Breast cancer among young African-American women: a summary of data and literature and of issues discussed during the Summit Meeting on Breast Cancer Among African American Women, Washington, DC, September 8-10, 2000

Lifetime alcohol consumption patterns and young-onset breast cancer by subtype among Non-Hispanic Black and White women in the Young Women's Health History Study

PURPOSE

The role of alcohol in young-onset breast cancer (YOBC) is unclear. We examined associations between lifetime alcohol consumption and YOBC in the Young Women's Health History Study, a population-based case-control study of breast cancer among Non-Hispanic Black and White women < 50 years of age.

METHODS

Breast cancer cases (n = 1,812) were diagnosed in the Metropolitan Detroit and Los Angeles County SEER registry areas, 2010-2015. Controls (n = 1,381) were identified through area-based sampling and were frequency-matched to cases by age, site, and race. Alcohol consumption and covariates were collected from in-person interviews. Weighted multivariable logistic regression was conducted to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for associations between alcohol consumption and YOBC overall and by subtype (Luminal A, Luminal B, HER2, or triple negative).

RESULTS

Lifetime alcohol consumption was not associated with YOBC overall or with subtypes (all ptrend ≥ 0.13). Similarly, alcohol consumption in adolescence, young and middle adulthood was not associated with YOBC (all ptrend ≥ 0.09). An inverse association with triple-negative YOBC, however, was observed for younger age at alcohol use initiation (< 18 years vs. no consumption), aOR (95% CI) = 0.62 (0.42, 0.93). No evidence of statistical interaction by race or household poverty was observed.

CONCLUSIONS

Our findings suggest alcohol consumption has a different association with YOBC than postmenopausal breast cancer-lifetime consumption was not linked to increased risk and younger age at alcohol use initiation was associated with a decreased risk of triple-negative YOBC. Future studies on alcohol consumption in YOBC subtypes are warranted.

Premenopausal Breast Cancer Risk Factors and Associations with Molecular Subtypes: A Case-Control Study

Background

Breast cancer (BC) is the most prevalent cancer in women and the leading cause of women's cancer-related deaths and morbidity worldwide. In Rwanda, BC incidence is increasing with an unacceptably high mortality rate in premenopausal women.

Objectives

The purpose was to identify modifiable BC risk factors and assess associations between common breast cancer risks factors and molecular subtypes in premenopausal women in Rwanda.

Methods

This was a case-control study. Premenopausal women with histological confirmation of BC and frequency-matched for age controls were recruited. A preestablished questionnaire was administered to both cases and controls for sociodemographics, BC probable risk factors, and clinical and pathological characteristics. BC was classified into luminal A, luminal B, HER2-type, basal-like (triple negative), and unclassified molecular subtypes by immunohistochemistry (IHC). Odds ratio (OR) and 95% confidence interval (CI) were estimated using multivariate logistic regression analysis.

Results

340 participants were recruited into the study (170 cases vs. 170 controls). The median age was 39 years. The majority of cases presented at advanced stages of the disease (51.2% in stages III and IV) and had invasive ductal carcinoma (98.2%). 60.6% had subtypes of poor prognosis (HER2 enriched 14.7%, triple negative 12.9%, and unclassified 32.9%). Alcohol intake (AOR = 3.73, 95%CI 2.19 - 6.32, p < 0.001), obesity/overweight in adolescence or early adulthood (AOR = 10.86, 95%CI 4.82 - 24.4, p < 0.001), history of primary infertility (AOR = 33.8, 95%CI 3.5 - 321.5, p = 0.002), nulliparity (AOR = 3.75, 95%CI 1.61 - 8.75, p = 0.002), and a history of benign breast disease (AOR = 6.06, 95%CI 1.19 - 30.73, p = 0.03) were associated with the occurrence of premenopausal breast cancer. There was no significant difference between risk factor stratification per molecular subtype.

Conclusion

Several reproductive, environmental, and lifestyle risk factors have been identified to be associated with premenopausal BC. Among them, alcohol intake and obesity/overweight during adolescence/early adulthood can be modified. Interventions targeting alcohol consumption and obesity/overweight in adolescents and young adults may decrease the incidence of premenopausal breast cancer.

Exploring serum and immunoglobulin G N-glycome as diagnostic biomarkers for early detection of breast cancer in Ethiopian women

BACKGROUND

Alterations in protein glycosylation patterns have potentially been targeted for biomarker discovery in a wide range of diseases including cancer. Although there have been improvements in patient diagnosis and survival for breast cancer (BC), there is no clinically validated serum biomarker for its early diagnosis. Here, we profiled whole serum and purified Immunoglobulin G (IgG) fraction N-glycome towards identification of non-invasive glycan markers of BC.

METHODS

We employed a comprehensive glycomics approach by integrating glycoblotting-based glycan purification with MALDI-TOF/MS based quantitative analysis. Sera of BC patients belonging to stages I-IV and normal controls (NC) were collected from Ethiopian women during 2015-2016. IgG was purified by affinity chromatography using protein G spin plate and further subjected to glycoblotting for glycan release. Mass spectral data were further processed and evaluated rigorously, using various bioinformatics and statistical tools.

RESULTS

Out of 35 N-glycans that were significantly up-regulated in the sera of all BC patients compared to the NC, 17 complex type N-glycans showed profound expression abundance and diagnostic potential (AUC = 0.8-1) for the early stage (I and II) BC patients. Most of these glycans were core-fucosylated, multiply branched and sialylated structures, whose abundance has been strongly associated with greater invasive and metastatic potential of cancer. N-glycans quantified form IgG confirmed their abundance in BC patients, of which two core-fucosylated and agalactosylated glycans (m/z 1591, 1794) could specifically distinguish (AUC = 0.944 and 0.921, p ≤ 0.001) stage II patients from NC. Abundance of such structural features in IgG is associated with a decrease in its immunosuppressive potential towards tumor cells, which in part may correlate with the aggressive nature of BC commonly noticed in black population.

CONCLUSIONS

Our comprehensive study has addressed for the first time both whole serum and IgG N-glycosylation signatures of native black women suffering from BC and revealed novel glyco-biomarkers with marked overexpression and distinguishing ability at early stage patients. Further studies on direct identification of the intact glycoproteins using a glycoprteomics approach will provide a deeper understanding of specific biomarkers towards their clinical utility.

Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers

Breast cancer is the most commonly diagnosed cancer and a leading cause of death from cancer among U.S. women. Studies have suggested that breastfeeding reduces breast cancer risk among parous women, and there is mounting evidence that this association may differ by subtype such that breastfeeding may be more protective of some invasive breast cancer types. The purpose of this review is to discuss breast cancer disparities in the context of breastfeeding and the implications for black mothers. Black women in the U.S. have lower rates of breastfeeding and nearly twice the rates of triple-negative breast cancer (an aggressive subtype) compared with white women. In addition to individual challenges to breastfeeding, black women may also differentially face contextual barriers such as a lack of social and cultural acceptance in their communities, inadequate support from the healthcare community, and unsupportive work environments. More work is needed to improve the social factors and policies that influence breastfeeding rates at a population level. Such efforts should give special consideration to the needs of black mothers to adequately address disparities in breastfeeding among this group and possibly help reduce breast cancer risk. Interventions such as peer counseling, hospital policy changes, breastfeeding-specific clinic appointments, group prenatal education, and enhanced breastfeeding programs have been shown to be effective in communities of color. A comprehensive approach that integrates interventions across multiple levels and settings may be most successful in helping mothers reach their breastfeeding goals and reducing disparities in breastfeeding and potentially breast cancer incidence.

Understanding Supportive Care Factors Among African American Breast Cancer Survivors

INTRODUCTION

Comprehensive breast cancer care includes not only diagnosis, staging, and treatment of cancer but also assessment and management of the physical, psychological, social, and informational needs, collectively known as supportive care. Several studies have documented the importance of addressing supportive care factors among breast cancer survivors. However, there appears to be a paucity of research concerning African American breast cancer survivors (AABCS). Therefore, the purpose of this study was to describe and understand the patient-centered supportive care factors among self-identified AABCS.

METHOD

Using a qualitative descriptive approach, an open-ended question explored supportive care factors that were used by N = 155 AABCS.

RESULTS

Four supportive care factors were identified: faith, supportive structures, optimism, and access to information.

DISCUSSION

An understanding of these factors might facilitate discussion between survivors and the health care team. The resultant effect could also inform and promote the delivery of culturally specific health care to address the supportive care needs among these women.

A perfect storm: How tumor biology, genomics, and health care delivery patterns collide to create a racial survival disparity in breast cancer and proposed interventions for change

It is well known that there is a significant racial divide in breast cancer incidence and mortality rates. African American women are less likely to be diagnosed with breast cancer than white women but are more likely to die from it. This review explores the factors that may contribute to the racial survival disparity. Consideration is paid to what is known about the role of differences in tumor biology, genomics, cancer screening, and quality of cancer care. It is argued that it is the collision of 2 forces, tumor biology and genomics, with patterns of care that leads to the breast cancer mortality gap. The delays, misuse, and underuse of treatment for African American patients are of increased significance when these patients are presenting with more aggressive forms of breast cancer. In the current climate of health care reform ushered in by the Affordable Care Act, this article also evaluates interventions to close the disparity gap. Prior interventions have been too narrowly focused on the patient rather than addressing the system and improving care across the continuum of breast cancer evaluation and treatment. Lastly, areas of future investigation and policy initiatives aimed at reducing the racial survival disparity in breast cancer are discussed.

Breast cancer incidence and mortality in women under 50 years of age in Brazil

Many countries have reported an increase in breast cancer incidence in young women. The current study's objective was to explore breast cancer distribution in women less than 50 years of age in Brazil. A descriptive study on breast cancer incidence (selected cities) and mortality (Brazil and selected cities) in 2002-2004 was carried out, and the results were compared with those from other countries. The study also analyzed the trend in hospital morbidity and incidence rates for breast cancer. Porto Alegre (Rio Grande do Sul State) showed the highest incidence rates (17.9 and 165.5/100,000 in the 15-39 and 40-49-year age strata, respectively). Regarding mortality, Belo Horizonte (Minas Gerais State) showed the highest rate in the 15-39-year group and Porto Alegre in the 40-49-year group (2.8 and 25.5/100,000). Hospital admissions and incidence rates for breast cancer suggest a change in epidemiological distribution. The results reveal an epidemiological pattern of breast cancer in young Brazilian women with regional distribution characteristics.

Reproductive factors and risk of premenopausal breast cancer by age at diagnosis: are there differences before and after age 40?

We examined the relationship between reproductive factors and risk of premenopausal breast cancer among women less than age 40 compared with older premenopausal women. We documented 374 incident cases of breast cancer diagnosed before age 40, and 2,533 cases diagnosed at age 40 and older among premenopausal women in the Nurses' Health Study cohorts. Biennial questionnaires were used to determine age at menarche, age at first birth, parity, breastfeeding, and other reproductive factors. Multivariate relative risks (RR) and 95 % confidence intervals (CI) were calculated using Cox proportional hazards models within age at diagnosis groups. Tumors in younger women were significantly more likely to be higher grade, larger size, and hormone receptor negative than were tumors in older premenopausal women (p < 0.0001). There was no significant heterogeneity according to age in associations between reproductive factors and risk of premenopausal breast cancer. First birth at age 30 or older increased breast cancer risk in both age groups (age <40: RR 1.10, 95 % CI 0.80-1.50; age ≥ 40: RR 1.16, 95 % CI 1.02-1.32; p-heterogeneity = 0.44). Risk of premenopausal breast cancer decreased with each additional year of age at menarche in both age groups (age <40: RR 0.93, 95 % CI 0.87-0.99; p trend = 0.02; age ≥ 40: RR 0.94, 95 % CI 0.91-0.97; p trend = <0.0001). Among premenopausal parous women, breastfeeding was protective regardless of age at diagnosis (age <40: RR 0.84, 95 % CI 0.57-1.22; age ≥ 40: RR 0.85, 95 % CI 0.72-0.99; p-heterogeneity = 0.79). In the largest prospective examination of reproductive risk factors and risk of breast cancer before and after age 40, we found that younger women were more likely to develop tumors with less favorable prognostic characteristics. However, associations between reproductive factors and risk of breast cancer were similar regardless of age at diagnosis of premenopausal breast cancer.

Ethnic disparities in breast cancer

Breast cancer is the leading cause of cancer death for women worldwide. While breast cancer incidence is lower for many ethnic minority women than for white women, stage at diagnosis and survival are often worse. These disparities are most marked for African-American women, but are also present for Asians, Latinas, Native Americans and Hawaiians. The etiology of ethnic disparities in breast cancer is multifactorial, including differences in tumor characteristics, genetics, access to care and insurance, prevalence of risk factors, screening participation and processes of care, such as timeliness of diagnosis and quality of communication and treatment. This review will examine what is known regarding ethnic differences in all of these areas, what questions remain, and where researchers and policy makers should focus their future efforts.

Time for a re-evaluation of mammography in the young? Results of an audit of mammography in women younger than 40 in a resource restricted environment

Mammography in younger women is considered to be of limited value. In a resource restricted environment without access to magnetic resonance imaging (MRI) and with a high incidence of breast cancer in the young, mammography remains an important diagnostic tool. Recent technical advances and better regulation of mammography make a reassessment of its value in these conditions necessary. Data of all the mammograms performed at a tertiary hospital and private breast clinic between January 2003 and July 2009 in women less than 40 years of age were collected. Indications were the presence of a mass, follow-up after primary cancer therapy, and screening for patients perceived at high risk due to a family history or the presence of atypical hyperplasia. Data acquired were as follows: Demographics, prior breast surgery, indication for mammography, outcome of mammography, diagnostic procedures, and their results. Of 2,167 mammograms, 393 were performed for a palpable mass, diagnostic mammography. In these, the overall cancer detection rate was 40%. If the mammography was reported as breast imaging reporting and data system (BIRADS(®)) 5 versus BIRADS(®) 3 and 4 versus BIRADS(®) 1 and 2, a final diagnosis of malignancy was established in 96, 48, and 5%, respectively. Of 367 mammograms done for the follow-up after primary treatment of breast cancer, seven cancers were diagnosed for a detection rate of 1.9%. Of 1,312 mammograms performed for screening, the recall rate was 4%; the biopsy rate 2%, and the cancer diagnosis rate 3/1,000 examinations. In contrast to past series, this series has shown that recent advances in mammography have made it a useful tool in the management of breast problems in young women, notably in a resource-restricted environment. Women for screening should be selected carefully.

Strategies for Recruitment of Healthy Premenopausal Women into the African American Nutrition for Life (A NULIFE) Study

BACKGROUND

Although African American women have an overall lower incidence of breast cancer, African American women <40 years of age are more likely than Caucasian women of all ages and postmenopausal African American women to be diagnosed with breast cancer and exhibit tumor characteristics associated with poorer survival. To begin to address this disparity, studies must be conducted to examine breast cancer preventive factors in this subpopulation of women. However, the strategies needed to recruit younger African American women have not been well defined.

METHODS

In this study, we assessed methods used for recruiting and retaining healthy premenopausal African American women into the African American Nutrition for Life (A NULIFE) Study. The number of women contacted, enrolled, and retained by each recruitment strategy and the efficiency of individual strategies were calculated.

RESULTS

Overall, recruitment through social networking was most effective in contacting large numbers of healthy premenopausal African American women. The worksite recruitment method was the most efficient recruitment strategy employed, with a ratio of 40%. The study participants (n = 164) were more likely to be >or=35 years of age and have completed some college. Additionally, the interpersonal relationships recruitment approach proved most efficient (33%) in retaining participants who completed the yearlong study.

CONCLUSIONS

The findings from this study add to the evolving research literature on minority recruitment strategies for research studies but specifically address effective recruitment of healthy young premenopausal African American women. The results demonstrate the need to use multiple recruitment strategies when recruiting this subgroup of African American women.

Healthcare access, socioeconomic factors and late-stage cancer diagnosis: an exploratory spatial analysis and public policy implication

Patients diagnosed with late-stage cancer have lower survival rates than those with early-stage cancer. This paper examines possible associations between several risk factors and late-stage diagnosis for four types of cancer in Illinois: breast cancer, prostate cancer, colorectal cancer, and lung cancer. Potential risk factors are composed of spatial factors and nonspatial factors. The spatial factors include accessibility to primary healthcare and distance or travel time to the nearest cancer screening facility. A set of demographic and socioeconomic variables are consolidated into three nonspatial factors by factor analysis. The Bayesian model with convolution priors is utilised to analyse the relationship between the above risk factors and each type of late-stage cancer while controlling for spatial autocorrelation. The results for breast cancer suggest that people living in neighbourhoods with socioeconomic disadvantages and cultural barriers are more likely to be diagnosed at a late stage. In regard to prostate cancer, people in regions with low socioeconomic status are also more likely to be diagnosed at a late stage. Diagnosis of late-stage colorectal or lung cancer is not significantly associated with any of the abovementioned risk factors. The results have important implications in public policy.

Social determinants of Black-White disparities in breast cancer mortality: a review

Despite the recent decline in breast cancer mortality, African American women continue to die from breast cancer at higher rates than do White women. Beyond the fact that breast cancer tends to be a more biologically aggressive disease in African American than in White women, this disparity in breast cancer mortality also reflects social barriers that disproportionately affect African American women. These barriers hinder cancer prevention and control efforts and modify the biological expression of disease. The present review focuses on delineating social, economic, and cultural factors that are potentially responsible for Black-White disparities in breast cancer mortality. This review was guided by the social determinants of health disparities model, a model that identifies barriers associated with poverty, culture, and social injustice as major causes of health disparities. These barriers, in concert with genetic, biological, and environmental factors, can promote differential outcomes for African American and White women along the entire breast cancer continuum, from screening and early detection to treatment and survival. Barriers related to poverty include lack of a primary care physician, inadequate health insurance, and poor access to health care. Barriers related to culture include perceived invulnerability, folk beliefs, and a general mistrust of the health care system. Barriers related to social injustice include racial profiling and discrimination. Many of these barriers are potentially modifiable. Thus, in addition to biomedical advancements, future efforts to reduce disparities in breast cancer mortality should address social barriers that perpetuate disparities among African American and White women in the United States.

Abnormal mammogram follow-up: do community lay health advocates make a difference?

This pilot study evaluates a community lay health advocate (CLHA) intervention in promoting follow-up for abnormal mammograms among African American women. A controlled trial was implemented at an urban hospital in Atlanta, with 48 women in a CLHA intervention group and 35 in a usual care group. Participants were 25 or older and had an abnormal mammogram between March 25, 2002, and May 2, 2003. Intervention group women received CLHA support including encouragement of timely abnormal mammogram follow-up, reminders of follow-up appointments, identification and removal of barriers to follow-up, and accompaniment to follow-up appointments. Women in the intervention group were significantly more likely to keep their first abnormal mammogram follow-up appointment, all of their scheduled follow-up appointments, and their biopsy or fine needle aspiration appointment. CLHAs are effective in promoting abnormal mammogram followup among African American women and may be an important resource in reducing racial disparities in breast cancer mortality.

Epidemiology of basal-like breast cancer

Risk factors for the newly identified "intrinsic" breast cancer subtypes (luminal A, luminal B, basal-like and human epidermal growth factor receptor 2-positive/estrogen receptor-negative) were determined in the Carolina Breast Cancer Study, a population-based, case-control study of African-American and white women. Immunohistochemical markers were used to subtype 1,424 cases of invasive and in situ breast cancer, and case subtypes were compared to 2,022 controls. Luminal A, the most common subtype, exhibited risk factors typically reported for breast cancer in previous studies, including inverse associations for increased parity and younger age at first full-term pregnancy. Basal-like cases exhibited several associations that were opposite to those observed for luminal A, including increased risk for parity and younger age at first term full-term pregnancy. Longer duration breastfeeding, increasing number of children breastfed, and increasing number of months breastfeeding per child were each associated with reduced risk of basal-like breast cancer, but not luminal A. Women with multiple live births who did not breastfeed and women who used medications to suppress lactation were at increased risk of basal-like, but not luminal A, breast cancer. Elevated waist-hip ratio was associated with increased risk of luminal A in postmenopausal women, and increased risk of basal-like breast cancer in pre- and postmenopausal women. The prevalence of basal-like breast cancer was highest among premenopausal African-American women, who also showed the highest prevalence of basal-like risk factors. Among younger African-American women, we estimate that up to 68% of basal-like breast cancer could be prevented by promoting breastfeeding and reducing abdominal adiposity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adiposity, the metabolic syndrome, and breast cancer in African-American and white American women

Breast cancer, the second most common cause of cancer-related deaths in American women, varies substantially in incidence and mortality according to race and ethnicity in the United States. Although the overall incidence of breast cancer among African-American (AA) women is lower than in white American women, this cancer is more common in young premenopausal AA women, and AA breast cancer patients of all ages are more likely to have advanced disease at diagnosis, higher risk of recurrence, and poorer overall prognosis. Epidemiological studies indicate that these differences may be attributable in part to variation in obesity and body fat distribution. Additionally, AA women more frequently exhibit breast cancer with an aggressive and metastatic phenotype that may also be attributable to the endocrine and metabolic changes associated with upper body obesity. These changes include both elevated estrogen and androgen bioactivity, hyperinsulinemia, and perturbations of the adipokines. Type 2 diabetes and the metabolic syndrome, which are more common in AA women, have also been associated with breast cancer risk. Moreover, each of the individual components of the syndrome has been associated with increased breast cancer risk, including low levels of the adipocytokine, adiponectin. This review explores the specific roles of obesity, body fat distribution (particularly visceral and sc adipose tissue), type 2 diabetes, metabolic syndrome, and adipocytokines in explaining the differential patterns of breast cancer risk and prognosis between AA and white American women.

Polymorphic variations in exon 10 of the luteinizing hormone receptor: functional consequences and associations with breast cancer

Polymorphic variation of the LHR gene may affect receptor function and accordingly may influence ovarian steroid hormone action, including steroid hormone-dependent clinical outcome. The functional effects of two single nucleotide polymorphisms (SNPs), i.e. LHR 291Asn/Ser (rs12470652) and 312Ser/Asn (rs2293275) in the biologically interesting exon 10 of the LHR gene are described. Furthermore, ethnic diversity in allele frequencies and genotype distributions of both SNPs was determined. In addition associations with breast cancer were studied in 751 breast cancer patients. In vitro transfection studies revealed altered glycosylation status and increased receptor sensitivity for the 291Ser LHR variant. No functional consequences were observed for the 312SerAsn LHR SNP. The LHR 312Asn allele was slightly more often present in two independent breast cancer patient cohorts as compared to controls (OR=1.15; p=0.03 and 1.26; p=0.001, respectively). In conclusion, although functional changes of the LHR 291Ser candidate allele were observed, no associations with breast cancer were found, while the LHR 312Asn allele can be regarded as a weak breast cancer risk allele.

Molecular Breast Cancer Subtypes in Premenopausal African-American Women, Tumor Biologic Factors and Clinical Outcome

INTRODUCTION

Breast cancer is currently viewed as a heterogeneous disease made up of various subtypes, with distinct differences in prognosis. Our goal was to study the distribution and to characterize the clinical and biological factors that influence the behavior and clinical management of the different molecular breast cancer subtypes in premenopausal African-American women.

METHODS

A retrospective analysis of Howard University Hospital tumor registry, for all premenopausal African-American women aged less than 50 years, diagnosed with breast cancer from 1998-2005, was performed.

RESULTS

The luminal A subtype was the most prevalent (50.0%), vs basal-cell-like (23.2%), luminal B (14.1%), and HER-2/neu (12.7%). However when stratified by age groups, results showed that in the age group <35 years the basal-cell-like subtype was the most prevalent (55.6%), vs 25.9%, 14.8%, and 5.6% for luminal A, luminal B, and HER-2/neu subtypes, respectively (P < .000). P53 mutation was more prevalent in the basal-cell-like subtype compared to luminal A (48.0% vs 18.6%, P < .01). The expression of the Bcl-2 gene differed by subtype, with the luminal A and luminal B subtypes more likely to overexpress the Bcl-2 gene (89.1% luminal A, 80.0% luminal B vs 47.6% basal-cell-like and 40.0% HER-2/neu, P < .000). Though not statistically significant, HER-2/neu and basal-cell-like subtypes had the shortest survival time (P < .31).

CONCLUSION

The high prevalence of the basal-cell-like subtype in young premenopausal African-American women aged <35 years may contribute to the poorer prognosis observed in this cohort of African-American women.

Parity and disparity in first course treatment of invasive breast cancer

BACKGROUND

Adherence to first course treatment guidelines for breast cancer may not be uniform across racial/ethnic groups and could be a major contributing factor to disparities in outcome. In this population-based study, we assessed racial differences in initial treatment of breast cancer.

METHODS

Surveillance, Epidemiology, and End Results (SEER) program data were used to study all primary invasive breast cancers diagnosed during 2000-2001 among Black (n = 877) and White (n = 2437) female residents of the five Atlanta SEER counties, counties with several large teaching hospitals. Differences in treatment delay, cancer directed surgery, and receipt of chemotherapy, radiotherapy, or hormonal therapy were analyzed according to guidelines for treatment. Analyses utilized frequency distributions, chi(2) tests of independence and statistics in and across strata.

RESULTS

Black women experienced longer treatment delays, regardless of stage at diagnosis, and were 4-5 fold more likely to experience delays greater than 60 days (P < 0.001). For local-regional disease, more Black women did not receive cancer directed surgery (7.5% vs. 1.5% of white women, P < 0.001), but did receive breast conserving surgery (BCS) equivalently. Only 61% of Black vs. 72% of White women received radiation with BCS (P < 0.001). Black women eligible for hormonal therapy were less likely to receive it (P < 0.001).

CONCLUSION

Our findings suggest treatment standards are not adequately or equivalently met among Black and White women, even in an area where teaching hospitals provide a substantial portion of breast cancer care. Treatment differences can adversely affect outcome and reasons for the differences need to be addressed.

Personal care products that contain estrogens or xenoestrogens may increase breast cancer risk

Established models of breast cancer risk, such as the Gail model, do not account for patterns of the disease in women under the age of 35, especially in African Americans. With the possible exceptions of ionizing radiation or inheriting a known genetic mutation, most of the known risk factors for breast cancer are related to cumulative lifetime exposure to estrogens. Increased risk of breast cancer has been associated with earlier onset of menses or later age at menopause, nulliparity or late first parity, use of hormonal contraceptives or hormone replacement therapy, shorter lactation history, exposure to light at night, obesity, and regular ingestion of alcohol, all of which increase circulating levels of unbound estradiol. Among African Americans at all ages, use of hormone-containing personal care products (PCPs) is more common than among whites, as is premature appearance of secondary sexual characteristics among infants and toddlers. We hypothesize that the use of estrogen and other hormone-containing PCPs in young African American women accounts, in part, for their increased risk of breast cancer prior to menopause, by subjecting breast buds to elevated estrogen exposure during critical windows of vulnerability in utero and in early life. These early life and continuing exposures to estrogenic and xenoestrogenic agents may also contribute to the increased lethality of breast cancer in young women in general and in African American women of all ages. Public disclosure by manufacturers of proprietary hormonally active ingredients is required for this research to move forward.

Disparities across the breast cancer continuum

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Mammary cancer and social interactions: identifying multiple environments that regulate gene expression throughout the life span

Now that the human genome has been sequenced, along with those of major animal models, there is an urgent need to define those environments that interact with genes. The traditional view focuses on ways that gene products interact with the nuclear environment to regulate cell function, causing the physiologic changes, behaviors, and diseases manifest throughout development and aging. Although this view is essential, it is equally essential to understand the converse relationship, namely, to identify those environments at higher levels of organization that regulate the expression of specific genes. Given the vastness of this problem, one effective strategy is to start with a trait for which some of the genes have already been identified, such as malignant disease. In rats, social isolation and hypervigilance increase the incidence of mammary tumors, accelerate aging, and shorten the life span. We propose that similar environmental regulation of gene expression may underlie the disproportionately high mortality from premenopausal breast cancer of Blacks, a minority group that can experience high levels of loneliness and hypervigilance. Our goal is to identify which environments-social, psychological, hormonal, and cellular-regulate genetic mechanisms of mammary cancer risk as well as the specific times in the life span when they do so.

Jewish ethnicity and Black race: contrasting influences on the prognosis of breast cancer

BACKGROUND AND OBJECTIVES

For reasons that are incompletely understood, race and ethnicity are associated with differing mortality from breast cancer. This investigation was undertaken to evaluate racial and ethnic influences on survival of women with breast cancers and to identify influential factors.

METHODS

A population of 766 racially and ethnically defined women with newly diagnosed invasive breast cancers in a clinical practice were prospectively evaluated and observed on a continuing basis. Survivals were compared with multiple demographic and clinicopathologic variables.

RESULTS

Compared to White, non-Jewish patients, no significant difference was found in survival of Jewish patients. Stage of cancers at diagnosis and measures of tumor biology were also comparable. By contrast, the survival of Black patients was significantly worse than that of White patients. Advanced tumor stage at diagnosis, unfavorable tumor biology and poor ancillary health all appeared to contribute to the poor survival of Black women.

CONCLUSION

No adverse influence of Jewish ethnicity was found on the prognosis of breast cancer. The poor prognosis of Black women compared to White women appeared to be the result of multiple untoward influences.

Gender disparities in health: attending to the particulars

As we get a feel for this new century, collective creativity is called for while we confront the challenges presented. Globalization, with its flow of ideas, people, and materials is no longer a theoretical concept and its advantages and disadvantages are becoming clear. While the axiom that "all politics are local" remains relevant, world events touch all corners of the globe. In the world of science, there are exciting advances being made,but many of these are accompanied by concerns about unequal access to biomedicine and technology, and misplaced health care priorities. One of the effects of transnationalism is that multiculturalism becomes the norm so that the label "minority" begins to lose its meaning. In the field of women's health, the issues have not changed as much as the conceptualization of them. The fact that biology and society contribute to sex differences is well known, but understanding how these interact at all levels (from the molecular to the community level) requires innovative research strategies. Efforts to describe gender disparities in health status are inadequate unless they are linked with actions that will improve the well being of diverse populations. An approach suggested in this article is to direct research and policy attention to the lifestyles and needs of particular women living in a particular time and place in society. This is the first step before meaningful interventions can be implemented and the women's health paradigm expanded.