Ethnic differences in risk and prognostic factors for breast cancer

Is Immediate Lymphatic Reconstruction on Breast Cancer Patients Oncologically Safe? A Preliminary Study

Background

In breast cancer patients receiving axillary lymph node dissection (ALND), immediate lymphatic reconstruction (ILR) with lymphovenous anastomosis is an emerging technique for reducing the risk of arm lymphedema. However, the oncologic safety of surgically diverting lymphatic ducts directly into venules in a node-positive axilla is still a concern of inadvertently inducing metastasis of remaining cancer cells. This study aimed to assess the oncologic safety of ILR.

Methods

From January 2020 to January 2022, 95 breast cancer patients received ALND, and 45 of them also received ILR. Patients with recurrent cancer, with follow-up less than 12 months, and with missed data were excluded. Variables were compared between ILR and non-ILR groups, and the outcome of interest was the rate of distant recurrence after follow-up for at least 1 year.

Results

Thirty-four patients in the ILR group and 32 patients in the non-ILR group fulfilled the inclusion criteria for analysis. No statistically significant difference was noted between groups in terms of age, body mass index, type of breast surgery, pathologic cancer staging, histologic type and grade of breast cancer, molecular subtypes, frequency of axillary lymph node metastasis, or adjuvant therapy. For the patients receiving follow-up for at least 1 year, no statistically significant difference was found in terms of distant recurrence rates between ILR and non-ILR groups (P = 0.44).

Conclusion

For breast cancer patients receiving ALND, ILR with lymphovenous anastomosis is oncologically safe, within an average follow-up period of 21 months.

A scoping review of interactive and personalized web-based clinical tools to support treatment decision making in breast cancer

The increasing attention on personalized breast cancer care has resulted in an explosion of new interactive, tailored, web-based clinical decision tools for guiding treatment decisions in clinical practice. The goal of this study was to review, compare, and discuss the clinical implications of current tools, and highlight future directions for tools aiming to improve personalized breast cancer care. We searched PubMed, Embase, PsychInfo, Cochrane Database of Systematic Reviews, Web of Science, and Scopus to identify web-based decision tools addressing breast cancer treatment decisions. There was a total of 17 articles associated with 21 unique tools supporting decisions related to surgery, radiation therapy, hormonal therapy, bisphosphonates, HER2-targeted therapy, and chemotherapy. The quality of the tools was assessed using the International Patient Decision Aid Standard instrument. Overall, the tools considered clinical (e.g., age) and tumor characteristics (e.g., grade) to provide personalized outcomes (e.g., survival) associated with various treatment options. Fewer tools provided the adverse effects of the selected treatment. Only one tool was field-tested with patients, and none were tested with healthcare providers. Future studies need to assess the feasibility, usability, acceptability, as well as the effects of personalized web-based decision tools on communication and decision making from the patient and clinician perspectives.

Prognostic value of depression and anxiety on breast cancer recurrence and mortality: a systematic review and meta-analysis of 282,203 patients

Depression and anxiety are common comorbidities in breast cancer patients. Whether depression and anxiety are associated with breast cancer progression or mortality is unclear. Herein, based on a systematic literature search, 17 eligible studies involving 282,203 breast cancer patients were included. The results showed that depression was associated with cancer recurrence [1.24 (1.07, 1.43)], all-cause mortality [1.30 (1.23, 1.36)], and cancer-specific mortality [1.29 (1.11, 1.49)]. However, anxiety was associated with recurrence [1.17 (1.02, 1.34)] and all-cause mortality [1.13 (1.07, 1.19)] but not with cancer-specific mortality [1.05 (0.82, 1.35)]. Comorbidity of depression and anxiety is associated with all-cause mortality [1.34 (1.24, 1.45)] and cancer-specific mortality [1.45 (1.11, 1.90)]. Subgroup analyses demonstrated that clinically diagnosed depression and anxiety, being female and of younger age (<60 years), and shorter follow-up duration (≤5 years) were related to a poorer prognosis. Our study highlights the critical role of depression/anxiety as an independent factor in predicting breast cancer recurrence and survival. Further research should focus on a favorable strategy that works best to improve outcomes among breast cancer patients with mental disorders.

Impact of Different Sociodemographic Factors on Mental Health Status of Female Cancer Patients Receiving Chemotherapy for Recurrent Disease

Context:

Deterioration in mental health and poor quality of life (QOL) among women suffering from breast and ovarian cancer is not a direct result of the illness but mediated by many other psychosocial variables.

Aims:

The study intended to examine if there was any effect of educational level, residential status, family type, duration of treatment, and income level of family on anxiety, depression, and QOL among the breast and ovarian cancer patients, undergoing second- or subsequent-line chemotherapy.

Subjects and Methods:

Forty married female cancer patients with breast and ovarian cancer, aging between 40 and 60 years, education level ranges from no formal education to postgraduate degree, income level ranges from Rs. 1000 per month to Rs. 20000 per month, and undergoing second- or subsequent-line chemotherapy for the past 1–10 years were studied. Levels of anxiety and depression were determined by Hospital Anxiety and Depression Scale. The QOL was measured by using WHO QOLBREF scale.

Statistical Analysis Used:

Mean and standard deviation and Levene's F values were calculated. If Levene's F value was significant, then Mann–Whitney U-test was done or else independent samples t-test was used.

Results:

Among all the variables, education, residential status, and income affect significantly on anxiety, depression, and QOL.

Conclusions:

Early detection of psychosocial variables is essential for better screening of the cancer patients undergoing chemotherapy, and therefore, further psychological intervention can be planned accordingly.

Characteristics and treatment of human epidermal growth factor receptor 2 positive breast cancer: 43,485 cases from the National Cancer Database treated in 2010 and 2011

BACKGROUND

Although identification of human epidermal growth factor receptor 2 (Her2) positive breast cancer represents one of the greatest advances over the past 3 decades, it has not been studied extensively on a national level.

METHODS

The National Cancer Database is a joint project of the American Cancer Society and the American College of Surgeons and contains data on about 70% of the cancer cases in the United States. Data on Her2 have been collected since 2010 and was used for this study.

RESULTS

Of 298,937 cases of invasive breast cancer with known Her2 status diagnosed in 2010 and 2011, 43,485 (14.5%) were Her2 positive. Her2 positivity was greatest in Asian/Pacific Islanders and least in non-Hispanic Whites and was markedly more common in younger women. The incidence of Her2 positive tumors ranged from a low of 13.9% in the Mountain West region to a high of 16.0% in the West South Central region (P < .001). Compared with Her2 negative tumors, Her2 positive tumors were larger (2.6 vs 2.2 cm, P < .001), more likely to have positive nodes (39% vs 31% P < .001), have lymphovascular invasion (30% vs 20%, P < .001), and be high grade (56% vs 29%, P < .001). There were also differences by histology: invasive ductal 16.4%, invasive lobular 5.5%, tubular 2.3%, inflammatory 36%, and Paget's with invasion 59%. When adjusted for age, race, tumor size, and nodal status Her2 positive tumors were much more likely to receive chemotherapy (odds ratio = 5.5, confidence interval = 5.2 to 6.0) and somewhat less likely to undergo breast preservation (odds ratio = .78, confidence interval = .76 to .80).

CONCLUSIONS

Her2 positive tumors have distinct epidemiologic, clinical, and treatment characteristics.

Increased expression of tumor proliferation genes in Hispanic women with early-stage breast cancer

Hispanic women have higher breast cancer mortality compared to non-Hispanic whites. We evaluated for Proliferation Axis Score differences, as determined by Oncotype Dx, in Hispanic and non-Hispanic white women with newly diagnosed breast cancer. We matched 219 women, based upon age, stage, and nodal status. Compared to non-Hispanic whites, Hispanic women with hormone-sensitive, HER2-negative early-stage breast cancer had a higher Proliferation Axis Score. No differences were seen in Recurrence Score, ER, PR, or HER2 by Oncotype DX. CCNB1 and AURKA were significantly higher in Hispanic women. These tumor differences may help explain breast cancer outcome differences between the two ethnicities.

Disparities in breast cancer outcomes between Caucasian and African American women: a model for describing the relationship of biological and nonbiological factors

Breast cancer is the most common malignancy in women in the United States but significant disparities exist for African American women compared to Caucasian women. African American women present with breast cancer at a younger age and with a greater incidence under the age of 50 years, develop histologically more aggressive tumors that are at a more advanced stage at presentation, and have a worse disease-free and overall survival than Caucasian women. The biological characteristics of the primary tumor play an important role in determining the outcome of the disparity, and significant differences have been identified between African American and Caucasian breast cancer in steroid receptor and growth factor receptor content, mutations in cell cycle components, chromosomal abnormalities, and tumor suppressor and other cancer genes. The consequences of the biological factors are influenced by a variety of nonbiological factors, including socioeconomic, health care access, reproductive, and confounding factors. The nonbiological factors may act directly to enhance (or inhibit) the consequences of the biological changes, indirectly to facilitate outcome of the disparity, or as a cofounding factor, driving the association between the biological factors and the disparity. The prevention and management of the disparities will require an understanding of the relationship of biological and nonbiological factors. The present review was undertaken to promote this understanding by describing the biological basis of the four major disparities - early age of onset, more advanced stage of disease, more aggressive histologic changes, and worse survival - and the important relationship to the nonbiological factors. A model is proposed to provide a comprehensive view of this relationship, with the goal of facilitating an understanding of each disparity and the issues that need to be addressed to eliminate the disparity.

Cell Proliferation (KI-67) Expression Is Associated with Poorer Prognosis in Nigerian Compared to British Breast Cancer Women

Background. Black women with breast cancer (BC) in Nigeria have higher mortality rate compared with British women. This study investigated prognostic features of cell proliferation biomarker (Ki-67) in Nigerian breast cancer women. Materials and Methods. The protein expression of Ki-67 was investigated in series of 308 Nigerian women, prepared as a tissue microarray (TMA), using immunohistochemistry. Clinic-pathological parameters, biomarkers, and patient outcome of tumours expressing Ki-67 in Nigerian women were correlated with UK grade-matched series. Results. A significantly larger proportion of breast tumours from Nigerian women showed high Ki-67 expression. Those tumours were significantly correlated with negative expression of the steroid hormone receptors (ER and PgR), p21, p27, E-cadherin, BRCA-1, and Bcl-2 (all P < 0.001), but positively associated with EGFR (P = 0.003), p53, basal cytokeratins: CK56, CK14, triple negative, and basal phenotype using Nielsen's classification (all P < 0.001) compared to UK women. Multivariate analyses showed that race was also associated with BCSS independent of tumour size, lymph node status, and ER status. Conclusion. Ki-67 expression was observed to have contributed to the difference in the BCSS in Nigerian compared with British BC women. Therefore, targeting Ki-67 in the indigenous black women with BC might improve the patient outcome in the black women with BC.

Pathological characteristics of BRCA-associated breast cancers in Hispanics

The immunophenotype of BRCA-associated breast cancer has been studied in predominantly non-Hispanic whites (NHW). We evaluated the pathological characteristics of BRCA-associated invasive breast cancer in Hispanics. A case-control study was conducted on breast cancers from Hispanic and NHW women who enrolled in an IRB-approved registry and underwent BRCA gene analysis. BRCA negative controls (41 Hispanic, 39 NHW) were matched on age and ethnicity to BRCA positive cases (39 Hispanic, 35 NHW). A tissue array was constructed to characterize the expression of estrogen receptor (ER), progesterone receptor (PR), HER2, Ki-67 and p53 by immunohistochemistry. Mean age at diagnosis was 37.1 years (range 24-59) for Hispanics (80% with Mexican ancestry) and 40.1 years (range 21-63) for NHW (P = 0.03). Hispanic BRCA1 cases were more likely than BRCA negative controls to have tumors that were ER-negative (P < 0.001) and PR-negative (P = 0.001), had higher levels of Ki-67 (P = 0.001) and p53 expression, and lower levels of HER2 overexpression. When stratified by genes, there were no significant differences in expression of ER, Ki-67, HER2, and p53 by ethnicity among mutation carriers. However, a significantly higher proportion of BRCA-positive Hispanics had PR-negative tumors compared to BRCA-positive NHW (80 vs. 57%, OR = 2.9, 95% CI 1.0-8.1, P = 0.04). Hispanic BRCA-associated breast cancers were found to have the unique immunophenotype associated with BRCA mutations; however, there was a trend toward a difference in PR expression among Hispanic BRCA1 and BRCA2 cases. Additional research on the molecular mechanisms involved in the loss of PR in this population is warranted as it could have important implications for the treatment and prevention of breast cancer in Hispanics.

Women's cognitive and affective reactions to breast cancer survivor stories: a structural equation analysis

OBJECTIVE

Compare the immediate affective and cognitive reactions to cancer survivor stories about mammography and breast cancer vs. a didactic, informational approach.

METHODS

Participants (N=489) were African American women age 40 years and older (mean=61). Most had ≤high school education (67%), annual household income ≤$20,000 (77%), and a prior mammogram (89%). Participants completed surveys before and after watching the narrative or informational video. We used structural equation modeling to examine the large number of inter-related latent constructs.

RESULTS

Women who watched the narrative video experienced more positive and negative emotions, found it easier to understand the video, had more positive evaluations of the video, reported stronger identification with the message source (i.e., perceived similarity, trust, liking), and were more engaged with the video.

CONCLUSION

Narratives elicited immediate reactions consistent with theorized pathways of how communication affects behavior. Future studies should examine whether and how these immediate outcomes act as mediators of the longer term effects of narratives on affect, cognitions, and behavior.

PRACTICE IMPLICATIONS

Stories of other women's experiences may be more powerful than a didactic presentation when encouraging African American women to get a mammogram.

Use of partnership strategies to build radiation oncology disparities research programs in five Western Pennsylvania communities: an organizational case study

Many cancer treatment and prevention trials as well as surveillance programs suffer from a disproportionately low rate of accrual and a high rate of noncompliance or dropouts of racial minorities and the poor. One suggested strategy to help remediate this trend is to directly involve those targeted populations within the development, implementation, and evaluation of these services. The Radiation Oncology Community Outreach Group (ROCOG) and Neighborhood Cancer Care Cooperative (NCCC) are designed based upon this type of highly collaborative organizational structure, consistent with the general principles of community-based participatory research. Funded by the National Cancer Institute Cancer Disparities Research Partnership program, ROCOG/NCCC provide oncology-focused, community hospital-based initiatives intended to help close the cancer disparities gap. This article presents a descriptive case study of the organizational and political process that preceded our grant proposal submission, the potential benefits and difficulties associated with our extensive collaborative model, and an example of how highly competitive health care organizations can become partners in narrowly focused initiatives aimed at a greater social good.

Clinical evaluation of the simultaneous determination of CA 15-3, CA 125 and sHER2 in breast cancer

OBJECTIVE

We investigated serum levels of CA 15-3, sHER2 and CA 125, and their usefulness in the detection of metastatic disease in breast cancer patients.

METHODS

The levels of CA 15-3, sHER2 and CA 125 tumour markers were determined in 60 patients, 40 with localized and 20 with metastatic breast carcinoma. The control group consisted of 10 healthy women.

RESULTS

We found that, at the time of diagnosis, serum levels of all three tumour markers were elevated in patients with distant metastases, but of minute importance in the detection of any breast cancer. When the data for the individual markers were combined the overall sensitivity of metastases detection with all three markers improved. In this regard, 90% of patients with distant metastases had an increase in serum level of at least one of tested tumour markers. Similar results were obtained using receiver operating characteristic curve (ROC). Moreover, using ROC we defined cut-off values for metastasis detection for each of the tested markers.

CONCLUSION

Our findings indicate that measurement of CA 15-3 serum values in conjunction with sHER2 and CA 15-3 can increase sensitivity in metastasis detection.

Race/ethnicity and breast cancer estrogen receptor status: impact of class, missing data, and modeling assumptions

OBJECTIVE

To test whether reported associations between race/ethnicity and breast cancer estrogen receptor (ER) status are inflated due to missing ER data, lack of socioeconomic data, and use of the odds ratio (OR) rather than the prevalence ratio (PR).

METHODS

We geocoded and added census tract socioeconomic data to all cases of primary invasive breast cancer (n = 42,420) among women diagnosed between 1998 and 2002 in two California cancer registries (San Francisco Bay Area; Los Angeles County) and analyzed the data using log binomial regression.

RESULTS

Adjusting for socioeconomic position and tumor characteristics, in models using the imputed data, reduced the PR for the black versus white excess risk of being ER--from 1.76 (95% CI: 1.66, 1.86; adjusted for age and catchment area) to 1.47 (95% CI: 1.38, 1.56). The latter parameter estimate was 16% greater (i.e., 1.56) in models excluding women with missing ER data, and was 43% greater when estimated using the OR (i.e., 1.82).

CONCLUSION(S)

Studies on race/ethnicity and ER status that fail to account for missing data and socioeconomic data and report the OR are likely to yield inflated estimates of racial/ethnic disparities in ER status.

The effects of race and age on axillary lymph node involvement in breast cancer patients at a Midwestern safety-net hospital

BACKGROUND

Black and premenopausal patients have been shown to have poorer stage for stage survival than the overall population. The purpose of this study was to define the effects of age and race on axillary lymph node involvement at a Midwestern safety-net hospital. The hypothesis was that black patients under the age of 50 would be found to have increased rates of axillary involvement in breast cancer.

METHODS

A retrospective case review was performed of 184 breast cancer patients from 2000 to 2005. Statistical analysis was performed by race and age. Patients under 50 years of age were defined as premenopausal.

RESULTS

The overall rate of axillary involvement was 47.8%. Black patients had an overall rate of axillary involvement of 52.9%. However, premenopausal black patients had a 70.8% rate of axillary involvement (P < .05). Premenopausal white patients had a 46.3% rate of axillary involvement. Logistic regression analysis was performed, and premenopausal age and tumor size were found to be independent predictors of positive lymph node status in black patients.

CONCLUSION

In our study, premenopausal black patients had a much higher rate of axillary lymph node involvement than any other group. This finding was consistent even when tumor size was taken into account. More research needs to be done to better define this difference and to detect this disease at an earlier stage.

Population differences in breast cancer severity

Breast cancer incidence and mortality vary among different populations. African-American, Hispanic, Asian and Native American women have lower incidence but higher mortality compared with non-Hispanic white women. Explanations for the observed variation include social and economic factors such as education, income level, health insurance coverage, use of mammography, parity, breastfeeding and diet. Breast cancer may be a heterogeneous disease with different subtypes of tumors having different genetic and environmental risk factors. The difference in frequency of particular tumor subtypes between populations may explain some of the differences in incidence and mortality. Known genetic variants explain a small fraction of breast cancer cases, and so far there are no susceptibility genes that explain population differences in incidence and mortality. Studies evaluating the risk for particular tumor subtypes combining genetic and environmental variables and analyzing cases from different populations are needed to understand population differences in the severity of breast cancer.

Breast Cancer and Ethnicity: Strong Association between Reproductive Risk Factors and Estrogen Receptor Status in Asian Patients?A Retrospective Study

Breast cancer characteristics vary in racial/ethnic groups. Reproductive risk factors have been associated with estrogen receptor positive disease. We examined the association between reproductive risk factors and receptor status in different racial/ethnic groups to determine if some of the variation can be explained by a different reproductive risk profile. A retrospective chart review of all new breast cancer cases presenting to Elmhurst Hospital Center (Elmhurst, NY) between 1997 and 2004 was conducted. Data including patient characteristics and tumor characteristics were obtained. Four hundred ninety-nine patients were divided into two groups: the first group consisted of patients with estrogen positive disease and the second of those with estrogen negative disease. Association between reproductive risk factors and estrogen receptor status was examined for each racial group. There was a significant variability in patient age, age at menarche, parity, rates of nulliparity, age at first birth, and rates of menopause between the different ethnic groups. We found a strong, statistically significant association between reproductive risk factors and estrogen positive disease in the Asian group, where 96% of breast cancer patients who were either nulliparous or had late onset of first childbirth were found to have estrogen positive disease, whereas only 52% of those without these risk factors were found to be estrogen positive. For black patients the rates were 55% versus 56%, for Hispanic patients 64% versus 61%, and for non-Hispanic whites 74% versus 81%. In our patient population, differences in breast cancer characteristics could not be ascribed to a different reproductive risk pattern.

Differential expression of HER-2/NEU receptor of invasive mammary carcinoma between Caucasian and African American patients in the Detroit metropolitan area. Correlation with overall survival and other prognostic factors

GOALS

HER-2/neu overexpression in invasive mammary carcinoma is associated with more aggressive biologic behavior. Breast cancer in African American (AA) women has been associated with a shorter survival rate than that seen in Caucasians (C). This study evaluated the frequency of HER-2/neu overexpression in C compared to AA patients and the association of HER-2/neu expression with overall survival and other prognostic factors.

METHODS

A retrospective review of the SEER data of Karmanos Cancer Institute for patients with invasive mammary carcinoma was conducted between 1998 and 2001. Pathology reports and pathology slides were obtained for those patients with missing data. Available data and material on 608 patients were found. The median follow-up interval was 35 months with a range of 1-91 months. 46.7% of the study population was C while 53.3% was AA. The differential of HER-2/neu expression in C and AA was evaluated. The association of HER-2/neu expression and other prognostic factors with overall survival was carried out by univariate and multivariable analyses using Cox's proportional hazards regression model.

PRINCIPLE RESULTS

No statistically significant difference was found in HER-2/neu expression between C and AA patients. Overexpression of HER-2/neu did not correlate with decreased overall survival in this analysis.

MAJOR CONCLUSIONS

Breast cancer HER-2/neu expression in AA patients is not statistically different from that of Caucasians. HER-2/neu expression is not associated with overall survival. Among the other prognostic factors analyzed, ER status and histologic grade were not statistically significant.

Geographic patterns of advanced breast cancer in Los Angeles: associations with biological and sociodemographic factors (United States)

OBJECTIVE

Examination of patterns of advanced breast cancer may provide evidence needed to direct health care resources to those communities or population groups in greatest need. We assessed to what degree biologic, ethnic, and sociodemographic factors could explain such patterns within Los Angeles County.

METHODS

The proportion of cases of advanced disease among all breast cancer cases identified during 1992-1996 were analyzed using generalized linear mixed models with random census tract effects. Models included characteristics of the individual and her tumor, census tract of residence, and aggregated health districts.

RESULTS

Approximately 6% of cases, ranging from 4% for Asian to 10% for Black women, were diagnosed as advanced, exhibiting striking geographic patterns. Tumor histology and hormone receptor status were most predictive of advanced disease. Sociodemographic variables such as marital status, median income, and distance to nearest mammography unit showed additional association with risk.

CONCLUSIONS

These models explain most of the geographical patterns and eliminate differences between White and Hispanic but not Asian or Black women, identify subpopulations at high risk of advanced disease, and suggest cancer control opportunities.

Multiple births and breast cancer prognosis: a population based study

Survival in relation to endocrine or reproductive factors has rarely been studied since the focus of most studies has been on the risk of breast cancer. In this study we analysed the effect of multiple birth compared to single births on breast cancer survival. A population based cohort of 30619 women born after 1935 and diagnosed with primary breast cancer, between 1958 and 1998, was generated by linking a number of Swedish registries including Swedish Cancer Registry, Cause of Death Registry, Swedish Generation Registry and the Registry of Population and Population changes. Then we quantified the association between singleton and multiple births to breast cancer specific fatality using the Cox proportional hazards model. We found the singleton and multiple births were associated with increased fatality if breast cancer was diagnosed within 5 years of childbirth, this effect dying out to nil at 5 years after childbirth. Thereafter there was a protective effect on survival with time. Although childbirth is known to decrease breast cancer risk, this study demonstrates that a survival disadvantage exists for breast cancer diagnosed within the first 5 years of singleton and multiple births. It is concluded that breast cancer diagnosed within 5 years of childbirth, particularly if this or prior pregnancies have been multiple, should be regarded as a negative prognostic factor and considered in counselling and treatment of these patients.

An association between a common variant (G972R) in the IRS-1 gene and sex hormone levels in post-menopausal breast cancer survivors

Insulin receptor substrate-1 (IRS-1) is a key downstream signaling molecule common to both the insulin and IGF signaling pathways that can interact with the estrogen pathway to regulate breast cell growth. We investigated whether a putative functional variant for IRS-1 (G972R) influences circulating levels of sex hormones, sex hormone binding globulin (SHBG), C-peptide, and insulin-like growth factor 1 (IGF-1) levels among post-menopausal African-American and non-Hispanic white breast cancer patients enrolled in the Health, Eating, Activity, and Lifestyle (HEAL) Study. Circulating levels of sex hormones and growth factors can influence breast cancer recurrence and survival. Serum estrone, estradiol, testosterone, SHBG, IGF-1 and C-peptide were measured in 468 patients at 30+ months post diagnosis. Non-protein bound hormone levels (free estradiol, free testosterone) were calculated. In African-American patients, the IRS-1 variant was associated with increased serum levels of estrone (p = 0.02), free estradiol (p = 0.04), total testosterone (p = 0.04), free testosterone (p = 0.006) and decreased levels of sex hormone-binding globulin (p = 0.02). No association was present for white patients. Our findings provide suggestive evidence that IRS-1 G972R variant may be associated with circulating levels of sex hormones and SHBG in African American breast cancer survivors.

Race modifies the association between breast carcinoma pathologic prognostic indicators and the positive status for HER-2/neu

BACKGROUND

Inferences about the variations in the biology of breast carcinoma between African-Americans and Caucasians have been reported. The difference in the prevalence of positive HER-2/neu breast carcinoma was evaluated and the race-specific risk was assessed for positive HER-2/neu among a cohort of women diagnosed with their first primary breast carcinoma, given the accepted prognostic pathologic indicators for positive HER-2/neu status.

METHODS

Demographic, clinical, and pathologic data were collected from existing databases. The status of HER-2/neu was considered positive if the immunohistochemistry score was 3+ or if the fluorescent in situ hybridization indicated a ratio greater than 2. Multivariable logistic regression was used to determine the race-specific risk for HER-2/neu positive breast carcinoma.

RESULTS

The difference in the prevalence of HER-2/neu-positive status between African-American and Caucasian women was not statistically significant (P = 0.46). For Caucasian women the likelihood for positive HER-2/neu was statistically significant and increased almost linearly within each stage with nuclear grade dedifferentiation relative to the reference group, women with Stage 1, Grade 1 carcinomas. For African-American women, this risk was not significantly associated with stage, nuclear grade, their interaction term, or other pathologic prognostic indicators.

CONCLUSIONS

The findings suggest that race modifies the association between the pathologic prognostic indicators of breast carcinoma and the likelihood of HER-2/neu-positive carcinoma. So far, clinical correlative studies of HER-2/neu have not included race as an independent variable. Concerns about the limited generalizability and the need for validation of the findings across racial lines have been expressed previously.

African-American/White differences in breast carcinoma: p53 alterations and other tumor characteristics

BACKGROUND

Despite mounting evidence that breast tumors in African-American (AA) women are more aggressive compared with breast tumors in white (W) women, little is known regarding racial/ethnic differences in genetic alterations that may be of prognostic importance.

METHODS

In this population-based cohort of 322 AA women (45%) and W women (55%) who were diagnosed with breast carcinoma between 1987-1989, the authors evaluated available archived tumor tissue (n = 247 samples) for racial differences in selected genetic alterations and other prognostic indicators. Tumor characteristics were assessed by immunohistochemistry and/or expert review.

RESULTS

Alterations in p53 were significantly more common in AA women compared with W women (odds ratio, 4.00; 95% confidence interval, 1.77-9.01) and remained statistically significant in models that were adjusted for disease stage at diagnosis, according to American Joint Committee on Cancer (AJCC) criteria, and for other prognostic indicators. No racial difference with regard to HER-2/neu status was observed, but alterations in c-met were more common in AA women once the model was adjusted for negative confounders (not significant). Among other tumor characteristics, significant findings included later AJCC stage and higher histologic and nuclear grade tumors in AA women. In addition, the burden of aggressive tumor characteristics was greater in AA women because they were more likely to be at high risk on multiple factors (e.g., both high histologic grade and high nuclear grade [P = 0.03] and negative status for both estrogen receptors and progesterone receptors [P = 0.01]).

CONCLUSIONS

Data from this population-based cohort confirmed that breast tumors in AA women most likely are more aggressive compared with breast tumors in W women and offer new evidence for possible racial/ethnic differences with regard to p53 alterations.

Effects of obesity on breast cancer stage at diagnosis in Korean women

This study was carried out to test the hypothesis that palpation for lumps may be more difficult in large breasts than in small breasts, resulting in a delay in the detection and diagnosis of breast cancer, and to determine whether this hypothesis is confirmed in Asian women. Of 833 new breast cancer patients registered in the Daegu Cancer Registry in 1997-1999, 579 were used in the final data analysis, after excluding patient records containing many missing data on study variables related with cancer staging. There was no difference in means of body mass index (BMI) according to tumour, either in all cases or in those under 49 years of age. In the 50+ age group, the means+/-standard deviations of BMI of T1, T2 and T3 were 23.7+/-2.8, 24.2+/-3.0, and 26.2+/-4.3, respectively (P=0.01). In univariate logistic regression of tumour characteristics with BMI, no statistically significant odds ratios were found either by continuous or quartiles of BMI. In conclusion, these results suggest that the hypothesis is partially confirmed in Korean breast cancer patients and further studies are needed to clarify the relationship between BMI and tumour stage at diagnosis.

Racial differences in the expression of cell cycle-regulatory proteins in breast carcinoma

BACKGROUND

African-American (AA) women are more likely to be diagnosed with an advanced stage of breast carcinoma than are white women. After adjustment for disease stage, many studies indicate that tumors in AA women are more likely than tumors in white women are to exhibit a high level of cell proliferation and features of poor prognosis. The purpose of the current study was to compare tumor characteristics and cell cycle alterations in AA women and white women that might affect the aggressiveness of breast carcinoma.

METHODS

The study included 124 AA and 397 white women, ages 20-54 years. These women were enrolled in a case-control study in Atlanta, Georgia, between 1990 and 1992. Breast tumor specimens obtained from these women were centrally reviewed for histologic characteristics and evaluated for expression of estrogen and progesterone receptors (ER/PR), c-ErbB-2, Ki-67, p53, cyclin E, cyclin D1, p27, p16, pRb, and p21 by immunohistochemistry. Logistic regression models were used to assess the age- and stage-adjusted associations of various tumor characteristics with race.

RESULTS

The odds of a breast carcinoma diagnosis at a younger age and at a later stage were higher for AA women than for white women. After adjustment for disease stage and age at diagnosis, AA women also were found to have increased odds of having a higher-grade tumor, a higher mitotic index, marked tumor necrosis, ductal histology, loss of ER and PR, overexpression of cyclin E, p16, and p53 and low expression of cyclin D1 at diagnosis.

CONCLUSIONS

The observed differences between tumor specimens obtained from AA women and tumor specimens obtained from white women, independent of stage and age at diagnosis, indicated that race may be a determinant, or a surrogate for other determinants, of aggressive breast carcinoma and specific cell cycle defects.

Prevalence and Spectrum of p53 Mutations in White Hispanic and Non-Hispanic Women with Breast Cancer

Hispanic women differ from non-Hispanics in breast cancer incidence, stage at diagnosis, and survival. Ethnic differences in genetic makeup, reproductive patterns, diet, socioeconomic status, physical activity, and other unidentified cultural factors may be responsible for the disparity. This study investigated occurrences of p53 tumor suppressor gene mutations in South Florida white Hispanic and white non-Hispanic women with primary breast cancer. Tumor tissues were obtained from a consecutive series of women with breast cancer who underwent breast resection at the Jackson Memorial Hospital, Miami, Florida between 1984 and 1986. A total of 231 women with primary breast cancer, aged 31-85 years, were included in the study. Among them, 64 (27.7%) were white Hispanic and 167 (72.3%) were white non-Hispanic. The majority of the patients were white non-Hispanics (72.3%). Compared to white non-Hispanics, however, white Hispanics had significantly higher proportions of tumors larger than 2 cm (53.1% v.s. 28.7%, p = 0.00) as well as larger tumor size at diagnosis (mean: 4.2 v.s. 3.0 cm, p = 0.00). The p53 gene mutation rate was significantly lower in white Hispanics than in white non-Hispanics (51.6% v.s. 70.7%, p = 0.01). Furthermore, among node-negative breast cancer patients, after adjustment for tumor size at diagnosis, logistic regression results showed that white Hispanics were 71% less likely than white non-Hispanics to carry p53 mutations (OR = 0.29 and 95% CI = 0.09-0.91). We conclude that white Hispanic women with breast cancer might have lower p53 gene mutation prevalence than white non-Hispanic women.

Influences of ethnicity, treatment, and comorbidity on breast cancer survival in Hawaii

The purpose of this study was to examine factors contributing to the ethnic discrepancies in breast cancer survival described previously. Through the use of the Hawaii Tumor Registry and insurance claims data, 1,052 breast cancer patients' survival times were examined in relation to demographics, disease characteristics, comorbidity, and treatment patterns as compared to national guidelines for breast cancer treatment. In stepwise and hierarchical Cox regression models, TNM stage was the strongest predictor of survival and explained all of the ethnic survival differences. In addition, comorbidity and treatment patterns were significant in predicting survival. In this population of health plan members, ethnic differences in survival were not a result of differential treatment, but due to variations in early detection. These results support the hypothesis that pre-existing conditions and treatment patterns are related to breast cancer survival even after controlling for stage at diagnosis indicating the usefulness of insurance claims data in this research field.

Prognostic Indices in Breast Cancer are Related to Race

African-American (AA) women have a higher mortality from breast cancer than Caucasians (C). This may be attributed to stage of disease at presentation, but specific prognostic factors are not well identified. We sought to identify prognostic factors in our database of early-stage (stage I and II) breast cancer from 1990 to 1999. There were 153 tumors in 150 AA women and 773 tumors in 760 C women. Prognostic factors are listed according to race with relative risk (RR) and 95 per cent confidence intervals. AA women presented significantly more often than C women under the age of 50 years (RR = 1.8) with palpable disease (RR = 1.3), higher-grade tumors (RR = 1.5), more estrogen receptor-negative disease (RR = 1.7), more progesterone receptor-negative disease (RR = 1.4), higher proliferation indices (RR = 1.9), and more lymph node-positive disease (RR = 1.6). Many of these adverse prognostic features persisted in “good” prognostic groups, i.e., those women over the age of 50 years with tumors <20 mm and having node-negative disease. We conclude that prognostic factors are related to race with AA women presenting at an earlier age and more often with palpable disease. More importantly AA women presented significantly more often with higher-grade tumors, hormone receptor-negative tumors, higher proliferation indices, and node-positive disease. These findings may explain a higher breast cancer mortality in AA women.

Socioeconomic status and breast carcinoma survival in four racial/ethnic groups: a population-based study

BACKGROUND

Although overall survival for invasive breast carcinoma remains high, black women experience poorer survival than whites. Less is known about the survival of Hispanics and Asians, who may share clinical and socioeconomic risk factors similar to blacks. To better understand racial/ethnic survival patterns, we investigated the effect of socioeconomic status (SES) and disease stage on racial/ethnic differences in breast carcinoma survival in a large population-based cohort.

METHODS

Using data from the Surveillance, Epidemiology, and End Results program (SEER), we identified 10,414 white, 940 black, 1100 Hispanic, and 1180 Asian females diagnosed with breast carcinoma in the Greater San Francisco Bay Area between 1988 and 1992. We used the Kaplan-Meier method to generate survival rates and Cox proportional hazards regression to estimate the risk of death by race/ethnicity, after adjustment for clinical, demographic, and census-derived SES variables.

RESULTS

The 10-year unadjusted survival rates were 81% for whites, 69% for blacks, 75% for Hispanics, and 79% for Asians. Adjusting for stage decreased the relative risk of mortality for blacks from 1.81 to 1.29; the stage-adjusted relative risk for Hispanics (1.11) and Asians (1.02) did not differ significantly from whites. Additional adjustment for age, tumor characteristics, and treatment factors did little to alter the relative risk in blacks; adding blue-collar status to the model further decreased the relative risks for blacks to 1.22. Residing in a blue-collar neighborhood was independently associated with a 1.16 increase in risk of death.

CONCLUSIONS

After adjustment for multiple factors, blacks continue to have slight but significantly poorer survival after breast carcinoma compared with whites, whereas the survival of Hispanics and Asians did not differ from whites.

Histopathology of breast cancer among African-American women

Although the overall incidence of breast cancer in African-American women is lower than in white women, African-American women younger than 50 years old have a higher incidence of breast cancer than white women. African-American women with breast cancer have a poorer survival rate than white women and are more likely to die of breast cancer in almost every age group. To explain this disparity, we studied a substantial body of literature that reported a biologic difference in the tumors found in African-American and white women. Specifically, more aggressive histopathologic patterns have been described among African-American patients with breast cancer when compared with white women. In addition, there are data that support an ethnicity-related variation in the expression of breast tumor hormonal markers. The objective of this study was to critically evaluate the existing published data on the histologic features of breast cancer to determine whether breast cancer in African-American women is a histologically more aggressive disease than in white women. We conclude that the aggressive tumor histology reported in African-American women has not been analyzed carefully with respect to the age of the patient at the time of diagnosis and the stage of disease at presentation. Furthermore, there is a need for central pathology review using accepted, published criteria for diagnosis of uncommon and controversial histologic subtypes of breast cancer.

Reducing disparities in breast cancer survival: a Columbia University and Avon Breast Cancer Research and Care Network Symposium

On November 8th, 2001, faculty from Universities, government and non-profit community organizations met to determine how, separately and together, they could address disparities in survival of women with breast cancer in the diverse patient populations served by their institutions. Studies and initiatives directed at increasing access had to date met modest success. The day was divided into three sections, defining the issues, model programs, government initiatives and finally potential collaborations. By publishing these proceedings, interested readers will be aware of the ongoing programs and studies and can contact the investigators for more information. The Avon Foundation funded this symposium to bring together interested investigators to share programmatic experiences, data and innovative approaches to the problem.

Mammography screening and differences in stage of disease by race/ethnicity

OBJECTIVES

We examined the effect of routine screening on breast cancer staging by race/ethnicity.

METHODS

We used a 1990 to 1998 mammography database (N = 5182) of metropolitan Denver, Colo, women to examine each racial/ethnic cohort's incident cancer cases (n = 1902) and tumor stage distribution given similar patterns of routine screening use.

RESULTS

Regardless of race/ethnicity, women participating in routine screenings had earlier-stage disease by 5 to 13 percentage points. After control for possible confounding factors, White women were more likely to have early-stage disease compared with Black and Hispanic women.

CONCLUSIONS

Lack of screening coverage in certain racial/ethnic populations has often been cited as a reason for tumor stage differences at detection. In this study, correcting for screening did not completely reduce stage differentials among Black and Hispanic women.

Can obesity explain the racial difference in stage of breast cancer at diagnosis between black and white women?

OBJECTIVE

Black women are more likely to be diagnosed at a more advanced stage of breast cancer than are white women. Traditionally, this has been attributed in part to social or cultural factors. Given that black women are more likely to be obese than white women and that being obese is associated with a more advanced stage at diagnosis, this study aims to assess to what extent the racial difference in stage at diagnosis can be explained by racial differences in obesity.

METHODS

Incident cases of breast cancer between 1991 and 1997 (white, n = 585; black, n = 381) were identified from hospitals in the Baltimore metropolitan area. Information, including age, race, weight, height, and pathology reports, was obtained from hospital medical records.

RESULTS

Black women were more likely than white women to be diagnosed with breast cancer at tumor-node-metastasis (TNM) stage II or greater (age-adjusted odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.15-1.99). Further, black women were more likely than white women to be overweight or obese. A high body mass index (BMI) was significantly associated with an advanced stage of breast cancer at diagnosis. Adjustment for the higher prevalence of obesity in black women attenuated the risk estimate of more advanced stage of breast cancer at diagnosis in black women compared with white women by approximately 30%.

CONCLUSIONS

Our results suggest that the higher prevalence of obesity among black women plays an important role in explaining their relative disadvantage in stage at diagnosis of breast cancer. Nonetheless, a racial difference in stage of breast cancer at diagnosis persists after adjustment for obesity.

Hormone receptors in breast cancer: racial differences in distribution and survival

The purpose of this study was to describe hormone receptor status and analyze the effect of receptors on survival from breast cancer. Comparisons were made between African-American and Caucasian racial categories. Breast cancer data from 1990 through 1997 collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program were analyzed. Subjects were 993 Caucasian men, 12,303 African-American women, and 141,045 Caucasian women. The number of African-American men was too small to analyze separately (n = 93). In addition to analysis of estrogen and progesterone receptor status by sex and race, tumor and patient characteristics included age, stage at time of diagnosis, and tumor histology. The proportion of Caucasian men with hormone receptor positive tumors remained relatively high and stable for all ages. In women, the proportion of hormone receptor positive tumors increased with age, with African-American women having the highest proportion of hormone receptor negative tumors. Caucasian men had highest proportions of hormone receptor positive tumors in all histology and stage groups, while African-American women had lowest proportions of hormone receptor positive tumors in all stage and histologic categories. Survival for African-American women was significantly worse for each hormone receptor category. In multivariate analyses, race was a significant independent predictor of survival, but sex was not. Although reasons for differences in hormone receptor status by sex and race are unknown, several hypotheses are discussed with respect to differences in tumor histopathology and risk factors.

Body mass and stage of breast cancer at diagnosis

Obesity is a well-known risk factor for postmenopausal breast cancer. In contrast, the relationship between obesity and stage of breast cancer at diagnosis is less clear. We hypothesized that increased breast size in obese women may delay discovery of breast tumors. Thus, the purpose of our study was to examine whether there is an association between body mass and stage of breast cancer at diagnosis using hospital medical records. Newly diagnosed breast cancer cases (n = 966) in the Baltimore metropolitan area from 1991 to 1997 were included in our study. Patient information including age, ethnicity, weight, height and pathology data were obtained from hospital medical records. High body mass was significantly associated with late stage of breast cancer at diagnosis. Women who were obese (body mass index [BMI] > or = 27.3) were more likely to be at an advanced stage at diagnosis compared with women with a BMI of < 27.3 (multivariate-adjusted odds ratio [OR] 1.57, 95% confidence interval [CI] 1.15-2.14). The association between body mass and stage at diagnosis was stronger among women younger than 50 years (OR 2.34, 95% CI 1.34-4.08) compared with women 50 years or older (OR 1.30, 95% CI 0.89-1.91). Our study suggests that higher body mass is associated with advanced stage of breast cancer at diagnosis. This finding may be of considerable concern, given the increasing prevalence of obesity in women in the United States and the poor prognosis associated with late-stage tumors.

Conditional median survival of patients with advanced carcinoma: surveillance, epidemiology, and end results data

BACKGROUND

Conditional survival is clinically useful, particularly for patients with malignant disease who have a poor prognosis. However, there are no published data on the conditional median survival of patients with advanced carcinoma on a population basis.

METHODS

Data on 217,573 patients with breast, colorectal, lung, or prostate carcinoma who were newly diagnosed with distant disease between 1973 and 1995 and who were followed through the end of 1997 were extracted from the Surveillance, Epidemiology, and End Results (SEER) data base of the National Cancer Institute. The Kaplan-Meier method was employed to estimate conditional median survival and 95% confidence intervals at 0-5 years after the initial diagnosis.

RESULTS

The conditional median survival increased as time elapsed after the initial diagnosis. The increase was slowest and almost leveled off among patients with prostate carcinoma. The median survival of patients with breast carcinoma increased relatively linearly with time, i.e., 5-6 months per year. Conversely, there was a rapid increase in the conditional median survival according to the amount of time since diagnosis for patients with lung and colorectal carcinoma. The trend was most pronounced for patients with colorectal carcinoma. At 5 years after the initial diagnosis, the remaining median survival was longest for patients with colorectal carcinoma, almost 6 years (71.5 months), followed by patients with lung carcinoma (52.5 months), breast carcinoma (42.5 months), and prostate carcinoma (34.5 months). Although race was a correlate with initial survival, gender and age had more impact on late conditional survival.

CONCLUSIONS

The conditional median survival provides useful and encouraging information for patients who survive with advanced disease and for healthcare professionals who treat these patients. However, the information should be used carefully, taking the limitations of these data into account.

Tumor characteristics in African American and white women

BACKGROUND

Previous studies provide evidence that breast cancers occurring in different age and ethnic groups are not evenly distributed with regard to their biologic, pathologic and clinical characteristics. We evaluated the distributions of 11 pathological and biological variables between African-American (AA) and white patients and between three different age groups (20-39, 40-59 and 60-74 years). We examined whether racial differences existed across levels of age.

METHODS

Data were obtained from the Carolina Breast Cancer Study (CBCS), a population-based, case-control study of breast cancer in North Carolina. Eighty hundred and sixty one women with a first diagnosis of invasive breast cancer participated in Phase I of the CBCS. Diagnostic paraffin blocks were obtained from 807 cases. One representative block was scored for histologic type and grade (architectural, nuclear, mitotic and overall). Medical chart review yielded tumor size, lymph node status, distant metastases, stage, hormone receptor status (ER/PR) and DNA ploidy.

RESULTS

Pathologically advanced tumors (large size, high grade, high stage, ER/PR negative) were significantly more common in young and AA women. Racial differences varied by age. Among younger, AAs and whites differed only with respect to ER/PR status, while among older women AAs and whites differed only with respect to stage at diagnosis.

CONCLUSIONS

The results of this study confirm the presence of poorer prognosis breast cancer among AA and younger women. They also highlight the need for age and race to be considered together when evaluating pathologic and biologic characteristics of disease and when making inferences regarding tumor aggressiveness.

Survival differences in breast cancer among racial/ethnic groups: a population-based study

In women, breast cancer is the most frequent solid tumor and the second leading cause of cancer death. Differences in survival of breast cancer have been noted among racial/ethnic groups, but the reasons are unclear. This report presents the characteristics and the survival experience of four racial/ethnic groups and evaluates the effects of stage, age, histology, and treatment on survival time. The distributions of prognostic factors and treatment among racial/ethnic groups are compared using female breast cancer patients from two population-based registries in Southern California. The main end points are observed survival time and survival by cause of death. The Cox model is used to estimate the relative risk of death in three minority groups compared with non-Hispanic whites, while controlling for several covariates. Breast cancer cases included in this study were 10,937 non-Hispanic whites, 185 blacks, 875 Hispanics, and 412 Asians. The median follow-up period was 76 months (range: 48-132). The median age at diagnosis was 64 years among non-Hispanic whites, 55 years among Hispanics (p = 0.001), 52 years among blacks (p = 0.001), and 50 years among Asians (p = 0. 001). There was more localized disease among non-Hispanic whites (61. 4%) than among blacks (50.8%) and Hispanics (52.2%), but not compared to Asians (59.7%). After controlling for stage, age, histology, treatment, and registry, overall survival significantly differed between non-Hispanic whites and blacks [relative risk (RR) = 2.27, 95% confidence interval (95% CI) 1.82-2.84) and between non-Hispanic whites and Hispanics (RR = 1.18, 95% CI 1.04-1.34). The same results were found for breast cancer death in blacks (RR = 2.32, 95% CI 1.76-3.07) and Hispanics (RR = 1.28, 95% CI 1.10-1.50). We found no difference between Asians and non-Hispanic whites in overall and cancer-related survival. These results show that stage of disease, age at diagnosis, histologic features and treatment for breast cancer differed among racial/ethnic groups. Moreover, black women, in particular, and Hispanic women with breast cancer had a higher risk of death compared to non-Hispanic white women, even after controlling for prognostic factors. These findings underline the necessity of improved screening and access to appropriate treatment among minority women for breast cancer.

Early onset of breast carcinoma in African American women with poor prognostic factors

The purpose of this study was to determine prognostic significance of age and race as independent variables and to see role of age at the onset of breast carcinoma. A retrospective study was conducted of African American and white women with breast cancer treated at SUNY-Health Science Center Brooklyn and Kings County Hospital Center from 1983 to 1993. The objective was to analyze the differences in patterns of disease onset, as related to age and prognostic factors. A total of 738 patients were analyzed for race-adjusted comparison of stage, grade, disease-free survival, and median survival. Age at the time of diagnosis was analyzed to conduct age-specific comparisons of African American (AA) and white patients. The multivariate analysis indicated that AA women develop breast cancer 10 years earlier than white women (p = 0.00001). Corrected by stage and grade, i.e., chi2 test for stage-by-stage and grade-by-grade analysis has revealed that the AA women present with higher stage (p = 0.009), increased number of positive nodes (p = 0.00007), and more estrogen receptor/ progesterone receptor-negative tumors (p = 0.005). Further studies are required to probe into the etiologic possibilities of this significant difference. The important contributing factors could be hormonal, genetic, environmental, and socioeconomic. Obesity and dietary factors also need to be evaluated. Further studies to explore genetic susceptibility by ploidy is recommended to explain this significant difference. We conclude that the onset of breast cancer among AA women occurs at a significantly younger age than in white women, and their prognostic factors are poorer.

Breast cancer in African American women: epidemiology and tumor biology

This review of published data on the epidemiology, pathology, and molecular biology of breast cancer in African American women seeks to identify how the etiology and presentation of the disease differ from those in white women. The crossover from higher to lower age-specific incidence rates in African American women at age 45 cannot be explained by current data on the distribution of risk factors. Data from six case-control studies suggest that the relative risks associated with both established and probable breast cancer risk factors are similar in African American and white women. Lower survival in African American compared to white women is primarily attributable to diagnosis at a later stage. However, evidence from a number of studies suggests that tumors in African American women may exhibit a more aggressive phenotype, which could also contribute to the survival disparity. Tumors in African American women are more likely to occur at a younger age, to be poorly differentiated and estrogen receptor negative, and to exhibit high grade nuclear atypia, more aggressive histology (more medullary and less lobular), and higher S-phase. Overexpression of p53 and erbB-2 occurs with similar frequency in African American and white women, although limited data suggest the former may exhibit different p53 mutation spectra. One study found high risk associated with a specific CYP1A1 polymorphism in African American but not white women. Additional studies of molecular differences in African American and white women are needed, with multifactorial assessment of the independent effects of molecular and conventional risk attributes.