| | - Michelle Y Martin
- Center for Innovation in Health Equity Research, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | | | - Gregory A Vidal
- West Cancer Center and Research Institute, Germantown, Tennessee.,School of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Kim H, Wang H, Demanelis K, Clump DA, Vargo JA, Keller A, Diego M, Gorantla V, Smith KJ, Rosenzweig MQ. Factors associated with ductal carcinoma in situ (DCIS) treatment patterns and patient-reported outcomes across a large integrated health network. Breast Cancer Res Treat 2023; 197:683-692. [PMID: 36526807 PMCID: PMC9883362 DOI: 10.1007/s10549-022-06831-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE To examine associations between ductal carcinoma in situ (DCIS) patients' characteristics, treating locations and DCIS treatments received and to pilot assessing quality-of-life (QoL) values among DCIS patients with diverse backgrounds. METHODS We performed a retrospective tumor registry review of all patients diagnosed and treated with DCIS from 2018 to 2019 in the UPMC-integrated network throughout central and western Pennsylvania. Demographics, clinical information, and administered treatments were compiled from tumor registry records. We categorized contextual factors such as different hospital setting (academic vs. community), socioeconomic status based on the neighborhood deprivation index (NDI) as well as age and race. QoL survey was administered to DCIS patients with diverse backgrounds via QoL questionnaire breast cancer module 23 and qualitative assessment questions. RESULTS A total of 912 patients were reviewed. There were no treatment differences noted for age, race, or NDI. Mastectomy rate was higher in academic sites than community sites (29 vs. 20.4%; p = 0.0045), while hormone therapy (HT) utilization rate was higher in community sites (74 vs. 62%; p = 0.0012). QoL survey response rate was 32%. Only HT side effects negatively affected in QoL scores and there was no significant difference in QoL domains and decision-making process between races, age, NDI, treatment groups, and treatment locations. CONCLUSION Our integrated health network did not show chronically noted disparities arising from social determinates of health for DCIS treatments by implementing clinical pathways and system-wide peer review. Also, we demonstrated feasibility in collecting QoL for DCIS women with diverse backgrounds and different socioeconomic statuses.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA.
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women's Hospital, 300 Halket Street, Pittsburgh, PA, 15213, USA.
| | - Hong Wang
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kathryn Demanelis
- Department of Biostatistics, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - David A Clump
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Andrew Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Mia Diego
- Department of Breast Surgery, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Vikram Gorantla
- Department of Medical Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research On Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Margaret Q Rosenzweig
- Department of Nursing, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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27
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Alvarez A, Bernal AM, Anampa J. Racial disparities in overall survival after the introduction of cyclin-dependent kinase 4/6 inhibitors for patients with hormone receptor-positive, HER2-negative metastatic breast cancer. Breast Cancer Res Treat 2023; 198:75-88. [PMID: 36562909 DOI: 10.1007/s10549-022-06847-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE CDK4/6 inhibitors (CDK4/6i) combined with endocrine therapy have improved HR + /HER2- metastatic breast cancer (MBC) outcomes. However, it is still unclear whether the response to CDK4/6i is similar for all races. Therefore, we aimed to assess overall survival (OS) trends stratified by race in patients with HR + /HER2- MBC after the approval of CDK4/6i, as part of the standard of care, in 2015. METHODS We performed a population-based study using the SEER database. Patients with HR + /HER2- MBC were divided into two time-based cohorts: 1) pre-CDK4/6i era (diagnosed in 2011-2013) and 2) post-CDK4/6i era (diagnosed in 2015-2017). We used propensity score matching and identified 2,684 patients in each cohort that matched in several characteristics. Kaplan-Meier methods were used to estimate 2-year OS. Association between cohort and OS was evaluated using marginal Cox proportional hazards models with robust sandwich variance estimator. We conducted competing risk analysis to estimate the risk of breast cancer death in both cohorts. RESULTS The 2-year OS rate was 65% for the post-CDK4/6i era and 62% for the pre-CDK4/6i era (stratified log-rank p = 0.025). The 2-year OS for non-Hispanic White (NHW) patients improved in the post-CDK4/6i era compared to the pre-CDK4/6i era (67% vs. 63%, p = 0.033). However, OS did not improve for non-Hispanic Black (NHB) (54% vs. 54%, p = 0.876) or Hispanic (67% vs. 65%, p = 0.617) groups. The risk of breast cancer death decreased in the post-CDK4/6i era as compared to the pre-CDK4/6i era (2-year risk of breast cancer death: 33% vs. 30%, p = 0.015); however, this effect was observed only in NHW (sHR 0.84, p = 0.005) women, but not in NHB (sHR 0.94, p = 0.630) or Hispanic (sHR 0.91, p = 0.550) women. CONCLUSIONS Our study confirms that outcomes for HR + /HER2- MBC have improved after CDK4/6i were introduced in 2015. However, this effect is primarily driven by the improved OS in NHW patients, without significant improvement in OS in NHB or Hispanics.
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Affiliation(s)
- Alvaro Alvarez
- Department of Medicine, Hematology/Oncology, Carole and Ray Neag Comprehensive Cancer Center, UCONN Health, Farmington, CT, USA
| | - Ana M Bernal
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, 1695 Eastchester Rd, Bronx, NY, 10461, USA
| | - Jesus Anampa
- Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, 1695 Eastchester Rd, Bronx, NY, 10461, USA.
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Freedman RA, Ko NY, Lederman RI, Gagnon H, Fikre T, Gundersen DA, Revette AC, Odai-Afotey A, Kantor O, Hershman DL, Crew KD, Keating NL. Breast cancer knowledge and understanding treatment rationales among diverse breast cancer survivors. Breast Cancer Res Treat 2022; 196:623-633. [PMID: 36220997 PMCID: PMC9552717 DOI: 10.1007/s10549-022-06752-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/18/2022] [Indexed: 12/02/2022]
Abstract
Purpose The degree to which breast cancer survivors know about their tumors and understand treatment rationales is not well understood. We sought to identify information gaps within a diverse sample and explore whether knowledge about breast cancer and treatment may impact care. Methods We conducted a one-time, interviewer-administered survey of women who were diagnosed with breast cancer during 2013–2017 and received care at one of three centers in Boston, MA, and New York, NY. We examined knowledge of breast cancer and treatment rationales, information preferences, and treatment receipt. Results During 2018–2020, we interviewed 313 women (American Association for Public Opinion Research Cooperation Rates 58.4–76.5% across centers) who were 56.9% White, 23.6% Black, 14.1% Hispanic, and 5.4% other. Among the 296 included in analyses, we observed high variability in knowledge of breast cancer and treatment rationales, with a substantial number demonstrating limited knowledge despite feeling highly informed; > 25% actively avoided information. Black and Hispanic (vs. White) women consistently knew less about their cancers. Lack of understanding of treatment rationales for chemotherapy, radiation, and hormonal therapy was common but not consistently different by race and ethnicity. Understanding treatment rationale (but not cancer knowledge) was associated with treatment initiation, but small sample sizes limited in-depth examination. Conclusions Our study highlights the need for enhanced informational support for breast cancer survivors, who are challenged with complex information during the decision-making process and beyond. More research is needed to understand how to further educate and empower diverse populations of patients with breast cancer. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-022-06752-8.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA. .,Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.
| | - Naomi Y Ko
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Ruth I Lederman
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haley Gagnon
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Tsion Fikre
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Daniel A Gundersen
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anna C Revette
- Survey and Qualitative Methods Core, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Olga Kantor
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Dawn L Hershman
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Katherine D Crew
- Department of Medicine and Epidemiology, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Nancy L Keating
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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Zhang Y, Lin L, Wu Y, Bing P, Zhou J, Yu W. Upregulation of TIMM8A is correlated with prognosis and immune regulation in BC. Front Oncol 2022; 12:922178. [PMID: 36248992 PMCID: PMC9559820 DOI: 10.3389/fonc.2022.922178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/12/2022] [Indexed: 11/25/2022] Open
Abstract
Backgrounds Breast cancer is a common malignant tumors in women. TIMM8A was up-regulated in different cancers. The aim of this work was to clarify the value of TIMM8A in the diagnosis, prognosis of Breast Cancer (BC), and its association with immune cells and immune detection points. Gene mutations. Methods The transcription and expression profile of TIMM8A between BC and normal tissues was downloaded from The Cancer Genome atlas (TCGA). The expression of TIMM8A protein was evaluated by human protein map. The correlation between TIMM8A and clinical features was analyzed using the R package to establish a ROC diagnostic curve. cBioPortal and MethSurv were used to identify gene alterations and DNA methylation and their effects on prognosis. The tumor immune estimation resource (TIMER) database and tumor immune system interaction database (TISIDB) database were used to determine the relationship between TIMM8A gene expression levels and immune infiltration. The CTD database was used to predict related drugs that inhibit TIMM8A, and the PubChem database was used to determine the molecular structure of potentially effective drug small molecules. Results The expression of TIMM8A in breast cancer tissues was significantly higher than that in normally adjacent tissues to cancer. ROC curve analysis showed that the AUC value of TIMM8A was 0.679. Kaplan-Meier method showed that patients with high TIMM8A had a lower prognosis (Overall Survival HR = 1.83 (1.31 − 2.54), P < 0.001) than patients with low TIMM8A expression of breast cancer (148.5 months vs. 115.4 months, P < 0.001). Methylation levels at seven CpG were associated with prognosis. Correlation analysis showed that TIMM8A expression was associated with tumor immune cell infiltration. There was a significant positive correlation of TIMM8A with PDL-1, and CTLA-4 in BC. In addition, CTD database analysis identified 15 small molecular drugs that target TIMM8A, such as Cyclosporine, Leflunomide, and Tretinoin, which might be effective therapies for targeted inhibition of TIMM8A. Conclusion In breast cancer, up-regulated TIMM 8A was significantly related to lower survival rate and higher immune invasiveness. Our research showed that TIMM 8A could be used as a biomarker for poor prognosis of breast cancer and a potential target of immunotherapy.
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Affiliation(s)
- Yu Zhang
- Endoscopy Center, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Lin Lin
- Department of Medical Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Yunfei Wu
- Department of Thoracic Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Pingping Bing
- Academician Workstation, Changsha Medical University, Changsha, China
| | - Jun Zhou
- Academician Workstation, Changsha Medical University, Changsha, China
- *Correspondence: Jun Zhou, ; Wei Yu,
| | - Wei Yu
- Department of Clinical Pharmacy, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
- *Correspondence: Jun Zhou, ; Wei Yu,
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30
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Hu X, Walker MS, Stepanski E, Kaplan CM, Martin MY, Vidal GA, Schwartzberg LS, Graetz I. Racial Differences in Patient-Reported Symptoms and Adherence to Adjuvant Endocrine Therapy Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer. JAMA Netw Open 2022; 5:e2225485. [PMID: 35947386 PMCID: PMC9366541 DOI: 10.1001/jamanetworkopen.2022.25485] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Adjuvant endocrine therapy (AET) reduces breast cancer recurrence, but symptom burden is a key barrier to adherence. Black women have lower AET adherence and worse health outcomes than White women. OBJECTIVE To investigate the association between symptom burden and AET adherence differences by race. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using electronic health records with patient-reported data from a large cancer center in the US. Patients included Black and White women initiating AET therapy for early-stage breast cancer from August 2007 to December 2015 who were followed for 1 year from AET initiation. Sixty symptoms classified into 7 physical and 2 psychological symptom clusters were evaluated. For each cluster, the number of symptoms with moderate severity at baseline, and symptoms with 3-point or greater increases during AET were counted. Adherence was measured as the proportion of days covered by AET during the first-year follow-up. Multivariable regressions for patients' adherence adjusting for race, symptom measures, sociodemographic characteristics, and clinical characteristics were conducted. Kitagawa-Blinder-Oaxaca decomposition was used to quantify racial differences in adherence explained by symptoms and patient characteristics. Analyses were conducted from July 2021 to January 2022. EXPOSURES Physical and psychological symptoms at baseline and changes during AET. RESULTS Among 559 patients (168 [30.1%] Black and 391 [69.9%] White; mean [SD] age 65.5 [12.1] years), Black women received diagnoses younger (mean [SD] age at diagnosis, 58.7 [13.7] vs 68.5 [10.0] years old) than White women, with more advanced stages (30 Black participants [17.9%] vs 31 White participants [7.9%] had stage III disease at diagnosis), and lived in areas with fewer adults attaining high school education (mean [SD], 78.8% [7.8%] vs 84.0% [9.3%]). AET adherence in the first year was 78.8% for Black and 82.3% for White women. Black women reported higher severity in most symptom clusters than White women. Neuropsychological, vasomotor, musculoskeletal, cardiorespiratory, distress, and despair symptoms at baseline and increases during the follow-up were associated with 1.2 to 2.6 percentage points decreases in adherence, which corresponds to 4 to 9 missed days receiving AET in the first year. After adjusting for psychological symptoms, being Black was associated with 6.5 percentage points higher adherence than being White. CONCLUSIONS AND RELEVANCE In this cohort study, severe symptoms were associated with lower AET adherence. Black women had lower adherence rates that were explained by their higher symptom burden and baseline characteristics. These findings suggest that better symptom management with a focus on psychological symptoms could improve AET adherence and reduce racial disparities in cancer outcomes.
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Affiliation(s)
- Xin Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | - Cameron M. Kaplan
- Gehr Family Center for Health Systems Science and Innovation, Keck School of Medicine, University of Southern California, Los Angeles
| | - Michelle Y. Martin
- Center for Innovation in Health Equity Research, Department of Preventive Medicine, College of Medicine, University of Tennessee Health Science Center, Memphis
| | - Gregory A. Vidal
- West Cancer Center and Research Institute, Germantown, Tennessee
- Division of Hematology and Oncology, College of Medicine, University of Tennessee Health Science Center, Memphis
| | | | - Ilana Graetz
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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