Contribution of clinical and socioeconomic factors to differences in breast cancer subtype and mortality between Hispanic and non-Hispanic white women

Racial/ethnic differences in the clinical presentation and survival of breast cancer by subtype

Background

Breast cancer (BC) affects racial and ethnic groups differently, leading to disparities in clinical presentation and outcomes. It is unclear how Hispanic ethnicity affects BC outcomes based on geographic location and proximity to the United States (U.S.)/Mexico border. We hypothesized that the impact of race/ethnicity on BC outcomes depends on geographic location and country of origin within each BC subtype.

Methods

We analyzed BC data from the Texas Cancer Registry by race/ethnicity/birthplace according to BC subtype (luminal A/luminal B/human epidermal growth factor receptor 2 [HER2]/triple-negative breast cancer[TNBC]). Other covariates included age, geographic location (U.S., Mexico), residency (border, non-border), treatments, and comorbidities. Crude and adjusted effects of race/ethnicity and birthplace on overall survival (OS) were analyzed using Cox regression methods.

Results

Our analysis of 76,310 patient records with specific BC subtypes revealed that Hispanic and non-Hispanic Black (NHB) patients were diagnosed at a younger age compared with non-Hispanic White (NHW) patients for all BC subtypes. For the 19,748 BC patients with complete data on race/ethnicity/birthplace/residency, Hispanic patients had a higher mortality risk in the Luminal A subtype, regardless of birthplace, whereas U.S.-born Hispanics had a higher risk of death in the TNBC subtype. In contrast, NHB patients had a higher mortality risk in the Luminal A and HER2 subtypes. Residence along the U.S./Mexico border had little impact on OS, with better outcomes in Luminal A patients and worse outcomes in Luminal B patients aged 60-74 years.

Conclusion

Race/ethnicity, geographic birth location, and residency were significant predictors of survival in BC. Migration, acculturation, and reduced healthcare access may contribute to outcome differences.

Deregulated miRNA Expression in Triple-Negative Breast Cancer of Ancestral Genomic-Characterized Latina Patients

Among patients with triple-negative breast cancer (TNBC), several studies have suggested that deregulated microRNA (miRNA) expression may be associated with a more aggressive phenotype. Although tumor molecular signatures may be race- and/or ethnicity-specific, there is limited information on the molecular profiles in women with TNBC of Hispanic and Latin American ancestry. We simultaneously profiled TNBC biopsies for the genome-wide copy number and miRNA global expression from 28 Latina women and identified a panel of 28 miRNAs associated with copy number alterations (CNAs). Four selected miRNAs (miR-141-3p, miR-150-5p, miR-182-5p, and miR-661) were validated in a subset of tumor and adjacent non-tumor tissue samples, with miR-182-5p being the most discriminatory among tissue groups (AUC value > 0.8). MiR-141-3p up-regulation was associated with increased cancer recurrence; miR-661 down-regulation with larger tumor size; and down-regulation of miR-150-5p with larger tumor size, high p53 expression, increased cancer recurrence, presence of distant metastasis, and deceased status. This study reinforces the importance of integration analysis of CNAs and miRNAs in TNBC, allowing for the identification of interactions among molecular mechanisms. Additionally, this study emphasizes the significance of considering the patients ancestral background when examining TNBC, as it can influence the relationship between intrinsic tumor molecular characteristics and clinical manifestations of the disease.

Association of genetic ancestry with HER2, GRB7 AND estrogen receptor expression among Colombian women with breast cancer

Background

Our previous study reported higher mRNA levels of the human epidermal growth factor receptor 2 (HER2)-amplicon genes ERBB2 and GRB7 in estrogen receptor (ER)-positive breast cancer patients with relatively high Indigenous American (IA) ancestry from Colombia. Even though the protein expression of HER2 and GRB7 is highly correlated, they may also express independently, an event that could change the patients' prognosis. In this study, we aimed to explore the differences in ER, HER2 and GRB7 protein expression according to genetic ancestry, to further assess the clinical implications of this association.

Methods

We estimated genetic ancestry from non-tumoral breast tissue DNA and assessed tumoral protein expression of ER, HER2, and GRB7 by immunohistochemistry in a cohort of Colombian patients from different health institutions. We used binomial and multinomial logistic regression models to test the association between genetic ancestry and protein expression. Kaplan-Meier and log-rank tests were used to evaluate the effect of HER2/GRB7 co-expression on patients' survival.

Results

Our results show that patients with higher IA ancestry have higher odds of having HER2+/GRB7- breast tumors, compared to the HER2-/GRB7- subtype, and this association seems to be stronger among ER-positive tumors (ER+/HER2+/GRB7-: OR=3.04, 95% CI, 1.47-6.37, p<0.05). However, in the multivariate model this association was attenuated (OR=1.80, 95% CI, 0.72-4.44, p=0.19). On the other hand, it was observed that having a higher European ancestry patients presented lower odds of ER+/HER2+/GRB7- breast tumors, this association remained significant in the multivariate model (OR=0.36, 95% CI, 0.13 - 0.93, p= 0.0395). The survival analysis according to HER2/GRB7 co-expression did not show statistically significant differences in the overall survival and recurrence-free survival.

Conclusions

Our results suggest that Colombian patients with higher IA ancestry and a lower European fraction have higher odds of ER+/HER2+/GRB7- tumors compared to ER+/HER2-/GRB7- disease. However, this association does not seem to be associated with patients' overall or recurrence-free survival.

Breast cancer diagnosis in Inner-City African American and Hispanic women: The importance of early screening

PURPOSE

To evaluate the diagnosis of breast cancer in inner-city African-American and Hispanic women under age 50 to support the importance of screening in this population.

METHODS

This retrospective chart review included women newly diagnosed with breast cancer from 1/1/2015 to 1/1/2019 in a city hospital mainly serving minority patients. Chi-square and Fisher's exact tests were used for analysis.

RESULTS

In this cohort of 108 newly diagnosed African-American (63%) and Hispanic (31%) women, 60/108 (56%) presented with a site of palpable concern for diagnostic workup, and the remaining were diagnosed via asymptomatic screening. Women ages 30-49 were significantly more likely to present with a site of palpable concern when compared to women ages 50-69 (68% vs. 44%, p = 0.045). Additionally, women ages 30-49 were more likely to have triple-negative breast cancer (TNBC) than women ages 50-69 (20% vs. 10%, p = 0.222). However, women ages 30-49 were less likely to have prior mammogram than women ages 50-69 (24% vs. 46%, p = 0.062).

CONCLUSION

African-American and Hispanic women ages 30-49 were more likely to present with a site of palpable concern and TNBC than those ages 50-69. However, these young minority women ages 30-49 were less likely to have prior screening mammograms when compared to those ages 50-69. Our data highlights the importance of starting screening mammography no later than age 40 in African-American and Hispanic women. In addition, these women should have risk assessment for breast cancer no later than age 30 and be screened appropriately.

Provider discussion of genetic counseling among high-risk Spanish-preferring Latina breast cancer survivors

Among high-risk breast cancer (BC) survivors, genetic counseling (GC) and genetic testing (GT) may inform cascade testing and risk management. Compared to non-Hispanic White BC survivors, Spanish-preferring Latina BC survivors are less likely to report discussing GC with a healthcare provider. However, few studies have examined Latinas' experiences with GC/GT, particularly outside of the mainland USA. This study aimed to compare frequency of provider discussion of GC between Spanish-preferring Latina BC survivors living in Florida (FL) and Puerto Rico (PR). We conducted secondary data analysis of baseline assessments from a randomized pilot of an educational intervention for Spanish-preferring Latina BC survivors. Participants (N = 52) were GC/GT-naive, but met clinical criteria for GC/GT referral. Participants self-reported sociodemographic, clinical, and cultural variables, including previous provider discussion of GC. Descriptive statistics characterized frequency of GC discussion. Logistic regression examined the relationships between sociodemographic, clinical, and cultural characteristics and GC discussion. Only 31% of participants reported previous GC discussion. More participants from PR reported having GC discussions (43% vs. 21% in the mainland USA). In multivariable analyses, greater likelihood of GC discussion was associated with PR (vs. mainland USA) residence (odds ratio [OR] = 6.00, p = .03), older age at baseline (OR = 1.19, p = .04), and younger age at BC diagnosis (OR = 0.80, p = .03). Few high-risk Spanish-preferring Latina BC survivors in the mainland USA and PR had discussed GC with their providers. These results highlight a gap in the implementation of evidence-based genetics guidelines. Provider-directed interventions may be needed to increase uptake of GC/GT among Latina BC survivors.

Sociodemographic and Clinical Characteristics Associated With Worst Pain Intensity Among Cancer Patients

AIMS

Patients with cancer have pain due to their cancer, the cancer treatment and other causes, and the pain intensity varies considerably between individuals. Additional research is needed to understand the factors associated with worst pain intensity. Our study aim was to determine the association between worst pain intensity and sociodemographics and cancerspecific factors among patients with cancer.

DESIGN

A total of 1,280 patients with cancer recruited from multiple cancer centers over 25 years in the United States were asked to complete a questionnaire that collected respondents' demographic, chronic pain, and cancer-specific information.

SETTINGS

Worst, least, and current pain intensities were captured using a modified McGill Pain Questionnaire (pain intensity measured on 0-10 scale). A generalized linear regression analysis was utilized to assess the associations between significant bivariate predictors and worst pain intensity scores.Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain.

CONCLUSIONS

Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. Findings identified being Hispanic and having previous severe toothache, stomachache, and headache pain as significant predictors of worst pain intensity among patients with cancer. After controlling for selected covariates, we did not note statistical differences in worst pain during a 25-year period. Therefore,studies focused on improving the management of pain among patients with cancer should target interventions for those with Hispanic heritage and those with past history of severe common pain.

Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

BACKGROUND

There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies.

METHODS

Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed.

RESULTS

Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index.

CONCLUSIONS

This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.

Depression among Underserved Rural and Urban Caregivers of Latinas with Breast Cancer

Among Latino/as, informal caregiving duties are often deemed a family responsibility. Understanding psychological outcomes tied to caregivers of Latina breast cancer survivors is important to identify the impacts of cancer. Secondary analysis of baseline data collected in a randomized clinical trial (RCT) from 230 Latina breast cancer survivor-caregiver dyads. Characteristics of caregivers residing in rural/underserved and urban areas were compared using t- or chi-square tests. General linear models were used to analyze depressive symptoms in relation to residence, survivor-caregiver relationship, acculturation, obligation, reciprocity, and comorbidities. Urban residence was significantly associated with higher levels of depression controlling for survivor-caregiver relationship acculturation, obligation, reciprocity, and comorbidities. Mother caregivers had significantly higher levels of depression than other caregivers. Depression among Latino/a caregiver's providing care to an adult child is an important consideration as Latino/as are less likely to seek out/have access to mental health services than other groups.

Differences in somatic TP53 mutation type in breast tumors by race and receptor status

PURPOSE

Somatic driver mutations in TP53 are associated with triple-negative breast cancer (TNBC) and poorer outcomes. Breast cancers in women of African ancestry (AA) are more likely to be TNBC and have somatic TP53 mutations than cancers in non-Hispanic White (NHW) women. Missense driver mutations in TP53 have varied functional impact including loss-of-function (LOF) or gain-of-function (GOF) activity, and dominant negative (DNE) effects. We aimed to determine if there were differences in somatic TP53 mutation types by patient ancestry or TNBC status.

METHODS

We identified breast cancer datasets with somatic TP53 mutation data, ancestry, age, and hormone receptor status. Mutations were classified for functional impact using published data and type of mutation. We assessed differences using Fisher's exact test.

RESULTS

From 96 breast cancer studies, we identified 2964 women with somatic TP53 mutations: 715 (24.1%) Asian, 258 (8.7%) AA, 1931 (65.2%) NHW, and 60 (2%) Latina. The distribution of TP53 mutation type was similar by ancestry. However, 35.8% of tumors from NHW individuals had GOF mutations compared to 29% from AA individuals (p = 0.04). Mutations with DNE activity were positively associated with TNBC (OR 1.37, p = 0.03) and estrogen receptor (ER) negative status (OR 1.38; p = 0.005).

CONCLUSIONS

Somatic TP53 mutation types did not differ by ancestry overall, but GOF mutations were more common in NHW women than AA women. ER-negative and TNBC tumors are less likely to have DNE+ TP53 mutations which could reflect biological processes. Larger cohorts and functional studies are needed to further elucidate these findings.

Delays in Care Associated With Non-English-Speaking Patients With Breast Cancer

BACKGROUND

Breast cancer care requires coordination between multiple diagnostic and treatment modalities. Disparities such as age, race/ethnicity, and socioeconomic status are associated with delays in care. This study investigates whether primary language is associated with delays in breast cancer diagnosis and treatment before and through radiotherapy (RT).

PATIENTS AND METHODS

This study was an institutional retrospective matched-cohort analysis of women treated with breast RT over 2 years. A total of 65 non-English-speaking (NES) patients were matched with 195 English-speaking (ES) patients according to stage, age, and chemotherapy delivery. Key time intervals along the breast cancer care path from initial findings through RT were recorded. Data were analyzed in a mixed model with matching as the random effect. The impact of race and insurance status was analyzed in addition to language.

RESULTS

Significant delays were found for NES patients, which varied by race. NES Latina patients experienced the longest delay, with a mean total care-path time of 13.53 months (from initial findings to end of RT) versus 8.18 months for all ES patients (P<.0001). Specifically, their mean total care-path time was 5.97 months longer than that of ES Latina patients (P=.001) and 5.80 months longer than that of ES White patients (P<.0001). In addition, NES Latina patients had a significantly longer total care-path time than NES patients of other races/ethnicities (P=.001). Delays were specifically seen between initial clinical or radiographic findings and diagnostic mammogram (P=.001) and between biopsy and resection (P=.044). Beyond language, race/ethnicity was itself associated with delays between resection and start of RT (P=.032) and between start and end of RT (P=.022).

CONCLUSIONS

Language is associated with pre-RT delays in breast cancer care, especially for NES Latina patients. Delays are most pronounced before diagnostic mammograms, but they also exist before resection and RT. Future work should target NES patients to assist their progress along the care path.

Revisiting social MPE: an integration of molecular pathological epidemiology and social science in the new era of precision medicine

INTRODUCTION

Molecular pathological epidemiology (MPE) is an integrative transdisciplinary area examining the relationships between various exposures and pathogenic signatures of diseases. In line with the accelerating advancements in MPE, social science and its health-related interdisciplinary areas have also developed rapidly. Accumulating evidence indicates the pathological role of social-demographic factors. We therefore initially proposed social MPE in 2015, which aims to elucidate etiological roles of social-demographic factors and address health inequalities globally. With the ubiquity of molecular diagnosis, there are ample opportunities for researchers to utilize and develop the social MPE framework.

AREAS COVERED

Molecular subtypes of breast cancer have been investigated rigorously for understanding its etiologies rooted from social factors. Emerging evidence indicates pathogenic heterogeneity of neurological disorders such as Alzheimer's disease. Presenting specific patterns of social-demographic factors across different molecular subtypes should be promising for advancing the screening, prevention, and treatment strategies of those heterogeneous diseases. This article rigorously reviewed literatures investigating differences of race/ethnicity and socioeconomic status across molecular subtypes of breast cancer and Alzheimer's disease to date.

EXPERT OPINION

With advancements of the multi-omics technologies, we foresee a blooming of social MPE studies, which can address health disparities, advance personalized molecular medicine, and enhance public health.

Socio-economic factors do not affect overall survival in soft tissue sarcoma when patients treated at a single high-volume center

BACKGROUND

Treatments for soft tissue sarcoma (STS) include extensive surgical resection, radiation and chemotherapy, and can necessitate specialized care and excellent social support. Studies have demonstrated that socioeconomic factors, such as income, marital status, urban/rural residence, and educational attainment as well as treatment at high-volume institution may be associated with overall survival (OS) in STS.

METHODS

In order to explore the effect of socio-economic factors on OS in patients treated at a high-volume center, we performed a retrospective analysis of STS patients treated at a single institution.

RESULTS

Overall, 435 patients were included. Thirty-seven percent had grade 3 tumors and 44% had disease larger than 5 cm. Patients were most commonly privately insured (38%), married (67%) and retired or unemployed (43%). Median distance from the treatment center was 42 miles and median area deprivation index (ADI) was 5 (10 representing most deprived communities). The majority of patients (52%) were treated with neoadjuvant therapy followed by resection. As expected, higher tumor grade (HR 3.1), tumor size > 5 cm (HR 1.3), and involved lymph nodes (HR 3.2) were significantly associated with OS on multivariate analysis. Demographic and socioeconomic factors, including sex, age at diagnosis, marital status, employment status, urban vs. rural location, income, education, distance to the treatment center, and ADI were not associated with OS.

CONCLUSIONS

In contrast to prior studies, we did not identify a significant association between socioeconomic factors and OS of patients with STS when patients were treated at a single high-volume center. Treatment at a high volume institution may mitigate the importance of socio-economic factors in the OS of STS.

Disparities in Cardiovascular Disease Risk Among Hispanic Breast Cancer Survivors in a Population-Based Cohort

Background

Breast cancer is the leading cause of cancer death among Hispanic women. The aim of our study was to estimate cardiovascular disease (CVD) risk among Hispanic and non-Hispanic White (NHW) breast cancer survivors compared with their respective general population cohorts.

Methods

Cohorts of 17 469 breast cancer survivors (1774 Hispanic and 15 695 NHW) in the Utah Cancer Registry diagnosed between 1997 and 2016, and 65 866 women (6209 Hispanic and 59 657 NHW) from the general population in the Utah Population Database were identified. Cox proportional hazards models were used to estimate hazard ratios (HRs) for CVD.

Results

The risk of diseases of the circulatory system was higher in Hispanic than NHW breast cancer survivors 1-5 years after cancer diagnosis, in comparison with their respective general population cohorts (HR_Hispanic = 1.94, 99% confidence interval [CI] = 1.49 to 2.53; H_NHW = 1.38, 99% CI = 1.33 to 1.43; 2-sided P_{heterogeneity} = .01, respectively). Increased risks were observed for both Hispanic and NHW breast cancer survivors for diseases of the heart and the veins and lymphatics, compared with the general population cohorts. More than 5 years after cancer diagnosis, elevated risk of diseases of the veins and lymphatics persisted in both ethnicities. The CVD risk due to chemotherapy and hormone therapy was higher in Hispanic than NHW breast cancer survivors but did not differ for distant stage, higher baseline comorbidities, or baseline smoking.

Conclusions

We observed a risk difference for diseases of the circulatory system between Hispanic and NHW breast cancer survivors compared with their respective general population cohorts but only within the first 5 years of cancer diagnosis.

Liver Cancer Incidence and Area-Level Geographic Disparities in Pennsylvania-A Geo-Additive Approach

Many neighborhood socioeconomic index measures (nSES) that capture neighborhood deprivation exist but the impact of measure selection on liver cancer (LC) geographic disparities remains unclear. We introduce a Bayesian geoadditive modeling approach to identify clusters in Pennsylvania (PA) with higher than expected LC incidence rates, adjusted for individual-level factors (age, sex, race, diagnosis year) and compared them to models with 7 different nSES index measures to elucidate the impact of nSES and measure selection on LC geospatial variation. LC cases diagnosed from 2007–2014 were obtained from the PA Cancer Registry and linked to nSES measures from U.S. census at the Census Tract (CT) level. Relative Risks (RR) were estimated for each CT, adjusted for individual-level factors (baseline model). Each nSES measure was added to the baseline model and changes in model fit, geographic disparity and state-wide RR ranges were compared. All 7 nSES measures were strongly associated with high risk clusters. Tract-level RR ranges and geographic disparity from the baseline model were attenuated after adjustment for nSES measures. Depending on the nSES measure selected, up to 60% of the LC burden could be explained, suggesting methodologic evaluations of multiple nSES measures may be warranted in future studies to inform LC prevention efforts.

Patient characteristics associated with adherence to pulmonary nodule guidelines

BACKGROUND

While pulmonary nodule guidelines provide follow-up recommendations based on nodule size and malignancy risk, these are inconsistently followed in clinical practice. In this study, we sought to identify patient characteristics associated with guideline-concordant nodule follow-up.

METHODS

We conducted a retrospective cohort study of patients diagnosed with a pulmonary nodule between 2011 and 2014 at Boston Medical Center. Appropriate nodule follow-up evaluation was based upon the 2005 Fleischner Society Guidelines. In primary analysis, we compared patients with guideline-concordant follow-up to those with delayed or absent follow-up. In secondary analysis, we compared those with any follow-up to those without follow-up as well as the rate of guideline-concordant follow-up in patients seen by a pulmonologist.

RESULTS

Of 3916 patients diagnosed with a pulmonary nodule, 1117 were included for analysis. Overall, 598 (53.5%) patients received guideline-concordant follow-up. Lower rates of guideline concordance were seen in patients of Hispanic ethnicity (OR 0.60, 95% CI 0.36-1.00), while higher rates were seen for nodules 7-8 mm (OR 1.55, 95% CI 1.02-2.35) and nodules >8 mm (OR 1.49, 95% CI 1.01-2.20). Having a history of COPD (OR 1.75, 95% CI 1.26-2.43), and being seen by a pulmonologist (OR 1.97, 95% CI 1.51-2.58) were also associated with guideline concordance. Among patients seen by a pulmonologist, 62.2% received guideline-concordant follow-up.

CONCLUSION

Overall rates of pulmonary nodule follow-up are low. Patient ethnicity, COPD history, nodule size and involvement of a pulmonologist may impact follow-up rates and are potential targets for implementation interventions to improve pulmonary nodule follow-up.

Nativity, ethnic enclave residence, and breast cancer survival among Latinas: Variations between California and Texas

BACKGROUND

Among Latinas with breast cancer, residence in an ethnic enclave may be associated with survival. However, findings from prior studies are inconsistent.

METHODS

The authors conducted parallel analyses of California and Texas cancer registry data for adult (aged ≥18 years) Latinas who were diagnosed with invasive breast cancer from 1996 to 2005, with follow-up through 2014. Existing indices applied to tract-level 2000 US Census data were used to measure Latinx enclaves and neighborhood socioeconomic status (nSES). Multivariable Cox proportional hazard models were fit for all-cause and breast cancer-specific survival adjusted for year of diagnosis, patient age, nativity (with multiple imputation), tumor stage, histology, grade, size, and clustering by census tract.

RESULTS

Among 38,858 Latinas, the majority (61.3% in California and 70.5% in Texas) lived in enclaves. In fully adjusted models for both states, foreign-born women were found to be more likely to die of breast cancer and all causes when compared with US-born women. Living in enclaves and in neighborhoods with higher SES were found to be independently associated with improved survival from both causes. When combined into a 4-level variable, those in low nSES nonenclaves had worse survival for both causes compared with those living in low nSES enclaves and, in the all-cause but not breast cancer-specific models, those in high nSES neighborhoods, regardless of enclave status, had improved survival from all causes.

CONCLUSIONS

Applying the same methods across 2 states eliminated previously published inconsistent associations between enclave residence and breast cancer survival. Future studies should identify specific protective effects of enclave residence to inform interventions.

Hospital Characteristics and Breast Cancer Survival in the California Breast Cancer Survivorship Consortium

INTRODUCTION

Racial/ethnic disparities in breast cancer survival are well documented, but the influence of health care institutions is unclear. We therefore examined the effect of hospital characteristics on survival.

METHODS

Harmonized data pooled from 5 case-control and prospective cohort studies within the California Breast Cancer Survivorship Consortium were linked to the California Cancer Registry and the California Neighborhoods Data System. The study included 9,701 patients with breast cancer who were diagnosed between 1993 and 2007. First reporting hospitals were classified by hospital type-National Cancer Institute (NCI) -designated cancer center, American College of Surgeons (ACS) Cancer Program, other-and hospital composition of the neighborhood socioeconomic status and race/ethnicity of patients with cancer. Multivariable Cox proportional hazards models adjusted for clinical and patient-level prognostic factors were used to examine the influence of hospital characteristics on survival.

RESULTS

Fewer than one half of women received their initial care at an NCI-designated cancer center (5%) or ACS program (38%) hospital. Receipt of initial care in ACS program hospitals varied by race/ethnicity-highest among non-Latina White patients (45%), and lowest among African Americans (21%). African-American women had superior breast cancer survival when receiving initial care in ACS hospitals versus other hospitals (non-ACS program and non-NCI-designated cancer center; hazard ratio, 0.67; 95% CI, 0.55 to 0.83). Other hospital characteristics were not associated with survival.

CONCLUSION

African American women may benefit significantly from breast cancer care in ACS program hospitals; however, most did not receive initial care at such facilities. Future research should identify the aspects of ACS program hospitals that are associated with higher survival and evaluate strategies by which to enhance access to and use of high-quality hospitals, particularly among African American women.

Leveraging an Implementation Science Framework to Adapt and Scale a Patient Navigator Intervention to Improve Mammography Screening Outreach in a New Community

Helping Her Live (HHL) is a community health worker-led outreach model that navigates women from vulnerable communities to mammography screening and diagnostic follow-up. The objective of this study was to evaluate HHL implementation on the southwest side of Chicago. HHL has been implemented on the west side of Chicago since 2008, where it has increased mammogram completion and diagnostic follow-up rates among Black and Hispanic women from resource poor communities. In 2014, HHL was translated to the southwest side of Chicago; implementation success was evaluated by comparing outreach, navigation request, and mammogram completion metrics with the west side. During January 2014-December 2015, outreach was less extensive in the southwest setting (SW) compared to the benchmark west setting (W); however, the proportion of women who completed mammograms in SW was 50%, which compared favorably to the proportion observed in the benchmark setting W (42%). The distribution of insurance status and the racial and ethnic makeup of individuals met on outreach in the W and SW were significantly different (p < 0.0005). This successful expansion of HHL in terms of both geographic and demographic reach justifies further studies leveraging these results and tailoring HHL to additional underserved communities.

Impact of preexisting type 2 diabetes mellitus and antidiabetic drugs on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer

BACKGROUND

We investigated the influence preexisting type 2 diabetes mellitus (T2DM) and antidiabetic drugs have on all-cause and cause-specific mortality among Medicaid-insured women diagnosed with breast cancer.

METHODS

9221 women aged <64 years diagnosed with breast cancer and reported to the New York State (NYS) Cancer Registry from 2004 to 2016 were linked with Medicaid claims. Preexisting T2DM was determined by three diagnosis claims for T2DM with at least one claim prior to breast cancer diagnosis and a prescription claim for an antidiabetic drug within three months following breast cancer diagnosis. Estimated menopausal status was determined by age (premenopausal age <50; postmenopausal age ≥50). Hazard ratios (HR) and 95 % confidence intervals (95 %CI) were calculated with Cox proportional hazards regression, adjusting for confounders.

RESULTS

Women with preexisting T2DM had greater all-cause (HR = 1.40; 95 %CI 1.21, 1.63), cancer-specific (HR = 1.24; 95 %CI 1.04, 1.47), and cardiovascular-specific (HR = 2.46; 95 %CI 1.54, 3.90) mortality hazard compared to nondiabetic women. In subgroup analyses, the association between T2DM and all-cause mortality was found among non-Hispanic White (HR 1.78 95 %CI 1.38, 2.30) and postmenopausal (HR = 1.47; 95 %CI 1.23, 1.77) women, but not among other race/ethnicity groups or premenopausal women. Additionally, compared to women prescribed metformin, all-cause mortality hazard was elevated among women prescribed sulfonylurea (HR = 1.44; 95 %CI 1.06, 1.94) or insulin (HR = 1.54; 95 %CI 1.12, 2.11).

CONCLUSION

Among Medicaid-insured women with breast cancer, those with preexisting T2DM have an increased mortality hazard, especially when prescribed sulfonylurea or insulin. Further research is warranted to determine the role antidiabetic drugs have on survival among women with breast cancer.

Breast Cancer Health Disparities in Hispanics/Latinas

Purpose of the review

Breast cancer incidence and mortality rates are lower in some Hispanic/Latino subpopulations compared to Non-Hispanic White women. However, studies suggest that the risk of breast cancer-specific mortality is higher in US Hispanics/Latinas. In this review we summarized current knowledge on factors associated with breast cancer incidence and risk of mortality in women of Hispanic/Latino origin.

Recent findings

Associative studies have proposed a multiplicity of factors likely contributing to differences in breast cancer incidence and survival between population groups, including socioeconomic/sociodemographic factors, lifestyle choices as well as access to and quality of care. Reports of association between global genetic ancestry overall as well as subtype-specific breast cancer risk among Hispanic/Latinas suggest that incidence and subtype distribution could result from differential exposure to environmental and lifestyle related factors correlated with genetic ancestry as well as germline genetic variation.

Summary

Hispanic/Latino in the United States have been largely underrepresented in cancer research. It is important to implement inclusive programs that facilitate the access of this population to health services and that also include education programs for the community on the importance of screening. In addition, it is important to continue promoting the inclusion of Hispanics/Latinos in genomic studies that allow understanding the biological behavior of this disease in the context of all human genetic diversity.

Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer Is Associated with Indigenous American Ancestry in Latin American Women

Women of Latin American origin in the United States are more likely to be diagnosed with advanced breast cancer and have a higher risk of mortality than non-Hispanic White women. Studies in U.S. Latinas and Latin American women have reported a high incidence of HER2 positive (+) tumors; however, the factors contributing to this observation are unknown. Genome-wide genotype data for 1,312 patients from the Peruvian Genetics and Genomics of Breast Cancer Study (PEGEN-BC) were used to estimate genetic ancestry. We tested the association between HER2 status and genetic ancestry using logistic and multinomial logistic regression models. Findings were replicated in 616 samples from Mexico and Colombia. Average Indigenous American (IA) ancestry differed by subtype. In multivariate models, the odds of having an HER2+ tumor increased by a factor of 1.20 with every 10% increase in IA ancestry proportion (95% CI, 1.07-1.35; P = 0.001). The association between HER2 status and IA ancestry was independently replicated in samples from Mexico and Colombia. Results suggest that the high prevalence of HER2+ tumors in Latinas could be due in part to the presence of population-specific genetic variant(s) affecting HER2 expression in breast cancer. SIGNIFICANCE: The positive association between Indigenous American genetic ancestry and HER2+ breast cancer suggests that the high incidence of HER2+ subtypes in Latinas might be due to population and subtype-specific genetic risk variants.

Integrated copy number and miRNA expression analysis in triple negative breast cancer of Latin American patients

Triple negative breast cancer (TNBC), a clinically aggressive breast cancer subtype, affects 15–35% of women from Latin America. Using an approach of direct integration of copy number and global miRNA profiling data, performed simultaneously in the same tumor specimens, we identified a panel of 17 miRNAs specifically associated with TNBC of ancestrally characterized patients from Latin America, Brazil. This panel was differentially expressed between the TNBC and non-TNBC subtypes studied (p ≤ 0.05, FDR ≤ 0.25), with their expression levels concordant with the patterns of copy number alterations (CNAs), present mostly frequent at 8q21.3-q24.3, 3q24-29, 6p25.3-p12.2, 1q21.1-q44, 5q11.1-q22.1, 11p13-p11.2, 13q12.11-q14.3, 17q24.2-q25.3 and Xp22.33-p11.21. The combined 17 miRNAs presented a high power (AUC = 0.953 (0.78–0.99);95% CI) in discriminating between the TNBC and non-TNBC subtypes of the patients studied. In addition, the expression of 14 and 15 of the 17miRNAs was significantly associated with tumor subtype when adjusted for tumor stage and grade, respectively. In conclusion, the panel of miRNAs identified demonstrated the impact of CNAs in miRNA expression levels and identified miRNA target genes potentially affected by both CNAs and miRNA deregulation. These targets, involved in critical signaling pathways and biological functions associated specifically with the TNBC transcriptome of Latina patients, can provide biological insights into the observed differences in the TNBC clinical outcome among racial/ethnic groups, taking into consideration their genetic ancestry.

Black-White Breast Cancer Incidence Trends: Effects of Ethnicity

Recent reports of converging black and white breast cancer incidence rates have gained much attention, potentially foreshadowing a worsening of the black-white breast cancer mortality disparity. However, these incidence rates also reflect the sum of non-Hispanics and Hispanics that may mask important ethnicity-specific trends. We therefore assessed race- and ethnicity-specific breast cancer trends using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 13 Registries Database (1992-2014). Age-period-cohort models projected rates for 2015-2030. Results confirmed merging of age-standardized incidence rates for blacks and whites circa 2012, but not for non-Hispanic black (NHB) and non-Hispanic white (NHW) women. Incidence rates were highest for NHW women (n = 382 290), followed by NHB women (n = 51 074), and then Hispanic white women (n = 48 651). The sample size for Hispanic blacks was too small for analysis (n = 693). Notably, future incidence rates are expected to slowly increase (2015 through 2030) among NHW women (0.24% per year, 95% confidence interval [CI] = 0.17 to 0.32) and slowly decrease for NHB women (-0.14% per year, 95% CI = -0.15 to -0.13). A putative worsening of the black-white mortality disparity, therefore, seems unlikely. Ethnicity matters when assessing race-specific breast cancer incidence rates.

An Interactive Resource to Probe Genetic Diversity and Estimated Ancestry in Cancer Cell Lines

Recent work points to a lack of diversity in genomics studies from genome-wide association studies to somatic (tumor) genome analyses. Yet, population-specific genetic variation has been shown to contribute to health disparities in cancer risk and outcomes. Immortalized cancer cell lines are widely used in cancer research, from mechanistic studies to drug screening. Larger collections of cancer cell lines better represent the genomic heterogeneity found in primary tumors. Yet, the genetic ancestral origin of cancer cell lines is rarely acknowledged and often unknown. Using genome-wide genotyping data from 1,393 cancer cell lines from the Catalogue of Somatic Mutations in Cancer (COSMIC) and Cancer Cell Line Encyclopedia (CCLE), we estimated the genetic ancestral origin for each cell line. Our data indicate that cancer cell line collections are not representative of the diverse ancestry and admixture characterizing human populations. We discuss the implications of genetic ancestry and diversity of cellular models for cancer research and present an interactive tool, Estimated Cell Line Ancestry (ECLA), where ancestry can be visualized with reference populations of the 1000 Genomes Project. Cancer researchers can use this resource to identify cell line models for their studies by taking ancestral origins into consideration.

Breast Cancer Outcomes in a Racially and Ethnically Diverse Cohort of Insured Women

Background

It is unknown how subsequent breast cancer outcomes vary by biologic subtype and race/ethnicity in a diverse cohort of breast cancer survivors.

Methods

We conducted a prospective cohort study of 6,154 insured breast cancer survivors (AJCC TNM stages 0-IV) diagnosed between 1996-2007 and followed them through 1/1/2010 for subsequent breast cancer events (recurrence, contralateral breast cancer, metastasis, mortality). We compared subsequent breast cancer rates by race/ethnicity groups and biologic subtype (luminal A, luminal B, HER2-enriched, and triple negative). We calculated hazard ratios (HRs) with 95% CIs using multivariable Cox proportional hazards models, adjusted for sociodemographics, cancer treatments, and tumor characteristics.

Results

The cohort was diverse: 62.4% non-Hispanic White, 13.2% Hispanic, 14.9% African American, and 9.5% Asian. We identified 1,456 subsequent breast cancer events over 22,830 person-years. Although certain Asian women had higher crude subsequent breast cancer rates compared with Whites, within each biologic subtype category, these disparities disappeared in the multivariable analyses. After accounting for race/ethnicity, compared with women with luminal A tumors (reference), women with luminal B (adjusted HR=3.65, 95% CI: 3.08-4.32), HER2-enriched (adjusted HR=2.81, 95% CI: 2.25-3.51) and triple negative (adjusted HR=1.25, 95% CI: 1.01-1.54) tumors had statistically increased risks of subsequent breast cancer. Factors that were statistically significantly associated with increased risk included higher stage, larger tumor size, positive lymph nodes, and no adjuvant endocrine or chemotherapy (all P<.025).

Discussion

Our data suggest that disparities in subsequent breast cancer outcomes were more strongly associated with tumor characteristics and non-use of adjuvant treatments than race/ethnicity.

Unpacking Hispanic Ethnicity-Cancer Mortality Differentials Among Hispanic Subgroups in the United States, 2004-2014

Introduction: National data on the epidemiology of cancer are commonly reported by broad racial/ethnic categories, such as "Hispanic." However, few studies have disaggregated Hispanic groups and explored mortality differentials in this heterogeneous population. This paper aims to further examine cancer mortality differentials among Hispanic subgroups in the U.S. Materials and Methods: The study examined cancer deaths in the United States from 2004 to 2014 among decedents classified as Mexican, Puerto Rican, Cuban, Dominican, Central/South American and non-Hispanic white on the death certificate among those who were 20 years or older at the time of death. Data were obtained from the National Vital Statistics System. Sex-specific age-adjusted mortality rates were computed for a 10-year period and each individual year, for all cancers combined. Differences by age group, cancer sites, and age distribution were also assessed. Results: A total of 296,486 Hispanic cancer deaths were identified. Mortality rates of the Hispanic subgroups compare favorably with those of non-Hispanic whites. The mortality rates for Mexicans are very similar to those of all Hispanics combined, whereas the rates for Cuban and Puerto Ricans are higher. Dominicans and Central/South Americans had the overall lowest mortality rates. Statistically significant decreases in cancer mortality rates were noted in some sub-groups, but rates increased among Dominican women. Age-adjusted mortality rates by cancer site varied among Hispanics subgroups and gender. Among Cubans, only 5% of cancer deaths occurred before the age of 50 compared to 16% of cancer deaths among Central/South American. Conclusion: While it is common to present data on the burden of cancer among Hispanics as an aggregate group, this study illustrates that the burden of cancer varies by Hispanic subgroups. The disaggregation of Hispanics by ancestry/country of origin allows for a clearer understanding of the health status of this growing population and is needed if health disparities are to be adequately identified, understood and addressed.

The "Empowering Latinas to Obtain Breast Cancer Screenings" study: Rationale and design

BACKGROUND

Latinas suffer disproportionately from breast cancer (BC) in part due to lower guideline-concordant screening. Multiple intervention approaches have been developed to promote screening through direct patient education and empowerment approaches (i.e., training community members to share BC information). This study compares the relative effects of these approaches on: 1) women's BC screening; and, 2) women's dissemination of BC information within their social networks.

DESIGN/METHODS

Our quasi-experimental trial is being implemented in community venues in two predominantly Latino neighborhoods in South and West Chicago. Eligible participants: 1) are female; 2) are 52-74 years old; 3) have not obtained a mammogram in the past 2 years; and, 4) have not previously participated in health-related volunteerism. Based on their geographic location, participants are assigned to one of two group-based interventions. Both interventions consist of three two-hour sessions, which includes BC early detection education. The education intervention sessions also covers BC prevention (diet, physical activity), whereas the empowerment intervention covers sharing information with family/friends, and health volunteerism. Navigation is provided for all women who wish to obtain mammograms. Primary outcomes include: 1) receipt of BC screening; and, 2) participants' dissemination of BC information. Secondary outcomes include positive changes in 1) participants' self-reported psychosocial facilitators; and, 2) social network members' BC behaviors.

DISCUSSION

The design of our program allows for a preliminary comparison of the effectiveness of these two approaches. This work will inform larger comparativeness trials and offers a new approach to intervention evaluation via social network analysis.

Income Inequality and Mortality Owing to Breast Cancer: Evidence From Brazil

BACKGROUND

The relationship between breast cancer and inequality income is unclear. This study analyzed the correlation between income inequality and mortality standardized by age and proportional mortality owing to breast cancer among Brazilian women.

PATIENTS AND METHODS

This is an ecological study using data of the federative units and Federal District of Brazil in 2010. The age-standardized mortality owing to breast cancer was estimated using data from the Department of Informatics of Brazil's Unified Health System. Income inequality indicators used included the Gini index, Theil-L index, Palma index, and the ratio of income distribution quintiles obtained from the United Nations Development Program. We used Pearson correlation and linear regression adjusted for income per capita and other variables.

RESULTS

An increase of 0.1 in the Gini index was associated with increases of 9.8 deaths per 100,000 women (95% confidence interval [CI], 1.7-17.9); an increase in the Palma index was associated with increases in mortality of 0.7 deaths per 100,000 women (95% CI, 0.1-1.4), an increase in the Theil-L index was associated with increases in mortality of 4.9 deaths per 100,000 women (95% CI, 1.9-7.9), and of 0.8 (95% CI, 0.2-1.5) in the proportional mortality.

CONCLUSION

Income inequality, as assessed by the Gini, Palma, and Theil-L indexes, is positively associated with an increase in breast cancer mortality in Brazil.