Black:white disparities in breast cancer mortality in the 50 largest cities in the United States, 2005–2014

A closer examination of the "rural mortality penalty": Variability by race, region, and measurement

BACKGROUND

Racial health disparities are well documented and pervasive across the United States. Evidence suggests there is a "rural mortality penalty" whereby rural residents experience poorer health outcomes than their urban counterparts. However, whether this penalty is uniform across demographic groups and U.S. regions is unknown.

OBJECTIVE

To assess how rural-urban differences in mortality differ by race (Black vs. White), U.S. region, poverty status, and how rural-urban status is measured.

METHODS

Age-standardized mortality rates (ASMRs)/100,000 by U.S. county (2015-2019) were obtained by race (Black/White) from the CDC Wonder National Vital Statistics System (2015-2019) and were merged with county-level social determinants from the US Census Bureau and County Health Rankings. Multivariable generalized linear models assessed the associations between rurality (index of relative rurality [IRR] decile, rural-urban continuum codes, and population density) and race-specific ASMR, overall, and by Census region and poverty level.

RESULTS

Overall, average ASMR was significantly higher in rural areas than urban areas for both Black (rural ASMR = 949.1 per 100,000 vs. urban ASMR = 857.7 per 100,000) and White (rural ASMR = 903.0 per 100,000 vs. urban ASMR = 791.6 per 100,000) populations. The Black-White difference was substantially higher (p < 0.001) in urban than in rural counties (65.1 per 100,000 vs. 46.1 per 100,000). Black-White differences and patterns in ASMR varied notably by poverty status and U.S. region.

CONCLUSION

Policies and interventions designed to reduce racial health disparities should consider and address key contextual factors associated with geographic location, including rural-urban status and socioeconomic status.

Social and clinical drivers of stress responses in African American breast cancer survivors

Racial differences in breast cancer morbidity and mortality have been examined between Black/African American women and White women as part of efforts to characterize multilevel drivers of disease risk and outcomes. Current models of cancer disparities recognize the significance of physiological stress responses, yet data on stress hormones in Black/African American women with breast cancer and their social risk factors are limited. We examined cortisol levels in Black/African American breast cancer patients and tested their association with social and clinical factors to understand the relationship between stress responses and women's lived experiences. Seventy-two patients who completed primary surgical treatment were included in this cross-sectional study. Data on sociodemographic characteristics and chronic diseases were obtained by self-report. Breast cancer stage and diagnosis date were abstracted from electronic health records. Cortisol levels were determined from saliva samples. Compared to those without hypertension, patients with hypertension were 6.84 (95% CI 1.33, 35.0) times as likely to have high cortisol (p = 0.02). The odds of having high cortisol increased by 1.42 (95% CI 1.03, 1.95, p = 0.03) times for every point increase in negative life events. Hypertension and negative life events are associated with high cortisol levels in Black/African American patients. These findings illustrate the importance of understanding the lived experiences of these patients to enhance cancer health equity.

Effect of neighborhood deprivation index on breast cancer survival in the United States

PURPOSE

To analyze the association between the Neighborhood Deprivation Index (NDI) and clinical outcomes of locoregional breast cancer (BC).

METHODS

Surveillance, Epidemiology and End Results (SEER) database is queried to evaluate overall survival (OS) and disease-specific survival (DSS) of early- stage BC patients diagnosed between 2010 and 2016. Cox multivariate regression was performed to measure the association between NDI (Quintiles corresponding to most deprivation (Q1), above average deprivation (Q2), average deprivation (Q3), below average deprivation (Q4), least deprivation (Q5)) and OS/DSS.

RESULTS

Of the 88,572 locoregional BC patients, 27.4% (n = 24,307) were in the Q1 quintile, 26.5% (n = 23,447) were in the Q3 quintile, 17% (n = 15,035) were in the Q2 quintile, 13.5% (n = 11,945) were in the Q4 quintile, and 15.6% (n = 13,838) were in the Q5 quintile. There was a predominance of racial minorities in the Q1 and Q2 quintiles with Black women being 13-15% and Hispanic women being 15% compared to only 8% Black women and 6% Hispanic women in the Q5 quintile (p < 0.001). In multivariate analysis, in the overall cohort, those who live in Q2 and Q1 quintile have inferior OS and DSS compared to those who live in Q5 quintile (OS:- Q2: Hazard Ratio (HR) 1.28, Q1: HR 1.2; DSS:- Q2: HR 1.33, Q1: HR 1.25, all p < 0.001).

CONCLUSION

Locoregional BC patients from areas with worse NDI have poor OS and DSS. Investments to improve the socioeconomic status of areas with high deprivation may help to reduce healthcare disparities and improve breast cancer outcomes.

GIS Mapping and Breast Cancer Health Care Access Gaps for African American Women

Black women face an unequal opportunity to survive breast cancer compared with White women. One would expect that US metropolitan areas with high percentages of Black people should report similar racial disparities in breast health. Yet, this is not the case. To provide insights about breast cancer disparities in cities with above-average and below-average racial disparities, we use GIS analysis. We depict racial composition and income categories on the same map with mammography facility locations to distinguish unique patterns of mammography access, a critical resource for breast cancer care. Looking more closely at low health disparities cities, a general and consistent pattern arises. Both White and Black people are concentrated in middle-income neighborhoods. Further, MQSA-certified facilities are not clustered in affluent areas but tend to be centrally located in the middle of the city or highly dispersed across the city, regardless of income. Our findings are consistent with the hypothesis that metropolitan areas that have a preponderance of racially segregated low-income Black households-a characteristic of neighborhoods that have experienced a history of racism and disinvestment-are more likely to experience disparities in access to primary breast care than middle-income Black, middle-income White, or high-income White neighborhoods.

Effect of Neighborhood Deprivation Index on Breast Cancer Survival in the United States

Purpose To analyze the association between the Neighborhood Deprivation Index (NDI) and clinical outcomes of early-stage breast cancer (BC). Methods Surveillance, Epidemiology and End Results (SEER) database is queried to evaluate overall survival (OS) and disease-specific survival (DSS) of early- stage BC patients diagnosed between 2010-2016. Cox multivariate regression was performed to measure the association between NDI (Quintiles corresponding to most deprivation (Q1), above average deprivation (Q2), average deprivation (Q3), below average deprivation (Q4), least deprivation (Q5)) and OS/DSS. Results Of the 88,572 early-stage BC patients, 27.4% (n = 24,307) were in the Q1 quintile, 26.5% (n = 23,447) were in the Q3 quintile, 17% (n = 15,035) were in the Q2 quintile, 13.5% (n = 11,945) were in the Q4 quintile, and 15.6% (n = 13,838) were in the Q5 quintile. There was a predominance of racial minorities in the Q1 and Q2 quintiles with Black women being 13-15% and Hispanic women being 15% compared to only 8% Black women and 6% Hispanic women in the Q5 quintile (p < 0.001). In multivariate analysis, in the overall cohort, those who live in Q2 and Q1 quintile have inferior OS and DSS compared to those who live in Q5 quintile (OS:- Q2: Hazard Ratio (HR) 1.28, Q1: HR 1.2; DSS:- Q2: HR 1.33, Q1: HR 1.25, all p < 0.001). Conclusion Early-stage BC patients from areas with worse NDI have poor OS and DSS. Investments to improve the socioeconomic status of areas with high deprivation may help to reduce healthcare disparities and improve breast cancer outcomes.

Trends in breast cancer mortality by race/ethnicity, age, and US census region, United States─1999-2020

BACKGROUND

Breast cancer remains a leading cause of morbidity and mortality among women in the United States. Previous analyses show that breast cancer incidence increased from 1999 to 2018. The purpose of this article is to examine trends in breast cancer mortality.

METHODS

Analysis of 1999 to 2020 mortality data from the Centers for Disease Control and Prevention, National Center for Health Statistics, among women by race/ethnicity, age, and US Census region.

RESULTS

It was found that overall breast cancer mortality is decreasing but varies by race/ethnicity, age group, and US Census region. The largest decrease in mortality was observed among non-Hispanic White women, women aged 45 to 64 years of age, and women living in the Northeast; whereas the smallest decrease in mortality was observed among non-Hispanic Asian or Pacific Islander women, women aged 65 years or older, and women living in the South.

CONCLUSION

This report provides national estimates of breast cancer mortality from 1999 to 2020 by race/ethnicity, age group, and US Census region. The decline in breast cancer mortality varies by demographic group. Disparities in breast cancer mortality have remained consistent over the past two decades. Using high-quality cancer surveillance data to estimate trends in breast cancer mortality may help health care professionals and public health prevention programs tailor screening and diagnostic interventions to address these disparities.

Racial Disparities in Clinical Outcomes on Investigator-Initiated Breast Cancer Clinical Trials at an Urban Medical Center

BACKGROUND

Black women are 40% more likely to die of breast cancer compared to White women. Inadequate representation of Black patients in clinical trials may contribute to health care inequity. We aimed to assess breast cancer clinical outcomes in Non-Hispanic Black (Black) versus Non-Hispanic White (White) women with metastatic breast cancer (MBC) enrolled on investigator-initiated clinical trials at Winship Cancer Institute at Emory University, given the significant number of patients from underrepresented minority groups seen at Winship.

MATERIALS AND METHODS

Black and White women with MBC on investigator-initiated trials at Emory between 2009 and 2019 were retrospectively evaluated. Univariate analyses and multiple logistic regression models were used to assess clinical response and treatment toxicities. Differences in overall survival between groups was assessed using quantile analysis.

RESULTS

Sixty-two women with MBC were included (66% White vs. 34% Black). Black patients had less clinical benefit from the trial therapy as only 57% had partial response or stable disease as best response compared to 78% of White women (P = .09). Quantile analysis showed significant difference in mean survival between Whites and Blacks by the end of follow up (64 vs. 38 months). There were no significant differences in toxicities between groups.

CONCLUSION

Participation rates of Black women with MBC on investigator-initiated clinical trials at an urban cancer center were higher compared to key national trials. Black women had worse treatment response and survival. These results reinforce the need for assessment of tumor differences by ancestry and continued improvement in minority representation on clinical trials.

Oncology distress screening within predominately Black Veterans: Outcomes on supportive care utilization, hospitalizations, and mortality

BACKGROUND

We evaluated whether patients' initial screening symptoms were related to subsequent utilization of supportive care services and hospitalizations, and whether patient-level demographics, symptoms, hospitalizations, and supportive care service utilization were associated with mortality in primarily low-income, older, Black Veterans with cancer.

METHODS

This quality improvement project created collaborative clinics to conduct cancer distress screenings and refer to supportive care services at an urban, VA medical center. All patients completed a distress screen with follow-up screening every 3 months. Supportive care utilization, hospitalization rates, and mortality were abstracted through medical records. Poisson regression models and cox proportional hazard models were utilized.

RESULTS

Five hundred and eighty five screened patients were older (m = 72), mostly Black 70% (n = 412), and had advanced cancer 54%. Fifty-eight percent (n = 340) were screened only once with 81% (n = 470) receiving ≥1 supportive care service and 51.5% (n = 297) being hospitalized ≥1 time 18 months following initial screen. Symptom severity was significantly related to number of hospitalizations. Low mood was significantly related to higher supportive services (p < 0.001), but not hospitalizations (p ≥ 0.52). Pain, fatigue, physical function, nutrition, and physical symptoms were significantly associated with more supportive services and hospitalizations (p < 0.01). Twenty percent (n = 168) died; Veterans who were Black, had lower stage cancers, better physical health, and utilized less supportive care services had lower odds of mortality (p ≤ 0.01).

CONCLUSION

Individuals with elevated distress needs and those reporting lower physical function utilized more supportive care services and had higher hospitalization rates. Lower physical function, greater supportive care use, higher stage cancer, and being non-Black were associated with higher odds of death.

Association of Race and Area Deprivation With Breast Cancer Survival Among Black and White Women in the State of Georgia

Importance

Increasing evidence suggests that low socioeconomic status and geographic residence in disadvantaged neighborhoods contribute to disparities in breast cancer outcomes. However, little epidemiological research has sought to better understand these disparities within the context of location.

Objective

To examine the association between neighborhood deprivation and racial disparities in mortality among Black and White patients with breast cancer in the state of Georgia.

Design, Setting, and Participants

This population-based cohort study collected demographic and geographic data from patients diagnosed with breast cancer between January 1, 2004, and February 11, 2020, in 3 large health care systems in Georgia. A total of 19 580 patients with breast cancer were included: 12 976 from Piedmont Healthcare, 2285 from Grady Health System, and 4319 from Emory Healthcare. Data were analyzed from October 2, 2020, to August 11, 2022.

Exposures

Area deprivation index (ADI) scores were assigned to each patient based on their residential census block group. The ADI was categorized into quartile groups, and associations between ADI and race and ADI × race interaction were examined.

Main Outcomes and Measures

Cox proportional hazards regression models were used to compute hazard ratios (HRs) and 95% CIs associating ADI with overall mortality by race. Kaplan-Meier curves were used to visualize mortality stratified across racial and ADI groups.

Results

Of the 19 580 patients included in the analysis (mean [SD] age at diagnosis, 58.8 [13.2] years), 3777 (19.3%) died during the course of the study. Area deprivation index contributed differently to breast cancer outcomes for Black and White women. In multivariable-adjusted models, living in a neighborhood with a greater ADI (more deprivation) was associated with increased mortality for White patients with breast cancer; compared with the ADI quartile of less than 25 (least deprived), increased mortality HRs were found in quartiles of 25 to 49 (1.22 [95% CI, 1.07-1.39]), 50 to 74 (1.32 [95% CI, 1.13-1.53]), and 75 or greater (1.33 [95% CI, 1.07-1.65]). However, an increase in the ADI quartile group was not associated with changes in mortality for Black patients with breast cancer (quartile 25 to 49: HR, 0.81 [95% CI, 0.61-1.07]; quartile 50 to 74: HR, 0.91 [95% CI, 0.70-1.18]; and quartile ≥75: HR, 1.05 [95% CI, 0.70-1.36]). In neighborhoods with an ADI of 75 or greater, no racial disparity was observed in mortality (HR, 1.11 [95% CI, 0.92-1.36]).

Conclusions and Relevance

Black women with breast cancer had higher mortality than White women in Georgia, but this disparity was not explained by ADI: among Black patients, low ADI was not associated with lower mortality. This lack of association warrants further investigation to inform community-level approaches that may mitigate the existing disparities in breast cancer outcomes in Georgia.

Barriers to breast cancer screening in Atlanta, GA: results from the Pink Panel survey at faith-based institutions

Purpose

Our research sought to describe barriers to mammography screening among a sample of predominantly Black women in metropolitan Atlanta, Georgia.

Methods

The Pink Panel project convened community leaders from faith-based institutions to administer an offline survey to women via convenience sampling at fourteen churches in Atlanta in late 2019 and early 2020. With the COVID-19 pandemic, the research team switched to an online survey. The survey included seven questions about breast cancer awareness, barriers to breast cancer screening, and screening status. We used residence information to attain the 9-digit zip code to link to the Area Deprivation Index at the Census Block Group neighborhood level. We report results as descriptive statistics of the barriers to mammography screening.

Results

The 643 women represented 21 counties in Georgia, predominantly from metropolitan Atlanta, and 86% identified as Black. Among women aged 40 and older, 90% have ever had a mammogram. Among all women, 79% have ever had a mammogram, and 86% indicated that they would get a mammogram if offered in their neighborhood. The top barriers to mammography screening were lack of health insurance and high cost. Barriers to mammography screening did not differ substantially by Area Deprivation Index.

Conclusion

Among metropolitan Atlanta women aged 40+ , nearly all reported ever having a mammogram. However, addressing the barriers, including lack of health insurance and high cost, that women reported may further improve mammography screening rates.

Initiation and tolerance of chemoprevention among women with high-risk breast lesions: the potential of low-dose tamoxifen

PURPOSE

High-risk lesions (HRLs) of the breast are an indication for chemoprevention, yet uptake is low, largely due to concerns about side effects. In 2019, low-dose (5 mg) tamoxifen was demonstrated to reduce breast cancer risk with improved tolerance. We describe chemoprevention uptake in an academic clinic before and after the introduction of low-dose tamoxifen.

METHODS

Females age ≥ 35 with HRLs who established care from April 2017 through January 2020 and eligible for chemoprevention were included. Rates of chemoprevention initiation before and after the introduction of low-dose tamoxifen (pre-2019 vs. post-2019) were compared with chi-squared tests. Logistic regression identified demographic and clinical factors associated with chemoprevention initiation. Kaplan-Meier methods determined the rates of discontinuation.

RESULTS

Among 660 eligible females with HRLs, 22.7% initiated chemoprevention. Median time from first visit to chemoprevention initiation was 54 days (interquartile range (IQR): 0-209); 31.0% (46/150) started chemoprevention > 6 months after their initial visit. Chemoprevention uptake was not significantly different pre-2019 vs. post-2019 (21.2% vs. 26.3%, p = 0.16); however, post-2019, low-dose tamoxifen became the most popular option (41.5%, 34/82). On multivariable analyses, age and breast cancer family history were significantly associated with chemoprevention initiation. Discontinuation rates at 1 year were lowest for low-dose tamoxifen (6.7%) vs. tamoxifen 20 mg (15.0%), raloxifene (20.4%), or an aromatase inhibitor (20.0%).

CONCLUSION

In this modern cohort, 22.7% of females with HRLs initiated chemoprevention with 31.0% initiating chemoprevention > 6 months after their first visit. Low-dose tamoxifen is now the most popular choice for chemoprevention, with low discontinuation rates at 1 year.

"Nobody Will Tell You. You've Got to Ask!": An Examination of Patient-Provider Communication Needs and Preferences among Black and White Women with Early-Stage Breast Cancer

Patient-provider communication is a critical component of healthcare and is associated with treatment quality and outcomes for women with breast cancer. This qualitative study examines similarities and differences in patient perspectives of communication needs between Black and White breast cancer survivors. We conducted four focus groups (N = 28) involving women with early-stage breast cancer on adjuvant endocrine therapy (AET), stratified by race and length of time on AET (< 6 months and >6 months). Each group was moderated by a race-concordant moderator and analyzed by emergent themes. Participants expressed common patient-provider communication needs, namely increased sensitivity from oncologists during the initial cancer diagnosis, personalized information to facilitate treatment decisions, emotional support during the transition from active treatment to maintenance, and rapid provider responses to mobile app-based queries. Communication differences by race also emerged. Black women were less likely than White women to describe having their informational needs met. White women praised longstanding relationships with providers, while Black women shared personal stories of disempowered interactions and noted the importance of patient advocates. White women more often reported privacy concerns about technology use. Unlike White women, Black women reported willingness to discuss sensitive topics, both online and offline, but believed those discussions made their providers feel uncomfortable. Early-stage breast cancer patients on AET, regardless of race, have similar needs for patient-centered communication with their oncologists. However, Black women were more likely to report experiencing poorer communication with providers than White women, which may be improved by technology and advocates.

Radiologists' Increasing Role in Population Health Management: AJR Expert Panel Narrative Review

Population health management (PHM) is the holistic process of improving health outcomes of groups of individuals through the support of appropriate financial and care models. Radiologists' presence at the intersection of many aspects of healthcare, including screening, diagnostic imaging, and image-guided therapies, provides significant opportunity for increased radiologist engagement in PHM. Further, innovations in artificial intelligence and imaging informatics will serve as critical tools to improve value in healthcare through evidence-based and equitable approaches. Given radiologists' limited engagement in PHM to date, it is imperative to define the specialty's PHM priorities so that the radiologists' full value in improving population health is realized. In this expert review, we explore programs and future directions for radiology in PHM.

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Characterization of Clinical Symptoms by Race Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer Before Starting Chemotherapy

IMPORTANCE

Race disparities persist in breast cancer mortality rates. One factor associated with these disparities may be differences in symptom burden, which may reduce chemotherapy tolerance and increase early treatment discontinuation.

OBJECTIVES

To compare symptom burden by race among women with early-stage breast cancer before starting chemotherapy and quantify symptom differences explained by baseline characteristics.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of symptom burden differences by race among Black and White women with a diagnosis of stage I to III, hormone receptor-positive breast cancer who had a symptom report collected before chemotherapy initiation in a large cancer center in the southern region of the US from January 1, 2007, through December 31, 2015. Analyses were conducted from November 1, 2019, to March 31, 2021. Blinder-Oaxaca decomposition was used, adjusting for baseline sociodemographic and clinical characteristics.

MAIN OUTCOMES AND MEASURES

Four symptom composite scores with a mean (SD) of 50 (10) were reported before starting chemotherapy (baseline) and were derived from symptom items: general physical symptoms (11 items), treatment adverse effects (8 items), acute distress (4 items), and despair (7 items). Patients rated the severity of each symptom they experienced in the past week on a scale of 0 to 10 (where 0 indicates not a problem and 10 indicates as bad as possible).

RESULTS

A total of 1338 women (mean [SD] age, 54.6 [11.6] years; 420 Black women [31.4%] and 918 White women [68.6%]) were included in the study. Before starting chemotherapy, Black women reported a statistically significantly higher (ie, worse) symptom composite score than White women for adverse effects (44.5 vs 43.8) but a lower acute distress score (48.5 vs 51.0). Decomposition analyses showed that Black patients' characteristics were associated with higher symptom burden across all 4 scores. However, these differences were offset by relatively greater, statistically significant, unexplained physical, distress, and despair symptom reporting by White patients.

CONCLUSIONS AND RELEVANCE

In this study, before starting chemotherapy, Black patients with early-stage breast cancer reported significantly higher burden for symptoms that may be exacerbated with chemotherapy and lower distress symptoms compared with White patients. Future studies should explore how symptoms change before and after treatment and differ by racial/ethnic groups and how they are associated with treatment adherence and mortality disparities.

Association of Health-Care System with Prostate Cancer-Specific Mortality in African American and Non-Hispanic White Men

BACKGROUND

Disparities in prostate cancer-specific mortality (PCSM) between African American and non-Hispanic White (White) patients have been attributed to biological and systemic factors. We evaluated drivers of these disparities in the Surveillance, Epidemiology and End Results (SEER) national registry and an equal-access system, the Veterans Health Administration (VHA).

METHODS

We identified African American and White patients diagnosed with prostate cancer between 2004-2015 in SEER (N = 311,691) and the VHA (N = 90,749). We analyzed the association between race and metastatic disease at presentation using multivariable logistic regression adjusting for sociodemographic factors, and PCSM using sequential competing-risks regression adjusting for disease and sociodemographic factors.

RESULTS

The median follow-up was 5.3 years in SEER and 4.7 years in the VHA. African American men were more likely than White men to present with metastatic disease in SEER (adjusted odds ratio = 1.23, 95% confidence interval [CI] = 1.17-1.30), but not in the VHA (adjusted odds ratio = 1.07, 95% CI = 0.98-1.17). African American versus White race was associated with an increased risk of PCSM in SEER (subdistribution hazard ratio [SHR] = 1.32, 95% CI = 1.10-1.60), but not in the VHA (SHR = 1.00, 95% CI: 0.93-1.08). Adjusting for disease extent, PSA, and Gleason score eliminated the association between race and PCSM in SEER (aSHR 1.04, 95% CI 0.93-1.16).

CONCLUSIONS

Racial disparities in PCSM were present in a nationally representative registry, but not in an equal-access healthcare system, due to differences in advanced disease at presentation. Strategies to increase healthcare access may bridge the racial disparity in outcomes. Longer follow-up is needed to fully assess mortality outcomes.Disparities between African American and non-Hispanic White (White) patients in cancer-specific mortality have been described across numerous cancer types and healthcare systems[1-5]. The survival gap between African American and White patients with prostate cancer has been well-characterized, with two-fold higher prostate cancer-specific mortality (PCSM) rates among African American patients depending on the setting[1, 6-10]. This disparity has been attributed to differences in prostate cancer biology in African American men, in addition to systemic factors in mediating this disparity, such as differential access to healthcare, Prostate-Specific Antigen (PSA) screening, and distrust in the healthcare system[1, 11-16].The Veterans Health Administration (VHA) is a relatively equal-access healthcare system that treats a large, ethnically diverse population of veterans. The Surveillance, Epidemiology and End Results (SEER) program is a national cancer registry program that collects data from the general United States (US) population. The goals of the present investigation were to 1) Compare PCSM between African American and White men within SEER and the VHA and 2) Identify modifiable system-level contributors to these disparities. We hypothesized that PCSM would be comparable among African American and White men in an equal-access setting, the VHA, but not in a national registry, SEER, and that this disparity in SEER would be in part driven by more advanced disease at presentation.

Comparing denominator sources for real-time disease incidence modeling: American Community Survey and WorldPop

Across the United States public health community in 2020, in the midst of a pandemic and increased concern regarding racial/ethnic health disparities, there is widespread concern about our ability to accurately estimate small-area disease incidence rates due to the absence of a recent census to obtain reliable population denominators. 2010 decennial census data are likely outdated, and intercensal population estimates from the Census Bureau, which are less temporally misaligned with real-time disease incidence data, are not recommended for use with small areas. Machine learning-based population estimates are an attractive option but have not been validated for use in epidemiologic studies. Treating 2010 decennial census counts as a "ground truth", we conduct a case study to compare the performance of alternative small-area population denominator estimates from surrounding years for modeling real-time disease incidence rates. Our case study focuses on modeling health disparities in census tract incidence rates in Massachusetts, using population size estimates from the American Community Survey (ACS), the most commonly-used intercensal small-area population data in epidemiology, and WorldPop, a machine learning model for high-resolution population size estimation. Through simulation studies and an analysis of real premature mortality data, we evaluate whether WorldPop denominators can provide improved performance relative to ACS for quantifying disparities using both census tract-aggregate and race-stratified modeling approaches. We find that biases induced in parameter estimates due to temporally incompatible incidence and denominator data tend to be larger for race-stratified models than for area-aggregate models. In most scenarios considered here, WorldPop denominators lead to greater bias in estimates of health disparities than ACS denominators. These insights will assist researchers in intercensal years to select appropriate population size estimates for modeling disparities in real-time disease incidence. We highlight implications for health disparity studies in the coming decade, as 2020 census counts may introduce new sources of error.

Racial/Ethnic Disparities in Survival after Breast Cancer Diagnosis by Estrogen and Progesterone Receptor Status: A Pooled Analysis

BACKGROUND

Limited studies have investigated racial/ethnic survival disparities for breast cancer defined by estrogen receptor (ER) and progesterone receptor (PR) status in a multiethnic population.

METHODS

Using multivariable Cox proportional hazards models, we assessed associations of race/ethnicity with ER/PR-specific breast cancer mortality in 10,366 California women diagnosed with breast cancer from 1993 to 2009. We evaluated joint associations of race/ethnicity, health care, sociodemographic, and lifestyle factors with mortality.

RESULTS

Among women with ER/PR⁺ breast cancer, breast cancer-specific mortality was similar among Hispanic and Asian American women, but higher among African American women [HR, 1.31; 95% confidence interval (CI), 1.05-1.63] compared with non-Hispanic White (NHW) women. Breast cancer-specific mortality was modified by surgery type, hospital type, education, neighborhood socioeconomic status (SES), smoking history, and alcohol consumption. Among African American women, breast cancer-specific mortality was higher among those treated at nonaccredited hospitals (HR, 1.57; 95% CI, 1.21-2.04) and those from lower SES neighborhoods (HR, 1.48; 95% CI, 1.16-1.88) compared with NHW women without these characteristics. Breast cancer-specific mortality was higher among African American women with at least some college education (HR, 1.42; 95% CI, 1.11-1.82) compared with NHW women with similar education. For ER^-/PR^- disease, breast cancer-specific mortality did not differ by race/ethnicity and associations of race/ethnicity with breast cancer-specific mortality varied only by neighborhood SES among African American women.

CONCLUSIONS

Racial/ethnic survival disparities are more striking for ER/PR⁺ than ER^-/PR^- breast cancer. Social determinants and lifestyle factors may explain some of the survival disparities for ER/PR⁺ breast cancer.

IMPACT

Addressing these factors may help reduce the higher mortality of African American women with ER/PR⁺ breast cancer.

Obesity, comorbidities, and treatment selection in Black and White women with early breast cancer

BACKGROUND

This study investigates obesity and comorbidity in Black and White women with early breast cancer (stages I-III) and their potential impact on treatment decisions for patients with hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) tumors.

METHODS

In this retrospective chart review, comparisons of frequencies for Black and White patients were calculated with the Fisher exact test. Log binomial regression was used to estimate prevalence ratios (PRs) with 95% confidence intervals for total and individual comorbidities, and multivariable modeling was used to estimate PRs adjusted for age and body mass index (BMI).

RESULTS

In a sample of 548 patients, 26% were Black, and 74% were White. Sixty-two percent of Black patients and 32% of White patients were obese (BMI ≥ 30 kg/m² ; P < .0001). Seventy-five percent of Black patients and 87% of White patients had HR+ tumors (P = .001). Significant intergroup differences were seen for 2 or more total comorbidities (62% of Blacks vs 47% of Whites; P = .001), 2 or more obesity-related comorbidities (33% vs 10%; P < .0001), hypertension (60% vs 32%; P < .0001), diabetes mellitus (23% vs 6%; P < .0001), hypercholesterolemia or hyperlipidemia (28% vs 18%; P = .02), and hypothyroidism (4% vs 11%; P = .012). In women with HR+/HER2- tumors, there were no intergroup differences in treatment decisions regarding the type of surgery, chemotherapy regimen, radiation, or endocrine treatment despite significant differences in the prevalence of obesity and comorbidities.

CONCLUSIONS

This study documents significant disparities between Black and White women with early breast cancer with regard to high rates of obesity, overall comorbidities, and obesity-related comorbidities, and it highlights the prevalence of competing risks that may complicate outcomes in breast cancer.

Novel semi-automated algorithm for high-throughput quantification of adipocyte size in breast adipose tissue, with applications for breast cancer microenvironment

The size distribution of adipocytes in fat tissue provides important information about metabolic status and overall health of patients. Histological measurements of biopsied adipose tissue can reveal cardiovascular and/or cancer risks, to complement typical prognosis parameters such as body mass index, hypertension or diabetes. Yet, current methods for adipocyte quantification are problematic and insufficient. Methods such as hand-tracing are tedious and time-consuming, ellipse approximation lacks precision, and fully automated methods have not proven reliable. A semi-automated method fills the gap in goal-directed computational algorithms, specifically for high-throughput adipocyte quantification. Here, we design and develop a tool, AdipoCyze, which incorporates a novel semi-automated tracing algorithm, along with benchmark methods, and use breast histological images from the Komen for the Cure Foundation to assess utility. Speed and precision of the new approach are superior to conventional methods and accuracy is comparable, suggesting a viable option to quantify adipocytes, while increasing user flexibility. This platform is the first to provide multiple methods of quantification in a single tool. Widespread laboratory and clinical use of this program may enhance productivity and performance, and yield insight into patient metabolism, which may help evaluate risks for breast cancer progression in patients with comorbidities of obesity.

ABBREVIATIONS

BMI: body mass index.

Disparities in mortality-to-incidence ratios by race/ethnicity for female breast cancer in New York City, 2002-2016

Background

Racial disparities in New York City (NYC) breast cancer incidence and mortality rates have previously been demonstrated. Disease stage at diagnosis and mortality‐to‐incidence ratio (MIR) may present better measures of differences in screening and treatment access. Racial/ethnic trends in NYC MIR have not previously been assessed.

Methods

Mammogram rates were compared using the NYC Community Health Survey, 2002‐2014. Breast cancer diagnosis, stage, and mortality were from the New York State Cancer Registry, 2000‐2016. Primary outcomes were MIR, the ratio of age‐adjusted mortality to incidence rates, and stage at diagnosis. Joinpoint regression analysis identified significant trends.

Results

Mammogram rates in 2002‐2014 among Black and Latina women ages 40 and older (79.9% and 78.4%, respectively) were stable and higher than among White (73.6%) and Asian/Pacific‐Islander women (70.4%) (P < .0001). There were 82 733 incident cases of breast cancer and 16 225 deaths in 2000‐2016. White women had the highest incidence, however, rates among Black, Latina, and Asian/Pacific Islander women significantly increased. Black and Latina women presented with local disease (Stage I) less frequently (53.2%, 57.6%, respectively) than White (62.5%) and Asian/Pacific‐Islander women (63.0%). Black women presented with distant disease (Stage IV) more frequently than all other groups (Black 8.7%, Latina 5.8%, White 6.0%, and Asian 4.2%). Black women had the highest breast cancer mortality rate and MIR (Black 0.25, Latina 0.18, White 0.17, and Asian women 0.11).

Conclusions

More advanced disease at diagnosis coupled with a slower decrease in breast cancer mortality among Black and Latina women may partially explain persistent disparities in MIR especially prominent among Black women. Assessment of racial/ethnic differences in screening quality and access to high‐quality treatment may help identify areas for targeted interventions to improve equity in breast cancer outcomes.

Racial/ethnic minority segregation and low birth weight in five North American cities

Comparisons of communities across cities are rare in social epidemiology. Our prior work exploring racial/ethnic segregation and the prevalence of low birth weight (LBW) in communities from two large urban cities showed a strong relationship in Chicago and a very weak relationship in Toronto. This study extends that work by examining the association between racial/ethnic minority segregation and LBW in total of 307 communities in five North American cities: Baltimore, Boston, Chicago, Philadelphia, and Toronto. We used Pearson correlation coefficients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW, controlling for community-level unemployment. In a combined model with community-level data from all cities, a 10% increase in minority composition is associated with a 0.7% increase in LBW. While racial/ethnic minority segregation and unemployment are not associated with LBW in Toronto, these social determinants have strong and significant associations with LBW across communities in the four US cities in the analysis. Subsequent models revealed opposite effects for percentage non-Hispanic Black and percentage Hispanic. Across communities in the US cities in this analysis, there is considerable similarity in the strength of the effect of racial/ethnic segregation on LBW. Future work should incorporate communities from additional cities, looking to identify community assets and public policies that allow some minority communities to thrive, while other minority communities suffer from a high prevalence of LBW. More work is also needed on the generalizability of these patterns to other health outcomes.

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.

Invasive breast cancer among Alaska Native women in Alaska

Female breast cancer is the most common cancer diagnosed among Alaska Native (AN) women. We examined characteristics of and trends for female breast cancer among AN women. We assessed descriptive statistics, incidence trends (1969-2014), and cause-specific survival for female breast cancers recorded in the Alaska Native Tumor Registry. Results indicated that the majority of breast cancers among AN were diagnosed among women aged over 50 years, at local stage, and with Hormone receptor (HR)+/Human Epidermal Growth Factor (HER) 2- subtype. Five-year average incidence (95% CI) in the most recent time-period (2009-2014) was 145.0/100,000 (130.4, 159.5)); this was not statistically different from the previous time-period. Survival from breast cancer was high and varied by stage and cancer subtype. Hazard of death was greater among those diagnosed with regional/distant/unknown disease, relative to local disease (HR (95%CI): 4.65 (1.66, 12.98)), and higher among those with HER2-/HR- cancers, relative to those with HER2-/HR+ cancers (HR (95%CI): 6.59 (2.23, 19.49)). This study provides a comprehensive description of breast cancer among AN women, providing new and updated information on clinical and demographic factors, cancer incidence trends, regional variations and breast cancer survival. Abbreviations: AIAN: American Indian/Alaska Native; AN: Alaska Native; ANMC: Alaska Native Medical Center; ANTR: Alaska Native Tumor Registry; CI: Confidence Interval; HR: Hazard Ratio; ICD-O-3: International Classification of Diseases for Oncology - Third Edition; NHW - Non-Hispanic Whites; SEER: Surveillance, Epidemiology and End Results.

Breast cancer statistics, 2019

This article is the American Cancer Society's biennial update on female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Over the most recent 5-year period (2012-2016), the breast cancer incidence rate increased slightly by 0.3% per year, largely because of rising rates of local stage and hormone receptor-positive disease. In contrast, the breast cancer death rate continues to decline, dropping 40% from 1989 to 2017 and translating to 375,900 breast cancer deaths averted. Notably, the pace of the decline has slowed from an annual decrease of 1.9% during 1998 through 2011 to 1.3% during 2011 through 2017, largely driven by the trend in white women. Consequently, the black-white disparity in breast cancer mortality has remained stable since 2011 after widening over the past 3 decades. Nevertheless, the death rate remains 40% higher in blacks (28.4 vs 20.3 deaths per 100,000) despite a lower incidence rate (126.7 vs 130.8); this disparity is magnified among black women aged <50 years, who have a death rate double that of whites. In the most recent 5-year period (2013-2017), the death rate declined in Hispanics (2.1% per year), blacks (1.5%), whites (1.0%), and Asians/Pacific Islanders (0.8%) but was stable in American Indians/Alaska Natives. However, by state, breast cancer mortality rates are no longer declining in Nebraska overall; in Colorado and Wisconsin in black women; and in Nebraska, Texas, and Virginia in white women. Breast cancer was the leading cause of cancer death in women (surpassing lung cancer) in four Southern and two Midwestern states among blacks and in Utah among whites during 2016-2017. Declines in breast cancer mortality could be accelerated by expanding access to high-quality prevention, early detection, and treatment services to all women.

Metastatic breast cancer survival improvement restricted by regional disparity: Surveillance, Epidemiology, and End Results and institutional analysis: 1990 to 2011

Background

The extent of breast cancer outcome disparity can be measured by comparing Surveillance, Epidemiology, and End Results (SEER) breast cancer‐specific survival (BCSS) by region and with institutional cohort (IC) rates.

Methods

Patients who were diagnosed with a first primary, de novo, stage IV breast cancer at ages 25 to 84 years from 1990 to 2011 were studied. The change in 5‐year BCSS over time from 1990 to 2011 was compared using the SEER 9 registries (SEER 9) without the Seattle‐Puget Sound (S‐PS) region (n = 12,121), the S‐PS region alone (n = 1931), and the S‐PS region IC (n = 261). The IC BCSS endpoint was breast cancer death confirmed from chart and/or death certificate and cause‐specific survival for SEER registries. BCSS was estimated using the Kaplan‐Meier method. Hazard ratios (HzR) were calculated using Cox proportional‐hazards models.

Results

For SEER 9 without the S‐PS region, 5‐year BCSS improved 7% (from 19% to 26%) over time, it improved 14% for the S‐PS region (21% to 35%), and it improved 27% for the S‐PS IC (29% to 56%). In the IC Cox proportional‐hazards model, recent diagnosis year, chemotherapy, surgery, and age <70 years were associated with better survival. For SEER 9, additional significant factors were white race and positive hormone receptor status and S‐PS region was associated with better survival (HzR, 0.87; 95% CI, 0.84‐0.90). In an adjusted model, hazard of BC death decreased in the most recent time period (2005‐2011) by 28% in SEER 9 without S‐PS, 43% in the S‐PS region and 45% in the IC (HzR, 0.72 [95% CI, 0.67‐0.76], 0.57 [95% CI, 0.49‐0.66], and 0.55 [95% CI, 0.39‐0.78], respectively).

Conclusions

Over 2 decades, the survival of patients with metastatic breast cancer improved nationally, but with regional survival disparity and differential improvement. To achieve equitable outcomes, access and treatment approaches will need to be identified and adopted.

The observation of a greater improvement in survival with metastatic breast cancer by region indicates progress in treatment and a possible statistical cure, in that patients may be able to live long enough with disease to die of other causes. The direct identification of specific factors related to differential survival rates, such as access to care and molecular subtype‐appropriate treatment, is warranted.

Racial Disparities in Breast Cancer Outcomes in the Metropolitan Atlanta Area: New Insights and Approaches for Health Equity

BACKGROUND

Racial disparities in breast cancer (BC) outcomes persist where non-Hispanic black (NHB) women are more likely to die from BC than non-Hispanic white (NHW) women, and the extent of this disparity varies geographically. We evaluated tumor, treatment, and patient characteristics that contribute to racial differences in BC mortality in Atlanta, Georgia, where the disparity was previously characterized as especially large.

METHODS

We identified 4943 NHW and 3580 NHB women in the Georgia Cancer Registry with stage I-IV BC diagnoses in Atlanta (2010-2014). We used Cox proportional hazard regression to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) comparing NHB vs NHW BC mortality by tumor, treatment, and patient characteristics on the additive and multiplicative scales. We additionally estimated the mediating effects of these characteristics on the association between race and BC mortality.

RESULTS

At diagnosis, NHB women were younger-with higher stage, node-positive, and triple-negative tumors relative to NHW women. In age-adjusted models, NHB women with luminal A disease had a 2.43 times higher rate of BC mortality compared to their NHW counterparts (95% CI = 1.99 to 2.97). High socioeconomic status (SES) NHB women had more than twice the mortality rates than their white counterparts (HR = 2.67, 95% CI = 1.65 to 4.33). Racial disparities among women without insurance, in the lowest SES index, or diagnosed with triple-negative BC were less pronounced.

CONCLUSIONS

In Atlanta, the largest racial disparities are observed in luminal tumors and most pronounced among women of high SES. More research is needed to understand drivers of disparities within these treatable features.

Standardized activities for lay patient navigators in breast cancer care: Recommendations from a citywide implementation study

BACKGROUND

There is a need for guidelines on patient navigation activities to promote both the quality of patient navigation and the standards of reimbursement for these services because a lack of reimbursement is a major barrier to the implementation, maintenance, and sustainability of these programs.

METHODS

A broad community-based participatory research process was used to identify the needs of patients for navigation. A panel of stakeholders of clinical providers was convened to identify specific activities for navigators to address the needs of patients and providers with the explicit goal of reducing delays in the initiation of cancer treatment and improving adherence to the care plan.

RESULTS

Specific activities were identified that could be generalized to all patient navigation programs for care during active cancer management to address the needs of vulnerable communities.

CONCLUSIONS

Oncology programs that seek to implement lay patient navigation may benefit from the adoption of these activities for quality monitoring. Such activities are necessary as we consider reimbursement strategies for navigators without clinical training or licensure.

Cancer statistics for African Americans, 2019

In the United States, African American/black individuals bear a disproportionate share of the cancer burden, having the highest death rate and the lowest survival rate of any racial or ethnic group for most cancers. To monitor progress in reducing these inequalities, every 3 years the American Cancer Society provides the estimated number of new cancer cases and deaths for blacks in the United States and the most recent data on cancer incidence, mortality, survival, screening, and risk factors using data from the National Cancer Institute, the North American Association of Central Cancer Registries, and the National Center for Health Statistics. In 2019, approximately 202,260 new cases of cancer and 73,030 cancer deaths are expected to occur among blacks in the United States. During 2006 through 2015, the overall cancer incidence rate decreased faster in black men than in white men (2.4% vs 1.7% per year), largely due to the more rapid decline in lung cancer. In contrast, the overall cancer incidence rate was stable in black women (compared with a slight increase in white women), reflecting increasing rates for cancers of the breast, uterine corpus, and pancreas juxtaposed with declining trends for cancers of the lung and colorectum. Overall cancer death rates declined faster in blacks than whites among both males (2.6% vs 1.6% per year) and females (1.5% vs 1.3% per year), largely driven by greater declines for cancers of the lung, colorectum, and prostate. Consequently, the excess risk of overall cancer death in blacks compared with whites dropped from 47% in 1990 to 19% in 2016 in men and from 19% in 1990 to 13% in 2016 in women. Moreover, the black-white cancer disparity has been nearly eliminated in men <50 years and women ≥70 years. Twenty-five years of continuous declines in the cancer death rate among black individuals translates to more than 462,000 fewer cancer deaths. Continued progress in reducing disparities will require expanding access to high-quality prevention, early detection, and treatment for all Americans.

Enrollment and biospecimen collection in a multiethnic family cohort: the Northern California site of the Breast Cancer Family Registry

PURPOSE

Racial/ethnic minorities are often assumed to be less willing to participate in and provide biospecimens for biomedical research. We examined racial/ethnic differences in enrollment of women with breast cancer (probands) and their first-degree relatives in the Northern California site of the Breast Cancer Family Registry from 1996 to 2011.

METHODS

We evaluated participation in several study components, including biospecimen collection, for probands and relatives by race/ethnicity, cancer history, and other factors.

RESULTS

Of 4,780 eligible probands, 76% enrolled in the family registry by completing the family history and risk factor questionnaires and 68% also provided a blood or mouthwash sample. Enrollment was highest (81%) for non-Hispanic whites (NHWs) and intermediate (73-76%) for Hispanics, African Americans, and all Asian American subgroups, except Filipina women (66%). Of 4,279 eligible relatives, 77% enrolled in the family registry, and 65% also provided a biospecimen sample. Enrollment was highest for NHWs (87%) and lowest for Chinese (68%) and Filipinas (67%). Among those enrolled, biospecimen collection rates were similar for NHW, Hispanic, and African American women, both for probands (92-95%) and relatives (82-87%), but lower for some Asian-American subgroups (probands: 72-88%; relatives: 71-88%), foreign-born Asian Americans, and probands those who were more recent immigrants or had low English language proficiency.

CONCLUSIONS

These results show that racial/ethnic minority populations are willing to provide biospecimen samples for research, although some Asian American subgroups in particular may need more directed recruitment methods. To address long-standing and well-documented cancer health disparities, minority populations need equal opportunities to contribute to biomedical research.

Practice-Based Research Networks: Strategic Opportunities to Advance Implementation Research for Health Equity

While the vast majority of people receive their medical care in community primary and specialty care clinics, most clinical research is performed in academic tertiary care hospitals and hospital clinics. Practice-based research networks are most commonly collections of primary care practices that work together to ask and answer health questions for their patients and communities and are an integral part of the translational pathway from discovery to practice to community health. Community primary care practices are at the front line of health equity issues; equity in clinical care, equity in community health, equity in social determinants of health, and equity in health outcomes. Practice-based research networks can gather and combine data from dozens of communities, hundreds of practices and thousands of patients to address health equity and disparities across the full spectrum of community and public health to clinical and primary care. This article will briefly outline the history of PBRNs, types of PBRNs, locations, topics, and patient outcomes over the past 25 years. Current PBRN efforts to address health disparities and improve health equity will be described. New PBRN opportunities to address health disparities and approaches to advance implementation research for health equity in the practice and community will be described. Readers will be challenged to consider ways to engage practice-based research networks in their health equity efforts.

A qualitative exploration of race-based differences in social support needs of diverse women with breast cancer on adjuvant therapy

OBJECTIVE

Social support is a critical component of breast cancer care and is associated with clinical and quality of life outcomes. Significant health disparities exist between Black and White women with breast cancer. Our study used qualitative methods to explore the social support needs of Black and White women with hormone receptor-positive breast cancer on adjuvant endocrine therapy (AET).

METHODS

We conducted four focus group (FG) interviews (N = 28), stratified by race (ie, Black and White) and time on AET. FGs were audiotaped, transcribed, and analyzed according to conventions of thematic analysis.

RESULTS

Participants noted the importance of having their informational and emotional social support needs met by friends and family members. White participants reported support provided by others with breast cancer was crucial; Black women did not discuss other survivors as part of their networks. Notably, both White and Black participants used the FG environment to provide experiential social support to each other.

CONCLUSIONS

White participants noted that having other breast cancer survivors in their support network was essential for meeting their social support needs. However, Black participants did not reference other breast cancer survivors as part of their networks. Cancer centers should consider reviewing patients' access to experiential support and facilitate opportunities to connect women in the adjuvant phase.

Examining Associations of Racial Residential Segregation With Patient Knowledge of Breast Cancer and Treatment Receipt

BACKGROUND

The effect of racial residential segregation on breast cancer treatment disparities is unclear. We examined whether racial segregation is associated with adjuvant treatment receipt and patient knowledge of disease.

PATIENTS AND METHODS

We surveyed a population-based sample of women in Northern California with stage I to III breast cancer diagnosed in 2010 to 2011 (participation rate = 68.5%, 500 patients). For black, Hispanic, and white women, we measured black and Hispanic segregation using the location quotient (LQ) of racial residential segregation, a proportional measure of the size of a minority group in the census tract compared with the larger metropolitan statistical area. We categorized LQ values for black and Hispanic participants into quartiles, with quartile 1 representing a lower relative level of segregation than quartile 4. We used multivariable logistical regression to assess the odds of receiving guideline-recommended adjuvant therapy and patient knowledge of tumor characteristics according to relative residential segregation.

RESULTS

We observed greater residential segregation for black versus Hispanic patients (P < .05). Overall, there were no treatment differences according to Hispanic or black LQ, except for black LQ quartile 3 (vs. 1) for which we observed higher odds of hormonal therapy. Knowledge of disease did not vary according to black LQ, but patients in the Hispanic LQ quartile 3 (vs. quartile 1) had less tumor knowledge.

CONCLUSION

We did not find clear associations for racial residential segregation and treatment or cancer knowledge in Northern California, an area with low levels of segregation. Additional research should assess the effect of segregation on breast cancer treatment disparities in a variety of geographical locations.

Health Behaviors and Lifestyle Interventions in African American Breast Cancer Survivors: A Review

Background: African American breast cancer survivors have a higher incidence of estrogen receptor negative and basal-like (e.g., triple negative) tumors, placing them at greater risk for poorer survival when compared to women of other racial and ethnic groups. While access to equitable care, late disease stage at diagnosis, tumor biology, and sociodemographic characteristics contribute to health disparities, poor lifestyle characteristics (i.e., inactivity, obesity, and poor diet) contribute equally to these disparities. Lifestyle interventions hold promise in shielding African American survivors from second cancers, comorbidities, and premature mortality, but they are often underrepresented in studies promoting positive behaviors. This review examined the available literature to document health behaviors and lifestyle intervention (i.e., obesity, physical activity, and sedentary behavior) studies in African American breast cancer survivors. Methods: We used PubMed, Academic Search Premier, and Scopus to identify cross-sectional and intervention studies examining the lifestyle behaviors of African American breast cancer survivors. Identified intervention studies were assessed for risk of bias. Other articles were identified and described to provide context for the review. Results: Our systematic review identified 226 relevant articles. The cross-sectional articles indicated poor adherence to physical activity and dietary intake and high rates of overweight and obesity. The 16 identified intervention studies indicated reasonable to modest study adherence rates (>70%), significant reductions in weight (range -1.9 to -3.6%), sedentary behavior (-18%), and dietary fat intake (range -13 to -33%) and improvements in fruit and vegetable intake (range +25 to +55%) and physical activity (range +13 to +544%). The risk of bias for most studies were rated as high (44%) or moderate (44%). Conclusions: The available literature suggests that African American breast cancer survivors adhere to interventions of various modalities and are capable of making modest to significant changes. Future studies should consider examining (a) mediators and moderators of lifestyle behaviors and interventions, (b) biological outcomes, and (c) determinants of enhanced survival in this population.

Predictors of breast cancer mortality among white and black women in large United States cities: an ecologic study

PURPOSE

We employed a city-level ecologic analysis to assess predictors of race-specific (black and white) breast cancer mortality rates.

METHODS

We used data from the National Center for Health Statistics and the US Census Bureau to calculate 2010-2014 race-specific breast cancer mortality rates (BCMR) for 47 of the largest US cities. Data on potential city-level predictors (e.g., socioeconomic factors, health care resources) of race-specific BCMR were obtained from various publicly available datasets. We constructed race-specific multivariable negative binomial regression models to estimate rate ratios (RR) and 95% confidence intervals (CIs).

RESULTS

Predictors of the white BCMR included white/black differences in education (RR 0.95; CI 0.91-0.99), number of religious congregations (RR 0.87; CI 0.77-0.97), and number of Medicare primary care physicians (RR 1.15; CI 1.04-1.28). Predictors of the black rate included white/black differences in household income (RR 1.03; CI 1.01-1.05), number of mammography facilities (RR 1.07; CI 1.03-1.12), and mammogram use (RR 0.93; CI 0.89-0.97).

CONCLUSIONS

Our ecologic analysis found that predictors of breast cancer mortality differ for the black and white rate. The results of this analysis could help inform interventions at the local level.

Alcohol and Tobacco Use in an Ethnically Diverse Sample of Breast Cancer Patients, Including Sea Island African Americans: Implications for Survivorship

Background/Objective: Data suggest that modifiable risk factors such as alcohol and tobacco use may increase the risk of breast cancer (BC) recurrence and reduce survival. Female BC mortality in South Carolina is 40% higher among African Americans (AAs) than European Americans (EAs). Given this substantial racial disparity, using a cross-sectional survey design we examined alcohol and tobacco use in an ethnically diverse statewide study of women with recently diagnosed invasive breast cancer. This included a unique South Carolina AA subpopulation, the Sea Islanders (SI), culturally isolated and with the lowest European American genetic admixture of any AA group.

Methods: Participants (42 EAs, 66 non-SI AAs, 29 SIs), diagnosed between August 2011 and December 2012, were identified through the South Carolina Central Cancer Registry and interviewed by telephone within 21 months of diagnosis. Self-reported educational status, alcohol consumption and tobacco use were obtained using elements of the Behavior and Risk Factor Surveillance System questionnaire.

Results:Alcohol: EAs were approximately twice as likely to consume alcohol (40%) and to be moderate drinkers (29%) than either AA group (consumers: 24% of non-SI AAs, 21% of SIs; moderate drinkers 15 and 10% respectively). Users tended to be younger, significantly among EAs and non-SI AAs, but not SIs, and to have attained more education. Heavy drinking was rare (≤1%) and binge drinking uncommon (≤10%) with no differences by race/ethnicity. Among both AA subgroups but not EAs, alcohol users were six to nine times more likely to have late stage disease (Regional or Distant), statistically significant but with wide confidence intervals. Tobacco: Current cigarette smoking (daily or occasional) was reported by 14% of EAs, 14% of non-SI AAs and 7% of SIs. Smoking was inversely associated with educational attainment. Use of both alcohol and cigarettes was reported by 3–6% of cases.

Conclusions: Prevalences of alcohol and cigarette use were similar to those in the general population, with alcohol consumption more common among EAs. Up to half of cases used alcohol and/or tobacco. Given the risks from alcohol for disease recurrence, and implications of smoking for various health outcomes, these utilization rates are of concern.

Breast Cancer Disparities Among Women in Underserved Communities in the USA

Purpose of Review

Breast cancer disparities that exist between high-income countries (HIC) and low- and middle-income countries (LMICs) are also reflected within population subgroups throughout the United States (US). Here we examine three case studies of US populations "left behind" in breast cancer outcomes/equity.

Recent Findings

African Americans in Chicago, non-Latina White women in Appalachia, and Latinas in the Yakima Valley of Washington State all experience a myriad of factors that contribute to lower rates of breast cancer detection and appropriate treatment as well as poorer survival. These factors, related to the social determinants of health, including geographic isolation, lack of availability of care, and personal constraints, can be addressed with interventions at multiple levels.

Summary

Although HICs have reduced mortality of breast cancer compared to LMICs, there remain inequities in the US healthcare system. Concerted efforts are needed to ensure that all women have access to equitable screening, detection, treatment, and survivorship resources.

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.

First international TNBC conference meeting report

Recently, Georgia State University's Centennial Hall was the premier location for the 2017 International Conference on Triple Negative Breast Cancer (TNBC): Illuminating Actionable Biology, which was held from Sept. 18 to 20, 2017, in Atlanta, USA. The conference featured a stellar line-up of domestic and international speakers and diverse participants including TNBC survivors, luminaries in breast cancer research, medical students and fellows, clinicians, translational researchers, epidemiologists, biostatisticians, bioinformaticians, and representatives from the industry. This report distills the burning questions that spiked the event and summarizes key themes, findings, unique opportunities and future directions that emerged from this confluence of thought leaders.

Biopsychosocial Challenges and Needs of Young African American Women with Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) is a subtype of breast cancer known to have poorer prognoses and lower survival rates compared with other types of breast cancer. In addition, TNBC is overrepresented in premenopausal African American women. Using grounded theory as the qualitative methodological approach, the present article elucidates unique biopsychosocial challenges and needs of young African American women with TNBC. A study group of six women with TNBC and a comparison group of six women with estrogen receptor-positive breast cancer were interviewed longitudinally over three time points throughout the cancer treatment trajectory. Major themes that were unique to the study group of women with TNBC include (a) longer, more aggressive treatment trajectories; (b) more difficult struggles with feminine identity; (c) the presence of fertility and parenting issues; (d) higher burdens of care; (e) barriers to separation and individuation as a maturation milestone; and (f) feeling out of place compared with peers. These themes provide a foundation to inform how social workers care for this underserved group of women.

Disparity in breast cancer mortality by age and geography in 10 racially diverse US cities

OBJECTIVES

Assess geographic variation in breast cancer racial mortality disparity by age cohorts in US and ten cities with large African American populations.

METHODS

Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) female breast cancer mortality rates and NHB:NHW rate ratio (RR) (disparity) were calculated by four age group categories: <40, 40-49, 50-64 and 65+ with time period 1999-2013.

RESULTS

In all 10 cities and the US, the most pronounced breast cancer disparities, measured by RR, were seen among younger women. In age group <40, the RR ranges from 1.71 in Houston to 5.37 in Washington, DC. For age group 50-64, the disparity was less pronounced, ranging from 1.24 in New York to 1.72 in Chicago. For 65+ age group, there was wide city to city variation in breast cancer mortality disparity. Three cities had higher mortality for NHW compared to NHB; Baltimore 0.78, Washington DC 0.94 and New York 0.98. One city had no statistically significant racial variation in breast cancer mortality in this age group and six cities had increased NHB: NHW mortality disparities.

CONCLUSIONS

While the mortality rate for breast cancer is lower among younger women, the NHB:NHW disparities, as measured by rate ratios, are most pronounced in these age groups. Given the absence of available data regarding incidence, stage and subtypes, further research is necessary and such research is important, given the possible policy implications of these results with respect to screening guidelines and coverage for mammography and breast cancer treatment in particular for younger NHB women.

Obesity and survival in the neoadjuvant breast cancer setting: role of tumor subtype in an ethnically diverse population

BACKGROUND

Obesity may negatively affect survival in breast cancer (BC), but studies are conflicting, and associations may vary by tumor subtypes and race/ethnicity groups.

METHODS

In a retrospective review, we identified 273 women with invasive BC administered Adriamycin/Taxane-based neoadjuvant chemotherapy from 2004 to 2016 with body mass index (BMI) data at diagnosis. Obesity was defined as BMI ≥30. Associations between obesity and event-free survival (EFS), using STEEP events, and overall survival (OS), using all-cause mortality, were assessed overall and stratified by tumor subtype [[Hormone Receptor Positive (HR+)/HER2-, HER2+, and Triple-Negative Breast Cancer (TNBC])] in our diverse population.

RESULTS

Median follow-up was 32.6 months (range 5.7-137.8 months). Overall, obesity was associated with worse EFS (HR 1.71, 95% CI 1.03-2.84, p = 0.04) and a trend towards worse OS (p = 0.13). In HR+/HER2- disease (n = 135), there was an interaction between obesity and hormonal therapy with respect to OS but not EFS. In those receiving tamoxifen (n = 33), obesity was associated with worse OS (HR 9.27, 95% CI 0.96-89.3, p = 0.05). In those receiving an aromatase inhibitor (n = 89), there was no association between obesity and OS. In TNBC (n = 44), obesity was associated with worse EFS (HR 2.62, 95% CI 1.03-6.66, p = 0.04) and a trend towards worse OS (p = 0.06). In HER2+ disease (n = 94), obesity was associated with a trend towards worse EFS (HR 3.37, 95% CI 0.97-11.72, p = 0.06) but not OS. Race/ethnicity was not associated with survival in any subtype, and there were no interactions with obesity on survival.

CONCLUSIONS

Obesity may negatively impact survival, with differences among tumor subtypes.

Breast cancer statistics, 2017, racial disparity in mortality by state

In this article, the American Cancer Society provides an overview of female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Approximately 252,710 new cases of invasive breast cancer and 40,610 breast cancer deaths are expected to occur among US women in 2017. From 2005 to 2014, overall breast cancer incidence rates increased among Asian/Pacific Islander (1.7% per year), non-Hispanic black (NHB) (0.4% per year), and Hispanic (0.3% per year) women but were stable in non-Hispanic white (NHW) and American Indian/Alaska Native (AI/AN) women. The increasing trends were driven by increases in hormone receptor-positive breast cancer, which increased among all racial/ethnic groups, whereas rates of hormone receptor-negative breast cancers decreased. From 1989 to 2015, breast cancer death rates decreased by 39%, which translates to 322,600 averted breast cancer deaths in the United States. During 2006 to 2015, death rates decreased in all racial/ethnic groups, including AI/ANs. However, NHB women continued to have higher breast cancer death rates than NHW women, with rates 39% higher (mortality rate ratio [MRR], 1.39; 95% confidence interval [CI], 1.35-1.43) in NHB women in 2015, although the disparity has ceased to widen since 2011. By state, excess death rates in black women ranged from 20% in Nevada (MRR, 1.20; 95% CI, 1.01-1.42) to 66% in Louisiana (MRR, 1.66; 95% CI, 1.54, 1.79). Notably, breast cancer death rates were not significantly different in NHB and NHW women in 7 states, perhaps reflecting an elimination of disparities and/or a lack of statistical power. Improving access to care for all populations could eliminate the racial disparity in breast cancer mortality and accelerate the reduction in deaths from this malignancy nationwide. CA Cancer J Clin 2017;67:439-448. © 2017 American Cancer Society.

Sequential matched analysis of racial disparities in breast cancer hospitalization outcomes among African American and White patients

BACKGROUND

The purpose of this study is to determine if racial disparities in inpatient outcomes persist among hospitalized patients comparing African American and White breast cancer patients matched on demographics, presentation and treatment.

METHODS

A total of 136,211 African American and White breast cancer patients from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) database, matched on demographics alone, demographics and presentation or demographics, presentation and treatment were studied. Conditional logistic regression was conducted to evaluate post-surgical complications, length of stay and in-hospital mortality outcomes. Analysis was further stratified by age (≤65 years and >65years) to evaluate whether disparities were larger in younger or older patients. All analysis was conducted using SAS 9.3.

RESULTS

White women had significantly shorter hospital length of stay when matched on demographics (β=-0.87, p-value=<0.0001), demographics and presentation (β=-0.63, p-value=<0.0001), and demographics, presentation and treatment (β=-0.51, p-value=<0.0001) compared with African Americans. White women also had lower odds of mortality compared with African American women when matched on demographics (OR: 0.72, 95% CI: 0.65-0.79), demographics and presentation (OR: 0.77, 95% CI: 0.71-0.85), or matched on demographics, presentation and treatment (OR: 0.80, 95% CI: 0.73-0.88). The racial difference observed in length of stay and mortality was larger in the age group ≤65 years compared with >65years CONCLUSION: African American women experienced higher odds of inpatient mortality and longer length of stay compared with White women even after accounting for differences in demographics, presentation and treatment characteristics.

Changes in the racial disparity in breast cancer mortality in the ten US cities with the largest African American populations from 1999 to 2013: The reduction in breast cancer mortality disparity in Chicago

PURPOSE

Assess progress made to reduce racial disparity in breast cancer mortality in Chicago compared to nine other cities with largest African American populations and the US.

METHODS

The Non-Hispanic Black (NHB) and Non-Hispanic White (NHW) female breast cancer mortality rates and rate ratios (RR) (disparity) were compared between 1999 and 2005 and 2006 and 2013.

RESULTS

Between the two periods, the NHB breast cancer mortality rate in Chicago decreased by 13.9% (95% CI [-13.81, -13.92] compared to 7.7% (95% CI [-7.52, -7.83]) for NHW. A drop of 20% in the disparity was observed, from 51% (RR: 1.51, 95% CI [-7.52, -7.83]) to 41% (RR: 1.41, 95% CI [1.30, 1.52]). Whereas from 1999 to 2005 Chicago's disparity was above that of the U.S., from 2006 to 2013, it is now slightly lower. For the remaining nine cities and the US, the mortality disparity either grew or remained the same.

CONCLUSIONS

Chicago's improvement in NHB breast cancer mortality and disparity reduction occurred in the context of city-wide comprehensive public health initiatives and shows promise as a model for other cities with high health outcome disparities.