Impact of breast carcinoma on African-American women: the Detroit experience

Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis

PURPOSE

Two randomized trials published in 2001 provided level 1 evidence for the use of cytoreductive nephrectomy (CyNx) for the treatment of metastatic renal cell carcinoma (mRCC). However, the regulatory approval of vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) in 2005 has left an "evidence void" regarding the use of CyNx. We evaluated the patterns in the use of CyNx in the cytokine and VEGFR-TKI eras, and the patient characteristics associated with the use of CyNx.

METHODS

The Surveillance, Epidemiology, and End Results registry was used to identify patients with histologically or cytologically confirmed stage IV RCC between 2001 and 2008. Patients were classified as treated during the cytokine (2001-2005) or VEGFR-TKI (2006-2008) eras. A multivariate logistic regression analysis was performed to calculate the odds of undergoing CyNx according to treatment era and socioeconomic characteristics.

RESULTS

Overall, 1,112 of 2,448 patients (45%) underwent CyNx. CyNx use remained stable between 2001 and 2005 (50%), but decreased to 38% in 2008. Logistic regression analysis revealed that older age (OR 0.82, 95% CI: 0.68, 0.99), black race (OR 0.64, 95% CI: 0.46, 0.91), Hispanic ethnicity (OR 0.71, 95% CI: 0.54, 0.93), and treatment in the VEGFR-TKI era (OR 0.82, 95% CI: 0.68, 0.99) were independently associated with decreased use of CyNx.

CONCLUSIONS

Use of CyNx in the United States has declined in the VEGFR-TKI era. Older patients and minorities are less likely to receive CyNx. Results of ongoing phase III trials are needed to refine the role of this treatment modality.

Trends in the use of cytoreductive nephrectomy in the United States

BACKGROUND

Two randomized trials published in 2001 established CyNx for patients with metastatic renal carcinoma (mRCC) as a treatment standard in the cytokine era. However, first-line systemic therapy for mRCC changed in 2005 with FDA approval of VEGFR TKIs. We evaluated the patterns of use of CyNx from 2000 to 2008.

MATERIALS AND METHODS

The National Cancer Database was queried for patients diagnosed with mRCC. Patients who underwent CyNx were identified and were further categorized by pre-VEGFR versus VEGFR TKI era, race, insurance status, and hospital. For these subcategories, prevalence ratios (PRs) were generated using the proportion of patients with mRCC undergoing CyNx versus those not undergoing CyNx.

RESULTS

Of the 47,417 patients (pts) identified with mRCC, the prevalence of cytoreductive nephrectomy increased 3% each year from 2000 to 2005 (P < .0001), then decreased 3% each year from 2005 to 2008 (P = .0048), with a significant difference between the eras (0.97 vs. 1.025; P < .0001). Black and Hispanic pts were less likely than Caucasian pts to undergo CyNx. Pts with Medicaid, Medicare, and no insurance were less likely than pts with private insurance to undergo CyNx. Pts diagnosed at community hospitals were significantly less likely than pts at teaching hospitals to undergo CyNx.

CONCLUSION

The use of CyNx has declined in the VEGFR-TKI era. In addition, racial and socioeconomic disparities exist in the use of CyNx. The results of pending randomized trials evaluating the role of CyNx in the VEGFR-TKI era are awaited to optimize use of this modality and address potential disparities.

Trends and variations in utilization of nephron-sparing procedures for stage I kidney cancer in the United States

PURPOSE

The incidental detection of early-stage kidney tumors is increasing in the United States. Nephron-sparing approaches (NS) to managing these tumors are equivalent to radical nephrectomy (RN) in oncologic outcomes and have a decreased impact on renal function. Our objective was to evaluate trends in the use of NS over the past decade and the socioeconomic factors associated with its use.

METHODS

The National Cancer Database was queried to identify patients with stage I kidney cancer between 2000 and 2008. Patients were classified by the type of surgery as NS (local destruction and local excision) or RN. Patients were further categorized by age, race, insurance status, and income. Log-binomial regression was used to estimate prevalence ratios (PR) for the proportion of NS to RN according to demographic and socioeconomic characteristics.

RESULTS

From 2000 to 2008, there were 142,194 cases of kidney cancer reported to the NCDB. In these cases, 43,034 (30.3 %) patients had NS, and 86,431 (60.78 %) patients had RN. The prevalence of NS increased 10 % per year (PR = 1.10, p < 0.0001)-from 20.0 % in 2000 to 45.1 % in 2008. Older age, lower income, Black race, Hispanic ethnicity, and lack of health insurance were associated with a decreased prevalence of NS.

CONCLUSIONS

NS as a treatment for stage I kidney cancer has increased steadily since 2000. Age, racial, and socioeconomic differences may exist in the utilization of NS. Additional analyses, with patient level data, are required to address the independent significance of these variables in an effort to develop strategies to mitigate these potential disparities.

Medical barriers to mammography screening of African American women in a high cancer mortality area: implications for cancer educators and health providers

African American women have a higher breast cancer mortality rate than whites even when cancer subtype is considered, are more likely to be diagnosed at a later stage, and are less likely to have mammography screening. Structural barriers limit screening but may be less important than clinical care and personal barriers among minority and lower income women. A random sample of 178 African American females aged >40 years from a high cancer risk area was surveyed to associate mammography screening with clinical, structural, and personal barriers. Clinical barriers including patient education and communication were significantly associated with lack of screening in previous 2 years. Personal barriers (lack of trust and knowledge) and structural barriers (lack of insurance, facilities, and providers) also reduced screening. Results reveal that medical practitioners should be more pro-active in reducing clinical barriers to mammography screening among lower income African American women. Improved patient physician communication, education about breast cancer to build knowledge and reduce fears, referral for mammography, and building trust are indicated.

Racial/Ethnic differences in the health-related quality of life of cancer patients

Previous research has suggested that, when compared to European Americans (EAs), African Americans (AAs) are at higher risk of metastatic disease at time of cancer diagnosis, and a higher risk of shorter survival. Although AA patients have reported worse physical health than EA patients, studies have rarely addressed whether racial/ethnic disparities exist on the social, emotional, and functional aspects of health-related quality of life. Five hundred and two AA and 396 EA patients with AIDS-related malignancies or breast, colon, head/neck, and lung cancers seeking treatment within the contiguous United States and Puerto Rico participated in the present study. Responses on the Functional Assessment of Cancer Therapy-General were analyzed for possible racial/ethnic disparities using multivariable regression models and item response theory modeling to detect differential item functioning. Differential item functioning was found in six items of the Functional Assessment of Cancer Therapy-General, indicating that AA and EA participants had different probabilities of responding to these items. Compared to EAs at the same level of health-related quality of life, AAs reported more severe symptomatology on items that reflected malaise and ability to work, and less severe symptomatology on items that reflected fatigue, treatment side effects, and outlook on life. At the subscale level, AAs reported poorer physical and social well-being, but better emotional well-being, than EAs. Similar to previous studies, AA patients reported poorer physical functioning than a comparable group of EA patients. Some items appear to be responded to differently by AAs and EAs, suggesting it is important to consider race/ethnicity when evaluating responses to questions about health-related quality of life.

Developing a partnership model for cancer screening with community-based organizations: the ACCESS breast cancer education and outreach project

There is growing enthusiasm for community-academic partnerships to promote health in underserved communities. Drawing upon resources available at a comprehensive cancer center, we developed the ACCESS program to guide community based organizations through a flexible program planning process. Over a three-year period, ACCESS partnered with 67 agencies serving various medically underserved populations. Organizations included hospitals, parishes, senior centers, harm reduction programs, and recreational facilities. Program outcomes at the organizational level were quantified in terms of introduction of new cancer information, referral or screening programs, as well as organizational capacity building. ACCESS represents a viable model for promoting partnership to transfer behavioral health programs and adapt interventions for new audiences. Plans to further evaluate and enhance this model to promote cancer screening efforts are discussed. We argue that, ultimately, formation and development of community partnerships need to be understood as a fundamental area of practice that must be systematically integrated into the mission of major academic medical institutions in every area of public health.

Racial disparity in outcomes of a clinical trial population with metastatic renal cell carcinoma

OBJECTIVES

Population studies have revealed that black Americans with renal cell carcinoma (RCC) have a shorter survival than do white Americans. Differences in socioeconomic status and treatment are frequently cited as the reasons for this disparity. The effect of these social obstacles may be reduced by studying a patient population with advanced RCC enrolled in clinical trials, because patients in these trials are likely to be similar in terms of their access to care, compliance, and performance status.

METHODS

A retrospective review of all patients with metastatic RCC enrolled in clinical trials at Wayne State University from 1992 to 2002 was conducted. Log-rank survival analysis by age, sex, race, smoking history, nephrectomy history, prior therapy, type of protocol therapy (immunotherapy versus other), performance status (0 versus 1 to 2), and number of metastatic sites was conducted. Univariate and multivariate comparisons by race were performed for overall survival and time to progression.

RESULTS

A total of 122 patients (median age 57 years) were enrolled; 21 (17%) were black and 101 (83%) were white. Overall survival was significantly shorter for the black Americans (P = 0.0027). The median survival for black Americans and white Americans was 6.9 and 11.5 months, respectively. On multivariate analysis, black race and performance status of 0 versus 1 and 2 were significant predictors of shorter survival. The presence of liver metastases and/or the absence of prior nephrectomy also influenced the length of overall survival through an interaction effect.

CONCLUSIONS

Within a clinical trial patient population with RCC, race was a significant predictor of overall survival.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Racial disparity in incidence patterns and outcome of kidney cancer

OBJECTIVES

To identify the subgroups that primarily contribute to the greater incidence and mortality of renal cancer in black Americans compared with white Americans.

METHODS

We analyzed age, stage, and race-related differences in the incidence and survival among patients with renal cancer using the national Surveillance, Epidemiology, and End Results (SEER) registry database. White and black patients with renal cell carcinoma who were older than 19 years of age and had been diagnosed between 1975 and 1998 were included. Incidence trends were analyzed by joinpoint regression with the statistical significance level at P <0.05. The Cox proportional hazards model was used to determine the overall survival of patients with renal cell carcinoma by race (white versus black), age (20 to 59 versus 60+ years), and stage (local versus regional/distant).

RESULTS

Localized disease predominantly accounted for the rise in incidence. Both black age groups with localized disease had a greater estimated annual percentage of incidence increase (4.46% for 20 to 59 years and 4.35% for 60+ years) compared with their white counterparts (2.87% and 3.06%, respectively). The magnitude of survival difference was largest between black versus white patients younger than 60 years of age who had local stage disease, with a median survival time of 190 and 259 months, respectively (P <0.0001).

CONCLUSIONS

Young black patients with localized renal cancer appear to have had a greater rise in incidence and a poorer outcome than white patients of the same age and disease stage. Additional investigation is warranted to define the role of these race, stage, and age-related disparities in the etiology, prognosis, treatment, and follow-up of kidney cancer.

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.

Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community

BACKGROUND

Our previous report showed that the disparity in breast carcinoma survival between black and white women because of advanced stage of disease at presentation in poor black women is related to their low socioeconomic status and lack of health insurance. This observation led to establishment of a community-oriented free cancer screening service.

STUDY DESIGN

To evaluate the impact of screening on breast cancer stage at diagnosis, analysis of data from the Harlem Hospital Tumor Registry between 1995 and 2000 was performed and compared with our 1964-1986 report.

RESULTS

Twenty-three percent of cancers (324 of 1,405) diagnosed between 1995 and 2000 were breast carcinoma. Data confirm that lack of insurance remains a major problem among poor black women. We observed a marked fall, from 49% in our earlier report to 21% in this study, in late-stage (III and IV) disease at presentation. This fall is associated with significant (p < 0.001) improvement in early detection of breast cancer, with 41% of cancers in stages 0 and I in this data compared with 6% in the previous study. Of note, 53% of women with breast carcinoma had breast-conserving surgery and 45% had modified radical mastectomy in this study; 71% had radical or modified radical mastectomy in the earlier report.

CONCLUSIONS

This study confirms the importance of a free cancer screening program in the improvement of early-stage breast cancer detection, treatment, and survival in a poor urban community.

Ethnicity related differences in the survival of young breast carcinoma patients

BACKGROUND

African-American women face an increased risk of early-onset breast carcinoma compared to white American women, and breast carcinoma has been reported to be particularly aggressive in premenopausal women.

METHODS

Surveillance, Epidemiology, and End Results Program data were analyzed for 507 African-American and 1378 white patients from Detroit diagnosed with breast carcinoma under the age of 40 between 1990 and 1999.

RESULTS

The proportion of in situ disease detected in African-American patients between 1995 and 1999 nearly doubled compared to the 1990-1994 interval (11.3% compared to 6.4%) but was consistently lower than the proportion of in situ disease seen in white patients for the same intervals (15.7% and 16.4% respectively). Evaluation of patients with invasive disease revealed that African-American patients had larger mean tumor size (3.4 cm versus 2.6 cm; P < 0.001), lower rates of localized disease (42.4% versus 52.1%; P < 0.001), higher rates of estrogen receptor negativity (61.9% versus 44.4%; P < 0.001), and higher proportions of medullary tumors (5.8% versus 3.3%; P = 0.021). Cox proportional hazards survival analysis adjusted for age, tumor size, nodal status, hormone receptor status, and histology showed higher mortality rates for African-American patients at all disease stages. Relative risk of death for African-American patients was 1.94 in patients with localized disease (95% confidence interval [CI], 1.23-3.05), 1.58 for regional disease (95% CI = 1.18-2.11), and 2.32 for distant disease (95% CI = 1.15-4.69).

CONCLUSIONS

These findings show that young African-American breast carcinoma patients face an increased mortality risk. Additional studies evaluating risk and treatment response in this subset of patients are warranted.