Existing data on breast cancer in African-American women: what we know and what we need to know

Assessing the Impact of CALGB 9343 on Surgical Trends in Elderly-Women With Stage I ER+ Breast Cancer: A SEER-Based Analysis

Purpose: Lumpectomy (L) and breast radiotherapy (RT) results in equivalent outcomes in comparison to mastectomy (M) for early-stage breast cancer (BC) based on randomized controlled trials (RCT). Since 2004, RCT support that L without RT yields equivalent survival and acceptable local-regional outcomes in women ≥70-years old with T1N0 hormone-sensitive (ER+) BC on endocrine therapy. Based on this, we hypothesized that M rates should decrease substantially after 2004 in this low-risk elderly population.

Methods: We used the Surveillance Epidemiology and End Results registry data to conduct this study. We included women with T1N0 ER+ BC from 2000 to 2014. We compared M rates in women diagnosed from 2000 to 2004 vs. 2005–2012 using the Chi-Square test. Logistic regression analyses was performed to examine demographic/clinical factors associated with mastectomy.

Results: 67,506 women met the study criteria. In elderly Stage I ER+ BC, the M rate decreased by 6.3%: 29.0% before 2004 to 22.7% after 2004 (p < 0.0001). M rates remained higher in elderly non-Hispanic black (NHB, 27.1%, p < 0.0001), non-Hispanic Asian-Pacific-Islander (NHAPI, 30.1%, p < 0.0001), and Hispanics (24.4%, p = 0.0004) vs. non-Hispanic White (NHW, 21.5%). Treatment in the modern cohort was associated with decreased odds of mastectomy (OR = 0.71, 95% CI 0.68-0.74, p < 0.0001) while NH-API race was associated with the highest increased odds of mastectomy (OR = 1.65, 95% 1.53-1.78, p < 0.0001). In the modern cohort specifically (2005–2014), Hispanic women (OR = 1.12, p = 0.014), NHB women (OR = 1.21, p < 0.0001), and NHAPI women (OR = 1.73, p < 0.0001) all had higher odds of undergoing mastectomy relative to NHW women after adjusting for all other patient and tumor related factors.

Conclusions: In elderly patients with stage I, ER+ BC, M rates have decreased modestly since 2004. These trends are driven mostly be decreases in the M rate in NHW women, but M rates remain ~25% in Hispanic, NHB, and NHAPI women. Further research is needed to identify why M, which is associated with higher cost and morbidity than L alone, has not changed substantially in elderly, low-risk BC.

Disparities in breast cancer tumor characteristics, treatment, time to treatment, and survival probability among African American and white women

African American (AA) women have a 42% higher breast cancer death rate compared to white women despite recent advancements in management of the disease. We examined racial differences in clinical and tumor characteristics, treatment and survival in patients diagnosed with breast cancer between 2005 and 2014 at a single institution, the James Cancer Hospital, and who were included in the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Cancer Registry in Columbus OH. Statistical analyses included likelihood ratio chi-square tests for differences in proportions, as well as univariate and multivariate Cox proportional hazards regressions to examine associations between race and overall and progression-free survival probabilities. AA women made up 10.2% (469 of 4593) the sample. Average time to onset of treatment after diagnosis was almost two times longer in AA women compared to white women (62.0 days vs 35.5 days, p < 0.0001). AA women were more likely to report past or current tobacco use, experience delays in treatment, have triple negative and late stage breast cancer, and were less likely to receive surgery, especially mastectomy and reconstruction following mastectomy. After adjustment for confounding factors (age, grade, and surgery), overall survival probability was significantly associated with race (HR = 1.33; 95% CI 1.03–1.72). These findings highlight the need for efforts focused on screening and receipt of prompt treatment among AA women diagnosed with breast cancer.

African Americans with breast cancer wait longer to get treated and then live shorter than white women, a US cancer center’s records show. Electra Paskett and her colleagues from Ohio State University in Columbus examined racial differences in tumor characteristics and patient outcomes among the 4,593 women treated for breast cancer at their institution’s affiliated hospitals between 2005 and 2014. They found that the time between diagnosis and treatment onset was longer for African Americans — 62 days compared to 35.5 days for white women. African Americans were also more likely to have harder-to-treat forms of disease and they were less likely to undergo surgery. Even accounting for many of these factors, African American women still had worse outcomes, as measured by survival probability. The findings highlight the need address racial disparities in breast cancer treatment.

Change in Mammography Use Following the Revised Guidelines from the U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) recommended screening mammography every 1-2 years for women 40 years and older in 2002, and changed its recommendations in 2009 to no routine screening for women between 40 and 49 years of age; and biennial screening for women between 50 and 74 years of age. This study evaluates the change in mammographic use after the issuance of the revised recommendations. Women who participated in a cross-sectional study of breast cancer risk factors from 2007 to 2013 were asked if they had received a mammogram in the preceding 2 years. All 3442 study participants who enrolled in the study after January 1, 2011 were matched by race, age, and educational level with women enrolled between 2007 and 2010. The proportions of women who stated they had received a mammogram in the past 2 years were compared between the two groups. One fourth of the participants were African American and 39% were 40-49 years of age. Among white women, significant decreases in recent mammogram use from 2007-2010 to 2011-2013 were detected for women 40-49 years of age (-10.3%, p < 0.001) and 50-74 years of age (-8.8%, p < 0.001). Among African-American women, the change in recent mammogram use was not statistically significant for women 40-49 years of age (-2.7%, p = 0.440) or 50-74 years of age (-2.2%, p = 0.398). Following the change in the USPSTF guidelines, mammography use among white women declined; however, no change was observed among African-American women.

Impact of race and tumor subtype on second malignancy risk in women with breast cancer

Purpose

Women with breast cancer are at increased risk of second malignancy (SM). However, the impact of race and the hormone receptor (HR) status of the primary breast tumor on risk of SM are not known. The purpose of this study is to analyze the incidence of SM in women with a history of breast cancer according to race and HR status.

Methods

In the surveillance, epidemiology, and end results database, multiple primary standardized incidence ratio sessions were used to compare the incidence of SM in women with a history breast cancer to the cancer incidence in the general population. Analyses of SM by age, race, and hormone-receptor status were performed using the absolute excess risk (AER) and observed/expected (O/E) ratio.

Results

Younger black women (under the age of 50) were at greater risk of SM with an AER = 76.03 (O/E = 2.3, 95 % CI = 12.19–2.4) compared to younger white women who had an AER = 38.59 (O/E = 1.55, 95 % CI = 1.53–1.58). Older black women (50 years and older) had at an increased risk of SM with an AER = 42.26 (O/E = 1.3, 95 % CI = 1.26–1.34) compared to older white women who had an AER = 11.56 (O/E = 1.07, 95 % CI = 1.06–1.08). Second breast malignancy is the predominant SM in both black and white women. Women with hormone-receptor (HR)-negative breast cancer had higher risk of SMs with an AER = 43.53 (O/E = 1.41, 95 % CI = 1.38– 0.145–3.31) compared to women with HR-positive disease with an AER = 21.43 (O/E = 1.17, 95 % CI = 1.16–0.1.18). In HR-negative women, younger black women had an AER = 96.46 (O/E = 2.99, 95 % CI = 2.70–3.31), younger white women had an AER = 66 (O/E = 2.25, 95 % CI = 2.13–2.36), older black women had an AER = 58.58 (O/E = 1.45, 95 % CI = 1.34–1.57), and older white women had an AER = 20.88 (O/E = 1.14, 95 % CI = 1.11–1.18).

Conclusions

Black breast cancer survivors and women with HR-negative breast cancer are at increased risk of SM, which deserves further evaluation to understand the biological and clinical basis for this increased risk.

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.

Reducing inequalities in cancer outcomes: what works?

Despite efforts to reduce disparities in cancer outcomes among vulnerable populations, certain subgroups do not experience the gains made in the reduction of cancer incidence and mortality. In this article, we review recent trial data reporting on patient-, physician-, and system-centered interventions to improve quality and reduce disparities in cancer care spanning patient navigation to health reform. We conclude with data from a state that implemented a multitiered approach, targeting patient and systems barriers, that serves as a guide for future endeavors.

Triple-negative breast cancers: a view from 10,000 feet

Triple-negative breast cancer is more likely to affect younger premenopausal women and despite being responsive to traditional chemotherapy, continues to carry a poor overall prognosis. Traditional protective factors for breast cancer such as multiparity and early primaparity actually increase the risk for the triple-negative variant. Unlike other breast cancers, the incidence of this disease is also much higher in African American and West African women. Among those with triple-negative disease in the United States, the mortality rates are also highest in African American women. Variations in risk factors and socioeconomic status, lack of treatment, delays in treatment, and inadequate dosing of chemotherapy are just a few of the many reasons that may explain why this incidence and survival disparity persists.

Do lifestyle or social factors explain ethnic/racial inequalities in breast cancer survival?

Despite numerous studies documenting ethnic inequalities in breast cancer survival between minority and majority ethnic groups worldwide, reasons for these inequalities remain unclear. The authors performed a systematic review of published literature to identify studies that investigated the explanatory power of smoking, alcohol consumption, body mass index (BMI), and socioeconomic position (SEP) on ethnic inequalities in breast cancer survival. Sixteen studies were included in the review. From 5 studies, the authors found that differences in breast cancer survival between ethnic groups may be in part explained by BMI, but there was little evidence to implicate smoking or alcohol consumption as explanatory factors of this inequality. From 12 studies, the authors found that SEP explains part of the ethnic inequality in all-cause survival but that it was not evident for breast-cancer-specific survival. SEP explains more of the disparities among African-American versus white women in the United States compared with other ethnic comparisons. Furthermore, given social patterning of BMI and other lifestyle habits, it is possible that results for SEP and BMI are measuring the same effect. In this review, the authors make suggestions regarding the role of epidemiology in facilitating further research to better inform the development of effective policies to address ethnic differences in survival.

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.

How does social integration influence breast cancer control among urban African-American women? Results from a cross-sectional survey

BACKGROUND

Although social integration is a well-established influence on health, less is known about how the specific types of social connection (social roles, social networks, and social support) influence knowledge, attitudes, and practices for specific prevention goals, and how to utilize these influences in interventions with priority populations. This research examined the prevalence of social roles, networks and support among 576 urban African-American women age 45-93 in East Baltimore, Maryland, and the association of these social factors with breast cancer related knowledge, attitudes, and practices.

METHODS

Using data from 1997-1998 in-home interviews, we developed indices of six possible social roles, social networks of family, neighborhood and church, and instrumental and emotional social support. In multivariate models adjusting for age, education, and medical care, we examined the association of each social influence on breast cancer knowledge, attitudes, screening recency and intention, and treatment preferences.

RESULTS

We found substantial variation in social integration among these women, with social integration positively associated with overall health and well-being. Social roles and networks were positively associated with screening knowledge, and emotional support and church networks were positively associated with attitudes conducive to early detection and treatment. In regard to screening behaviors, family networks were associated with both screening recency and intention. Women with greater church networks and emotional support held more conservative attitudes towards lumpectomy, reconstruction, and clinical trials.

CONCLUSION

Overall, social integration is a positive influence on breast cancer control and should be utilized where possible in interventions, including identifying surrogate mechanisms for support for subgroups without existing social resources.

Cultural Values and Secondary Prevention of Breast Cancer in African American Women

Background

Improving mammography initiation and maintenance among African American women has been suggested as a strategy for reducing breast cancer mortality in this population.

Methods

We examined cultural values in relation to self-reported breast cancer screening among 572 low-income, urban, African American women. Cultural values examined included time orientation, family authority, employment aspirations, value of past vs modern life, and reliance on medical professionals. Also, implications for continued development of culturally tailored health interventions and opportunities for the consideration of cultural values in health communication are discussed.

Results

Bivariate analyses showed that more traditional values were associated with worse screening histories and lower intentions for future screening. In multivariate analyses, two interactions were observed between cultural values and age: for younger women, more traditional values were associated with lower odds of having ever received a mammogram, and for older women, more traditional values were associated with lower odds of intentions to receive a mammogram in the next 2 years.

Conclusions

This study adds to the evidence that cultural constructs, such as values, are associated with secondary prevention of breast cancer and supports the consideration of cultural constructs as important in increasing mammography and reducing breast cancer disparities for African American women.

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.

Unmet psychosocial needs of Pennsylvanians with cancer: 1986–2005

BACKGROUND

The purpose of the current study was to identify unmet psychosocial needs of cancer survivors, understand the distribution of needs across subgroups, and compare unmet needs in 2005 with those identified by Houts et al. in 1986.

METHODS

Using a sequential mixed methods design, qualitative interviews were conducted with 32 cancer survivors or family members to identify the psychosocial needs of people from the time of cancer diagnosis through survivorship. These data were used to modify a needs assessment that was mailed to a stratified random sample of survivors obtained from the Pennsylvania Cancer Registry.

RESULTS

A total of 614 survivors returned usable questionnaires. Nearly two-thirds of respondents reported experiencing at least 1 unmet psychosocial need, particularly emotional, physical, and treatment-related needs. It is likely that unmet needs in insurance, employment, information, and home care increased during the 20-year interval between surveys. Demographics associated with increased unmet need included later stage of disease at the time of diagnosis, younger age, more comorbidities, and lower income.

CONCLUSIONS

Unmet psychosocial need remains high despite 20 years of effort to address psychosocial issues. This may be due to a mismatch between needs and services. Unmet need may be related to access issues, a lack of awareness of resources, "new" needs that have arisen in a changing healthcare climate, and patient preferences for types of service. Cancer treatment staff should be especially alert for psychosocial problems in younger individuals with an additional illness burden.

The influence of race, ethnicity, and individual socioeconomic factors on breast cancer stage at diagnosis

OBJECTIVES

Previous research has generally found that racial/ethnic differences in breast cancer stage at diagnosis attenuate when measures of socioeconomic status are included in the analysis, although most previous research measured socioeconomic status at the contextual level. This study investigated the relation between race/ethnicity, individual socioeconomic status, and breast cancer stage at diagnosis.

METHODS

Women with stage 0 to III breast cancer were identified from population-based data from the Surveillance, Epidemiology, and End Results tumor registries in the Detroit and Los Angeles metropolitan areas. These data were combined with data from a mailed survey in a sample of White, Black, and Hispanic women (n=1700). Logistic regression identified factors associated with early-stage diagnosis.

RESULTS

Black and Hispanic women were less likely to be diagnosed with early-stage breast cancer than were White women (P< .001). After control for study site, age, and individual socioeconomic factors, the odds of early detection were still significantly less for Hispanic women (odds ratio [OR]=0.45) and Black women (OR = 0.72) than for White women. After control for the method of disease detection, the White/Black disparity attenuated to insignificance; the decreased likelihood of early detection among Hispanic women remained significant (OR=0.59).

CONCLUSION

The way in which racial/ethnic minority status and socioeconomic characteristics produce disparities in women's experiences with breast cancer deserves further research and policy attention.

Defining "success" in recruitment of underrepresented populations to cancer clinical trials: moving toward a more consistent approach

Although medically underserved groups bear a heavy burden of cancer disease and governmental agencies have required inclusion of minorities and women in cancer clinical trials since 1993, many of these groups are underrepresented in cancer prevention or treatment clinical trials. To assess and enhance recruitment of underrepresented populations into cancer-related clinical trials, investigators and governmental agencies need consistent measurement approaches for recruitment that can be applied to diverse settings where trials are conducted. We conducted a systematic review to evaluate what measurement approaches were used to evaluate the success of recruitment of underrepresented groups into cancer prevention or treatment trials, and whether these recruitment goals were stated a priori. Only two articles reported an a priori recruitment goal. The recruitment measurement approaches varied considerably, with no consistent standard, especially for individual trials. By using the empiric evidence from this review in conjunction with the National Institutes of Health (NIH) guidelines, we constructed a framework for choosing consistent a priori recruitment goals for underrepresented groups based on the research question and study location. Using consistent measurement approaches for underrepresented groups will improve comparability of recruitment strategies across trials, improve equity in distribution of benefits and burdens of cancer-related clinical trials, and may improve applicability of trial results to multiple populations.

Significance of micrometastases on the survival of women with T1 breast cancer

BACKGROUND

The most important factor in predicting survival among women with newly diagnosed breast cancer is the status of the axillary lymph nodes. Although straightforward to define, the impact of micrometastases on survival remains to be completely determined.

METHODS

A review of data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute was performed using 43,921 cases diagnosed from January 1988 through December 2001. Among women with invasive breast carcinomas <or=2 cm undergoing a resection of the primary malignancy and an axillary lymph node dissection, there were 42,197 cases without lymph node metastases and 1724 cases with micrometastases. Survival differences among these 2 groups were evaluated and are reported here.

RESULTS

Survival at 12 years was modestly affected by the presence of either solitary (5.0%) or multiple lymph nodes (3.6%) with micrometastases when compared with lymph node-negative cases. In subgroup analyses, the decreased survival associated with micrometastases was inconsistent. The most significant survival disadvantage associated with micrometastases was found in cases with Grade 3 carcinomas.

CONCLUSIONS

The modest and variable impact of micrometastases on long-term survival indicates that micrometastases are an important, but not a dominant, prognostic indicator.

Racial and ethnic disparities in breast cancer: a multilevel perspective

Although the etiology of racial and ethnic disparities in breast cancer is complex, the studies reviewed here suggest many possible culprits. In the authors' model, outcomes at the cellular level reflect not only genetic constitution and the hormonal milieu but also the interactions of predictors at multiple levels. At the societal level, important predictors include toxin and hormone exposure, access to care, quality of care, and social support. At the individual level, reproductive history, exogenous hormone use, diet,exercise, and response to stress all may influence cellular outcomes. The smooth transition from normal cell function to apoptosis occurs when the interactions between factors at the societal, individual, and cellular levels are harmonious. Perturbations at the societal level, however, such as inferior quality of care, or at the individual level, such as exogenous hormone use,can have profound effects on cell biology and predispose to neoplasia. When these perturbations are systematic and vary by race or ethnicity, disparities in breast cancer incidence and mortality result. Increasing incidence of breast cancer among both men and women likely reflects important trends at the societal and individual levels. These trends may include increased toxin exposure, increased obesity, and changes in the timing and number of births. Efforts to reduce breast cancer incidence and disparities must consider societal and individual factors and the important effects these factors can have on normal cell function.

Factors that affect breast cancer treatment: underserved and minority populations

Breast cancer treatment in underserved populations continues to deviate from established guidelines. Significant barriers persist at the system, physician, and patient levels that ultimately may affect survival adversely. Successful strategies to reduce the disparities must be developed to improve outcomes in this population of women.

The effect of age, race, tumor size, tumor grade, and disease stage on invasive ductal breast cancer survival in the U.S. SEER database

PURPOSE

To examine the effect of patient and tumor characteristics on breast cancer survival as recorded in the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database from 1973 to 1998.

METHODS

A sample of 72,367 female cases from 1973 to 1998 aged 21-90 years with invasive ductal breast cancer were examined with Cox proportional hazards regression to determine the effect of age at diagnosis, race, tumor size, tumor grade, disease stage, and year of diagnosis on disease-specific survival.

RESULTS

Larger tumor size and higher tumor grade were found to have large negative effects on survival. Blacks had a 47 % greater risk of death than whites. Year of diagnosis had a positive effect, with a 15 % reduction in risk for each decade in the time period under study. The effects of patient age and disease stage violated the proportional hazards assumption, with distant disease having much poorer short-term survival than one would expect from a proportional hazards model, and younger age groups matching or even falling below the survival rate of the oldest group over time.

CONCLUSION

Tumor size, grade, race, and year of diagnosis all have significant constant effects on disease-specific survival in breast cancer, while the effects of age at diagnosis and disease stage have significant effects that vary over time.

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.

Breast cancer research among African-American women: accurate racial categories?

This essay questions the appropriateness of racial categories in breast cancer research and recommends the discontinuation of "African-American" as a valid racial category in breast cancer research until better categories can be developed.