Race, socioeconomic status, and breast carcinoma in the U.S: what have we learned from clinical studies

Variation in patterns of second primary malignancies across U.S. race and ethnicity groups: a Surveillance, Epidemiology, and End Results (SEER) analysis

PURPOSE

One in six incident cancers in the U.S. is a second primary cancer (SPC). Although primary cancers vary considerably by race and ethnicity, little is known about the population-based occurrence of SPC across these groups.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER) 12 data and relative to the general population, we calculated standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for SPC among 2,457,756 Hispanics, non-Hispanic Asian American/Pacific Islanders (NHAAPI), non-Hispanic black (NHB), and non-Hispanic whites (NHW) cancer survivors aged 45 years or older when diagnosed with a first primary cancer (FPC) from 1992 to 2015.

RESULTS

The risk of second primary bladder cancer after first primary prostate cancer was higher than expected in Hispanic (SIR = 1.18, 95% CI: 1.01-1.38) and NHAAPI (SIR = 1.41, 95% CI: 1.20-1.65) men than NHB and NHW men. Among women with a primary breast cancer, Hispanic, NHAAPI, and NHB women had a nearly 1.5-fold higher risk of a second primary breast cancer, while NHW women had a 6% lower risk. Among men with prostate cancer whose SPC was diagnosed 2 to <12 months, NHB men were at higher risk for colorectal cancer and Hispanic and NHW men for non-Hodgkin's lymphoma. In the same time frame for breast cancer survivors, Hispanic and NHAAPI women were significantly more likely than NHB and NHW women to be diagnosed with a second primary lung cancer.

CONCLUSION

Future studies of SPC should investigate the role of shared etiologies, stage of diagnosis, treatment, and lifestyle factors after cancer survival across different racial and ethnic populations.

Breast cancer incidence and survival in Scotland by socio-economic deprivation and tumour subtype

Background

Women from socio-economically deprived areas are less likely to develop and then to survive breast cancer (BC). Whether associations between deprivation and BC incidence and survival differ by tumour molecular subtypes and mode of detection in Scotland are unknown.

Methods

Data consisted of 62,378 women diagnosed with invasive BC between 2000 and 2016 in Scotland. Incidence rates and time trends were calculated for oestrogen receptor positive (ER+) and negative (ER−) tumours and stratified by the Scottish Index of Multiple Deprivation (SIMD) quintiles and screening status. SIMD is an area-based measure derived across seven domains: income, employment, education, health, access to services, crime and housing. We calculated adjusted hazard ratios (aHR [95% confidence intervals]) for BC death by immunohistochemical surrogates of molecular subtypes for the most versus the least deprived quintile. We adjusted for mode of detection and other confounders.

Results

In Scotland, screen-detected ER+tumour incidence increased over time, particularly in the least deprived quintile [Average Annual Percentage Change (AAPC) = 2.9% with 95% CI from 1.2 to 4.7]. No marked differences were observed for non-screen-detected ER+tumours or ER− tumours by deprivation. BC mortality was higher in the most compared to the least deprived quintile irrespective of ER status (aHR = 1.29 [1.18, 1.41] for ER+ and 1.27 [1.09, 1.47] for ER− tumours). However, deprivation was associated with significantly higher mortality for luminal A and HER2−enriched tumours (aHR = 1.46 [1.13, 1.88] and 2.10 [1.23, 3.59] respectively) but weaker associations for luminal B and TNBC tumours that were not statistically significant.

Conclusions

Deprivation is associated with differential BC incidence trends for screen-detected ER+tumours and with higher mortality for select tumour subtypes. Future efforts should evaluate factors that might be associated with reduced survival in deprived populations and monitor progress stratified by tumour subtypes and mode of detection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-022-06632-1.

Breast Cancer Treatment Delay in SafetyNet Health Systems, Houston Versus Southeast Brazil

Background

Breast cancer outcomes among patients who use safety-net hospitals in the highly populated Harris County, Texas and Southeast Brazil are poor. It is unknown whether treatment delay contributes to these outcomes.

Methods

We conducted a retrospective cohort analysis of patients with non-metastatic breast cancer diagnosed between January 1, 2009 and December 31, 2011 at Harris Health Texas and Unicamp’s Women’s Hospital, Barretos Hospital, and Brazilian National Institute of Cancer, Brazil. We used Cox proportional hazards regression to evaluate association of time to treatment and risk of recurrence (ROR) or death.

Results

One thousand one hundred ninety-one patients were included. Women in Brazil were more frequently diagnosed with stage III disease (32.3% vs. 21.1% Texas; P = .002). Majority of patients in both populations had symptom-detected disease (63% in Brazil vs. 59% in Texas). Recurrence within 5 years from diagnosis was similar 21% versus 23%. Median time from diagnosis to first treatment defined as either systemic therapy (chemotherapy or endocrine therapy) or surgery, were comparable, 9.9 weeks versus 9.4 weeks. Treatment delay was not associated with increased ROR or death. Higher stage at diagnosis was associated with both increased ROR and death.

Conclusion

Time from symptoms to treatment was considerably long in both populations. Treatment delay did not affect outcomes.

Impact

Access to timely screening and diagnosis of breast cancer are priorities in these populations.

Ethnic, racial and socioeconomic disparities in breast cancer survival in two Brazilian capitals between 1996 and 2012

OBJECTIVE

To study the impact of socio-economic status and ethno-racial strata on excess mortality hazard and net survival of women with breast cancer in two Brazilian state capitals.

METHOD

We conducted a survival analysis with individual data from population-based cancer registries including women with breast cancer diagnosed between 1996 and 2012 in Aracaju and Curitiba. The main outcomes were the excess mortality hazard (EMH) and net survival. The associations of age, year of diagnosis, disease stage, race/skin colour and socioeconomic status (SES) with the excess mortality hazard and net survival were analysed using multi-level spline regression models, modelled as cubic splines with knots at 1 and 5 years of follow-up.

RESULTS

A total of 2045 women in Aracaju and 7872 in Curitiba were included in the analyses. The EMH was higher for women with lower SES and for black and brown women in both municipalities. The greatest difference in excess mortality was seen between the most deprived women and the most affluent women in Curitiba, hazard ratio (HR) 1.93 (95%CI 1.63-2.28). For race/skin colour, the greatest ratio was found in Curitiba (HR 1.35, 95%CI 1.09-1.66) for black women compared with white women. The most important socio-economic difference in net survival was seen in Aracaju. Age-standardised net survival at five years was 55.7% for the most deprived women and 67.2% for the most affluent. Net survival at eight years was 48.3% and 61.0%, respectively. Net survival in Curitiba was higher than in Aracaju in all SES groups."

CONCLUSION

Our findings suggest the presence of contrasting breast cancer survival expectancy in Aracaju and Curitiba, highlighting regional inequalities in access to health care. Lower survival among brown and black women, and those in lower SES groups indicates that early detection, early diagnosis and timely access to treatment must be prioritized to reduce inequalities in outcome among Brazilian women.

What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata

Background

Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices.

Methods

We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery.

Results

Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety.

Conclusions

Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients.

Lay Summary

The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices.

Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education.

Conversation aids with pictures and text helped women make better breast cancer surgery choices.

A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.

Risk factors and prediction of second primary cancer in primary female non-metastatic breast cancer survivors

This study aimed to investigate the risk factors of second primary cancer among female breast cancer (BC) survivors, with emphasis on the prediction of the individual risk conditioned on the patient's characteristics. We identified 208,474 BC patients diagnosed between 2004 and 2010 from the Surveillance, Epidemiology and End Results (SEER) database. Subdistribution proportional hazard model and competing-risk nomogram were used to explore the risk factors of second primary BC and non-BC, and to predict the 5- and 10-year probabilities of second primary BC. Model performance was evaluated via calibration curves and decision curve analysis. The overall 3-, 5-, and 10-year cumulative incidences for second primary BC were 0.9%, 1.6% and 4.4%, and for second primary non-BC were 2.3%, 3.9%, and 7.8%, respectively. Age over 70 years at diagnosis, black race, tumor size over 2 cm, negative hormone receptor, mixed histology, localized tumor, lumpectomy alone, and surgeries plus radiotherapy were significantly associated with increased risk of second BC. The risk of second non-BC was only related to age, race and tumor size. The proposed risk model as well as its nomogram was clinically beneficial to identify patients at high risk of developing second primary breast cancer.

A Step toward Understanding Diet Quality in Urban African-American Breast Cancer Survivors: A Cross-sectional Analysis of Baseline Data from the Moving Forward Study

PURPOSE

Little is known about the dietary behaviors of African-American breast cancer survivors (AABCS). We sought to describe dietary intake and quality in AABCS and examine associations with demographic, social, lifestyle, and body composition factors to potentially inform the development of effective dietary interventions.

METHODS

Baseline data from a prospective weight loss trial of 210 AABCS were assessed. A food frequency questionnaire was used to evaluate dietary intake and diet quality via the Healthy Eating Index 2010 (HEI-2010) and Alternative Healthy Eating Index 2010 (AHEI-2010). Linear regression analysis was conducted to determine the most influential variables on diet quality.

RESULTS

Mean HEI- and AHEI-2010 total scores were 65.11 and 56.83 indicating that diet quality needs improvement. Women were the least adherent to recommendations for intake of whole grains, dairy, sodium, empty calories, sugary beverages, red/processed meats, and trans-fat. Increased self-efficacy for healthy eating behaviors, more years of education (AHEI only), negative smoking status, smaller waist circumference, and increased physical activity (HEI only) were significantly associated with higher diet quality scores.

CONCLUSION

Our findings suggest the diet quality of AABCS needs improvement. Intervention programs may achieve higher diet quality in AABCS by focusing on increasing self-efficacy for healthy eating behaviors.

Disparities in Breast Cancer Survival by Socioeconomic Status Despite Medicare and Medicaid Insurance

Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.

CONTEXT

Disparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations.

METHODS

We conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors.

MEASUREMENTS

5-year and median survival.

FINDINGS

LSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls.

CONCLUSIONS

In Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Patterns of Care of Breast Cancer Patients in a Rural Cancer Center in Western India

Breast cancer is an emerging public health problem in low- and middle-income countries. The main objective is to describe the clinical characteristics and patterns of care of breast cancer patients diagnosed and treated in a rural cancer hospital in Barshi, Western India. The results from a cross-sectional study of 99 consecutive breast cancer patients diagnosed and treated between February 2012 and November 2014 in Nargis Dutt Memorial Cancer Hospital is reported. The case records of the patients were scrutinized and reviewed to abstract data on their clinical characteristics, diagnostic, and treatment details. The mean age at diagnosis of the patients was 52.8 ± 11.6 years; 83.5% of women were married, and 60.6% were illiterate. Sixty percent of patients had tumors measuring 5 cm or less. Almost half of the patients (46.4%) had stage I or II A disease and a third (36.0%) had axillary lymph node metastasis. Estrogen, progesterone, and human epidermal growth factor receptor2 receptor status were investigated in 41 (41.4%) of patients only. The median interval between diagnosis and initiation of treatment was 11 days. Modified radical mastectomy was done in 91% of patients, and nearly a third of patients who were prescribed chemotherapy did not complete treatment. The rural-based tertiary cancer care center has made treatment more accessible to breast cancer patients and has reduced the interval between diagnosis and treatment initiation. However, there are still many challenges like non-compliance to and incomplete treatments and poor follow-up that need to be addressed.

Mediating Effects of Frailty Indicators on the Risk of Sepsis After Cancer

BACKGROUND

Cancer survivors are at increased risk of sepsis, possibly attributed to weakened physiologic conditions. The aims of this study were to examine the mediation effect of indicators of frailty on the association between cancer survivorship and sepsis incidence and whether these differences varied by race.

METHODS

We performed a prospective analysis using data from the REasons for Geographic and Racial Differences in Stroke cohort from years 2003 to 2012. We categorized frailty as the presence of ≥2 frailty components (weakness, exhaustion, and low physical activity). We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer. We examined the mediation effect of frailty on the association between cancer survivorship and sepsis incidence using Cox regression. We repeated analysis stratified by race.

RESULTS

Among 28 062 eligible participants, 2773 (9.88%) were cancer survivors and 25 289 (90.03%) were no cancer history participants. Among a total 1315 sepsis cases, cancer survivors were more likely to develop sepsis (12.66% vs 3.81%, P < .01) when compared to participants with no cancer history (hazard ratios: 2.62, 95% confidence interval: 2.31-2.98, P < .01). The mediation effects of frailty on the log-hazard scale were very small: weakness (0.57%), exhaustion (0.31%), low physical activity (0.20%), frailty (0.75%), and total number of frailty indicators (0.69%). Similar results were observed when stratified by race.

CONCLUSION

Cancer survivors had more than a 2-fold increased risk of sepsis, and indicators of frailty contributed to less than 1% of this disparity.

A prospective study of cancer survivors and risk of sepsis within the REGARDS cohort

BACKGROUND

Hospitalized cancer patients are nearly 10 times more likely to develop sepsis when compared to patients with no cancer history. We compared the risk of sepsis between cancer survivors and no cancer history participants, and examined whether race was an effect modifier.

METHODS

We performed a prospective analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We categorized participants as "cancer survivors" or "no cancer history" derived from self-reported responses of being diagnosed with any cancer, excluding non-melanoma skin cancer. We defined sepsis as hospitalization for a serious infection with ≥2 systemic inflammatory response syndrome criteria. We performed Cox proportional hazard models to examine the risk of sepsis after cancer (adjusted for sociodemographics, health behaviors, and comorbidities), and stratified by race.

RESULTS

Among 29,693 eligible participants, 2959 (9.97%) were cancer survivors, and 26,734 (90.03%) were no cancer history participants. Among 1393 sepsis events, the risk of sepsis was higher for cancer survivors (adjusted HR: 2.61, 95% CI: 2.29-2.98) when compared to no cancer history participants. Risk of sepsis after cancer survivorship was similar for Black and White participants (p value for race and cancer interaction = 0.63).

CONCLUSION

In this prospective cohort of community-dwelling adults we observed that cancer survivors had more than a 2.5-fold increased risk of sepsis. Public health efforts should attempt to mitigate sepsis risk by awareness and appropriate treatment (e.g., antibiotic administration) to cancer survivors with suspected infection regardless of the number of years since cancer remission.

What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata

Background

Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata.

Methods

We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions’ sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed.

Discussion

Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality.

Trial registration

NCT03136367 at ClinicalTrials.gov

Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5109-2) contains supplementary material, which is available to authorized users.

Using Genetic Technologies To Reduce, Rather Than Widen, Health Disparities

Evidence shows that both biological and nonbiological factors contribute to health disparities. Genetics, in particular, plays a part in how common diseases manifest themselves. Today, unprecedented advances in genetically based diagnoses and treatments provide opportunities for personalized medicine. However, disadvantaged groups may lack access to these advances, and treatments based on research on non-Hispanic whites might not be generalizable to members of minority groups. Unless genetic technologies become universally accessible, existing disparities could be widened. Addressing this issue will require integrated strategies, including expanding genetic research, improving genetic literacy, and enhancing access to genetic technologies among minority populations in a way that avoids harms such as stigmatization.

Impact of patient demographics, tumor characteristics, and treatment type on treatment delay throughout breast cancer care at a diverse academic medical center

Purpose and objective

The aim of this study was to examine the impact of patient demographics, tumor characteristics, and treatment type on time to treatment (TTT) in patients with breast cancer treated at a safety net medical center with a diverse patient population.

Patients and methods

A total of 1,130 patients were diagnosed and treated for breast cancer between 2004 and 2014 at our institution. We retrospectively collected data on patient age at diagnosis, race/ethnicity, primary language spoken, marital status, insurance coverage, American Joint Committee on Cancer (AJCC) stage, hormone receptor status, and treatment dates. TTT was determined from the date of breast cancer biopsy to treatment start date. Nonparametric Mann-Whitney U-test (or Kruskal-Wallis test when appropriate) and multivariable quantile regression models were employed to assess for significant differences in TTT associated with each factor.

Results

Longer median TTT was noted for Black (P=0.002) and single (P=0.002) patients. AJCC stage IV patients had shorter TTT (27.5 days) compared to earlier AJCC patients (36, 35, 37, 37 days for stage 0, I, II, III, respectively), P=0.028. Age, primary language spoken, insurance coverage, and hormone receptor status had no significant impact on TTT. On multivariate analysis, race/ethnicity remained the only significant factor with Black reporting longer TTT, P=0.025. However, race was not a significant factor for time from first to second treatment. More Black patients were noted to be single (P<0.0001) and received chemotherapy as first treatment (P=0.008) compared to White, Hispanic, or other race/ethnicity patients.

Conclusion

In this retrospective analysis, Black patients had longer TTT, were more likely to receive chemotherapy as first treatment, and have a single marital status. These patient factors will help identify vulnerable patients and guide further research to understand the barriers to care and the impact of treatment delays on outcomes.

Association of Socioeconomic Status with Chronic Graft-versus-Host Disease Outcomes

Chronic graft-versus host disease (GVHD) is a chronic and disabling complication after hematopoietic cell transplantation (HCT). It is important to understand the association of socioeconomic status (SES) with health outcomes in patients with chronic GVHD because of the impaired physical health and dependence on intensive and prolonged health care utilization needs in these patients. We evaluated the association of SES with survival and quality of life (QOL) in a cohort of 421 patients with chronic GVHD enrolled on the Chronic GVHD Consortium Improving Outcomes Assessment study. Income, education, marital status, and work status were analyzed to determine the associations with patient-reported outcomes at the time of enrollment, nonrelapse mortality (NRM), and overall mortality. Higher income (P = .004), ability to work (P < .001), and having a partner (P = .021) were associated with better mean Lee chronic GVHD symptom scores. Higher income (P = .048), educational level (P = .044), and ability to work (P < .001) also were significantly associated with better QOL and improved activity. In multivariable models, higher income and ability to return to work were both significantly associated with better chronic GVHD Lee symptom scores, but income was not associated with activity level, QOL, or physical/mental functioning. The inability to return to work (hazard ratio, 1.82; P = .019) was associated with worse overall mortality, whereas none of the SES indicators were associated with NRM. Income, race, and education did not have statistically significant associations with survival. In summary, we did not observe an association between SES variables and survival or NRM in patients with chronic GVHD, although we found some association with patient-reported outcomes, such as symptom burden. Higher income status was associated with less severe chronic GVHD symptoms. More research is needed to understand the psychosocial, biological, and environmental factors that mediate this association of SES with major HCT outcomes.

Influence of clinical, societal, and treatment variables on racial differences in ER-/PR- breast cancer survival

BACKGROUND

African American (AA) women with breast cancer have persistently higher mortality compared to whites. We evaluated racial disparities in mortality among women with estrogen receptor (ER)/progesterone receptor (PR)-negative breast cancer.

METHODS

The study population included 542 women (45% AA) diagnosed with ER/PR-negative Stage I through III breast cancer treated at the Henry Ford Health System (HFHS) between 1996 and 2005. Linked datasets from HFHS, Metropolitan Detroit Cancer Surveillance System, and the U.S. Census Bureau were used to obtain demographic, socioeconomic, and clinical information. Economic deprivation was categorized using a previously validated deprivation index, which included 5 categories based on the quintile of census tract socioeconomic deprivation. Cox proportional hazards models were used to assess the relationship between race and mortality.

RESULTS

AA women were more likely to have larger tumors, have higher Charlson Comorbidity Indices (CCI), and to reside in economically deprived areas. In an unadjusted analysis, AA women demonstrated a significantly higher risk of death compared to whites [hazard ratio (HR) 1.47, 95% confidence interval (CI) 1.09-2.00]. Following adjustment for clinical factors (age, stage, CCI) and treatment (radiation and chemotherapy), AA race continued to have a significant impact on mortality (HR 1.51, CI 1.10-2.08 and HR 1.63, CI 1.20-2.21). Only after adjusting for deprivation was race no longer significant (HR 1.26, CI 0.84-1.87).

CONCLUSIONS

Social determinants of health play a large role in explaining racial disparities in breast cancer outcomes, especially among women with aggressive subtypes.

African American Race is an Independent Risk Factor in Survival from Initially Diagnosed Localized Breast Cancer

BACKGROUND: African American race negatively impacts survival from localized breast cancer but co-variable factors confound the impact.

METHODS: Data sets were analyzed from the Surveillance, Epidemiology and End Results (SEER) directories from 1973 to 2011 consisting of patients with designated diagnosis of breast adenocarcinoma, race as White or Caucasian, Black or African American, Asian, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, age, stage I, II or III, grade 1, 2 or 3, estrogen receptor or progesterone receptor positive or negative, marital status as single, married, separated, divorced or widowed and laterality as right or left. The Cox Proportional Hazards Regression model was used to determine hazard ratios for survival. Chi square test was applied to determine the interdependence of variables found significant in the multivariable Cox Proportional Hazards Regression analysis. Cells with stratified data of patients with identical characteristics except African American or Caucasian race were compared.

RESULTS: Age, stage, grade, ER and PR status and marital status significantly co-varied with race and with each other. Stratifications by single co-variables demonstrated worse hazard ratios for survival for African Americans. Stratification by three and four co-variables demonstrated worse hazard ratios for survival for African Americans in most subgroupings with sufficient numbers of values. Differences in some subgroupings containing poor prognostic co-variables did not reach significance, suggesting that race effects may be partly overcome by additional poor prognostic indicators.

CONCLUSIONS: African American race is a poor prognostic indicator for survival from breast cancer independent of 6 associated co-variables with prognostic significance.

Breast cancer survival in African-American women by hormone receptor subtypes

Breast cancer accounts for over 200,000 annual cases among women in the United States, and is the second leading cause of cancer-related deaths. However, few studies have investigated the association between breast cancer subtype and survival among African-American women. We analyzed cancer-related deaths among African-American women using data obtained from the SEER database linked to the 2000 U.S. census data. We examined distribution of baseline socio-demographic and clinical characteristics by breast cancer subtypes and used Cox proportional hazard models to determine associations between breast cancer subtypes and cancer-related mortality, adjusting for age, socio-economic status, stage at diagnosis, and treatment. Among 19,836 female breast cancer cases, 54.4% were diagnosed with the HER2-/HR+ subtype, with the majority of those cases occurring among women ages 55 and older. However, after adjusting for age, stage, and treatment type (surgery, radiation, or no radiation and/or cancer-directed surgery), TNBC (HR 2.34; 95% CI 1.95-2.81) and HER2+/HR- (HR 1.39, 95% CI 1.08-1.79) cases had significantly higher hazards of cancer-related deaths compared with HER2+/HR+ cases. Adjusting for socio-economic status did not significantly alter these associations. African-American women with TNBC were more likely to have a cancer-related death than African-American women with other breast cancer subtypes. This association remained after adjustments for age, stage, treatment, and socio-economic status. Further studies are needed to identify subtype-specific risk and prognostic factors aimed at better informing prevention efforts for all women.

Racial differences in breast cancer survival in a large urban integrated health system

BACKGROUND

African American (AA) women are known to have poorer breast cancer survival than whites, and the differences may be related to underlying disparities in their clinical presentation or access to care. This study evaluated the relationship between demographic, treatment, and socioeconomic factors and breast cancer survival among women in southeast Michigan.

METHODS

The population included 2387 women (34% AA) with American Joint Committee on Cancer stage I to III breast cancer who were treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked data sets from the HFHS, the Metropolitan Detroit Cancer Surveillance System, and the US Census Bureau were used to obtain demographic and clinical information. Comorbidities were classified with the modified Charlson comorbidity index (CCI). Economic deprivation was categorized with a census tract-based deprivation index (DI), which was stratified into 5 quintiles of increasing socioeconomic disadvantage.

RESULTS

Compared with whites, AA women were significantly more likely to have larger, hormone receptor-negative tumors and more comorbidities and to reside in an economically deprived area. In an unadjusted analysis, AAs had a significantly higher risk of death (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.16-1.59); however, after adjustments for clinical (age, stage, hormone receptor, and CCI) and societal factors (DI), the effect of race was not significant (HR, 1.13 [95% CI, 0.96-1.34] , and HR, 0.97 [0.80-1.19] respectively).

CONCLUSIONS

Racial differences in breast cancer survival can be explained by clinical and socioeconomic factors. Nonetheless, AA women with breast cancer remain disproportionately affected by unfavorable tumor characteristics and economic deprivation, which likely contribute to their increased overall mortality.

Racial and ethnic differences in risk of second primary cancers among breast cancer survivors

Disparities exist in breast cancer (BC) outcomes between racial and ethnic groups in the United States. Reasons for these disparities are multifactorial including differences in genetics, stage at presentation, access to care, and socioeconomic factors. Less is documented on racial/ethnic differences in subsequent risk of second primary cancers (SPC). The purpose of this study is to evaluate the risk of SPC among different racial/ethnic groups of women with BC. We conducted a retrospective cohort study of 134,868 Non-Hispanic White, 17,484 Black, 18,034 Hispanic, and 19,802 Asian/Pacific Islander (API) women with stages I-III BC in twelve Surveillance, Epidemiology and End Results Program registries between 2001 and 2010. Standardized incidence ratios (SIR), 95 % confidence intervals (CI), and absolute excess risks were calculated by comparing incidence of SPC in the cohort to incidence in the general population for specific cancer sites by race/ethnicity and stratified by index BC characteristics. All women were at increased risks of second primary BC and acute myeloid leukemia (AML), with higher risk among more advanced stage index BC. Black and API women had higher SIRs for AML [4.86 (95 % CI 3.05-7.36) and 5.00 (95 % CI 3.26-7.32)], respectively] which remained elevated among early-stage (I) BC cases. Women with a history of invasive BC have increased risk of SPC, most notable for second primary BC and AML. These risks for secondary cancers differ by race/ethnicity. Studies evaluating possible genetic and biobehavioral mechanisms underlying these differences are warranted. Strategies for BC adjuvant treatment and survivorship care may require further individualization with consideration given to race/ethnicity.

The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women

BACKGROUND

Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result. One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics. Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined. The current study examines the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics.

METHODS

We examined data from a total of 1,696 randomized patients from a randomized controlled trial, "the Patient Navigation in Medically Underserved Areas" study that explored the effect of navigation on breast health outcomes. We categorized participants' neighborhoods into three categories and compared the effect of navigation between these neighborhood types.

RESULTS

Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods. Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods.

CONCLUSION

Patient navigation interventions improve timely follow-up of abnormal mammogram. Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services. Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods. Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms. Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.

Age-related socio-economic and geographic disparities in breast cancer stage at diagnosis: a population-based study

BACKGROUND

This study aimed to determine the impact of socio-economic and geographic disparities on disease stage at diagnosis according to age in breast cancer (BC) patients. Secondary purpose was to describe survival

METHODS

All women with primary invasive BC, diagnosed from 1998 to 2009 in the department of Côte d'Or were retrospectively selected using data from the Côte d'Or BC registry. European transnational ecological deprivation index (French European Deprivation Index) was used to measure the socio-economic environment. Relationships between socio-geographic deprivation and disease stage at diagnosis according to age were assessed by a multilevel ordered logistic regression model. Relative survival rates (RSRs) were given at 5 years according to tumour and patients characteristics.

RESULTS

In total, 4364 women were included. In multivariable analysis, socio-economic deprivation was associated with disease stage at diagnosis. Women aged between 50 and 74 years and living in deprived areas were more often diagnosed with advanced tumour stages (stages II/III vs. I or stages IV vs. II/III) with odds ratio = 1.27 (1.01-1.60). RSRs were lowest in women living in the most deprived area compared with those living in most affluent area with RSR = 88.4% (85.9-90.4) and 92.6% (90.5-94.2), respectively.

CONCLUSIONS

Socio-economic factors affected tumour stage at diagnosis and survival. Living in a deprived area was linked to advanced-stage BC at diagnosis only in women aged 50-74 years. This is probably due to the socio-economic disparities in participation in organized BC screening programmes. Furthermore, living in deprived area was associated with a poor survival rate.

A comparative analysis of breast cancer stage between women enrolled in the National Breast and Cervical Cancer Early Detection Program and women not participating in the program

PURPOSE

To determine the proportional distribution of early- and late-stage breast cancers diagnosed in years 2004-2009 among women enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and to compare this distribution to that of geographically comparable non-enrolled women diagnosed with breast cancer.

METHODS

Using data from the National Program of Cancer Registries, we compared the demographic characteristics and cancer stage distribution of women enrollees and non-enrollees by use of conditional logistic regression using the odds ratio as a measure of association.

RESULTS

NBCCEDP enrollees were slightly younger and more likely to identify as African-American, API and AIAN than were non-enrollees. The proportion of late-stage breast cancer (regional and distant) decreased slightly over the study period. NBCCEDP enrollees generally were diagnosed at a later stage of breast cancer than were those not enrolled in the NBCCEDP.

CONCLUSIONS

The NBCCEDP has been effective in achieving its goal of enrolling racial and ethnic populations; however, enrollees had a poorer stage distribution of breast cancer than did non-enrollees underscoring the need to expand breast cancer control efforts among low-income, underserved populations.

Racial disparities in the type of postmastectomy reconstruction chosen

BACKGROUND

Racial disparities remain for women undergoing immediate breast reconstruction (IBR) after mastectomy. Understanding patterns of racial disparities in IBR utilization may present opportunities to tailor policies aimed at optimizing care across racial groups. The aim of this study was to determine if racial disparities exist for types of IBR chosen.

METHODS

A national, retrospective cohort study used the 2005-2011 American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression models were created to detect the odds by race for receiving each subtype of IBR after mastectomy-prosthetic, pedicled-transfer autologous tissue, or free-transfer autologous tissue. Secondary outcome was trends in IBR rates over time.

RESULTS

There were 44,597 women identified in the data set who underwent mastectomy. Thirty-seven percent of women (N = 16, 642) were noted to undergo IBR after mastectomy. Prosthetic reconstruction (84.4%, n = 37, 640) was the most common form of IBR compared with pedicled-autologous reconstruction (15.4%, n = 6868) and free transfer autologous reconstruction (4.9%, n = 2185), P < 0.001. In multivariate analysis, minorities had lower odds of undergoing IBR compared with whites (odds ratio [OR] 0.37 and 95% confidence interval [CI] 0.33-0.42 for Asians, OR 0.57 and 95% CI 0.52-0.61 for blacks, and OR 0.64 and 95% CI 0.58-0.71 for Hispanics, all P < 0.001). Compared with whites, Hispanics (OR 0.70, 95% CI 0.58-0.83) and blacks (OR 0.53, 95% CI 0.46-0.60) were less likely to use prosthetic reconstruction and more likely to use free-transfer autologous reconstruction (OR 1.66, 95% CI 1.26-2.18 for Hispanics, OR 2.13, 95% CI 1.73-2.63 for blacks), all P < 0.001. Racial disparities persisted from 2005-2011; as minority patients were less likely to undergo IBR than whites (P < 0.001).

CONCLUSIONS

Utilization of IBR may be a sensitive measure of disparities in access to high-quality care and underlying cultures. Strategies aimed at reducing racial disparities in IBR should be tailored to specific patterns of disparities among Asian, black, and Hispanic women.

Racial disparities in risk of second breast tumors after ductal carcinoma in situ

The purpose of the study was to examine the impact of race/ethnicity on second breast tumors among women with ductal carcinoma in situ (DCIS). We identified 102,489 women diagnosed with primary DCIS between 1988 and 2009 from the 18 NCI-SEER Registries. Cox proportional hazard regression was used to estimate race/ethnicity-associated relative risks (RRs) and their 95 % confidence intervals (CI) of ipsilateral breast tumors (IBT; defined as DCIS or invasive carcinoma in the ipsilateral breast) and contralateral breast tumors (CBT; defined as DCIS or invasive carcinoma in the contralateral breast). Overall, 2,925 women had IBT and 3,723 had CBT. Compared with white women, black (RR 1.46; 95 % CI 1.29-1.65), and Hispanic (RR 1.18; 95 % CI 1.03-1.36) women had higher IBT risk, which was similar for invasive IBT and ipsilateral DCIS. A significant increase in IBT risk among black women persisted, regardless of age at diagnosis, treatment, tumor grade, tumor size, and histology. The CBT risk was significantly increased among black (RR 1.21; 95 % CI 1.08-1.36) and Asian/PI (RR 1.16; 95 % CI 1.02-1.31) women compared with white women. The association was stronger for invasive CBT among black women and for contralateral DCIS among Asian/PI women (P heterogeneity < 0.0001). The black race-associated CBT risk was more pronounced among women ≥50 years at diagnosis and those with comedo DCIS; in contrast, a significant increase in risk among Asian/PI women was restricted to those <50 years and those with noncomedo DCIS. Racial/ethnic differences in risks of second breast tumors after DCIS could not be explained by pathologic features and treatment.

Neighborhood socioeconomic deprivation, tumor subtypes, and causes of death after non-metastatic invasive breast cancer diagnosis: a multilevel competing-risk analysis

The purpose of this study is to examine the associations of neighborhood socioeconomic deprivation and triple-negative breast cancer (TNBC) subtype with causes of death [breast cancer (BC)-specific and non-BC-specific] among non-metastatic invasive BC patients. We identified 3,312 patients younger than 75 years (mean age 53.5 years; 621 [18.8 %] TNBC) with first primary BC treated at an academic medical center from 1999 to 2010. We constructed a census-tract-level socioeconomic deprivation index using the 2000 U.S. Census data and performed a multilevel competing-risk analysis to estimate the hazard ratios (HR) and 95 % confidence intervals (CI) of BC-specific and non-BC-specific mortality associated with neighborhood socioeconomic deprivation and TNBC subtype. The adjusted models controlled for patient sociodemographics, health behaviors, tumor characteristics, comorbidity, and cancer treatment. With a median 62-month follow-up, 349 (10.5 %) patients died; 233 died from BC. In the multivariate models, neighborhood socioeconomic deprivation was independently associated with non-BC-specific mortality (the most- vs. the least-deprived quartile: HR = 2.98, 95 % CI = 1.33-6.66); in contrast, its association with BC-specific mortality was explained by the aforementioned patient-level covariates, particularly sociodemographic factors (HR = 1.15, 95 % CI = 0.71-1.87). TNBC subtype was independently associated with non-BC-specific mortality (HR = 2.15; 95 % CI = 1.20-3.84), while the association between TNBC and BC-specific mortality approached significance (HR = 1.42; 95 % CI = 0.99-2.03, P = 0.057). Non-metastatic invasive BC patients who lived in more socioeconomically deprived neighborhoods were more likely to die as a result of causes other than BC compared with those living in the least socioeconomically deprived neighborhoods. TNBC was associated with non-BC-specific mortality but not BC-specific mortality.

Psychosocial interventions addressing the needs of Black women diagnosed with breast cancer: a review of the current landscape

BACKGROUND

Poorer health outcomes and lower survival rates have been well documented among African American/Black (Black) women diagnosed with breast cancer. Black women are 41% more likely to die from breast cancer than White women despite a lower incidence rate. Apart from pharmacotherapy, psychosocial interventions are recommended by the Institute of Medicine as standard medical care for breast cancer patients at all phases of treatment. The current review is the first attempt to systematically evaluate the literature on the influence of psychosocial interventions for Black women diagnosed with breast cancer.

METHODS

This systematic review aimed to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comprehensive computerized literature search of CINAHL, PsycINFO, PubMed, and Web of Science was conducted to obtain relevant studies.

RESULTS

Interventions demonstrated improved mood, decreased distress, increased ability to cope with intrusive thoughts and cancer-related stress, personal growth, and improved social well-being. However, aspects unique to this population require additional scientific inquiry. Over 80% of empirical interventions focused on Black women diagnosed with breast cancer have been concentrated on the posttreatment phase. There is a paucity of work at the time of diagnosis and during treatment.

CONCLUSIONS

To address gaps in the scientific literature, more work is needed to better understand how psychosocial interventions can improve the health trajectory for Black women diagnosed with breast cancer particularly in the areas of seeking help and support, identifying culturally acceptable methods for engaging support networks, and identifying best practices for enhancing coping skills.

Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnic background: a cohort study

Objective

To evaluate surgical treatment delay disparities by race/ethnic group in a group of breast cancer patients treated in the New York region.

Design

Cohort study.

Setting

Two affiliated hospitals in the New York region.

Participants

Patients admitted at two affiliated hospitals in the New York region for breast cancer treatment during 2007–2011.

Main outcome measure

Time to receiving first surgery for breast cancer, defined as the time in days between initial diagnosis (biopsy) and definitive surgical treatment (lumpectomy or mastectomy). Predicted time to first surgery by race group was also analysed using a multivariate linear regression model with adjustments made for several demographic and clinical factors.

Results

Totally, 3071 patients who were first treated with surgery were identified. Racial background was classified as White, African American or Asian/other. Overall median time to surgery was 28 days: 28 days in whites, and 34 and 29 days in African Americans and Asian/others, respectively (p = 0.032). Multivariate analyses showed that only African Americans, not Asian/others, had significantly increased surgical delay compared to whites (p = 0.019).

Conclusions

This study demonstrates significant racial differences in surgical delay in a group of breast cancer patients treated in the New York region. These differences may reflect tacit attitudes of medical providers or processes insensitive to patient educational needs. Additional studies may improve our understanding of this delay.

Endocrine therapy initiation among Medicaid-insured breast cancer survivors with hormone receptor-positive tumors

PURPOSE

Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40%. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina.

METHODS

Medicaid claims data were matched to state cancer registry records for survivors aging 18-64 diagnosed with stage 0-II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year.

RESULTS

Of 222 women meeting the inclusion criteria, only 50% filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95% confidence interval [CI] 1.67-8.48; AOR for 2004 relative to 2007 2.80, 95% CI 1.03-7.62; AOR for 2005 relative to 2007 2.11, 95% CI 0.92-4.85).

CONCLUSIONS

Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET.

IMPLICATIONS FOR CANCER SURVIVORS

Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.

Disparities in survival after female breast cancer diagnosis: a population-based study

BACKGROUND

Despite advances in treatment and increased screening, female breast cancer survival is affected by race, ethnicity, and socioeconomic status (SES). The purpose of this study was to substantiate disparities in breast cancer mortality in a large and unique dataset containing 7 distinct racial groups, 31 comorbidities, demographic and clinical/pathological patient characteristics, and neighborhood poverty information.

METHODS

Florida Cancer Data System registry (1996-2007) linked with the Agency for Health Care Administration and U.S. Census tract (n = 127,754) explored median survival and 1-, 3-, and 5-year survival rates by the Kaplan-Meier method. Log-rank tests compared survival curves by race/ethnicity/SES. Cox proportional hazards regression models were used to obtain unadjusted and adjusted hazard ratios (HR) and 95% confidence intervals.

RESULTS

Native Americans had the lowest median survival (7.4 years) and Asians had the highest (12.6 years). For the univariate analysis, worse survival was seen for blacks (HR = 1.44; p < 0.001) and better survival for Asians (HR = 0.71; p < 0.001), Asian Indians or Pakistanis (HR = 0.65; p = 0.013), and Hispanics (HR = 0.92; p < 0.001). Multivariate analysis demonstrated sustained survival detriment for blacks (HR = 1.28; p < 0.001) and improved survival for Hispanics (HR = 0.90; p = 0.001). For SES, there was an incremental improvement in survival for each higher SES category in all analyses (p < 0.001).

CONCLUSIONS

Utilizing a large enriched state cancer registry controlling for multiple demographic, clinical, and comorbidities, we fully explored survival disparities in female breast cancer and found certain aspects of race, ethnicity, and SES to remain significantly associated with breast cancer survival. More research is needed to uncover the source of these ongoing disparities.

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample

PURPOSE

Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample.

PATIENTS AND METHODS

Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt.

RESULTS

The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt.

CONCLUSION

In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Effect of socioeconomic status as measured by education level on survival in breast cancer clinical trials

OBJECTIVES

This paper aims to investigate the effect of socioeconomic status, as measured by education, on the survival of breast cancer patients treated on 10 studies conducted by the Cancer and Leukemia Group B.

METHODS

Sociodemographic data, including education, were reported by the patient at trial enrollment. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival among patients with early stage and metastatic breast cancer, after adjustment for known prognostic factors.

RESULTS

The patient population included 1020 patients with metastatic disease and 5146 patients with early stage disease. Among metastatic patients, factors associated with poorer survival in the final multivariable model included African American race, never married, negative estrogen receptor status, prior hormonal therapy, visceral involvement, and bone involvement. Among early stage patients, significant factors associated with poorer survival included African American race, separated/widowed, post/perimenopausal, negative/unknown estrogen receptor status, negative progesterone receptor status, >4 positive nodes, tumor diameter >2 cm, and education. Having not completed high school was associated with poorer survival among early stage patients. Among metastatic patients, non-African American women who lacked a high school degree had poorer survival than other non-African American women, and African American women who lacked a high school education had better survival than educated African American women.

CONCLUSIONS

Having less than a high school education is a risk factor for death among patients with early stage breast cancer who participated in a clinical trial, with its impact among metastatic patients being less clear. Post-trial survivorship plans need to focus on women with low social status, as measured by education.

Outcomes in black patients with early breast cancer treated with breast conservation therapy

BACKGROUND

The race-specific impact of prognostic variables for early breast cancer is unknown for black patients undergoing breast conservation.

METHODS AND MATERIALS

This was a retrospective study of 1,231 consecutive patients ≥40 years of age with Stage I-II invasive breast cancer treated with lumpectomy and radiation therapy at the University of Chicago Hospitals and affiliates between 1986 and 2004. Patients were classified as either black or nonblack. Cox proportional hazards regression was used to model the effects of known prognostic factors and interactions with race.

RESULTS

Median follow-up for surviving patients was 82 months. Thirty-four percent of patients were black, and 66% were nonblack (Caucasian, Hispanic, and Asian). Black patients had a poorer 10-year overall survival (64.6% vs. 80.8%; adjusted hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.23-2.06) and 10-year disease-free survival (58.1% vs. 75.4%; HR 1.49; 95% CI, 1.18-1.89) compared with nonblack patients. Tumor sizes were similar between nonblack and black patients with mammographically detected tumors (1.29 cm vs. 1.20 cm, p = 0.20, respectively). Tumor size was significantly associated with overall survival (HR 1.48; 95% CI, 1.12-1.96) in black patients with mammographically detected tumors but not in nonblack patients (HR 1.09; 95% CI, 0.78-1.53), suggesting that survival in black patients depends more strongly on tumor size in this subgroup. Tests for race-size method of detection interactions were statistically significant for overall survival (p = 0.049), locoregional control (p = 0.036), and distant control (p = 0.032) and borderline significant for disease-free survival (p = 0.067).

CONCLUSION

Despite detection at comparable sizes, the prognostic effect of tumor size in patients with mammographically detected tumors is greater for black than in nonblack patients.

Socioeconomic status and survival after an invasive breast cancer diagnosis

BACKGROUND

Women who live in geographic areas with high poverty rates and low levels of education experience poorer survival after a breast cancer diagnosis than women who live in communities with indicators of high socioeconomic status (SES). However, very few studies have examined individual-level SES in relation to breast cancer survival or have assessed the contextual role of community-level SES independent of individual-level SES.

METHODS

The authors of this report examined both individual-level and community-level SES in relation to breast cancer survival in a population-based cohort of women ages 20 to 69 years who were diagnosed with breast cancer in Wisconsin between 1995 and 2003 (N = 5820).

RESULTS

Compared with college graduates, women who had no education beyond high school were 1.39 times more likely (95% confidence interval [CI], 1.10-1.76) to die from breast cancer. Women who had household incomes <2.5 times the poverty level were 1.46 times more likely (95% CI, 1.10-1.92) to die from breast cancer than women who had household incomes ≥5 times the poverty level. Adjusting the analysis for use of screening mammography, disease stage at diagnosis, and lifestyle factors eliminated the disparity by income, but the disparity by education persisted (hazard ratio [HR], 1.27; 95% CI, 0.99-1.61). In multilevel analyses, low community-level education was associated with increased breast cancer mortality even after adjusting for individual-level SES (HR, 1.57; 95% CI, 1.09-2.27 for ≥20% vs <10% of adults without a high school degree).

CONCLUSIONS

The current results indicated that screening and early detection explain some of the disparity according to SES, but further research will be needed to understand the additional ways in which individual-level and community-level education are associated with survival.

Changing trends of breast cancer survival in sultanate of oman

Breast cancer is the leading cause of cancer-associated mortality in women, with elevated incidence in developing countries. This retrospective study included all 122 patients diagnosed with breast cancer from January 2003 to December 2008 in the Sultanate of Oman. Age at presentation was 47.41 years (SD±12.88), with one-third of patients younger than 40 years. The majority of patients presented with stage III (41.2%) and IV (18.2%) breast cancer. T size (P = .023), skin involvement (P = .003), and stage at presentation (P = .004) were significantly associated with overall survival. Skin involvement at presentation (P = .003), T size (P = .09), lymph node status (P = .013), and stage (P = .003) were strong predictors of relapse-free survival. Patients had a 5-year survival of 78%, compared to 64% of breast cancer patients diagnosed between 1996 and 2002 identified in our previously published study. Thus, despite Omani breast cancer patients continuing to present with advanced breast cancer, survival rates have significantly improved.

Impact of race, age, and socioeconomic status on participation in pancreatic cancer clinical trials

OBJECTIVES

Over 18 years, 7 phase 2 trials in advanced pancreatic cancer (APC) were conducted at Karmanos Cancer Institute (KCI). We sought factors that influenced the selection of patients for clinical trials and explored differences in overall survival (OS) of patients treated on clinical trials versus standard of care.

METHODS

The target population was patients with APC diagnosed between January 1, 1986, and December 31, 2003. Patients were divided into 3 mutually exclusive groups: treated on clinical trials at KCI (t-KCI), treated at KCI but not on a clinical trial (KCI), or treated at non-KCI institutions (n-KCI).

RESULTS

Eight thousand two hundred thirty patients met study criteria: 6470 n-KCI, 1642 KCI, and 118 t-KCI. Significant differences were observed across the 3 groups with respect to age, race, stage, grade, and socioeconomic status. Median OS was higher in t-KCI (8.5 months) than in KCI (5.0 months) or n-KCI (2.8 months) and could not be accounted for by variations in baseline characteristics.

CONCLUSIONS

Patients enrolled on clinical trials were younger, had better socioeconomic status, and were less often African American. Patients with APC treated at academic institutions may have longer OS than patients treated in the community. Clinical trials seem to offer a survival advantage for patients with APC.

Triple-negative breast cancers are increased in black women regardless of age or body mass index

Introduction

We investigated clinical and pathologic features of breast cancers (BC) in an unselected series of patients diagnosed in a tertiary care hospital serving a diverse population. We focused on triple-negative (Tneg) tumours (oestrogen receptor (ER), progesterone receptor (PR) and HER2 negative), which are associated with poor prognosis.

Methods

We identified female patients with invasive BC diagnosed between 1998 and 2006, with data available on tumor grade, stage, ER, PR and HER2 status, and patient age, body mass index (BMI) and self-identified racial/ethnic group. We determined associations between patient and tumour characteristics using contingency tables and multivariate logistic regression.

Results

415 cases were identified. Patients were racially and ethnically diverse (born in 44 countries, 36% white, 43% black, 10% Hispanic and 11% other). 47% were obese (BMI > 30 kg/m2). 72% of tumours were ER+ and/or PR+, 20% were Tneg and 13% were HER2+. The odds of having a Tneg tumour were 3-fold higher (95% CI 1.6, 5.5; p = 0.0001) in black compared with white women. Tneg tumours were equally common in black women diagnosed before and after age 50 (31% vs 29%; p = NS), and who were obese and non-obese (29% vs 31%; p = NS). Considering all patients, as BMI increased, the proportion of Tneg tumours decreased (p = 0.08).

Conclusions

Black women of diverse background have 3-fold more Tneg tumours than non-black women, regardless of age and BMI. Other factors must determine tumour subtype. The higher prevalence of Tneg tumours in black women in all age and weight categories likely contributes to black women's unfavorable breast cancer prognosis.

Trends in area-socioeconomic and race-ethnic disparities in breast cancer incidence, stage at diagnosis, screening, mortality, and survival among women ages 50 years and over (1987-2005)

BACKGROUND

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States and varies systematically by race-ethnicity and socioeconomic status. Previous research has often focused on disparities between particular groups, but few studies have summarized disparities across multiple subgroups defined by race-ethnic and socioeconomic position.

METHODS

Data on breast cancer incidence, stage, mortality, and 5-year cause-specific probability of death (100 - survival) were obtained from the Surveillance, Epidemiology, and End Results program and data on mammography screening from the National Health Interview Survey from 1987 to 2005. We used four area-socioeconomic groups based on the percentage of poverty in the county of residence (<10, 10-15, 15-20, +20%) and five race-ethnic groups (White, Black, Asian, American Indian, and Hispanic). We used summary measures of disparity based on both rate differences and rate ratios.

RESULTS

From 1987 to 2004, area-socioeconomic disparities declined by 20% to 30% for incidence, stage at diagnosis, and 5-year cause-specific probability of death, and by roughly 100% for mortality, whether measured on the absolute or relative scale. In contrast, relative area-socioeconomic disparities in mammography use increased by 161%. Absolute race-ethnic disparities declined across all outcomes, with the largest reduction for mammography (56% decline). Relative race-ethnic disparities for mortality and 5-year cause-specific probability of death increased by 24% and 17%, respectively.

CONCLUSIONS

Our analysis suggests progress towards race-ethnic and area-socioeconomic disparity goals for breast cancer, especially when measured on the absolute scale. However, greater progress is needed to address increasing relative socioeconomic disparities in mammography and race-ethnic disparities in mortality and 5-year cause-specific probability of death.

Racial disparities in the development of breast cancer metastases among older women: a multilevel study

BACKGROUND

Distant metastases are the most common and lethal type of breast cancer relapse. The authors examined whether older African American breast cancer survivors were more likely to develop metastases compared with older white women. They also examined the extent to which 6 pathways explained racial disparities in the development of metastases.

METHODS

The authors used 1992-1999 Surveillance, Epidemiology, and End Results (SEER) data with 1991-1999 Medicare data. They used Medicare's International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify metastases of respiratory and digestive systems, brain, bone, or other unspecified sites. The 6 pathways consisted of patient characteristics, tumor characteristics, type of treatment received, access to medical care, surveillance mammography use, and area-level characteristics (poverty rate and percentage African American) and were obtained from the SEER or Medicare data.

RESULTS

Of the 35,937 women, 10.5% developed metastases. In univariate analysis, African American women were 1.61 times (95% confidence interval [CI], 1.54-1.83) more likely to develop metastasis than white women. In multivariate analysis, tumor grade, stage at diagnosis, and census-tract percentage African American explained why African American women were more likely to develop metastases than white women (hazard ratio, 0.84; 95% CI, 0.68-1.03).

CONCLUSIONS

Interventions to reduce late-stage breast cancer among African Americans also may reduce racial disparities in subsequent increased risk of developing metastasis. African Americans diagnosed with high-grade breast cancer could be targeted to reduce their risk of metastasis. Future studies should identify specific reasons why the racial distribution in census tracts was associated with racial disparities in the risk of breast cancer metastases.

Embodiment and breast cancer among African American women

African American women have historically been screened for breast cancer less than other women, contributing to higher mortality rates. Previous research has focused on social and cultural factors, such as discrimination and religiosity, as shaping African American women's screening practices. This article extends this research by (a) examining the decisions and justifications of African American women with regard to screening practices, and (b) using a theoretical focus on embodiment to better understand women in relation to their own bodies. Ethnographic research consisted of 5 months of participant observation at an Indiana (USA) breast cancer care center, and 15 in-depth, semi-structured interviews along the continuum of screening practices. The results showed that embodied understandings of the body, personal (rather than biomedical) considerations of screening and treatment, and the quality of doctor/patient interactions all play a significant role in women's decisions about whether to screen for breast cancer or not. Based on these results and a review of the literature, six ways to include embodiment in public health initiatives are outlined.

Patient socioeconomic status as a prognostic factor for allo-SCT

The aim of the present study was to assess the influence of socioeconomic status (SeS) on the outcome of allo-SCT at a Brazilian SCT center. In total, 201 patients receiving HLA-identical related allo-SCTs were studied. The median age was 30 years. Overall, 163 patients had malignancies (CML 68, ALL/AML 63, myelodysplastic syndrome 12 and others 20). SeS was defined according to the Brazilian Association of Market Research Agencies classification, where people are clustered in groups A-E (richest to poorest). In total, 146 patients (72%) were classified as richest (A+B+C) and 55 (28%) as poorest (D+E). The D+E SeS group was associated with a higher incidence of chronic GVHD and acute GVHD (hazard ratio (HR)=2.61; P=0.001 and HR=2.62; P=0.001, respectively), better platelet and neutrophil engraftment (HR=1.94; P=<0.001 and HR=2.12; P=0.001) and with a higher TRM in multivariate analysis (HR=1.92; P=0.039). Estimated overall survival at 5 years was 55.2%. A D+E SeS (HR=2.13; P=0.001) was associated with a worse survival on multivariate analysis. In conclusion, a lower SeS is a strong prognostic factor in patients undergoing allo-SCT in Brazil, influencing engraftment, TRM and overall survival.

Patient education level as a predictor of survival in lung cancer clinical trials

PURPOSE

To investigate the effect of socioeconomic status, as measured by education, on the survival of 1,577 lung cancer patients treated on 11 studies conducted by the Cancer and Leukemia Group B.

PATIENTS AND METHODS

Sociodemographic data, including education, was reported by the patient at the time of clinical trial accrual. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival after adjustment for known prognostic factors.

RESULTS

The patient population included 1,177 patients diagnosed with non-small-cell lung cancer (NSCLC; stage III or IV) and 400 patients diagnosed with small-cell lung cancer (SCLC; extensive or limited). Patients with less than an eighth grade education (13% of patients) were significantly more likely to be male, nonwhite, and older; have a performance status (PS) of 1 or 2; and have chest pain. Significant predictors of poor survival in the final model included male sex, PS of 1 or 2, dyspnea, weight loss, liver or bone metastases, unmarried, presence of adrenal metastases and high alkaline phosphatase levels among patients with NSCLC, and high WBC levels among patients with advanced disease. Education was not predictive of survival.

CONCLUSION

The physical condition of patients with low education who enroll onto clinical trials is worse than patients with higher education. Once enrolled onto a clinical trial, education does not affect the survival of patients with SCLC or stage III or IV NSCLC. The standardization of treatment and follow-up within a clinical trial, regardless of education, is one possible explanation for this lack of effect.

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.

Effect of social class disparities on disease stage, quality of treatment and survival outcomes in breast cancer patients from developing countries

To assess the relationship between social class disparities on disease stage on presentation, quality of treatment, and survival outcome of breast cancer patients in Pakistan and compare our data with SEER (Surveillance, Epidemiology, and End Results) data from US on white and African-American women to evaluate differences in disease stage and survival outcomes. Patients were evaluated for age, tumor size, grade, receptor status, stage, and 5-year survival and were compared with SEER data. Socio-economic status was evaluated with financial income. Patients were divided in poor and middle/high groups. Excellent and comparable 5-year survival with SEER data was observed with localized disease in all groups from different strata. Advanced disease was more common in the disadvantaged group with negligible 5-year survivals. Development and implementation of early detection programs, public awareness, and clinical and breast self examination that are more pragmatic in the settings of countries with limited resources are essential.