Are there racial differences in breast cancer treatments and clinical outcomes for women treated at M.D. Anderson Cancer Center?

Accommodating time-varying heterogeneity in risk estimation under the Cox model: a transfer learning approach

Transfer learning has attracted increasing attention in recent years for adaptively borrowing information across different data cohorts in various settings. Cancer registries have been widely used in clinical research because of their easy accessibility and large sample size. Our method is motivated by the question of how to utilize cancer registry data as a complement to improve the estimation precision of individual risks of death for inflammatory breast cancer (IBC) patients at The University of Texas MD Anderson Cancer Center. When transferring information for risk estimation based on the cancer registries (i.e., source cohort) to a single cancer center (i.e., target cohort), time-varying population heterogeneity needs to be appropriately acknowledged. However, there is no literature on how to adaptively transfer knowledge on risk estimation with time-to-event data from the source cohort to the target cohort while adjusting for time-varying differences in event risks between the two sources. Our goal is to address this statistical challenge by developing a transfer learning approach under the Cox proportional hazards model. To allow data-adaptive levels of information borrowing, we impose Lasso penalties on the discrepancies in regression coefficients and baseline hazard functions between the two cohorts, which are jointly solved in the proposed transfer learning algorithm. As shown in the extensive simulation studies, the proposed method yields more precise individualized risk estimation than using the target cohort alone. Meanwhile, our method demonstrates satisfactory robustness against cohort differences compared with the method that directly combines the target and source data in the Cox model. We develop a more accurate risk estimation model for the MD Anderson IBC cohort given various treatment and baseline covariates, while adaptively borrowing information from the National Cancer Database to improve risk assessment.

Clinical Outcomes and Immune Markers by Race in a Phase I/II Clinical Trial of Durvalumab Concomitant with Neoadjuvant Chemotherapy in Early-Stage TNBC

PURPOSE

The incidence of triple-negative breast cancer (TNBC) is higher among Black or African American (AA) women, yet they are underrepresented in clinical trials. To evaluate safety and efficacy of durvalumab concurrent with neoadjuvant chemotherapy for stage I-III TNBC by race, we enrolled additional AA patients to a Phase I/II clinical trial.

PATIENTS AND METHODS

Our study population included 67 patients. The primary efficacy endpoint was pathologic complete response (pCR; ypT0/is, N0) rate. χ2 tests were used to evaluate associations between race and baseline characteristics. Cox proportional hazards models were used to assess association between race and overall survival (OS) and event-free survival (EFS). Multivariate logistic regression analyses were used to evaluate associations between race and pCR, immune-related adverse events (irAE) and recurrence.

RESULTS

Twenty-one patients (31%) self-identified as AA. No significant associations between race and baseline tumor stage (P = 0.40), PD-L1 status (0.92), and stromal tumor-infiltrating lymphocyte (sTIL) count (P = 0.57) were observed. pCR rates were similar between AA (43%) and non-AA patients (48%; P = 0.71). Three-year EFS rates were 78.3% and 71.4% in non-AA and AA patients, respectively [HR, 1.451; 95% confidence interval (CI), 0.524-4.017; P = 0.474]; 3-year OS was 87% and 81%, respectively (HR, 1.72; 95% CI, 0.481-6.136; P = 0.405). The incidence of irAEs was similar between AA and non-AA patients and no significant associations were found between irAEs and pathologic response.

CONCLUSIONS

pCR rates, 3-year OS and EFS after neoadjuvant immunotherapy and chemotherapy were similar in AA and non-AA patients. Toxicities, including the frequency of irAEs, were also similar.

Tumor immune microenvironment of self-identified African American and non-African American triple negative breast cancer

Differences in the tumor immune microenvironment may result in differences in prognosis and response to treatment in cancer patients. We hypothesized that differences in the tumor immune microenvironment may exist between African American (AA) and NonAA patients, due to ancestry-related or socioeconomic factors, that may partially explain differences in clinical outcomes. We analyzed clinically matched triple-negative breast cancer (TNBC) tissues from self-identified AA and NonAA patients and found that stromal TILs, PD-L1 IHC-positivity, mRNA expression of immune-related pathways, and immunotherapy response predictive signatures were significantly higher in AA samples (p < 0.05; Fisher's Exact Test, Mann-Whitney Test, Permutation Test). Cancer biology and metabolism pathways, TAM-M2, and Immune Exclusion were significantly higher in NonAA samples (p < 0.05; Permutation Test, Mann-Whitney Test). There were no differences in somatic tumor mutation burden. Overall, there is greater immune infiltration and inflammation in AA TNBC and these differences may impact response to immune checkpoint inhibitors and other therapeutic agents that modulate the immune microenvironment.

Assessing Real-World Racial Differences Among Patients With Metastatic Triple-Negative Breast Cancer in US Community Practices

Objective

Real-world data characterizing differences between African American (AA) and White women with metastatic triple-negative breast cancer (mTNBC) are limited. Using 9 years of data collected from community practices throughout the United States, we assessed racial differences in the proportion of patients with mTNBC, and their characteristics, treatment, and overall survival (OS).

Methods

This retrospective study analyzed de-identified data from 2,116 patients with mTNBC in the Flatiron Health database (January 2011 to March 2020). Characteristics and treatment patterns between AA and White patients with mTNBC were compared using descriptive statistics. OS was examined using Kaplan-Meier analysis and a multivariate Cox proportional hazards regression model.

Results

Among patients with metastatic breast cancer, more AA patients (23%) had mTNBC than White patients (12%). This difference was particularly pronounced in patients who lived in the Northeast, were aged 45–65, had commercial insurance, and had initial diagnosis at stage II. AA patients were younger and more likely to have Medicaid. Clinical characteristics and first-line treatments were similar between AA and White patients. Unadjusted median OS (months) was shorter in AA (10.3; 95% confidence interval [CI]: 9.1, 11.7) vs. White patients (11.9; 95% CI: 10.9, 12.8) but not significantly different. After adjusting for potential confounders, the hazard ratio for OS was 1.09 (95% CI: 0.95, 1.25) for AA vs. White patients.

Conclusions

The proportion of patients with mTNBC was higher in AA than White mBC patients treated in community practices. Race did not show an association with OS. Both AA and White patients with mTNBC received similar treatments. OS was similarly poor in both groups, particularly in patients who had not received any documented anti-cancer treatment. Effective treatment remains a substantial unmet need for all patients with mTNBC.

Metabolic Syndrome: does this influence breast cancer outcomes in the triple-negative population?

INTRODUCTION

Metabolic syndrome (MS) is defined by having at least 3 of 4 components: obesity, dyslipidemia, hypertension (HTN), and diabetes. Prior studies analyzed the individual components of MS for all breast cancers which are predominantly hormone positive. Our study is the first to evaluate MS in triple-negative breast cancer (TNBC).

METHODS

A retrospective review of TNBC from 2007 to 2013 identified 177 patients with complete information for statistical analysis. Cox proportional hazards models were used to test the association between MS, disease-free survival (DFS), and overall survival (OS).

RESULTS

48 (27%) patients had MS. After controlling for age, race, pathologic stage, surgery type, and additional comorbidities outside of MS, MS was significantly associated with poorer DFS (adjusted HR: 2.24, p = 0.030), but not associated with OS (adjusted HR: 1.92, p = 0.103). HTN was significantly associated with poorer DFS (adjusted HR: 3.63, p = 0.006) and OS (adjusted HR: 3.45, p = 0.035) in the univariable and multivariable analyses. Diabetes was not associated with worse OS or DFS. The 5-year age-adjusted OS rates for 60-year-old patients with and without diabetes were 85.8% and 87.3%, respectively. The age-adjusted 5-year OS rate for 60-year old patients was higher in patients with a body mass index (BMI) > 30 (90.2%) versus BMIs of 25-29.9 (88.2%) or < 25 (83.5%).

CONCLUSION

In the TNBC population, MS was significantly associated with poorer DFS, but not associated with OS. HTN was the only component of MS that was significantly associated with both DFS and OS. Obesity has a potential small protective benefit in the TNBC population.

Evaluation of Surgical Disparities Between African American and European American Women Treated for Breast Cancer Within an Equal-Access Military Hospital

BACKGROUND

Survival disparities between African American women (AAW) and European American women (EAW) with invasive breast cancer may be attributable, in part, to access to or quality of medical care. In this study, we evaluated surgical disparities between AAW and EAW treated within an equal-access military treatment facility (MTF).

METHODS

All AAW (N = 271) and EAW (N = 628) with Stage I-III breast cancer who had their initial diagnosis performed at Murtha Cancer Center at Walter Reed National Military Medical Center were identified. Differences in surgical interval (time between diagnosis and definitive breast surgery) and surgical procedures were evaluated using χ² and Student t-tests while survival was analyzed using Kaplan-Meier survival estimates and log-rank tests. A P value < 0.05 was used to define significance.

RESULTS

Surgical intervals did not differ significantly between populations with an average of 36.3 days in AAW and 33.9 days in EAW. Frequency of the percentage of women undergoing reexcision, mastectomy, and prophylactic removal of the contralateral breast did not differ significantly between populations. Likewise, frequency of sentinel lymph node biopsy and 5-year survival were not significantly different between AAW compared to EAW.

DISCUSSION

Surgical intervals and procedures were similar between AAW and EAW treated within an equal-access MTF. These data demonstrate that the availability of quality surgical care to all patients with stage I-III breast cancer may eliminate survival disparities between AAW and EAW, emphasizing the importance of equalizing access to breast care.

Obesity and Triple-Negative Breast Cancer: Disparities, Controversies, and Biology

Once considered a problem of Western nations, obesity (body mass index ≥30 kg/m²) has rapidly increased since the 1970s to become a major threat to world health. Since 1970, the face of obesity has changed from a disease of affluence and abundance to a disease of poverty. During the last 10 years, studies have mechanistically linked obesity and an obese tumor microenvironment with signaling pathways that predict aggressive breast cancer biology. For example, in the United States, African American women are more likely than non-Hispanic European American women to be obese and to be diagnosed with triple-negative breast cancer (TNBC). In 2008, the Carolina Breast Study found that obesity (increased waist/hip ratio) was linked to an increased incidence of TNBC in premenopausal and postmenopausal African American women. Subsequently, several groups have investigated the potential link between obesity and TNBC in African American women. To date, the data are complex and sometimes contradictory. We review epidemiologic studies that investigated the potential association among obesity, metabolic syndrome, and TNBC in African American women and mechanistic studies that link insulin signaling to the obese breast microenvironment, tissue inflammation, and aggressive TNBC biology.

Obesity and Triple-Negative Breast Cancer: Disparities, Controversies, and Biology

Once considered a problem of Western nations, obesity (body mass index ≥30 kg/m²) has rapidly increased since the 1970s to become a major threat to world health. Since 1970, the face of obesity has changed from a disease of affluence and abundance to a disease of poverty. During the last 10 years, studies have mechanistically linked obesity and an obese tumor microenvironment with signaling pathways that predict aggressive breast cancer biology. For example, in the United States, African American women are more likely than non-Hispanic European American women to be obese and to be diagnosed with triple-negative breast cancer (TNBC). In 2008, the Carolina Breast Study found that obesity (increased waist/hip ratio) was linked to an increased incidence of TNBC in premenopausal and postmenopausal African American women. Subsequently, several groups have investigated the potential link between obesity and TNBC in African American women. To date, the data are complex and sometimes contradictory. We review epidemiologic studies that investigated the potential association among obesity, metabolic syndrome, and TNBC in African American women and mechanistic studies that link insulin signaling to the obese breast microenvironment, tissue inflammation, and aggressive TNBC biology.

Getting Black Men to Undergo Prostate Cancer Screening: The Role of Social Capital

Despite higher rates of prostate cancer-related mortality and later stage of prostate cancer diagnosis, Black/African American men are significantly less likely than non-Hispanic White men to use early detection screening tools, like prostate-specific antigen (PSA) testing for prostate cancer. Lower screening rates may be due, in part, to controversy over the value of prostate cancer screenings as part of routine preventive care for men, but Black men represent a high-risk group for prostate cancer that may still benefit from PSA testing. Exploring the role of social factors that might be associated with PSA testing can increase knowledge of what might promote screening behaviors for prostate cancer and other health conditions for which Black men are at high risk. Using multilevel logistic regression, this study analyzed self-report lifetime use of PSA test for 829 Black men older than 45 years across 381 Philadelphia census tracts. This study included individual demographic and aggregated social capital data from the Public Health Management Corporation's 2004, 2006, and 2008 waves of the Community Health Database, and sociodemographic characteristics from the 2000 U.S. Census. Each unit increase in community participation was associated with a 3 to 3.5 times greater likelihood of having had a PSA test (odds ratio = 3.35). Findings suggest that structural forms of social capital may play a role in screening behaviors for Black men in Philadelphia. A better understanding of the mechanism underlying the link between social capital and screening behaviors can inform how researchers and interventionists develop tools to promote screening for those who need it.

Triple-negative breast cancer in African-American women: disparities versus biology

Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype that disproportionately affects BRCA1 mutation carriers and young women of African origin. There is evidence that African-American women with TNBC have worse clinical outcomes than women of European descent. However, it is unclear whether survival differences persist after adjusting for disparities in access to health-care treatment, co-morbid disease and income. It remains controversial whether TNBC in African-American women is a molecularly distinct disease or whether African-American women have a higher incidence of aggressive biology driven by disparities: there is evidence in support of both. Understanding the relative contributions of biology and disparities is essential for improving the poor survival rate of African-American women with TNBC.

Cost-effectiveness of alternative strategies for integrating MRI into breast cancer screening for women at high risk

BACKGROUND

Magnetic resonance imaging (MRI) is recommended for women at high risk for breast cancer. We evaluated the cost-effectiveness of alternative screening strategies involving MRI.

METHODS

Using a microsimulation model, we generated life histories under different risk profiles, and assessed the impact of screening on quality-adjusted life-years, and lifetime costs, both discounted at 3%. We compared 12 screening strategies combining annual or biennial MRI with mammography and clinical breast examination (CBE) in intervals of 0.5, 1, or 2 years vs without, and reported incremental cost-effectiveness ratios (ICERs).

RESULTS

Based on an ICER threshold of $100,000/QALY, the most cost-effective strategy for women at 25% lifetime risk was to stagger MRI and mammography plus CBE every year from age 30 to 74, yielding ICER $58,400 (compared to biennial MRI alone). At 50% lifetime risk and with 70% reduction in MRI cost, the recommended strategy was to stagger MRI and mammography plus CBE every 6 months (ICER=$84,400). At 75% lifetime risk, the recommended strategy is biennial MRI combined with mammography plus CBE every 6 months (ICER=$62,800).

CONCLUSIONS

The high costs of MRI and its lower specificity are limiting factors for annual screening schedule of MRI, except for women at sufficiently high risk.

The role of social capital in African-American women's use of mammography

Black/African-American women are more likely to get breast cancer at a young age and/or be diagnosed at a late disease stage, pointing to a greater need to promote mammography for Black women at earlier ages than are currently recommended. This study explores how perceived neighborhood social capital, that is, perceptions of how tight-knit a neighborhood is and what power that confers to neighborhood members, relates to use of mammography for Black women in Philadelphia. Living in a community with tight social ties (social cohesion) or that have a collective motivation for community change (collective efficacy) may increase the likelihood that an individual woman in that community will hear health messages from other community members and neighbors (diffusion of information) and will have access to health-related resources that allow them to engage in healthy behaviors. No prior studies have explored the role of social capital in decisions for mammography use. Using multilevel logistic regression, we analyzed self-report of mammography in the past year for 2586, Black women over age 40 across 381 Philadelphia, Pennsylvania USA census tracts. Our study included individual demographic and aggregates of individual-level social capital data from the Public Health Management Corporation's 2004, 2006, and 2008 Community Health Database waves, and 2000 US Census sociodemographic characteristics. Individual perceptions that a Black woman's neighborhood had high social capital, specifically collective efficacy, had a positive and statistically significant association with mammography use (OR = 1.40, CI: 1.05, 1.85). Our findings suggest that an individual woman's perception of greater neighborhood social capital may be related to increased mammography use. Although this analysis could not determine the direction of causality, it suggests that social capital may play a role in cancer preventive screening for African-American women in Philadelphia, which warrants further study.

Histo-biological comparative analysis of bilateral breast cancer

Bilateral breast cancer occurs in approximately 7% of surviving breast cancer patients. However, a dilemma exists concerning the notion of whether this represents a de novo second primary tumor versus a breast metastasis. We analyzed 81 patients with bilateral breast cancer, 47 (58%) synchronous tumors and 34 (42%) metachronous tumors. Additionally, charts were reviewed for age, family history, full histology data and biological receptors. We found there were no significant differences in concordance between the first and second primary tumors (in both synchronous and metachronous bilateral breast cancer) with respect to histology; grade; T-category; N-category; ER, PR and HER-2 status. In addition, there was no significant difference in the strength of correlation between ER and PR in the first and secondary primary tumors. Our findings suggest that the differentiation of the origin of contralateral breast cancer based on routine histological and biological concordance is inconclusive. Furthermore, the dilemma will continue to exist until additional molecular approaches are applied routinely for research purposes to resolve the debate.

Histo-biological comparative analysis of bilateral breast cancer

Bilateral breast cancer occurs in approximately 7% of surviving breast cancer patients. However, a dilemma exists concerning the notion of whether this represents a de novo second primary tumor versus a breast metastasis. We analyzed 81 patients with bilateral breast cancer, 47 (58%) synchronous tumors and 34 (42%) metachronous tumors. Additionally, charts were reviewed for age, family history, full histology data and biological receptors. We found there were no significant differences in concordance between the first and second primary tumors (in both synchronous and metachronous bilateral breast cancer) with respect to histology; grade; T-category; N-category; ER, PR and HER-2 status. In addition, there was no significant difference in the strength of correlation between ER and PR in the first and secondary primary tumors. Our findings suggest that the differentiation of the origin of contralateral breast cancer based on routine histological and biological concordance is inconclusive. Furthermore, the dilemma will continue to exist until additional molecular approaches are applied routinely for research purposes to resolve the debate.

Impact of obesity on cancer survivorship and the potential relevance of race and ethnicity

Evidence that obesity is associated with cancer incidence and mortality is compelling. By contrast, the role of obesity in cancer survival is less well understood. There is inconsistent support for the role of obesity in breast cancer survival, and evidence for other tumor sites is scant. The variability in findings may be due in part to comorbidities associated with obesity itself rather than with cancer, but it is also possible that obesity creates a physiological setting that meaningfully alters cancer treatment efficacy. In addition, the effects of obesity at diagnosis may be distinct from the effects of weight change after diagnosis. Obesity and related comorbid conditions may also increase risk for common adverse treatment effects, including breast cancer-related lymphedema, fatigue, poor health-related quality of life, and worse functional health. Racial and ethnic groups with worse cancer survival outcomes are also the groups for whom obesity and related comorbidities are more prevalent, but findings from the few studies that have addressed these complexities are inconsistent. We outline a broad theoretical framework for future research to clarify the specifics of the biological-social-environmental feedback loop for the combined and independent contributions of race, comorbid conditions, and obesity on cancer survival and adverse treatment effects. If upstream issues related to comorbidities, race, and ethnicity partly explain the purported link between obesity and cancer survival outcomes, these factors should be among those on which interventions are focused to reduce the burden of cancer.

Primary tumor size, not race, determines outcomes in women with hormone-responsive breast cancer

INTRODUCTION

We sought to determine if there was a difference in outcomes in African-American compared with Caucasian women with hormone-responsive breast cancer, and whether this was related to race or other tumor and treatment variables.

METHODS

We included 1,205 patients with hormone-responsive breast cancer were identified in the Kentucky Cancer Registry (1996-2007). The effect of race on survival was evaluated using Kaplan-Meier and Cox regression methodologies.

RESULTS

In this cohort, 76.9% were Caucasian and 21.7% were African American. Compared with Caucasians, African-American women were older (57 vs 55 years; P = .032) and more likely to have larger tumors (19 vs 17 mm; P = .009). No significant racial differences in grade, operative, or systemic treatment were noted. Univariate analysis found no significant differences in disease-specific overall survival (DSS) or disease-free survival (DFS) between Caucasians and African Americans (5-year actuarial DSS, 93.6% vs 90.7%, respectively; P = .205; 5-year actuarial DFS, 91.5% vs 90.4%, respectively; P = .829). On multivariate analysis, only tumor size remained an independent predictor of DSS (odds ratio [OR], 1.021; 95% confidence interval [CI], 1.013-1.028; P < .001). Controlling for age, tumor size, and insurance status, race did not influence DSS or DFS (P = .913 and P = .857).

CONCLUSION

African Americans present with larger tumors than Caucasians; treatment is similar. Tumor size, not race, affects disease-specific outcomes in patients with breast cancer.

Impact of high-dose chemotherapy on the ability to deliver subsequent local-regional radiotherapy for breast cancer: analysis of Cancer and Leukemia Group B Protocol 9082

PURPOSE

To report, from Cancer and Leukemia Group B Protocol 9082, the impact of high-dose cyclophosphamide, cisplatin, and BCNU (HD-CPB) vs. intermediate-dose CPB (ID-CPB) on the ability to start and complete the planned course of local-regional radiotherapy (RT) for women with breast cancer involving >or=10 axillary nodes.

METHODS AND MATERIALS

From 1991 to 1998, 785 patients were randomized. The HD-CPB and ID-CPB arms were balanced regarding patient characteristics. The HD-CPB and ID-CPB arms were compared on the probability of RT initiation, interruption, modification, or incompleteness. The impact of clinical variables and interactions between variables were also assessed.

RESULTS

Radiotherapy was initiated in 82% (325 of 394) of HD-CPB vs. 92% (360 of 391) of ID-CPB patients (p = 0.001). On multivariate analyses, RT was less likely given to patients who were randomized to HD treatment (odds ratio [OR] = 0 .38, p < 0.001), older (p = 0.005), African American (p = 0.003), postmastectomy (p = 0.02), or estrogen receptor positive (p = 0.03). High-dose treatment had a higher rate of RT interruption (21% vs. 12%, p = 0.001, OR = 2.05), modification (29% vs. 14%, p = 0.001, OR = 2.46), and early termination of RT (9% vs. 2%, p = 0.0001, OR = 5.35), compared with ID.

CONCLUSION

Treatment arm significantly related to initiation, interruption, modification, and early termination of RT. Patients randomized to HD-CPB were less likely to initiate RT, and of those who did, they were more likely to have RT interrupted, modified, and terminated earlier than those randomized to ID-CPB. The observed lower incidence of RT usage in African Americans vs. non-African Americans warrants further study.

Racial and socioeconomic disparities in adjuvant chemotherapy for older women with lymph node-positive, operable breast cancer

BACKGROUND

Consistent with findings from clinical trials, a recent population-based study indicated that adjuvant chemotherapy for lymph node-positive, operable breast cancer is effective at improving survival in older women, specifically those ages 65 years to 69 years; however, to the authors' knowledge, no conclusion has been reached about the relative benefit of chemotherapy for women aged > or =70 years, probably because of small number of patients. However, little is known about racial and socioeconomic disparities in adjuvant chemotherapy for breast cancer among older women.

METHODS

This study included 14,177 white women and 1277 black women aged > or =65 years who were diagnosed with operable breast cancer (stage II-IIIA) and positive lymph nodes between 1991 and 2002. These women were identified from the Surveillance, Epidemiology, and End Results and Medicare-linked database. Multivariate logistic regression was used to compute the odds ratios of receiving chemotherapy among black women compared with white women, and the causal step approach was used to test whether census tract-level poverty mediated racial disparities.

RESULTS

Interaction terms analyses indicated that regressions should be stratified by age group. In the group ages 65 years to 69 years, the adjusted odds ratio of receiving chemotherapy were lower for black women than for white women (odds ratio, 0.85; 95% confidence interval, 0.57-0.97). Poverty mediated the association between chemotherapy and race in this age group. No racial or socioeconomic disparities were observed among women aged > or =70 years.

CONCLUSIONS

This study documented racial disparities in adjuvant chemotherapy that were mediated by poverty in women ages 65 years to 69 years, an age group for which there is clear evidence for the efficacy of chemotherapy, but no disparities were observed among women aged > or =70 years. The authors concluded that it is important to work toward reducing treatment disparities among older women.

Cost-effectiveness analysis of mammography and clinical breast examination strategies: a comparison with current guidelines

PURPOSE

Breast cancer screening by mammography and clinical breast exam are commonly used for early tumor detection. Previous cost-effectiveness studies considered mammography alone or did not account for all relevant costs. In this study, we assessed the cost-effectiveness of screening schedules recommended by three major cancer organizations and compared them with alternative strategies. We considered costs of screening examinations, subsequent work-up, biopsy, and treatment interventions after diagnosis.

METHODS

We used a microsimulation model to generate women's life histories, and assessed screening and treatment effects on survival. Using statistical models, we accounted for age-specific incidence, preclinical disease duration, and age-specific sensitivity and specificity for each screening modality. The outcomes of interest were quality-adjusted life years (QALY) saved and total costs with a 3% annual discount rate. Incremental cost-effectiveness ratios were used to compare strategies. Sensitivity analyses were done by varying some of the assumptions.

RESULTS

Compared with guidelines from the National Cancer Institute and the U.S. Preventive Services Task Force, alternative strategies were more efficient. Mammography and clinical breast exam in alternating years from ages 40 to 79 years was a cost-effective alternative compared with the guidelines, costing $35,500 per QALY saved compared with no screening. The American Cancer Society guideline was the most effective and the most expensive, costing over $680,000 for an added QALY compared with the above alternative.

CONCLUSION

Screening strategies with lower costs and benefits comparable with those currently recommended should be considered for implementation in practice and for future guidelines.

African-American and low-socioeconomic status patients have a worse prognosis for invasive ductal and lobular breast carcinoma: do screening criteria need to change?

BACKGROUND

Determine the effect of race, socioeconomic status (SES) and other demographic variables on outcomes of patients with invasive ductal and lobular breast cancer.

STUDY DESIGN

Florida cancer registry and inpatient hospital data were queried for patients diagnosed with invasive breast cancer from 1998 to 2002.

RESULTS

A total of 63,472 patients with breast cancer were identified. Overall, 90.5% of patients were Caucasian, 7.6% African American, and 8.7% Hispanic. African-American patients presented at a younger age and with more-advanced disease, 10.5% presented with breast cancer before the age of 40 years, and 22.4% before 45 years of age. African-American patients were less likely to undergo operations. Similarly, low-SES patients were less likely to have operations and presented more often with larger tumors. Stepwise multivariate analysis revealed a substantial drop in the hazard ratio for African-American patients once correction for stage of presentation was made, suggesting that disparities in breast cancer outcomes are, in part, a result of advanced stage at presentation. Race and low SES were independent predictors of worse prognosis when controlling for patient comorbidities and treatment.

CONCLUSIONS

Dramatic disparities by patient race and SES exist in breast cancer. Our study integrates previous smaller studies, providing comprehensive insight into African-American patients and their outcomes for breast cancer. Earlier screening programs and greater access to cancer care for the poor and African Americans are needed. Successful institution of such programs will not completely erase disparities in outcomes for breast cancer in African-American patients.

Triple receptor-negative breast cancer: the effect of race on response to primary systemic treatment and survival outcomes

PURPOSE

The goal of this study was to describe the effect of race on pathologic complete response (pCR) rates and survival outcomes in women with triple receptor-negative (TN) breast cancers.

PATIENTS AND METHODS

Four hundred seventy-one patients with TN breast cancer diagnosed between 1996 and 2005 and treated with primary systemic chemotherapy were included. pCR was defined as no residual invasive cancer in the breast and axillary lymph nodes. Overall survival (OS) and recurrence-free survival (RFS) were estimated using the Kaplan-Meier product-limit method and compared between groups using the log-rank test. Cox proportional hazards models were fitted for each survival outcome to determine the relationship of patient and tumor variables with outcome.

RESULTS

Median follow-up time was 24.5 months. One hundred patients (21.2%) were black, and 371 patients (78.8%) were white/other race. Seventeen percent of black patients (n = 17) and 25.1% of white/other patients (n = 93) achieved a pCR (P = .091). Three-year RFS rates were 68% (95% CI, 56% to 76%) and 62% (95% CI, 57% to 67%) for black and white/other patients, respectively, with no significant difference observed between the two groups (P = .302). Three-year OS was similar for the two racial groups. After controlling for patient and tumor characteristics, race was not significantly associated with RFS (hazard ratio [HR] = 1.08; 95% CI, 0.69 to 1.68; P = .747) or OS (HR = 1.08; 95% CI, 0.69 to 1.68; P = .735) when white/other patients were compared with black patients.

CONCLUSION

Race does not significantly affect pCR rates or survival outcomes in women with TN breast cancer treated in a single institution under the same treatment conditions.

Prognostic role of detection method and its relationship with tumor biomarkers in breast cancer: the university of Texas M.D. Anderson Cancer Center experience

PURPOSE

To assess the effect of tumor detection method (screening versus symptom-based diagnosis) in predicting breast cancer survival and investigate how biological features of breast cancer are related to the tumor detection method.

PATIENTS AND METHODS

The study population consisted of 5,481 women diagnosed with primary invasive breast cancer between 1997 and 2005 and received their treatment at The University of Texas M. D. Anderson Cancer Center.

RESULTS

Patients with symptom-detected tumors had an increased risk of recurrence or death [relative risk (RR), 1.34; P = 0.006] and breast cancer-specific death (RR, 1.31; P = 0.117) than patients with screen-detected tumors after adjusting for tumor characteristics and treatments received. This relationship was especially evident among estrogen receptor (ER)-negative tumors (RR, 1.60 for breast cancer recurrence for ER-negative tumors; RR, 1.18 for ER-positive tumors). ER status and Ki-67 expression were statistically significantly associated with symptom detection rate after adjusting for patients' age, tumor stage, tumor size, and nuclear grade [odds ratio (OR) of ER negative versus ER positive, 1.35; P < 0.001; OR of Ki-67 10-30% versus <10%, 1.40; P = 0.005; OR of Ki-67 >30% versus <10%, 2.11; P < 0.001].

CONCLUSION

The method of detection was a statistically significant independent predictor of breast cancer recurrence. Information on the method of tumor detection should be collected to improve the prediction of prognosis of breast cancer patients.

Survival difference between non-Hispanic black and non-Hispanic white women with localized breast cancer: the impact of guideline-concordant therapy

OBJECTIVES

This study examined the impact of guideline-concordant therapy on the survival difference between non-Hispanic black (NHB) and non-Hispanic white (NHW) women with localized breast cancer.

METHODS

Data analyzed were from the CDC's NPCR Patterns of Care study in which seven population-based state cancer registries participated. We randomly selected 2,362 women who were diagnosed with a first primary localized breast cancer in 1997. Data were abstracted from hospital records, supplemented by information from physician offices and by linkages with state vital records and the National Death Index database.

RESULTS

NHB women were more likely than NHW women to receive breast conserving surgery without radiation therapy. In addition, the percentage of NHB women with hormone receptor-positive tumors who received hormonal therapy was lower than that of NHW women. Among those with a tumor size > 3 cm, NHB women were more likely than NHW women to receive multiagent chemotherapy. After controlling for age, the risk of dying from all causes of death was 2.35 times as high for NHB women compared to NHW women. Controlling for treatment further reduced black-white difference in survival with adjustment for sociodemographic and clinical variables.

CONCLUSION

NHB women were less likely than NHW women to receive guideline-concordant radiation therapy after breast conserving therapy and hormonal therapy but were more likely to receive chemotherapy. Racial differences in treatment contribute significantly to the worse survival of NHB women compared with NHW women.

Ethnic disparities in Americans of European descent versus Americans of African descent related to polymorphic ERCC1, ERCC2, XRCC1, and PARP1

Nucleotide excision repair (NER) and base excision repair (BER) pathways are DNA repair pathways that are important in carcinogenesis and in response to DNA-damaging chemotherapy. ERCC1 and ERCC2 are important molecular markers for NER; XRCC1 and PARP1 are important molecular markers for BER. Functional polymorphisms have been described that are associated with altered expression levels of these genes and with altered DNA repair capability. We assayed genomic DNA from 156 Americans of European descent and 164 Americans of African descent for the allelic frequencies of specific polymorphisms of ERCC1 N118N (500C>T), ERCC1 C8092A, ERCC2 K751Q (2282A>C), XRCC1 R399Q (1301G>A), XRCC1 R194W (685C>T), and PARP1 V762A (2446T>C). Differences were observed between Americans of European descent and Americans of African descent in the allelic frequencies of the ERCC1 N118N polymorphism (P < 0.000001). Differences were also observed between these two ethnic groups for ERCC2 K751Q (P = < 0.006675), XRCC1 R399Q (P < 0.000001), and PARP1 V762A (P = 0.000001). The ERCC1 N118N polymorphic variant that is seen most commonly in Americans of European descent is associated with a measurable reduction in NER function. ERCC1-mediated reduction in NER functionality affects the repair of cisplatin-DNA lesions.

Barriers to adequate follow-up during adjuvant therapy may be important factors in the worse outcome for Black women after breast cancer treatment

Introduction

Black women appear to have worse outcome after diagnosis and treatment of breast cancer. It is still unclear if this is because Black race is more often associated with known negative prognostic indicators or if it is an independent prognostic factor. To study this, we analyzed a patient cohort from an urban university medical center where these women made up the majority of the patient population.

Methods

We used retrospective analysis of a prospectively collected database of breast cancer patients seen from May 1999 to June 2006. Time to recurrence and survival were analyzed using the Kaplan-Meier method, with statistical analysis by chi-square, log rank testing, and the Cox regression model.

Results

265 female patients were diagnosed with breast cancer during the time period. Fifty patients (19%) had pure DCIS and 215 patients (81%) had invasive disease. Racial and ethnic composition of the entire cohort was as follows: Black (N = 150, 56.6%), Hispanic (N = 83, 31.3%), Caucasian (N = 26, 9.8%), Asian (N = 4, 1.5%), and Arabic (N = 2, 0.8%). For patients with invasive disease, independent predictors of poor disease-free survival included tumor size, node-positivity, incompletion of adjuvant therapy, and Black race. Tumor size, node-positivity, and Black race were independently associated with disease-specific overall survival.

Conclusion

Worse outcome among Black women appears to be independent of the usual predictors of survival. Further investigation is necessary to identify the cause of this survival disparity. Barriers to completion of standard post-operative treatment regimens may be especially important in this regard.