Racial differences in breast cancer survival in women under age 60

Factors associated with survival in paediatric and adolescent renal cell carcinoma: a population-based study

BACKGROUND

The purpose of this study was to conduct a population-based study to determine the prognosis of renal cell carcinoma (RCC) in children and adolescents.

METHODS

Patients with RCC who were registered in the Surveillance, Epidemiology, and End Results (SEER) program between 2000 and 2018 had their demographic and clinical characteristics evaluated retrospectively. The log-rank test was used to compare survival curves. Kaplan-Meier estimates were used to generate survival curves based on various factors. To identify factors associated with overall survival, Cox proportional-hazards regression was used.

RESULTS

A total of 251 patients were enrolled in the study. For all patients, the overall survival (OS) rates at 3- and 5- year were 93.5% and 92.0%, respectively. A multivariable study revealed that the following factors were independently associated with overall survival: sex, race, histologic type, SEER stage, AJCC stage, and type of surgery. Cox analysis showed that white patients had the lowest risk of mortality (hazard ratio (HR) 2.58, 95% confidence interval (CI), 1.33-4.99; P = 0.005), compared with black patients. Patients having metastatic disease had significantly higher mortality risk (HR 43, 95% CI, 14.8-125; P < 0.001) than the patients with localized tumour.

CONCLUSIONS

Our study emphasizes the importance of race, SEER stage, and surgery in the prognosis of paediatric RCC, providing valuable epidemiological evidence for clinical practice. Economic studies assessing a race/ethnic group specific strategy are also required.

Greater Survival Improvement in African American vs. Caucasian Women with Hormone Negative Breast Cancer

Background: African American women have not benefited equally from recently improved breast cancer survival. We investigated if this was true for all subsets.

Methods: We identified 395,170 patients with breast adenocarcinoma from the SEER database from 1990 to 2011 with designated race, age, stage, grade, ER and PR status, marital status and laterality, as control. We grouped patients into two time periods, 1990-2000 and 2001-2011, three age categories, under 40, 40-69 and ≥ 70 years and two stage categories, I-III and IV. We used the Kaplan-Meier and logrank tests to compare survival curves. We stratified data by patient- and tumor-associated variables to determine co-variation among confounding factors using the Pearson Chi-square test and Cox proportional hazards regression to determine hazard ratios (HR) to compare survival.

Results: Stage I-III patients of both races ≥ 70 years old, African American widowed patients and Caucasians with ER- and PR- tumors had worse improvements in survival in 2001-2011 than younger, married or hormone receptor positive patients, respectively. In contrast, African Americans with ER- (Cox HR 0.70 [95% CI 0.65-0.76]) and PR- (Cox HR 0.67 [95% CI 0.62-0.72]) had greater improvement in survival in 2001-2011 than Caucasians with ER- (Cox HR 0.81 [95% CI 0.78-0.84]) and PR- disease (Cox HR 0.75 [95% CI 0.73-0.78]). This was not associated with changes in distribution of tumor or patient attributes.

Conclusions: African American women with stage I-III ER- and PR- breast cancer had greater improvement in survival than Caucasians in 2001-2011. This is the first report of an improvement in racial disparities in survival from breast cancer in a subset of patients.

Racial Disparity Among Women Diagnosed With Invasive Breast Cancer in a Large Integrated Health System

Purpose

Reasons for the well-described disparity in outcomes between African American (AA) and non-Hispanic white (NHW) women with invasive breast cancer are unclear, making it difficult to identify solutions. This study examined the effects of demographics, biomarkers, tumor characteristics, cancer stage, morphology, and treatment variables on overall and cancer-free survival in these patient populations.

Methods

We retrospectively reviewed data for 6231 patients diagnosed with invasive breast cancer throughout an integrated health system from January 2006 through March 2015. Included for analysis were 5023 NHW and 413 AA women. All category and continuous variables in the study were described in the two groups using appropriate statistics. Kaplan-Meier method of survival with log-rank test was used to compare the two racial groups (NHW and AA). Cox proportional hazards regression was used to find hazard ratios for the predictors of survival and recurrence-free survival probability. Propensity probability match method (1:1) was used to match 319 NSW women to 319 similar AA women. Matching was done using all significant predictors, including demographic variables.

Results

Compared to NHW women, AA women presented with invasive breast cancer at a younger age (P<0.001) and had a higher proportion of stage IV cancers (P<0.001), which were more often infiltrating ductal carcinoma (P<0.003) and poorly differentiated (P<0.001). Within 10-year follow-up, AA women had shorter overall and recurrence-free survival (log-rank P<0.001), were 1.4 times more likely to die (P=0.009), and were twice as likely to have recurrence (P<0.001) than NHW women. In the matched groups, overall survival was similar for AA and NHW (log-rank P=0.0793); however, recurrence-free survival was higher in NHW than in AA women (P=0.047).

Conclusions

When presenting characteristics of AA and NHW women with invasive breast cancer are matched, disparity in overall mortality and rate of recurrence appears to be reduced or perhaps eliminated, suggesting invasive breast cancers in AA and NHW women respond similarly to treatment. Further study is needed to explore the true effect of biological factors; however, rectifying delivery of and access to care might be expected to mitigate, in large part, the racial disparity currently seen in breast cancer outcomes.

Breast cancer survival disparity between African American and Caucasian women in Arkansas: A race-by-grade analysis

Despite progress in breast cancer treatment, disparity persists in survival time between African American (AA) and Caucasian women in the US. Tumor stage and tumor grade are the major prognostic factors that define tumor aggressiveness and contribute to racial disparity between AA and Caucasian women. Studying the interaction of race with tumor grade or stage may provide further insights into the role of intrinsic biological aggressiveness in disecting the AA-Caucasian survival disparity. Therefore, the current study was performed to evaluate the interaction of race with tumor grade and stage at diagnosis regarding survival in a cohort of patients treated at the Winthrop P. Rockefeller Cancer Institute of the University of Arkansas for Medical Sciences (Little Rock, AR, USA). The cohort included 1,077 patients, 208 (19.3%) AA and 869 (80.7%) Caucasian, diagnosed with breast cancer between January 1997 and December 2005. Kaplan-Meier survival plots were generated and Cox regressions were performed to analyze the associations of race with breast cancer-specific survival time. Over a mean follow-up time of 1.5 years, AA women displayed increased mortality risk due to breast cancer-specific causes [hazard ratio (HR), 1.74; 95% confidence interval (CI), 1.23–2.46]. The magnitude of racial disparity varied strongly with tumor grade (race-x-grade interaction; P<0.001). No significant interaction was observed between race and tumor stage or race and age at diagnosis. Among women diagnosed with grade I tumors, the race disparity in survival time after controlling for tumor stage and age was strong (HR, 9.07; 95% CI, 2.11–38.95), but no significant AA-Caucasian disparity was observed among women with higher-grade tumors. The data suggest that, when diagnosed with grade I breast cancer, AA may experience poorer survival outcomes compared with Caucasian patients, regardless of tumor stage or age. The findings potentially provide significant clinical and public health implications and justify further investigation.

Female Body Mass Index and its Relationship With Triple Negative Breast Cancer and Ethnicity

BACKGROUND

Breast cancer in women is a relatively common malignancy in the western hemisphere and is perhaps one of the leading causes of mortality among females. We conducted a retrospect cohort study to investigate the association of body mass index (BMI) with triple negative breast cancer and ethnicity.

METHODS

Tumor Registry Database at the University of Florida, College of Medicine in Jacksonville was utilized for our cohort study. A total of 84 women with triple negative breast cancer, between 2004 and 2008 met our criteria and were selected for this study. For comparison, another 83 women with at least one hormone receptors positive breast cancer were randomly selected in the same time period. Chi-square testing was used to evaluate categorical variables, while the t-test analysis was used to analyze for the continuous variables.

RESULTS

Our data demonstrated that 27.4% of the triple negative group had BMI < 25 compared to the 14.5% of non-triple negative breast cancer, 73.6% of the triple negative group had BMI ≥ 25 compared to 86.5% in the non-triple negative group with a P-value of 0.245. In terms of ethnicity, triple negative breast cancer was found in 56% of African-American and 44% of Caucasian females. Non-triple negative breast cancer was found in 48.2% of African-Americans and 51.8% of Caucasians females with a P-value of 0.354.

CONCLUSIONS

We were not able to show any statistically significant association of body mass index triple with triple negative breast cancer or ethnicity. While our findings are not in agreement with the research published earlier, we do submit that our retrospective cohort study has shortcomings, including the small sample size pooled from a single center, which greatly limits our ability to deduce any definitive conclusions. In light of these shortcomings, we recommend a future multicenter study with a larger sample size.

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.

A mitotically active, cellular tumor stroma and/or inflammatory cells associated with tumor cells may contribute to intermediate or high Oncotype DX Recurrence Scores in low-grade invasive breast carcinomas

Oncotype DX is an RT-PCR-based 21-gene assay validated to provide prognostic and predictive information in the form of a Recurrence Score in patients with estrogen receptor-positive, lymph node-negative breast cancer. Although the Recurrence Score was shown to correlate with several histopathological tumor features, there is a significant proportion of cases showing an apparent discrepancy between Recurrence Score and risk estimates based on the traditional clinicopathological tumor features. In this study, we tested whether a proliferating, cellular stroma and/or admixed inflammatory cells may result in an artificially increased Recurrence Score in low-grade invasive breast cancers. We analyzed the histopathological features in 141 low-grade invasive breast carcinomas, including 41 special type (tubular, cribriform and mucinous) carcinomas, with available Recurrence Score. The tumor stroma was evaluated for increased cellularity and presence of inflammatory cells. Double immunohistochemical stains for pancytokeratin and Ki-67 was performed to assess the cell proliferation in tumor vs stromal/inflammatory cells. The clinicopathological features of tumors with Recurrence Score <18 (low risk) were compared with those with Recurrence Score ≥18 (intermediate/high risk). Carcinomas associated with Recurrence Score ≥18 showed lower progesterone receptor immunoreactivity, increased stromal cellularity and presence of inflammatory cells associated with the tumor. Double immunohistochemical stains showed significantly increased proliferation in stromal/inflammatory cells compared with carcinoma cells in cases associated with Recurrence Score ≥18. A Ki-67-positive stromal/tumor cells ratio of >1 predicted Recurrence Score ≥18 with an area under the curve of 0.8967 on receiver operator curve analysis (P<0.0001). Our results suggest that the presence of increased stromal cellularity and/or associated inflammatory cells in low-grade invasive breast carcinomas may contribute to an apparently increased risk of recurrence according to Oncotype DX Recurrence Score. Careful assessment and correlation with histopathological features in such cases may help in determining the appropriate patient management.

Female breast cancer mortality clusters within racial groups in the United States

Although breast cancer is the second leading cause of cancer deaths among women in the Unites States, to date there have been no nationwide studies systematically analyzing geographic variation and clustering. An assessment of spatial-temporal clusters of cancer mortality by age and race at the county level in the lower 48 United States indicated a primary cluster in the Northeast US for both younger (RR = 1.349; all RR are p < or = 0.001) and older (RR = 1.283) women in the all-race category. Similar cluster patterns in the North were detected for younger (RR = 1.390) and older (RR = 1.292) white women. The cluster for both younger (RR = 1.337) and older (RR = 1.251) black women was found in the Midwest. The clusters for all other racial groups combined were in the West for both younger (RR = 1.682) and older (RR = 1.542) groups. Regression model results suggest that lower socioeconomic status (SES) was more protective than higher status at every quartile step (Medium-high SES, OR = 0.374; Medium-low, OR = 0.137; Low, OR = 0.061). This study may provide insight to aid in identifying geographic areas and subpopulations at increased risk for breast cancer.

Underlying causes of the black-white racial disparity in breast cancer mortality: a population-based analysis

BACKGROUND

In the United States, a black-to-white disparity in age-standardized breast cancer mortality rates emerged in the 1980s and has widened since then.

METHODS

To further explore this racial disparity, black-to-white rate ratios (RRs(BW)) for mortality, incidence, hazard of breast cancer death, and incidence-based mortality (IBM) were investigated using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program on 244 786 women who were diagnosed with breast cancer from January 1990 through December 2003 and followed through December 2004. A counterfactual approach was used to examine the expected IBM RRs(BW), assuming equal distributions for estrogen receptor (ER) expression, and/or equal hazard rates of breast cancer death, among black and white women.

RESULTS

From 1990 through 2004, mortality RR(BW) was greater than 1.0 and widened over time (age-standardized breast cancer mortality rates fell from 36 to 29 per 100 000 for blacks and from 30 to 22 per 100 000 for whites). In contrast, incidence RR(BW) was generally less than 1.0. Absolute hazard rates of breast cancer death declined substantially for ER-positive tumors and modestly for ER-negative tumors but were persistently higher for blacks than whites. Equalizing the distributions of ER expression in blacks and whites decreased the IBM RR(BW) slightly. Interestingly, the black-to-white disparity in IBM RR(BW) was essentially eliminated when hazard rates of breast cancer death were matched within each ER category.

CONCLUSIONS

The black-to-white disparity in age-standardized breast cancer mortality was largely driven by the higher hazard rates of breast cancer death among black women, diagnosed with the disease, irrespective of ER expression, and especially in the first few years following diagnosis. Greater emphasis should be placed on identifying the etiology of these excess hazards and developing therapeutic strategies to address them.

A population-based analysis of 788 cases of yolk sac tumors: A comparison of males and females

Yolk sac tumors (YST) are a rare and aggressive germ cell tumor. The objective of this study is to compare the patient characteristics and survival of YST in males and females. Demographic and clinicopathologic information were obtained from the Surveillance, Epidemiology, and End Results Program from 1973 to 2003. Statistical analysis was performed using Independent-sample t-test, chi(2) test, Kaplan-Meier methods and Cox proportional hazards regression. Seven hundred eighty-eight patients were identified, 451 (57%) were males and 337 (43%) were females. The mean age at diagnosis was similar in males and females. The age at diagnosis showed a bimodal distribution with an increased incidence in the first 4 years of life and during the 2nd to 4th decade of life. The most common site of the primary tumor was gonadal, namely testis 336 (42.6%) and ovary 257 (32.6%). Among the extragonadal sites, tumor site of origin differed in males and females. The 5-year survival of extragonadal YST (66%) was worse than gonadal YST (86%) (p < 0.05). The overall median survival for the cohort was 87 months. This was similar in males (81 months) and females (91 months) (p > 0.05). As the year of diagnosis progressed from 1973 to 2003, survival of both males and females with YST consistently improved. The bimodal age distribution of YST generates the hypothesis that sex steroids may play a role in selected YST. Although the overall survival in all YST patients has improved over the past few decades, the primary sites of origin differ in males and females and impact prognosis.

Trends in survival over the past two decades among white and black patients with newly diagnosed stage IV breast cancer

PURPOSE

Overall, breast cancer mortality has been declining in the United States, but survival studies of patients with stage IV disease are limited. The aim of this study was to evaluate trends in and factors affecting survival in a large population-based cohort of patients with newly diagnosed stage IV breast cancer.

PATIENTS AND METHODS

We searched the Surveillance, Epidemiology, and End Results registry to identify female patients with stage IV breast cancer diagnosed between 1988 and 2003. Patients were divided into three groups according to year of diagnosis (1988 to 1993, 1994 to 1998, and 1999 to 2003). Survival outcomes were estimated by the Kaplan-Meier method, and Cox models were fit to determine the characteristics independently associated with survival.

RESULTS

We identified 15,438 patients. Median age was 62 years. Median follow-up was 16 months, 18 months, and 11 months in periods 1988 to 1993, 1994 to 1998, and 1999 to 2003, respectively. Median breast cancer-specific survival was 23 months. In the multivariate model, earlier year of diagnosis, grade 3 disease, increasing age, being unmarried, hormone receptor-negative disease, and no surgery were all independently associated with worse overall and breast cancer-specific survival. With each successive year of diagnosis, black patients had an increasingly greater risk of death compared with white patients (hazard ratio, 1.03; 95% CI, 1.00 to 1.06; P = .031).

CONCLUSION

The survival of patients with newly diagnosed stage IV breast cancer has modestly improved over time, but these data suggest that the disparity in survival between black and white patients has increased.

A complex web of risks for metabolic syndrome: race/ethnicity, economics, and gender

BACKGROUND

Metabolic syndrome is a recognizable clinical cluster of risks known to be associated in combination and independently with an increased risk for cardiovascular disease (CVD). Identifying and treating metabolic syndrome is one promising strategy to reduce CVD. The intersection of race/ethnicity, gender, and economic status complicates our understanding of who is at risk for metabolic syndrome, but understanding this social patterning is important for the development of targeted interventions. This study examines the relationship between metabolic syndrome (and the underlying contributing risk factors) and race/ethnicity, economic status, and gender.

METHODS

National Health and Nutrition Examination Survey data collected from 1999 through 2002 were used; analysis was completed in 2006-2007. Metabolic syndrome was defined using the Adult Treatment Panel III definition. Economic status was measured using income as a percentage of the poverty level. Prevalence of metabolic syndrome and each of its contributing risk factors were determined by race/ethnicity and economic group. Logistic regressions were estimated. All analyses were stratified by gender.

RESULTS

Economic effects were seen for women, but not men. Women in the lowest economic group were more likely to be at risk in four of the five risk categories when compared with women in the highest economic group. Differences in the contributing risk profiles for metabolic syndrome were seen by race/ethnicity.

CONCLUSIONS

Strategies to reduce CVD must be built on a clear understanding of the differences in contributing risk factors for metabolic syndrome across subgroups. The findings from this study provide further information to guide the targeting of these strategies.