Racial differences in follow-up of abnormal mammography findings among economically disadvantaged women

Cancer screening with multicancer detection tests: A translational science review

Multicancer detection (MCD) tests use a single, easily obtainable biospecimen, such as blood, to screen for more than one cancer concurrently. MCD tests can potentially be used to improve early cancer detection, including cancers that currently lack effective screening methods. However, these tests have unknown and unquantified benefits and harms. MCD tests differ from conventional cancer screening tests in that the organ responsible for a positive test is unknown, and a broad diagnostic workup may be necessary to confirm the location and type of underlying cancer. Among two prospective studies involving greater than 16,000 individuals, MCD tests identified those who had some cancers without currently recommended screening tests, including pancreas, ovary, liver, uterus, small intestine, oropharyngeal, bone, thyroid, and hematologic malignancies, at early stages. Reported MCD test sensitivities range from 27% to 95% but differ by organ and are lower for early stage cancers, for which treatment toxicity would be lowest and the potential for cure might be highest. False reassurance from a negative MCD result may reduce screening adherence, risking a loss in proven public health benefits from standard-of-care screening. Prospective clinical trials are needed to address uncertainties about MCD accuracy to detect different cancers in asymptomatic individuals, whether these tests can detect cancer sufficiently early for effective treatment and mortality reduction, the degree to which these tests may contribute to cancer overdiagnosis and overtreatment, whether MCD tests work equally well across all populations, and the appropriate diagnostic evaluation and follow-up for patients with a positive test.

Ensuring Safety While Achieving Beauty: An Evidence-Based Approach to Optimizing Mastectomy and Autologous Breast Reconstruction Outcomes in Patients with Obesity

BACKGROUND

Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients.

STUDY DESIGN

This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies.

RESULTS

We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021).

CONCLUSIONS

Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction.

The impact of race on outcomes following ruptured abdominal aortic aneurysm repair

OBJECTIVES

Racial differences in elective abdominal aortic aneurysm (AAA) repair outcomes have been previously reported; however, data on racial differences in ruptured AAA (rAAA) repair outcomes remain limited. This study assessed in-hospital and long-term mortality after rAAA repair in Black versus White patients.

METHODS

The Vascular Quality Initiative database was queried to identify all Black and White patients who underwent open or endovascular rAAA repair between 2003 and 2019. Baseline demographic and clinical characteristics were recorded, and independent t test and χ2 test were performed to assess differences between groups. In-hospital and 8-year mortality rates were the primary outcomes. Univariate and multivariate logistic regression and Cox proportional hazards analyses were conducted to analyze associations between race and outcomes.

RESULTS

Overall, 310 Black patients and 4679 White patients underwent rAAA repair. A greater proportion of Black patients underwent endovascular repair (73.2% vs 56.1%). Black patients had a lower mean age and were more likely to be female, with a greater proportion being Medicaid insured (9.7% vs 2.1%) or uninsured (4.8% vs 3.3%). Although Black patients were more likely to be current smokers and have hypertension, diabetes, and congestive heart failure, they were not more likely to receive risk reduction medications. The time from symptom onset to incision or access was higher for Black patients (median, 12.0 hours vs 7.0 hours). Similarly, the time from hospital admission to intervention was higher for Black patients (median, 2.8 hours vs 1.3 hours). In-hospital mortality was lower in Black patients (20.0% vs 28.6%; odds ratio [OR], 0.63; 95% confidence interval [CI], 0.47-0.83); however, this did not persist after adjusting for baseline characteristics (adjusted OR, 0.58; 95% CI, 0.30-1.07; P = .09). Furthermore, the 8-year survival was not different between groups (50.4% vs 46.6%; hazard ratio, 0.85; 95% CI, 0.57-1.26; P = .42), even when stratified by repair type.

CONCLUSIONS

This study identified racial differences in demographic, clinical, and procedural characteristics for patients undergoing rAAA repair. In particular, the door-to-intervention time for Black patients of 2.8 hours does not meet the Society for Vascular Surgery recommendation of 90 minutes. Despite these differences, the 8-year mortality is similar for Black and White patients. These differences should be investigated further, and there are opportunities to improve rAAA care for Black patients.

Racial Disparities in Breast Imaging Wait Times Before and After the Implementation of a Same-Day Biopsy Program

OBJECTIVE

To examine time from screening to diagnostic workup, biopsy, and surgery for non-Hispanic White (NHW) and Black women following implementation of a same-day biopsy program.

METHODS

All NHW and Black women with BI-RADS category 0 screening mammogram at Duke University Hospital were identified between August 1, 2020, and August 1, 2021. Patient characteristics were recorded. Time between screening mammogram, diagnostic workup, breast biopsy, surgical consultation, and surgery were recorded. Comparisons were made between NHW and Black women using a multivariable regression model. Diagnostic imaging to biopsy time interval was compared to historical averages before same-day biopsy implementation.

RESULTS

There were 2156 women: 69.9% NHW (1508/2156) and 30.1% Black (648/2156). Mean ± standard deviation time from screening to diagnostic imaging overall was 13.5 ± 32.5 days but longer for Black (18.0 ± 48.3 days) than for NHW women (11.5 ± 22.2 days) (P < 0.001). The mean time from diagnostic mammogram to biopsy was 5.9 ± 18.9 days, longer for Black (9.0 ± 27.9 days) than for NHW women (4.4 ± 11.8 days) (P = 0.017). The same-day biopsy program shortened the time from diagnostic imaging to biopsy overall (12.5 ± 12.4 days vs 5.9 ± 18.9 days; P < 0.001), with a significant reduction for NHW women (12.4 ± 11.7 days vs 4.4 ± 11.8 days) (P < 0.001) but not Black women (11.5 ± 9.9 days vs 9.0 ± 27.9 days) (P = 0.527).

CONCLUSION

Disparities exist along the breast imaging pathway. A same-day biopsy program benefited NHW women more than Black women.

Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery

BACKGROUND

Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes.

METHODS

A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation).

RESULTS

A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m², median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups.

CONCLUSIONS

Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.

Addressing Disparities Related to Access of Multimodality Breast Imaging Services Before and During the COVID-19 Pandemic

Despite technological advancements focused on reducing breast cancer mortality through early detection, there have been reported disparities in the access to these imaging services with underserved patient populations (including racial minority groups and patients of low socioeconomic status) showing underutilization compared to other patient groups. These underserved populations tend to have more advanced breast cancer presentations, in part due to delays in diagnosis resulting in later stage of disease presentation. To make matters worse, the COVID-19 pandemic declared in March 2020 has resulted in significant healthcare disruptions leading to extensive delays in breast imaging services which are expected to negatively impact breast cancer mortality long-term. Given the worsening disparity in breast cancer mortality among racial/ethnic minorities and financially disadvantaged groups, it is vital to address these disparity gaps with the goal of reducing the barriers to timely breast cancer diagnosis and addressing breast cancer mortality differences among breast cancer patients. Therefore, this review aims to provide a discussion highlighting the disparities related to breast imaging access, the effects of the COVID-19 pandemic on these disparities, current targeted interventions implemented in breast imaging practices to reduce these disparities, and future directions on the journey to reducing disparity gaps for breast imaging patients. Tackling the root cause factors of the persistent breast cancer-related disparities is critical to meeting the needs of patients who are disadvantaged and can lead to continued improvement in the quality of individualized care for patients who have higher breast cancer morbidity and mortality risks.

Decreasing the Interval Wait Times for Screening Mammogram Results Using the "Reflex Testing" Algorithm

OBJECTIVE

The purpose of this analysis was to determine whether our "reflex testing" (RefT) intervention, implemented to address barriers in scheduling, communication, and diagnostic order placement for resolving BI-RADS 0 screening mammograms, resulted in decreased interval wait times (IWT) for patients with abnormal screening mammograms (abSM).

METHODS

All BI-RADS 0 cases over two six-month periods (pre-RefT and post-RefT) were analyzed. Timelines were generated for each BI-RADS 0 case. Elapsed days were computed from date of BI-RADS 0 report to the date of biopsy, additional diagnostic testing, and final resolution. The means of each endpoint within the pre-RefT and post-RefT cohorts were statistically analyzed using Pearson chi-square analysis to assess whether IWT differed significantly after RefT implementation.

RESULTS

The analytic cohort consisted of 1523 BI-RADS 0 cases (n(pre-RefT) = 647, n(post-RefT) = 876). Reflex testing decreased the overall mean IWT from 23.5 to 8.2 days (P < 0.001). For patients not requiring biopsy (1190/1523, 78.1%), the mean IWT from the BI-RADS 0 designation to first diagnostic test or resolution decreased from 29.7 to 10.8 days (P < 0.010). For patients who had biopsy (333/1523, 21.9%), RefT significantly decreased the IWT from BI-RADS 0 to first diagnostic test from 31.4 to 7.7 days (P < 0.001) and also significantly decreased the IWT from first diagnostic test to biopsy (20.9 to 17.7 days; P < 0.013).

CONCLUSION

Reflex testing intervention streamlines the workflow and significantly decreases IWT for resolving BI-RADS 0 abSM. The RefT intervention could be considered to improve efficiency at other breast centers.

Increased disparities associated with black women and abnormal cervical cancer screening follow-up

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Timely follow-up and treatment after abnormal cervical cancer screening is lacking in over half of all women.

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Black women have the lowest rate of follow-up after abnormal screening.

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One-fourth of Black and Hispanic women have delayed follow-up.

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Insurance status is also associated with timely follow-up with abnormal cervical cancer screening.

Background

To determine whether race and ethnicity impacts patient adherence to follow-up for colposcopy after abnormal cervical cancer screening.

Methods

This retrospective chart review included women that were randomly selected from patients presenting to our colposcopy clinic from 1/2019 to 12/2019. Inclusion criteria were females age ≥21 years-old and appropriate referral for colposcopy. Patients were grouped into three categories: (1) ADHERENT to follow-up if they came to their first scheduled appointment; (2) DELAYED if they presented more than three months from their original referral (usually missing 1–3 appointments); and (3) NOT ADHERENT if they did not show for their appointment after referral. Analysis was performed using SPSS v.26.

Results

284 women met inclusion criteria for the study. The majority of women were Black (65.2 %) followed by non-Hispanic Whites (20.0 %) and Latinx (14.8 %). Overall, 39.1 % were ADHERENT, 18.6 % were DELAYED, and 42.3 % were NOT ADHERENT. When compared with non-Hispanic White women, there was a significant difference between race/ethnicity and timing of follow-up (p = 0.03). Blacks were more likely to be NOT ADHERENT (45.9 %; p = 0.03), and Latinx and Blacks were the most likely to be DELAYED (35.7 % and 21.1 %; p = 0.03). Private insurance patients were more likely to be ADHERENT for care compared with un-/underinsured patients (78.9 vs 27.8 %, p = 0.0001).

Conclusion

There is inadequate follow-up after abnormal cervical cancer screening across all races/ethnicities; however, lack of adherence is higher in Black patients. Moreover, 25% of Hispanic and Black women present in a delayed fashion. Culturally relevant assessments and interventions are needed to understand and address these gaps.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

BACKGROUND

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics.

OBJECTIVES

To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics.

DESIGN

Electronic medical record review of abnormal screening mammograms.

SUBJECTS

Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337).

MAIN MEASURES

Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors.

KEY RESULTS

Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively.

CONCLUSIONS

A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

Association of Race, Ethnicity, and Socioeconomic Status With Esthesioneuroblastoma Presentation, Treatment, and Survival

Objective

Socioeconomic and other demographic factors are associated with outcomes in head and neck cancer. This study uses a national cancer database to explore how patient race, ethnicity, and socioeconomic status (SES) are associated with esthesioneuroblastoma outcomes, including 5-year disease-specific survival (DSS), conditional DSS, stage at diagnosis, and treatment.

Study Design

Retrospective cohort analysis.

Setting

Patients with esthesioneuroblastomas between 1973 and 2015 from the SEER registry (Surveillance, Epidemiology, and End Results).

Methods

The National Cancer Institute Yost Index, a census tract–level composite score composed of 7 parameters, was used to categorize the SES of patients. Kaplan-Meier analysis and Cox regression were conducted to assess DSS. Conditional DSS was calculated per estimates from simplified Cox models. Logistic regression was conducted to identify risk factors for advanced cancer stage at diagnosis and the likelihood of receiving multimodal therapy.

Results

Complete data were included for 561 patients. DSS was significantly associated with SES (log-rank, P < .01) but not race. According to Cox regression, DSS was worse for the lowest SES tertile vs the highest (hazard ratio, 1.70 [95% CI, 1.05-2.75]; P = .03). Patients of the lowest SES tertile exhibited an increased risk of advanced cancer stage at diagnosis as compared with the highest SES tertile (odds ratio, 1.84 [95% CI, 1.06-3.30]; P = .035). Black patients (odds ratio, 0.44 [95% CI, 0.24-0.84]; P = .011) were less likely than other patients to receive multimodal therapy. SES alone was not associated with receiving multimodal therapy.

Conclusion

SES is significantly associated with DSS and conditional DSS for patients with esthesioneuroblastomas. Inequalities in access to care and treatment likely contribute to these disparities.

Racial Differences in Adherence to Lung Cancer Screening Follow-Up: A Systematic Review and Meta-Analysis

BACKGROUND

In 2013 the United States Preventive Services Taskforce (USPSTF) instituted recommendations for annual lung cancer screening (LCS) with low dose chest computed tomography for high-risk individuals. LCS reduces lung cancer mortality, with greater reduction observed in Black participants in clinical trials. While racial disparities in lung cancer mortality have been well documented, less is known about disparities in LCS participation and adherence to follow-up in clinical practice.

RESEARCH QUESTION

What is the association between race and adherence to LCS follow-up?

STUDY DESIGN & METHODS

A systematic review was conducted through a search of published studies in MEDLINE, PubMed, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature Database, from database inception through October 2020. We included studies that examined rates of adherence to LCS follow-up and compared rates by race. Studies were pooled using random-effects meta-analysis.

RESULTS

We screened 18,300 titles/abstracts and 229 studies were selected for full-text review. Nine studies met inclusion criteria; seven were included in the meta-analysis. Median adherent follow-up rate was 37% (range 16-82%). Notable differences among the studies included the proportion of the Black population (range 4-47%) and the structure of the LCS programs. The meta-analyses showed lower adherence to LCS follow-up in the Black population (Odds Ratio [OR]=0.67, [95% CI: 0.55, 0.80]). This disparity persisted across all malignancy risk levels determined by initial screening results.

INTERPRETATION

There is lower adherence to LCS follow-up in Black compared to White patients despite the higher potential lung cancer mortality benefit. Literature specifically addressing race-related barriers to LCS adherence is still limited. To ensure equity in LCS benefits, greater outreach to eligible Black patients should be implemented through increased physician education and utilization of screening program coordinators to focus on this patient population.

Impact of Socioeconomic Status on Paranasal Sinus Cancer Disease-Specific and Conditional Survival

OBJECTIVE

Socioeconomic status (SES) is often used to quantify social determinants of health. This study uses the National Cancer Institute SES index to examine the effect of SES on disease-specific survival and 5-year conditional disease-specific survival (CDSS; the change in life expectancy with increasing survivorship) in paranasal sinus cancer.

STUDY DESIGN

Cross-sectional analysis.

SETTING

National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program.

METHODS

A study of adults with sinus cancer between 1973 and 2015 was performed. The Yost index, a census tract-level composite score of SES, was used to categorize patients. Kaplan-Meier analysis and Cox regression for disease-specific survival were stratified by SES. CDSS was calculated with simplified models. Logistic regression was conducted to identify risk factors for advanced stage at diagnosis, multimodal therapy, and diagnosis of squamous cell carcinoma.

RESULTS

There were 3437 patients analyzed. In Cox models adjusting for patient-specific factors, the lowest SES tertile exhibited worse mortality (hazard ratio, 1.22; 95% CI, 1.07-1.39; P < .01). After addition of treatment and pathology, SES was not significant (P = .07). The lowest SES tertile was more often diagnosed at later stages (odds ratio [OR], 1.52; 95% CI, 1.12-2.06; P < .01). For those with regional/distant disease, the middle tertile (OR, 0.75; 95% CI, 0.63-0.90; P < .01) and lowest tertile (OR, 0.75; 95% CI, 0.62-0.91; P < .01) were less likely to receive multimodal therapy. SES tertiles primarily affected 5-year CDSS for regional/distant disease. CDSS for all stages converged over time.

CONCLUSION

Lower SES is associated with worse outcomes in paranasal sinus cancer. Research should be devoted toward understanding factors that contribute to such disparities, including tumor pathology and treatment course.

Social Determinants of Racial Disparities in Breast Cancer Mortality Among Black and White Women

INTRODUCTION

Mortality from breast cancer among Black women is 60% greater than that of White women in South Carolina (SC). The aim of this study was to assess racial differences in mortality among Black and White breast cancer patients based on variations in social determinants and access to state-based early detection programs.

METHODS

We obtained a retrospective record for breast cancer patients diagnosed between 2002 and 2010 from the SC Central Cancer Registry. Mortality was the main outcome while race-stratified Cox proportional hazard models were performed to assess disparities in mortality. We assessed effect modification, and we used an automated backward elimination process to obtain the best fitting models.

RESULTS

There were 3286 patients of which the majority were White women (2186, 66.52%). Compared with married White women, the adjusted hazard ratio (aHR) for mortality was greatest among Black unmarried women (aHR 2.31, CI 1.83, 2.91). Compared with White women who lived in the Low Country region mortality was greatest among Black women who lived in the Midland (aHR 2.17 CI 1.47, 3.21) and Upstate (aHR 2.96 CI 1.96, 2.49). Mortality was higher among Black women that were not receiving services in the Best Chance Network (BCN) program (aHR 1.70, CI 1.40, 2.04) compared with White women.

CONCLUSIONS

To reduce the racial disparity gap in survival in SC, Black breast cancer patients who live in the Upstate, are unmarried, and those that are not enrolled in the BCN program may benefit from more intense navigation efforts directed at early detection and linkage to breast cancer treatments.

Evaluation of Racial, Ethnic, and Socioeconomic Associations With Treatment and Survival in Uveal Melanoma, 2004-2014

Importance

Identifying disparities in uveal melanoma (UM) treatment patterns and survival across racial, ethnic, and socioeconomic (SES) groups reveals possible inequities in ophthalmologic health care.

Objective

To examine the association of race, ethnicity, and SES with UM treatment and survival.

Design, Setting, and Participants

A retrospective cohort analysis of 28% of the US population using the Surveillance, Epidemiology, and End Results (SEER) 18 registries from January 1, 2004, to December 31, 2014, was conducted. Data analysis was performed from April to July 2018. SEER identified 4475 individuals using International Classification of Diseases for Oncology, Third Edition site and morphology codes.

Exposures

Race, ethnicity, and SES estimated by tertile using Yost Index composite scores.

Main Outcomes and Measures

Treatment odds ratios (ORs), 1-year and 5-year survival estimates, mortality hazard ratios (HRs), and Kaplan-Meier survival curves. Hypothesis was formulated before data collection.

Results

Multivariate analyses of 4475 individuals (2315 [51.7%] men; non-Hispanic white, 4130 [92.3%]; nonwhite, 345 [7.7%]) showed that patients who were nonwhite (OR, 1.45; 95% CI, 1.12-1.88) and socioeconomically disadvantaged (lower SES: OR, 2.21; 95% CI, 1.82-2.68; middle SES: OR, 1.86; 95% CI, 1.56-2.21) were more likely to receive primary enucleation. No interactions were observed between race/ethnicity, SES, and stage at diagnosis. From 2004 to 2014, rates of primary enucleation decreased across all racial/ethnic and SES groups, but disparities persisted. Socioeconomically disadvantaged patients had lower 5-year all-cause survival rates (lower SES: 69.2%; middle SES: 68.1%; and upper SES: 73.8%), although disease-specific survival did not vary significantly by racial/ethnic or SES strata. Mortality risk was associated with older age at diagnosis (56-68 years: HR, 1.70; 95% CI, 1.44-2.01; ≥69 years: HR, 3.32; 95% CI, 2.85-3.86), advanced stage of UM (stage 2: HR, 1.40; 95% CI, 1.19-1.65; stage 3: HR, 2.26; 95% CI, 1.87-2.73; and stage 4: HR, 10.09; 95% CI, 7.39-13.77), and treatment with primary enucleation (HR, 2.14; 95% CI, 1.88-2.44) with no racial/ethnic or SES variation.

Conclusions and Relevance

In this study, SEER data from 2004 to 2014 suggest that nonwhite and socioeconomically disadvantaged patients with UM are more likely to be treated with primary enucleation, although no such variation appears to exist in disease-specific survival. These differences reveal opportunities to address issues regarding treatment choice in UM.

Location, Location, Location: The Association Between Imaging Setting and Follow-Up of Findings of Indeterminate Malignant Potential

PURPOSE

To evaluate the relationship between patient location at time of imaging and completion of relevant imaging follow-up for findings with indeterminate malignant potential.

METHODS

We used a mandatory hospital-wide standardized assessment categorization system to analyze all ultrasound, CT, and MRI examinations performed over a 7-month period. Multivariate logistic regression, adjusted for imaging modality, characteristics of patients, ordering clinicians, and interpreting radiologists, was used to evaluate the relationship between patient location (outpatient, inpatient, or emergency department) at the time of index examination and completion of relevant outpatient imaging follow-up.

RESULTS

Relevant follow-up occurred in 49% of index examinations, with a greater percentage among those performed in the outpatient setting compared with those performed in the inpatient or emergency department settings (62% versus 18% versus 17%, respectively). Compared with examinations obtained in the outpatient setting, examinations performed in the emergency department (adjusted odds ratio [aOR] 0.07; 95% confidence interval [CI], 0.03-0.19) and inpatient (aOR 0.14; 95% CI, 0.09-0.23) settings were less likely to be followed up. Black patients and those residing in lower-income neighborhoods were also less likely to receive relevant follow-up. Few lesions progressed to more suspicious lesions (4.6%).

CONCLUSIONS

Patient location at time of imaging is associated with the likelihood of completing relevant follow-up imaging for lesions with indeterminate malignant potential. Future work should evaluate health system-level care processes related to care setting, as well as their effects on appropriate follow-up imaging. Doing so would support efforts to improve appropriate follow-up imaging and reduce health care disparities.

A Comprehensive Analysis of How Environmental Risks of Breast Cancer are Portrayed on the Internet

BACKGROUND

Effective online communication about the environmental risk factors of breast cancer is essential because of the multitude of environmental exposures and debate regarding the conclusiveness of scientific evidence.

PURPOSE

The aim of this study was to assess the content, readability, and cultural sensitivity of online resources focused on the environmental risks factors of breast cancer.

METHODS

A purposive sample of webpages focused on environmental risk factors of breast cancer was obtained through a Google search using 17 search terms. Using nonparametric statistics, we assessed the content, readability, and cultural appropriateness of 235 webpages.

RESULTS

Eighty-two percent of webpages referred to research studies in their content. For the majority of sites, readability was at a high-school reading grade level. Webpages were not explicitly intended for specific racial/ethnic groups.

DISCUSSION

Technical language and non-culturally specific messages may hinder users' attention to and comprehension of online breast cancer information. Additional research is needed to examine in-depth the accuracy of this online content.

TRANSLATION TO HEALTH EDUCATION PRACTICE

Findings suggest that collaborations between scientists, health educators, website designers/media professionals, and the community will be critical to the delivery of accurate, up-to-date, plain-language, and culturally sensitive information about breast cancer and the environment.

Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography

BACKGROUND

Insurance may lengthen or inhibit time to follow-up after positive screening mammography. We assessed the association between insurance status and time to initial diagnostic follow-up after a positive screening mammogram.

METHODS

Using 1995-2010 data from a North Carolina population-based registry of breast imaging and cancer outcomes, we identified women with a positive screening mammogram. We compared receipt of follow-up within 60 days of screening using logistic regression and evaluated time to follow-up initiation using Cox proportional hazards regression.

RESULTS

Among 43,026 women included in the study, 73% were <65 years and 27% were 65+ years. Median time until initial diagnostic follow-up was similar by age group and insurance status. In the adjusted model for women <65, uninsured women experienced a longer time to initiation of diagnostic follow-up [HR, 0.47; 95% confidence interval (CI), 0.25-0.89] versus women with private insurance. There were increased odds of these uninsured women not meeting the Centers for Disease Control and Prevention guideline for follow-up within 60 days (OR, 1.59; 95% CI, 1.31-1.94). Among women ages 65+, women with private insurance experienced a faster time to follow-up (adjusted HR, 2.09; 95% CI, 1.27-3.44) than women with Medicare and private insurance. Approximately 10% of women had no follow-up by 365 days.

CONCLUSIONS

We found differences in time to initial diagnostic follow-up after a positive screening mammogram by insurance status and age group. Uninsured women younger than 65 years at a positive screening event had delayed follow-up.

IMPACT

Replication of these findings and examination of their clinical significance warrant additional investigation. Cancer Epidemiol Biomarkers Prev; 25(11); 1474-82. ©2016 AACR.

Disparities in Cancer Screening Practices among Minority and Underrepresented Populations

OBJECTIVES

To review current evidence about cancer screening challenges that lead to cancer health disparities in minority populations.

DATA SOURCES

Research reports, published journal articles, web sites, and clinical practice observations.

CONCLUSION

There are significant disparities that exist in cancer screening practices among racial and ethnic minority and underrepresented populations, resulting in disproportionately higher cancer mortality rates in these populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are positioned to lead in educating, promoting, and bringing awareness to cancer screening recommendationsand current cancer prevention guidelines for at-risk individuals, and help them to implement these guidelines to reduce incidence and mortality.

Time to follow-up of an abnormal mammogram in women with diabetes: a population-based study

Women with diabetes have a higher breast cancer incidence and mortality. They are also significantly less likely to undergo screening mammography and present with more advanced stage than women without diabetes. The purpose of this study was to examine if women with diabetes are more likely to have delays in follow-up of abnormal mammograms, compared to women without diabetes. Using population-based health databases, this retrospective cohort study examined women between the ages of 50 and 74, with and without diabetes, living in the province of Ontario, Canada, who underwent screening through a centralized program and who had an abnormal mammogram between 2003 and 2012. We compared rates of follow-up of a diagnostic test within 180 days, as well as likelihood of mastectomy or excision procedure and a diagnosis of breast cancer. Following an abnormal screening mammogram, 97.5% of women with diabetes had a diagnostic procedure within 180 days compared to 97.9% of women without diabetes. After adjustment for other factors, women with diabetes were only 3% less likely to have follow-up testing after an abnormal mammogram than women without diabetes (hazard ratio [HR] 0.97, 95% CI: 0.96-0.99, P < 0.001). The majority of Ontario women who underwent screening mammography through a centralized screening program had timely follow-up of an abnormal mammogram, with no meaningful delays in those who had diabetes. The results of this study suggest that diagnostic delays after screening do not significantly contribute to higher breast cancer mortality in women with diabetes.

Ethnic differences in social support after initial receipt of an abnormal mammogram

OBJECTIVES

We examine access to and type of social support after initial receipt of an abnormal mammogram across non-Latina White (NLW), African American, and Latina women.

METHOD

This cross-sectional study used a mixed method design, with quantitative and qualitative measures. Women were recruited through 2 community advocates and 3 breast-health-related care organizations.

RESULTS

With regard to access, African American women were less likely to access social support relative to NLW counterparts. Similar nonsignificant differences were found for Latinas. Women did not discuss results with family and friends to avoid burdening social networks and negative reactions. Networks' geographic constraints and medical mistrust influenced Latina and African American women's decisions to discuss results. With regard to type of social support, women reported emotional support across ethnicity. Latina and African American women reported more instrumental support, whereas NLW women reported more informational support in the context of their well-being.

CONCLUSIONS

There are shared and culturally unique aspects of women's experiences with social support after initially receiving an abnormal mammogram. Latina and African American women may particularly benefit from informational support from health care professionals. Communitywide efforts to mitigate mistrust and encourage active communication about cancer may improve ethnic disparities in emotional well-being and diagnostic resolution during initial receipt of an abnormal mammogram. (PsycINFO Database Record

Disparities in Breast Cancer Incidence, Mortality, and Quality of Care among African American and European American Women in South Carolina

OBJECTIVES

Breast cancer is the most frequently diagnosed cancer among women and the second-leading cause of female cancer deaths in the United States. African Americans and other minorities in the United States experience lower survival rates and have a worse prognosis than European Americans despite European Americans having a much higher incidence of the disease. Adherence to breast cancer treatment-quality measures is limited, particularly when the data are stratified by race/ethnicity.

METHODS

We aimed to examine breast cancer incidence and mortality trends in South Carolina by race and explore possible racial disparities in the quality of breast cancer treatment received in South Carolina.

RESULTS

African Americans have high rates of mammography and clinical breast examination screenings yet suffer lower survival compared with European Americans. For most treatment-quality metrics, South Carolina fairs well in comparison to the United States as a whole; however, South Carolina hospitals overall lag behind South Carolina Commission on Cancer-accredited hospitals for all measured quality indicators, including needle biopsy utilization, breast-conserving surgeries, and timely use of radiation therapy. Accreditation may a play a major role in increasing the standard of care related to breast cancer diagnosis and treatment.

CONCLUSIONS

These descriptive findings may provide significant insight for future interventions and policies aimed at eliminating racial/ethnic disparities in health outcomes. Further risk-reduction approaches are necessary to reduce minority group mortality rates, especially among African American women.

Delays in Cancer Care Among Low-Income Minorities Despite Access

INTRODUCTION

Narrowing the racial/ethnic and socioeconomic disparities in breast and cervical cancer requires an in-depth understanding of motivation for adherence to cancer screening and follow-up care. To inform patient-centered interventions, this study aimed to identify reasons why low-income women adhered to or delayed breast or cervical cancer screening, follow-up and treatment despite access to cancer care-related services.

METHODS

Semistructured qualitative interviews were conducted among women with access to cancer care-related services receiving care at an academic cancer center, federally qualified health centers, or free clinics in the Chicago metropolitan area. Transcripts were coded and analyzed for themes related to rationales for adherence.

RESULTS

Among 138 participants, most were African American (46%) or Hispanic (36%), English speaking (70%), and between ages 41 and 65 years (64%). Primary drivers of nonadherence included lack of knowledge of resources, denial or fear, competing obligations, and embarrassment. Facilitators included abnormality identification, patient activation, provider-initiated actions, and motivation from family or friends.

CONCLUSIONS

Interventions targeting increased adherence to care among low-income and ethnic minority women should direct efforts to proactive, culturally and patient-informed education that enables patients to access resources and use the health care system, address misconceptions about cancer, ensure health care providers' communication of screening guidelines, and leverage the patient's social support network.

Medical Advocacy and Supportive Environments for African-Americans Following Abnormal Mammograms

African-American women experience disproportionately adverse outcomes relative to non-Latina White women after an abnormal mammogram result. Research has suggested medical advocacy and staff support may improve outcomes among this population. The purpose of the study was to understand reasons African-American women believe medical advocacy to be important and examine if and how staff can encourage and be supportive of medical advocacy. A convenience-based sample of 30-74-year-old women who self-identified as African-American/Black/of African descent and who had received an abnormal mammogram result was recruited from community-based organizations, mobile mammography services, and the local department of health. This qualitative study included semi-structured interviews. Patients perceived medical advocacy to be particularly important for African-Americans, given mistrust and discrimination present in medical settings and their own familiarity with their bodies and symptoms. Respondents emphasized that staff can encourage medical advocacy through offering information in general in a clear, informative, and empathic style. Cultural competency interventions that train staff how to foster medical advocacy may be a strategy to improve racial disparities following an abnormal mammogram.

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.

Racial disparities in survival and age-related outcome in postsurgery breast cancer patients in a new york city community hospital

Breast cancer survival has significantly improved over the past two decades. However, the diagnosis of breast cancer is lower and the mortality rate remains higher, in African American women (AA) compared to Caucasian-American women. The purpose of this investigation is to analyze postoperative events that may affect breast cancer survival. This is a retrospective analysis of prospectively collected data from The Brooklyn Hospital Center cancer registry from 1997 to 2010. Of the 1538 patients in the registry, 1226 are AA and 269 are Caucasian. The study was divided into two time periods, 1997-2004 (period A) and 2005-2010 (period B), in order to assess the effect of treatment outcomes on survival. During period A, 5-year survival probabilities of 75.37%, 74.53%, and 78.70% were seen among all patients, AA women and Caucasian women, respectively. These probabilities increased to 87.62%, 87.15% and 89.99% in period B. Improved survival in AA women may be attributed to the use of adjuvant chemotherapy, radiation, and hormonal therapy. Improved survival in Caucasian patients was attributed to the use of radiation therapy, as well as earlier detection resulting in more favorable tumor grades and pathological stages.

The geographic distribution of mammography resources in Mississippi

OBJECTIVE: To determine whether the availability of mammography resources affected breast cancer incidence rates, stage of disease at initial diagnosis, mortality rates and/or mortality-to-incidence ratios throughout Mississippi. METHODS: Mammography facilities were geocoded and the numbers of residents residing within a thirty minute drive of a mammography facility were calculated. Other data were extracted from the Mississippi Cancer Registry, the U.S. Census, and the Mississippi Behavioral Risk Factor Surveillance Survey (BRFSS). RESULTS & DISCUSSION: There were no statistically-significant differences between breast cancer incidence rates in Black versus White females in Mississippi; however, there were significant differences in the use of mammography, percentages of advanced-stage initial diagnoses, mortality rates, and mortality-to-incidence ratios, where Black females fared worse in each category. No statistically-significant correlations were observed between breast cancer outcomes and the availability of mammography facilities. The use of mammography was negatively correlated with advanced stage of disease at initial diagnosis. By combining Black and White subsets, a correlation between mammography use and improved survival was detected; this was not apparent in either subset alone. There was also a correlation between breast cancer mortality-to-incidence ratios and the percentage of the population living below the poverty level. CONCLUSIONS: The accessibility and use of mammography resources has a greater impact on breast cancer in Mississippi than does the geographic resource distribution per se. Therefore, intensified mammography campaigns to reduce the percentage of advanced-stage breast cancers initially diagnosed in Black women, especially in communities with high levels of poverty, are warranted in Mississippi.

Does a bite cause cancer? Misperceptions of breast cancer etiology among low-income urban women in Miami, Florida

OBJECTIVES

To explore breast cancer beliefs among a cohort of low-income, urban, English-speaking women in Miami, Florida, who had undergone screening mammography.

METHODS

Four focus groups of 34 women were conducted. Discussions were transcribed verbatim and transcripts were analyzed separately by two investigators using an immersion-and-crystallization approach. Common risk factors were identified by consensus.

RESULTS

Participants were predominantly African American (82%) women of low income (77% with a household income <$20,000/year). Common risk factors included family history, environmental factors, trauma, and sexual activity. There also was a perception that breast cancer grows rapidly and causes detectable symptoms.

CONCLUSIONS

Women voiced some accurate and numerous inaccurate beliefs regarding the causes of breast cancer, suggesting a lack of knowledge about the potential benefits and harms of screening mammography before undergoing examination. These findings highlight the importance of identifying women's underlying beliefs when initiating a discussion of breast cancer screening and prevention to ensure that messages are mutually understood.

Patient navigation and time to diagnostic resolution: results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL

OBJECTIVES

The objective of this study was to evaluate a patient navigation (PN) program that attempts to reduce the time between a breast cancer screening abnormality and definitive diagnosis among medically underserved populations of Tampa Bay, Florida.

METHODS

The Moffitt Patient Navigation Research Program conducted a cluster randomized design with 10 primary care clinics. Patients were navigated from time of a breast screening abnormality to diagnostic resolution. This paper examined the length of time between breast abnormality and definitive diagnosis, using a shared frailty Cox proportional hazard model to assess PN program effect.

RESULTS

1,039 patients were eligible for the study because of an abnormal breast cancer screening/clinical abnormality (494 navigated; 545 control). Analysis of PN effect by two time periods of resolution (0-3 months and > 3 months) showed a lagged effect of PN. For patients resolving in the first three months, the adjusted Hazard Ratio (aHR) was 0.85 (95% Confidence Interval [CI]: 0.64-1.13) suggesting that PN had no effect on resolution time during this period. Beyond three months, however, navigated patients resolved more quickly to diagnostic resolution compared with the control group (aHR 2.8, 95%CI: 1.30-6.13). The predicted aHR at 3 months was 1.2, which was not statistically significant, while PN had a significant positive effect beyond 4.7 months.

CONCLUSIONS

PN programs may increase the timeliness of diagnostic resolution for patients with a breast cancer-related abnormality. PN did not speed diagnostic resolution during the initial three months of follow up but started to reduce time to diagnostic resolution after three months and showed a significant effect after 4.7 months.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00375024.

Patient navigation and time to diagnostic resolution: results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL

Objectives

The objective of this study was to evaluate a patient navigation (PN) program that attempts to reduce the time between a breast cancer screening abnormality and definitive diagnosis among medically underserved populations of Tampa Bay, Florida.

Methods

The Moffitt Patient Navigation Research Program conducted a cluster randomized design with 10 primary care clinics. Patients were navigated from time of a breast screening abnormality to diagnostic resolution. This paper examined the length of time between breast abnormality and definitive diagnosis, using a shared frailty Cox proportional hazard model to assess PN program effect.

Results

1,039 patients were eligible for the study because of an abnormal breast cancer screening/clinical abnormality (494 navigated; 545 control). Analysis of PN effect by two time periods of resolution (0-3 months and > 3 months) showed a lagged effect of PN. For patients resolving in the first three months, the adjusted Hazard Ratio (aHR) was 0.85 (95% Confidence Interval [CI]: 0.64-1.13) suggesting that PN had no effect on resolution time during this period. Beyond three months, however, navigated patients resolved more quickly to diagnostic resolution compared with the control group (aHR 2.8, 95%CI: 1.30-6.13). The predicted aHR at 3 months was 1.2, which was not statistically significant, while PN had a significant positive effect beyond 4.7 months.

Conclusions

PN programs may increase the timeliness of diagnostic resolution for patients with a breast cancer-related abnormality. PN did not speed diagnostic resolution during the initial three months of follow up but started to reduce time to diagnostic resolution after three months and showed a significant effect after 4.7 months.

Trial Registration

ClinicalTrials.gov NCT00375024

Individual and neighborhood socioeconomic status and healthcare resources in relation to black-white breast cancer survival disparities

Background. Breast cancer survival has improved significantly in the US in the past 10–15 years. However, disparities exist in breast cancer survival between black and white women. Purpose. To investigate the effect of county healthcare resources and SES as well as individual SES status on breast cancer survival disparities between black and white women. Methods. Data from 1,796 breast cancer cases were obtained from the Surveillance Epidemiology and End Results and the National Longitudinal Mortality Study dataset. Cox Proportional Hazards models were constructed accounting for clustering within counties. Three sequential Cox models were fit for each outcome including demographic variables; demographic and clinical variables; and finally demographic, clinical, and county-level variables. Results. In unadjusted analysis, black women had a 53% higher likelihood of dying of breast cancer and 32% higher likelihood of dying of any cause (P < 0.05) compared with white women. Adjusting for demographic variables explained away the effect of race on breast cancer survival (HR, 1.40; 95% CI, 0.99–1.97), but not on all-cause mortality. The racial difference in all-cause survival disappeared only after adjusting for county-level variables (HR, 1.27; CI, 0.95–1.71). Conclusions. Improving equitable access to healthcare for all women in the US may help eliminate survival disparities between racial and socioeconomic groups.

Factors influencing time to diagnosis after abnormal mammography in diverse women

BACKGROUND

Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram.

METHODS

Women aged 40-80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation.

RESULTS

In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < $10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis.

CONCLUSIONS

Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.

Racial differences in breast cancer stage at diagnosis in the mammography era

OBJECTIVES

We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.

METHODS

We calculated adjusted odds of distant (versus local or regional) tumors for 143,249 White and 13,571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.

RESULTS

Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black-White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).

CONCLUSIONS

In the mammography era, racial disparities remain in stage at diagnosis.

Mind the gap: racial differences in breast cancer incidence and biologic phenotype, but not stage, among low-income women participating in a government-funded screening program

Breast cancer mortality rates in South Carolina (SC) are 40 % higher among African-American (AA) than European-American (EA) women. Proposed reasons include race-associated variations in care and/or tumor characteristics, which may be subject to income effects. We evaluated race-associated differences in tumor biologic phenotype and stage among low-income participants in a government-funded screening program. Best Chance Network (BCN) data were linked with the SC Central Cancer Registry. Characteristics of breast cancers diagnosed in BCN participants aged 47-64 years during 1996-2006 were abstracted. Race-specific case proportions and incidence rates based on estrogen receptor (ER) status and histologic grade were estimated. Among 33,880 low-income women accessing BCN services, repeat breast cancer screening utilization was poor, especially among EAs. Proportionally, stage at diagnosis did not differ by race (607 cancers, 53 % among AAs), with about 40 % advanced stage. Compared to EAs, invasive tumors in AAs were 67 % more likely (proportions) to be of poor-prognosis phenotype (both ER-negative and high-grade); this was more a result of the 46 % lesser AA incidence (rates) of better-prognosis (ER+ lower-grade) cancer than the 32 % greater incidence of poor-prognosis disease (p values <0.01). When compared to the general SC population, racial disparities in poor-prognostic features within the BCN population were attenuated; this was due to more frequent adverse tumor features in EAs rather than improvements for AAs. Among low-income women in SC, closing the breast cancer racial and income mortality gaps will require improved early diagnosis, addressing causes of racial differences in tumor biology, and improved care for cancers of poor-prognosis biology.

Time to diagnosis and breast cancer stage by race/ethnicity

We examined differences in time to diagnosis by race/ethnicity, the relationship between time to diagnosis and stage, and the extent to which it explains differences in stage at diagnosis across racial/ethnic groups. Our analytic sample includes 21,427 non-Hispanic White (White), Hispanic, non-Hispanic Black (Black) and non-Hispanic Asian/Pacific Islander (Asian) women diagnosed with stage I to IV breast cancer between January 1, 2000 and December 31, 2007 at one of eight National Comprehensive Cancer Network centers. We measured time from initial abnormal mammogram or symptom to breast cancer diagnosis. Stage was classified using AJCC criteria. Initial sign of breast cancer modified the association between race/ethnicity and time to diagnosis. Among symptomatic women, median time to diagnosis ranged from 36 days among Whites to 53.6 for Blacks. Among women with abnormal mammograms, median time to diagnosis ranged from 21 days among Whites to 29 for Blacks. Blacks had the highest proportion (26 %) of Stage III or IV tumors. After accounting for time to diagnosis, the observed increased risk of stage III/IV breast cancer was reduced from 40 to 28 % among Hispanics and from 113 to 100 % among Blacks, but estimates remained statistically significant. We were unable to fully account for the higher proportion of late-stage tumors among Blacks. Blacks and Hispanics experienced longer time to diagnosis than Whites, and Blacks were more likely to be diagnosed with late-stage tumors. Longer time to diagnosis did not fully explain differences in stage between racial/ethnicity groups.

A cluster randomized trial evaluating the efficacy of patient navigation in improving quality of diagnostic care for patients with breast or colorectal cancer abnormalities

BACKGROUND

This study examines efficacy of a lay patient navigation (PN) program aimed to reduce time between a cancer abnormality and definitive diagnosis among racially/ethnically diverse and medically underserved populations of Tampa Bay, Florida.

METHODS

Using a cluster randomized design, the study consisted of 11 clinics (six navigated; five control). Patients were navigated from time of a breast or colorectal abnormality to diagnostic resolution, and to completion of cancer treatment. Using a generalized mixed-effects model to assess intervention effects, we examined: (i) length of time between abnormality and definitive diagnosis, and (ii) receipt of definitive diagnosis within the 6-month minimum follow-up period.

RESULTS

A total of 1,267 patients participated (588 navigated; 679 control). We also included data from an additional 309 chart abstractions (139 navigated arm; 170 control arm) that assessed outcomes at baseline. PN did not have a significant effect on time to diagnostic resolution in multivariable analysis that adjusted for race-ethnicity, language, insurance status, marital status, and cancer site (P = 0.16). Although more navigated patients achieved diagnostic resolution by 180 days, results were not statistically significant (74.5% navigated vs. 68.5% control, P = 0.07).

CONCLUSIONS

PN did not impact the overall time to completion of diagnostic care or the number of patients who reached diagnostic resolution of a cancer abnormality. Further evaluation of PN programs applied to other patient populations across the cancer continuum is necessary to gain a better perspective on its effectiveness.

IMPACT

PN programs may not impact timely resolution of an abnormality suspicious of breast or colorectal cancer.

A cluster randomized trial evaluating the efficacy of patient navigation in improving quality of diagnostic care for patients with breast or colorectal cancer abnormalities

BACKGROUND

This study examines efficacy of a lay patient navigation (PN) program aimed to reduce time between a cancer abnormality and definitive diagnosis among racially/ethnically diverse and medically underserved populations of Tampa Bay, Florida.

METHODS

Using a cluster randomized design, the study consisted of 11 clinics (six navigated; five control). Patients were navigated from time of a breast or colorectal abnormality to diagnostic resolution, and to completion of cancer treatment. Using a generalized mixed-effects model to assess intervention effects, we examined: (i) length of time between abnormality and definitive diagnosis, and (ii) receipt of definitive diagnosis within the 6-month minimum follow-up period.

RESULTS

A total of 1,267 patients participated (588 navigated; 679 control). We also included data from an additional 309 chart abstractions (139 navigated arm; 170 control arm) that assessed outcomes at baseline. PN did not have a significant effect on time to diagnostic resolution in multivariable analysis that adjusted for race-ethnicity, language, insurance status, marital status, and cancer site (P = 0.16). Although more navigated patients achieved diagnostic resolution by 180 days, results were not statistically significant (74.5% navigated vs. 68.5% control, P = 0.07).

CONCLUSIONS

PN did not impact the overall time to completion of diagnostic care or the number of patients who reached diagnostic resolution of a cancer abnormality. Further evaluation of PN programs applied to other patient populations across the cancer continuum is necessary to gain a better perspective on its effectiveness.

IMPACT

PN programs may not impact timely resolution of an abnormality suspicious of breast or colorectal cancer.

Genetic polymorphisms in RNA binding proteins contribute to breast cancer survival

The RNA-binding proteins TTP and HuR control expression of numerous genes associated with breast cancer pathogenesis by regulating mRNA stability. However, the role of genetic variation in TTP (ZFP36) and HuR (ELAVL1) genes is unknown in breast cancer prognosis. A total of 251 breast cancer patients (170 Caucasians and 81 African-Americans) were enrolled and followed up from 2001 to 2011 (or until death). Genotyping was performed for 10 SNPs in ZFP36 and 7 in ELAVL1 genes. On comparing both races with one another, significant differences were found for clinical and genetic variables. The influence of genetic polymorphisms on survival was analyzed by using Cox-regression, Kaplan-Meier analysis and the log-rank test. Univariate (Kaplan-Meier/Cox-regression) and multivariate (Cox-regression) analysis showed that the TTP gene polymorphism ZFP36*2 A > G was significantly associated with poor prognosis of Caucasian patients (HR = 2.03; 95% CI = 1.09-3.76; p = 0.025; log-rank p = 0.022). None of the haplotypes, but presence of more than six risk genotypes in Caucasian patients, was significantly associated with poor prognosis (HR=2.42; 95% CI = 1.17-4.99; p = 0.017; log-rank p = 0.007). The effect of ZFP36*2 A > G on gene expression was evaluated from patients' tissue samples. Both TTP mRNA and protein expression was significantly decreased in ZFP36*2 G allele carriers compared to A allele homozygotes. Conversely, upregulation of the TTP-target gene COX-2 was observed ZFP36*2 G allele carriers. Through its ability to attenuate TTP gene expression, the ZFP36*2 A > G gene polymorphism has appeared as a novel prognostic breast cancer marker in Caucasian patients.

Time to follow up after an abnormal finding in organized gastric cancer screening in Korea

Background

The prognosis for an abnormal medical finding is affected by both early detection and adherence to the presecribed schedule for follow-up examinations. In this study, we examined the time to follow up after an abnormal finding and determined the risk factors related to delays in follow up in a population-based screening program.

Methods

The study population consisted of patients who were newly diagnosed with gastric cancer through a gastric cancer screening program sponsored by the National Cancer Screening Program (NCSP) in 2005. Due to the skewed nature of the distribution of time to follow up, medians and interquartile ranges (IQR) are presented, and we analyzed the number of days preceding the follow-up time as a binary variable (≤90 days or >90 days). We used logistic regression analyses to evaluate the risk factors for a long delay.

Results

The median number of days to follow-up initiation after an abnormal finding was 11 (IQR 7–27); 13.9% of the patients with gastric cancer obtained their follow-up evaluation more than 90 days. Age, type of health insurance, screening method, and screening results were risk factors for delays in follow up.

Conclusions

This study examined delays from the time of the discovery of an abnormal finding to time of the follow-up evaluation. Because inadequate follow up of abnormal exam results undermines the potential benefits of cancer screening, it is important to organize services that minimize delays between cancer screening and treatment.

Lung cancer survival among black and white patients in an equal access health system

BACKGROUND

Racial disparities in lung cancer outcomes have been observed in the general population. However, it is unclear whether survival differences persist when patients have equal access to health care. Our objective was to determine if lung cancer survival differed among black and white patients in the U.S. Military Health System (MHS), an equal access health care system.

METHODS

The study subjects were 10,181 black and white patients identified through the Department of Defense's Automated Central Tumor Registry, who were 20 years old or more and diagnosed with lung cancer between 1990 and 2003. Racial differences in all-cause survival were examined using the Kaplan-Meier method and Cox proportional hazards regression models stratified by histology. For comparison, survival rates in the general population were calculated using Surveillance Epidemiology and End Results-9 data.

RESULTS

Analyses included 9,154 white and 1,027 black patients: 1,834 small cell lung cancers, 3,876 adenocarcinomas, 2,741 squamous cell carcinomas, and 1,730 large cell carcinomas. Although more favorable crude survival was observed among black patients than white patients with small cell lung cancer (P = 0.04), survival was similar between the two groups after covariate adjustment. Racial differences in survival were nonsignificant for adenocarcinomas, squamous cell carcinomas, and large cell carcinomas. Survival rates appeared to be better in the MHS than in the general population.

CONCLUSIONS AND IMPACT

All-cause survival was similar among black and white lung cancer patients in the MHS. Providing equal access to health care may eliminate racial disparities in lung cancer survival while improving the outcome of all cases.

Healthcare access and mammography screening in Michigan: a multilevel cross-sectional study

BACKGROUND

Breast cancer screening rates have increased over time in the United States. However actual screening rates appear to be lower among black women compared with white women.

PURPOSE

To assess determinants of breast cancer screening among women in Michigan USA, focusing on individual and neighborhood socio-economic status and healthcare access.

METHODS

Data from 1163 women ages 50-74 years who participated in the 2008 Michigan Special Cancer Behavioral Risk Factor Survey were analyzed. County-level SES and healthcare access were obtained from the Area Resource File. Multilevel logistic regression models were fit using SAS Proc Glimmix to account for clustering of individual observations by county. Separate models were fit for each of the two outcomes of interest; mammography screening and clinical breast examination. For each outcome, two sequential models were fit; a model including individual level covariates and a model including county level covariates.

RESULTS

After adjusting for misclassification bias, overall cancer screening rates were lower than reported by survey respondents; black women had lower mammography screening rates but higher clinical breast examination rates than white women. However, after adjusting for other individual level variables, race was not a significant predictor of screening. Having health insurance or a usual healthcare provider were the most important predictors of cancer screening.

DISCUSSION

Access to healthcare is important to ensuring appropriate cancer screening among women in Michigan.

Urban women's preferences for learning of their mammogram result: a qualitative study

Research suggests that communication of mammogram results is flawed for many low-income ethnic minority women. This study conducted four focus groups with low-income inner-city minority women (n = 34). The goals of our project were: (1) to elucidate women's experiences learning of their result; (2) to elicit their preferences as to how this communication could be improved; and (3) to gather information to help inform the development of a new tool for communicating mammogram results. Salient themes included dissatisfaction with result communication; difficulty elucidating the meaning of a typical results notification letter; a preference for direct verbal communication of results and for print materials that included pictures, testimonials, and an action plan including a hotline to call with questions; and a strong interest in advance education about the likelihood of having to return for additional follow up. Video and other programs to inform patients before the test about what happens after may improve patient satisfaction and enhance women's understanding of their personal result and follow up plan.

Patients' barriers to receipt of cancer care, and factors associated with needing more assistance from a patient navigator

BACKGROUND

Racial minorities have poorer cancer survival in the United States compared to whites. The purpose of this study was to better understand patients' barriers to cancer care and to determine which patients have a greater need for assistance from a patient navigator.

METHODS

Community health workers assisted newly-diagnosed breast and colorectal cancer patients during a randomized trial of patient navigation and collected information about patients' barriers. Barriers to care were characterized and compared between non-Hispanic white and minority patients. A multivariate model was constructed of factors associated with increased log navigation time, a measure of patients' need for assistance.

RESULTS

Patients' (n = 103) most commonly identified barriers to care included a lack of social support, insurance/financial concerns, and problems communicating with health care providers. Barriers differed between nonminority and minority patients, and minority patients faced a greater number of barriers (p = .0001). In univariate analysis, log navigation time was associated with race/ethnicity, education, income, employment, insurance type, health literacy, marital status, language, and comorbidity. A multivariate model (R2 = 0.43) for log navigation time was created using stepwise selection, and included the following factors: minority race/ethnicity (p = .032), non-full-time employment (p = .0004), unmarried status (p = .085), university center (p = .0005), and months in study (p <.0001).

CONCLUSIONS

Newly diagnosed cancer patients' most common barriers to care include lack of social support, insurance/financial concerns, and problems with health care communications. In this sample of patients, a greater need for assistance was independently associated with minority race/ethnicity and unemployment. These data may help in the design and targeting of interventions to reduce cancer health disparities.

Innovative approaches to reducing cancer health disparities: the Moffitt Cancer Center Patient Navigator Research Program

The Moffitt Cancer Center Patient Navigation Research Program (Moffitt PNRP) is evaluating the efficacy of patient navigation in reducing delays from screening abnormality to diagnostic resolution of a breast or colorectal abnormality. The Moffitt PNRP was conducted in three phases: (1) developing an acceptable, appealing, and culturally appropriate patient navigation program; (2) conducting a group randomized controlled trial to evaluate the patient navigation program; and (3) disseminating research findings and Moffitt PNRP intervention model. The patient navigation program was developed through significant formative research, input from the Moffitt PNRP Community Advisory Board, and through a close collaboration with the Tampa Bay Community Cancer Network. 1367 patients were enrolled in the Phase 2 group randomized trial of the Moffitt PNRP. Most Moffitt PNRP group randomized trial participants are Hispanic, female, and Spanish speaking, with minimal education and income. Analyses are currently being conducted to evaluate efficacy of the Moffitt PNRP.

Timeliness of follow-up after abnormal screening mammogram: variability of facilities

PURPOSE

To describe the timeliness of follow-up care in community-based settings among women who receive a recommendation for immediate follow-up during the screening mammography process and how follow-up timeliness varies according to facility and facility-level characteristics.

MATERIALS AND METHODS

This was an institutional review board-approved and HIPAA-compliant study. Screening mammograms obtained from 1996 to 2007 in women 40-80 years old in the Breast Cancer Surveillance Consortium were examined. Inclusion criteria were a recommendation for immediate follow-up at screening, or subsequent imaging, and observed follow-up within 180 days of the recommendation. Recommendations for additional imaging (AI) and biopsy or surgical consultation (BSC) were analyzed separately. The distribution of time to follow-up care was estimated by using the Kaplan-Meier estimator.

RESULTS

Data were available on 214,897 AI recommendations from 118 facilities and 35,622 BSC recommendations from 101 facilities. The median time to subsequent follow-up care after recommendation was 14 days for AI and 16 days for BSC. Approximately 90% of AI follow-up and 81% of BSC follow-up occurred within 30 days. Facilities with higher recall rates tended to have longer AI follow-up times (P < .001). Over the study period, BSC follow-up rates at 15 and 30 days improved (P < .001). Follow-up times varied substantially across facilities. Timely follow-up was associated with larger volumes of the recommended procedures but not notably associated with facility type nor observed facility-level characteristics.

CONCLUSION

Most patients with follow-up returned within 3 weeks of the recommendation.