Social and biological factors in relation to survival among black vs. white women with breast cancer

Area Deprivation Index in Patients with Invasive Lobular Carcinoma of the Breast: Associations with Tumor Characteristics and Outcomes

BACKGROUND

Although investigators have shown associations between socioeconomic status (SES) and outcomes in breast cancer, there is a paucity of such data for invasive lobular carcinoma (ILC), the second most common type of breast cancer. Herein we evaluated the relationship between SES with tumor features and outcomes in stage I to III patients with ILC.

METHODS

We analyzed a prospectively maintained institutional ILC database and utilized the area deprivation index (ADI) to determine neighborhood adversity, an indicator of SES. We used Cox proportional hazards models in Stata 17.0 to evaluate relationships between ADI quintile (Q), race, body mass index (BMI), clinicopathologic features, treatment type, and event-free survival (EFS).

RESULTS

Of 804 patients with ILC, 21.4% lived in neighborhoods classified as ADI Q1 (least resource-deprived) and 19.7% in Q5 (most resource-deprived). Higher deprivation was significantly associated with larger tumor size (3.6 cm in Q5 vs. 3.1 cm in Q1), increased presence of lymphovascular invasion (8.9% in Q5 vs. 6.7% in Q1), and decreased use of adjuvant endocrine therapy (67.1% in Q5 vs. 73.6% in Q1). On multivariable analysis, tumor size, receptor subtypes, and omission of adjuvant endocrine therapy were associated with reduced EFS.

CONCLUSIONS

These data show that patients with ILC and higher ADI experience more aggressive tumors and differences in treatment. More data evaluating the complex relationships between these factors is needed to optimize outcomes for patients with ILC, regardless of SES.

IMPACT

ADI is associated with differences in patients with ILC.

Survival probability and prognostic factors for breast cancer patients in Vietnam

Background

Breast cancer is becoming a public health problem in Vietnam. The mortality to incidence ratio of the disease was ranked second among the most common cancers in women. This study estimates the survival probability at 1, 3, and 5 years following diagnosis and determines prognostic factors for breast cancer mortality in Vietnam.

Methods

A survival analysis was conducted based on retrospective data from Hue Central Hospital and the Cancer Registry in Ho Chi Minh City. Using the Kaplan-Meier method, the survival probability of patients with breast cancer was estimated at 1, 3, and 5 years following diagnosis. The covariates among prognostic factors for survival time were studied using an extended Cox proportion hazards model, including time-dependent predictors.

Results

Overall survival rates at 1, 3, and 5 years following diagnosis were 0.94, 0.83 and 0.74 respectively. Marital status, education level, stage at diagnosis, and hormone therapy were prognostic factors for mortality. For the stage at diagnosis, the relation to the risk of death for breast cancer was 1.32 (95% CI, 1.22–1.41). Married women faced a risk of death nearly 1.59 times higher than unmarried women (95% CI, 1.09–2.33). Women with higher levels of education and who received hormone therapy had approximately 10% (hazard ratio [HR]: 0.92; 95% CI, 0.89–0.96) and 80% (HR: 0.22; 95% CI, 0.12–0.41) risk reduction of death respectively, compared with those classified as illiterate and those without hormone therapy.

Conclusions

The 5-year survival probability of breast cancer was lower in Vietnam than in countries with similar distributions of the stage at diagnosis. Screening programs and related support policies should be developed to increase the life expectancy of women with breast cancer in Vietnam.

Hormone receptor status and survival in a population-based cohort of patients with breast carcinoma

BACKGROUND

The objective of this study was to assess hormone receptor status as an independent predictor of survival in a population-based cohort of women with breast carcinoma who were followed for up to 11 years.

METHODS

Since 1990, the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program has collected data on hormone receptor status among patients with breast carcinoma. In a cohort of 205,736 women with breast carcinoma age > or = 20 years at diagnosis who were entered into the SEER data base between 1990 and 2000, the authors analyzed the association of hormone receptor status with year of diagnosis, patient age, disease stage, tumor histology, tumor grade, race/ethnicity, and metropolitan/statewide residence areas. Kaplan-Meier survival curves were compared according to hormone receptor status, and Cox proportional-hazards regression models were used to assess the association of hormone receptor status with breast carcinoma-specific and all-cause mortality controlling for age, disease stage, tumor grade, tumor histology, race/ethnicity, and SEER region.

RESULTS

Women who had tumors that were positive for both estrogen and progesterone hormone receptors had significantly better survival than other women with breast carcinoma in the overall cohort, within each stage, and in the younger and older age groups, although the survival advantage was greater among women age < or = 50 years than among older women. Hormone receptor status was associated with mortality even when patient age, disease stage, tumor grade, tumor histology, race/ethnicity, and metropolitan/statewide residence areas were taken into account.

CONCLUSIONS

Hormone receptor status was identified as an independent predictor of outcome in women with breast carcinoma. Data from clinical trials with long follow-up may shed light on whether and how the benefit of hormonal and other treatment varies with hormone receptor status.

Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma

BACKGROUND

Few studies have addressed the issue of whether delays in the interval between medical consultation and the diagnosis and treatment of breast carcinoma are greater for African American women than for white women. The authors examined differences with respect to these delays and analyzed the factors that may have contributed to such differences among women ages 20-54 years who had invasive breast carcinoma diagnosed between 1990 and 1992 and who lived in Atlanta, Georgia.

METHODS

A total of 251 African American women and 580 white women were interviewed and had their medical records reviewed. The authors estimated racial differences in delay times and used polytomous logistic regression to determine the contributions of various factors (socioeconomic and other) to these differences.

RESULTS

Although most women in both groups were treated within 3 months of initial consultation, 22.4% of African American women and 14.3% of white women had clinical delays of > 3 months. Compared with white women, African American women were more likely to experience delays in diagnosis and treatment. Access to care (as represented by method of detection and insurance status) and poverty index partially accounted for these differences in delay time; however, racial differences in terms of delayed treatment and diagnosis remained even after adjustment for contributing factors.

CONCLUSIONS

The findings of the current study suggest that among women ages 20-54 years who have breast carcinoma, potentially clinically significant differences in terms of delayed diagnosis and treatment exist between African American women and white women. Improvements in access to care and in socioeconomic circumstances may address these differences to some degree, but additional research is needed to identify other contributing factors.

A comparison of five immunohistochemical biomarkers and HER-2/neu gene amplification by fluorescence in situ hybridization in white and Korean patients with early-onset breast carcinoma

BACKGROUND

The objective of this article was to compare five tumor markers between white women in the U.S. and native Korean women with early-onset breast carcinoma.

METHODS

Sixty Korean women who were diagnosed with breast carcinoma at age 45 years or younger and 60 white women with breast carcinoma who were matched by age were selected for this study. The median age of both groups was 37 years. Paraffin embedded blocks of the primary tumor were processed for immunohistochemical staining of estrogen receptor (ER), progesterone receptor (PR), p53, cyclin D1, and HER-2/neu.

RESULTS

The proportion of tumors that stained positive for ER, PR, p53, and cyclin D1 in the Korean women were 47.5%, 42.4%, 28.8%, and 40.9%, respectively; in the white women, the proportions were 43.9%, 52.6%, 21.1%, and 59.1%, respectively. The differences between the white patients and the Korean patients were not statistically significant with respect to any of those variables. A significant difference was found in the expression of HER-2/neu. Specifically, positive HER-2/neu status was observed in 47.5% of Korean women, compared with overexpression in only 15.8% of white women (P < 0.001). Fluorescence in situ hybridization analysis for HER-2/neu gene amplification on all HER-2/neu positive samples that scored 2 + and 3 + demonstrated a significant difference (P = 0.007) in gene amplification between the two populations. Differences in HER-2/neu positivity were observed for the entire cohort as well as among the subsets of patients with negative and positive lymph node status. No association was found between immunoreactivity for the five markers and axillary lymph node metastasis.

CONCLUSIONS

The findings of high positivity of HER-2/neu expression and gene amplification in Korean women with early-onset breast carcinoma may have potential implications for local and systemic management of breast carcinoma, especially anti-HER-2/neu therapy for patients with hormone receptor negativity. Further research will be needed to identify biologic and genetic factors and their effects on the survival between different racial groups.

Histopathology of breast cancer among African-American women

Although the overall incidence of breast cancer in African-American women is lower than in white women, African-American women younger than 50 years old have a higher incidence of breast cancer than white women. African-American women with breast cancer have a poorer survival rate than white women and are more likely to die of breast cancer in almost every age group. To explain this disparity, we studied a substantial body of literature that reported a biologic difference in the tumors found in African-American and white women. Specifically, more aggressive histopathologic patterns have been described among African-American patients with breast cancer when compared with white women. In addition, there are data that support an ethnicity-related variation in the expression of breast tumor hormonal markers. The objective of this study was to critically evaluate the existing published data on the histologic features of breast cancer to determine whether breast cancer in African-American women is a histologically more aggressive disease than in white women. We conclude that the aggressive tumor histology reported in African-American women has not been analyzed carefully with respect to the age of the patient at the time of diagnosis and the stage of disease at presentation. Furthermore, there is a need for central pathology review using accepted, published criteria for diagnosis of uncommon and controversial histologic subtypes of breast cancer.

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

BACKGROUND

Whether African-American women have biologically more aggressive breast carcinoma compared with white women and whether race acts as a significant independent prognostic factor for survival have not been determined. Alternatively, race merely may be a surrogate for socioeconomic status (SES).

METHODS

A literature review was performed of clinical trials and retrospective studies in the U.S. that compared survival between white women and black women with breast carcinoma after adjustment for known prognostic factors (patient age, disease stage, lymph node status, and estrogen receptor status) to assess the impact of race and SES.

RESULTS

Single institutional and clinical studies suggest that, when black patients are treated appropriately and other prognostic variables are controlled, their survival is similar to the survival of white patients. Twelve retrospective studies and 1 analysis of a clinical trial included SES and race as variables for survival. Only three of those studies revealed race as a significant prognostic factor for survival after adjusting for SES.

CONCLUSIONS

SES replaces race as a predictor of worse outcome after women are diagnosed with breast carcinoma in many studies. However, black women present with more advanced disease that appear more aggressive biologically, and they present at a younger age compared with white women. Further research should be conducted concerning the precise elements of SES that account for the incidence of breast carcinoma, age at diagnosis, hormone receptor status, and survival to devise better strategies to improve outcome.

African-American ethnicity, socioeconomic status, and breast cancer survival: a meta-analysis of 14 studies involving over 10,000 African-American and 40,000 White American patients with carcinoma of the breast

BACKGROUND

African-American women are at increased risk for breast cancer mortality compared with white American women, and the extent to which socioeconomic factors account for this outcome disparity is unclear.

METHODS

A MEDLINE search was conducted to identify published studies that used a Cox proportional hazards regression model to evaluate the outcome of African-American women and white American women with breast carcinoma after adjusting for socioeconomic status. A meta-analysis was performed using specialized statistical software; the random-effects method of statistical evaluation was used because of the a priori impression that the studies reviewed would be at least moderately heterogeneous in study design and patient populations.

RESULTS

The initial literature search yielded 3962 studies. Fourteen studies met all criteria for inclusion in the meta-analysis, resulting in a sample size of 10,001 African-American patients and 42,473 white American patients with breast carcinoma. There was substantial variation in the method used for defining socioeconomic status. Summary statistics revealed a significant odds ratio of 1.22 (95% confidence interval, 1.13-1.30) for the adverse effect of African-American ethnicity on breast cancer mortality. Subset meta-analyses yielded similar results, supporting the robustness of this finding.

CONCLUSIONS

This meta-analysis revealed that African-American ethnicity is an independent predictor of a worse breast cancer outcome. The pooled analysis has added strength because of the aggregate sample size and indicates that the true biologic and/or therapeutic determinants of disparities in breast cancer outcome for different ethnic groups and for different socioeconomic strata are incompletely understood.

Racial differences in breast carcinoma survival

BACKGROUND

Survival after breast carcinoma diagnosis is significantly worse among African American women for reasons unknown. The purpose of this study was to update reports on the National Surveillance, Epidemiology, and End Results Program and to examine the effect of race on breast carcinoma survival.

METHODS

Subjects were 135,424 women diagnosed with primary breast carcinoma between 1988-1995. Patient age, tumor stage at the time of diagnosis, hormone receptor status, tumor histology, menopausal status, and survival were compared by race category.

RESULTS

African American women diagnosed with breast carcinoma (n = 11,159) had a significantly increased risk of death from breast carcinoma and from all cancers compared with white women (n = 124,265), independent of the effects of other predictor variables. African American women were significantly younger at the time of diagnosis, with approximately 33% of the population age </= 50 years, compared with slightly <25% of the white women belonging to that younger age group. African American women were significantly more likely to present with advanced stages of breast carcinoma and, within each stage category, had significantly poorer survival compared with white women. African American women were significantly less likely to have tumors positive for estrogen or progesterone receptors, as well as histologically confirmed lobular and tubular carcinomas, whereas they were more likely to have inflammatory, medullary, and papillary histology compared with white women.

CONCLUSIONS

The results of the current study show that race is an independent predictor of survival from breast carcinoma. These findings are consistent with other large, population-based studies of racial differences in breast carcinoma survival and have been comported by studies of racial differences in the molecular biology of breast carcinoma, thus providing support for the epidemiologic credibility of the independence of the association.

Breast cancer histology in Caucasians, African Americans, Hispanics, Asians, and Pacific Islanders

STUDY OBJECTIVES

To investigate the association between race/ethnicity and histologic types of breast cancer.

DESIGN

Cross-sectional study.

SETTING

Population-based data from the Northern California Tumor Registry, which is part of the National Cancer Institute's Surveillance, Epidemiology and End Results Program.

PARTICIPANTS

A total of 2759 breast cancer cases diagnosed in 1988.

MAIN RESULTS

Tumors were classified as ductal, lobular, and mixed/unspecified carcinoma. Ductal carcinoma was the most common (83.6%) and lobular carcinoma was the rarest. Most cases were diagnosed in the localized stage (56.3%). Caucasian women had the highest rates of total breast cancer (240.9/100,000), ductal and lobular. In African-American women, the odds of ductal carcinoma were twice that of lobular carcinoma, compared with Caucasian women (odds ratio [OR] = 2.0, 95% confidence interval [CI] 1.0-3.9) after adjusting for age, site, and stage at diagnosis. Similarly, Asian and Hispanic women also had higher, non-statistically significant odds of ductal versus lobular carcinoma compared with Caucasians (OR = 1.8 [95% CI 0.9-3.7] and 1.6 [95% CI 0.8-3.4], respectively).

CONCLUSIONS

Future studies should investigate how racial/ethnic differences in histology among breast cancer patients will influence life expectancy, against a backdrop of health care access, sociocultural issues, lifestyle habits, reproductive history, family history, and tumor characteristics.

A comparison of screening mammography results from programs for women of different socioeconomic status

BACKGROUND

The ability of screening mammography programs serving women of different socioeconomic status (SES) to diagnose early stage breast carcinoma in a comparably effective fashion has been questioned.

METHODS

Results of screening 50,653 women of lower SES were compared with those of screening 45,923 more socioeconomically advantaged women during the same period in New York State. Results were compared with those reported for the general population to the New York State cancer registry.

RESULTS

Additional workup was required for approximately 12% of the women in each group. Although more women of lower SES underwent biopsy, the positive predictive value of a biopsy recommendation was almost the same for the two populations (27% for women of higher SES vs. 25% for women of lower SES). Among women with breast carcinoma, ductal carcinoma in situ was diagnosed in 27% of more affluent women and 15% of women of lower SES, a considerable improvement from the 10% rate of diagnosis in the general population in New York State. Minimal cancers accounted for 54% of those diagnosed in more affluent women and at least 31% of those diagnosed in women of lower SES.

CONCLUSIONS

Screening mammography programs can be effective for women of lower SES and can be conducted as efficiently as they are for more affluent women. Differences in diagnosis of small cancers in the two groups reported in this article may reflect differences in age and patterns of prior screening experience in the two populations.

Prognosis among African-American women and white women with lymph node negative breast carcinoma: findings from two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP)

BACKGROUND

A disparity in breast carcinoma survival between African-American and white women has been noted over the past several decades. A major factor implicated in this disparity is stage of disease at diagnosis. In this study, survival and related endpoints were examined among African-American women and white women with lymph node negative breast carcinoma who participated in two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP).

METHODS

Patients from two studies, one conducted among patients with estrogen receptor (ER) negative tumors and the other among patients with ER positive tumors, were included. Study goals were to determine whether African-Americans and whites had comparable outcomes, accounting for ER status and differences in patient characteristics at diagnosis, and to determine whether treatment response was similar for African-Americans and whites.

RESULTS

Five-year survival rates were 83% for African-Americans and 85% for whites among ER negative patients, and 93% for African-Americans and 92% for whites among ER positive patients. Rates of disease free survival (DFS) (i.e., time to disease recurrence, second primary cancer, or death) were 71% for African-Americans and 74% for whites at 5 years among ER negative patients, and 81% for African-Americans and 80% for whites among ER positive patients. African-Americans tended to have less favorable baseline prognostic characteristics. Adjusted relative risk (RR) estimates indicated similar prognosis for African-Americans compared with whites for mortality (African-American/white RR = 1.02 with 95% confidence interval [CI], 0.66-1.56 among ER negative patients; RR = 1.14 with 95% CI, 0.84-1.54 among ER positive patients) and DFS (RR = 0.98 with 95% CI, 0.70-1.37 for ER negative patients; RR = 0.96 with 95% CI, 0.75-1.22 for ER positive patients). Estimated percent reductions in DFS events for patients receiving adjuvant therapy were 32% for ER negative African-Americans, 36% for ER negative whites, 20% for ER positive African-Americans, and 39% for ER positive whites.

CONCLUSIONS

African-American and white patients with localized breast carcinoma had similar outcomes and benefited equally from systemic therapy. These results suggest that early detection and appropriate therapy among African-American patients could result in a reduction in the current disparity in breast carcinoma mortality between African-Americans and whites.

Effects of race and socioeconomic status on survival of 1,332 black, Hispanic, and white women with breast cancer

BACKGROUND

A survival disadvantage for black women with breast cancer, which persists after controlling for stage of the disease, has been reported. This study investigates the effects of race and socioeconomic status (SES) on breast cancer survival after controlling for age, stage, histology, and type of treatment.

METHODS

Kaplan-Meier and Cox proportional hazards models were used to analyze the interaction between race and SES in predicting survival in a sample of 163 black, 205 Hispanic and 964 white women with breast cancer treated at M.D. Anderson Cancer Center a (1987-1991).

RESULTS

The results of univariate and multivariate analyses indicate that race was not a significant predictor of survival after adjusting for SES and other confounding factors such as demographic and disease characteristics. SES remained a significant predictor of survival after all adjustments were made. There was no evidence of differences in type of treatment by race or SES if adjustments were made for stage.

CONCLUSIONS

These results suggest that institutional factors, such as access to treatment, do not explain survival differences by race or SES. Other factors associated with low SES, such as life-style and behavior, may affect survival.

Breast cancer. Is ethnicity an independent prognostic factor for survival?

BACKGROUND

A survival difference between white and black females has been reported after diagnosis and treatment for breast carcinoma. Although multivariate analyses demonstrate that the survival difference is less or nonexistent when additional prognostic factors are considered, study results have been inconsistent. The objective of this study was to examine further the role of ethnicity as an independent prognostic factor for breast carcinoma survival among white and black females treated over a 30-year period.

METHODS

Among 3382 eligible white and black females who registered at M. D. Anderson Cancer Center (MDACC) from 1958 to 1987, ethnicity, age, socioeconomic status (SES), stage of disease, and treatment were examined. Data were obtained from the hospital tumor registry and survival was compared using actuarial life tables and multivariate Cox regression analyses.

RESULTS

Univariate analyses demonstrated that the survival difference between white and black females was significant, with black females having a 1.63 times higher risk of mortality at 5 years compared with white females (confidence interval (CI), 1.47-1.82), with ethnicity a significant predictor of survival (P < 0.001). After controlling for SES, stage, and treatment, the relative risk was 1.12 (CI, 1.00-1.25) and ethnicity was no longer a strong predictor of survival (P = 0.048).

CONCLUSIONS

In this hospital population, the white and black female survival difference, which was highly significant when only univariate analyses were considered, became marginally significant after controlling for other prognostic factors.

Limitations in upper-body strength associated with breast cancer: a comparison of black and white women

We examined differences in reported upper-body limitations between black and white breast cancer cases and controls aged 40 to 84 years at 3 and 12 months after diagnosis in the Detroit metropolitan area (n = 954 cases and 1000 controls at 3 months; n = 879 cases and 909 controls at 12 months). At 3 months black cases were more likely than white cases to report limitations in upper-body strength (30.4 versus 19.8%). No difference was found between black and white controls (8.0 versus 9.4%). At 12 months, the proportion of white patients with upper-body limitation returned to the same level as white controls. Black patients with limitations, however, did not return to the same level as black controls. Stage of disease was strongly associated with upper-body limitations, especially for black women. Race and stage differences in upper-body limitation could not be explained by differences in breast cancer treatment, financial adequacy, education, marital status, or comorbidity. Recommendations are made for more comprehensive studies of rehabilitation.

Breast cancer in African American women: epidemiology and tumor biology

This review of published data on the epidemiology, pathology, and molecular biology of breast cancer in African American women seeks to identify how the etiology and presentation of the disease differ from those in white women. The crossover from higher to lower age-specific incidence rates in African American women at age 45 cannot be explained by current data on the distribution of risk factors. Data from six case-control studies suggest that the relative risks associated with both established and probable breast cancer risk factors are similar in African American and white women. Lower survival in African American compared to white women is primarily attributable to diagnosis at a later stage. However, evidence from a number of studies suggests that tumors in African American women may exhibit a more aggressive phenotype, which could also contribute to the survival disparity. Tumors in African American women are more likely to occur at a younger age, to be poorly differentiated and estrogen receptor negative, and to exhibit high grade nuclear atypia, more aggressive histology (more medullary and less lobular), and higher S-phase. Overexpression of p53 and erbB-2 occurs with similar frequency in African American and white women, although limited data suggest the former may exhibit different p53 mutation spectra. One study found high risk associated with a specific CYP1A1 polymorphism in African American but not white women. Additional studies of molecular differences in African American and white women are needed, with multifactorial assessment of the independent effects of molecular and conventional risk attributes.

Racial differences in survival of female breast cancer in the Detroit metropolitan area

BACKGROUND

In the United States, breast cancer survival is worse among African-American women compared with white women. This difference in survival is likely due to several factors, including tumor biology and/or access to care. In this analysis, we evaluated the effects of sociodemographic and clinical variables on differences in breast cancer survival among African-American and white women.

METHODS

The study population included 10,502 women (82% white, 18% African-American), diagnosed between 1988 and 1992 and identified through the Metropolitan Detroit Cancer Surveillance System, a member of the Surveillance, Epidemiology and End-Results (SEER) Program. Cox proportional hazards regression was used to estimate the relative risk of death comparing African-American women with white women after controlling for variables believed to influence survival.

RESULTS

The mean age at diagnosis was 61 years and average length of follow-up was 34 months (range, 1-78 months). African-American women were more likely to present with regional or distant disease (45%) than were white women (37%). Although white women had better survival than African-American women during the first 4 years postdiagnosis (P < 0.0001), there were no significant differences in survival by race for women who lived longer than 4 years (P = 0.64). There was a significant interaction between age and race. The unadjusted relative risk of dying for African-American women compared with white women was 2.35 (95% confidence interval [CI], 1.88-2.93) for women younger than 50 years of age, and was 1.66 (95% CI, 1.46-1.88) for women age 50 years or older. After controlling for age, tumor size, stage, histologic grade, census-derived socioeconomic status, and residency training status, the relative risk was 1.68 (95% CI, 1.27-2.24) for women younger than 50 years of age and 1.33 (95% CI, 1.13-1.56) for women age 50 years and older. Adjustment for marital status, hospital size, and the proportion of Medicaid or Medicare discharges had no further effect on the relative risk.

CONCLUSIONS

Known factors that predict survival differences between African-American and white women are more prevalent among women younger than age 50.

Breast cancer screening in older black women

The objective of this study was to report findings about older black women's responses to breast health education and screening. Findings were reported from a community-based intervention designed to improve breast screening services for women in Erie County, New York. A 34-foot mobile screening and education clinic was used to overcome barriers such as accessibility and cost. Results from a sample of 271 older black women showed that they participated in breast health education programs and received clinical breast examinations when these services were offered in their neighborhoods. However, there was low participation in screening mammography offered at a local hospital. Low participation was attributed to structural and functional barriers in the delivery system. This study emphasizes the particular importance of education and screening offered as one unit of service. Further, it emphasizes the need to examine older black women's reported experiences after participation in screening.