Health disparities in breast cancer

Identifying Systemic Factors when Counseling Black Women of Christian Faith in the USA

When Black women of Christian faith in the USA receive secular help for psychological symptoms, their spiritual and religious communities often view the decision negatively. The women may feel shamed, ostracized, and condemned. They often experience emotional, physical, and spiritual trauma from the rejection that increases the frequency, duration, and intensity of their psychological symptoms. This article identifies specific community-based and systemic factors that exacerbate mental health issues in Black women of Christian faith. The authors discuss the influence of such factors on mental health and provide evidence-based practices for mental health clinicians working with Black women of Christian faith.

On crowns, caravans and windmills: Commentary on an essay by Turcotte P., et al

Patient-oriented research (POR) is a trend that has emerged over several decades and is particularly prominent in Canada, the United States and the United Kingdom. It involves patient and other stakeholder participation in the planning, conduct and dissemination of biomedical and health services research and it can be seen as a form of public participation and engagement in activities that affect the lives and well-being of communities. Criticisms of POR revolve around its susceptibility to tokenistic treatment of patient participants and paternalistic dominance of the research agenda by professional researchers, academics and clinicians. This commentary addresses one such critique by situating the POR agenda within the challenges and dilemmas faced by the health-related research enterprise over the past 30 years. It will explore the interface between POR, community activism and community-based participatory research. The contextual importance of the COVID-19 pandemic experience is stressed. The commentary will particularly focus on the US-based Patient Centred Outcomes Research Institute, its origins within a movement to enhance emphasis on publicly funded comparative effectiveness research, and its more recent evolution in the direction of community empowerment in POR.

Disparities in Breast Cancer Outcomes and How to Resolve Them

There has been a 40% decline in breast cancer age-adjusted death rate since 1990. Black American women have not experienced as great a decline; indeed, the Black-White disparity in mortality in the United States is greater today than it has ever been. Certain states (areas of residence), however, do not see such dramatic differences in outcome by race. This latter finding suggests much more can be done to reduce disparities and prevent deaths. Interventions to get high-quality care (screening, diagnostics, and treatment) involve understanding the needs and concerns of the patient and addressing those needs and concerns. Patient navigators are 1 way to improve outcomes.

Inclusion of the US Preventive Services Task Force Recommendation for Mammography in State Comprehensive Cancer Control Plans in the US

IMPORTANCE

The recommendations for the age and frequency that women at average risk for breast cancer should undergo breast cancer mammography screening have been a matter of emotional, political, and scientific debate over the past decades. Multiple national organizations provide recommendations for breast cancer screening age and frequency. US Centers for Disease Control and Prevention (CDC) funding for state comprehensive cancer control (CCC) planning requires compliance with stated objectives for attaining goals. US Preventive Services Task Force (USPSTF) recommendations on cancer prevention and control are currently used to require coverage of prevention services.

OBJECTIVES

To evaluate the consistency of state CCC plan objectives compared with the most current (2016) USPSTF recommendations for the age and frequency that individuals should undergo mammography screening and to make recommendations for improvement of state CCC plans.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a descriptive, point-in-time evaluation and was conducted from November 1, 2019, to June 30, 2021. In November 2019, the most recent CCC plans from 50 US states and the District of Columbia were downloaded from the CDC website. The recommended ages at which to begin and end mammography examinations and the frequency of mammography examinations were extracted from plan objectives.

MAIN OUTCOMES AND MEASURES

The recommendations found in CCC plan objectives regarding the ages at which to begin and end mammography examinations and the frequency of mammography examinations for women with average risk for breast cancer were compared with USPSTF recommendations.

RESULTS

Of the 51 CCC plans, 16 (31%) were consistent with all USPSTF recommendations for age and frequency that women at average risk should undergo mammography. Twenty-six plans (51%) were partially consistent with recommendations, and 9 plans (18%) were not consistent with any of the 3 guideline components.

CONCLUSIONS AND RELEVANCE

Compared with the USPSTF recommendation, state CCC plans are not homogenous regarding the age and frequency that women at average risk for breast cancer should undergo mammography. This variation is partially due to differences in state-specific planning considerations and discretion, variations in recommendations among national organizations, and publication of plans prior to the most current USPSTF recommendation (2016). Specifying the concept that high-risk populations need different age and frequency of screening recommendations than the general population may reduce heterogeneity among plans.

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.

SNPs in the interleukin-12 signaling pathway are associated with breast cancer risk in Puerto Rican women

Interleukin-12 (IL-12) is a proinflammatory cytokine that links innate and adaptive immune responses against tumor cells. Single Nucleotide Polymorphisms (SNPs) in IL-12 genes have been associated with cancer risk. However, limited studies have assessed the role of IL-12 in breast cancer (BC) risk comprehensively, and these were done in European and Asian populations. Here, we evaluated the association of the IL-12 signaling pathway and BC risk in Puerto Rican women. A genetic association study was completed with 461 BC cases and 463 non-BC controls. By logistic regression, IL-12 signaling SNPs were associated with an increased BC risk, including rs2243123 (IL12A), rs3761041, rs401502 and rs404733 (IL12RB1), rs7849191 (JAK2), rs280500 (TYK2) and rs4274624 (STAT4). Conversely, other SNPs were associated with reduced BC risk including rs438421 (IL12RB1), rs6693065 (IL12RB2), rs10974947, and rs2274471 (JAK2), rs10168266 and rs925847 (STAT4), and rs2069718 (IFNG). Analyses based in hormone receptors such as estrogen (ER) and progesterone (PR) receptors also revealed protective (for SNPs rs3212227-IL12B; rs3024896 and rs3821236-STAT4) and predisposing (for rs2069705-IFNG SNP) BC associations. Haplotype analysis showed a decreased BC risk for IL12B and STAT4 SNPs, whereas increased risk for IL12RB1 SNPs. This study suggests a role of the IL-12 signaling axis and BC risk. SNPs in this pathway may alter IL-12 induced anti-tumor responses and modulate BC predisposition in a population-specific context. Functional studies will be necessary to confirm these findings, which potentially may benefit IL-12 related immunotherapeutic approaches towards BC.

Timeliness of Treatment Initiation in Newly Diagnosed Patients With Breast Cancer

BACKGROUND

Evidence-based timeliness benchmarks have been established to assess quality of breast cancer care, as delays in treatment are associated with poor clinical outcomes. However, few studies have evaluated how current breast cancer care meets these benchmarks and what factors may delay the timely initiation of treatment.

PATIENTS AND METHODS

Demographic and disease characteristics of 377 newly diagnosed patients with breast cancer who initiated treatment at Tufts Medical Center (2009-2015) were extracted from electronic medical records. Time from diagnosis to initial surgery and time from diagnosis to initiation of hormone therapy were estimated with Kaplan-Meier curves. Multivariable regression analysis was used to identify factors associated with treatment delays. Thematic analysis was performed to categorize reasons for delay.

RESULTS

Of 319 patients who had surgery recommended as the first treatment, 248 (78%) met the 45-day benchmark (median, 28 days; 25th-75th %, 19-43). After adjusting for potential confounders, multivariable regression analysis revealed that negative hormone receptor status (odds ratio, 3.48; 95% confidence interval, 1.44-8.43) and mastectomy (odds ratio, 4.07; 95% confidence interval, 2.10-8.06) were significantly associated with delays in surgery. Delays were mostly owing to clinical complexity or logistical/financial reasons. Of 241 patients eligible for hormone therapy initiation, 232 (96%) met the 1-year benchmark (median, 147 days; 25th-75th %, 79-217).

CONCLUSION

Most patients met timeliness guidelines for surgery and initiation of hormone therapy, although risk factors for delay were identified. Knowledge of reasons for breast cancer treatment delay, including clinical complexity and logistical/financial issues, may allow targeting interventions for patients at greatest risk of care delays.

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.

Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

OBJECTIVES

The Patient Care Connect Program (PCCP), through lay navigators' distress assessments and assistance, was shown to lower healthcare utilization and costs in older cancer survivors. PCCP benefits and assistance needs for disadvantaged minorities (e.g., Black) vs. Whites are unknown.

MATERIALS AND METHODS

We examined the PCCP impact with retrospective analyses of Medicare claims (2012-2015). Outcomes were quarterly costs and utilization (emergency room (ER), hospitalizations) for navigated and matched survivors. Repeated measures generalized linear models with normal (costs), and Poisson (utilization) distributions assessed differences in trends overall and separately for Blacks and Whites. With distress data for navigated survivors, we assessed high distress (score > 3), ≥1 distress cause (overall, by domain), and ≥ 1 assistance request by minority group.

RESULTS

Beneficiaries were: 772 Black and 5350 White navigated, and 770 Black and 5348 White matched survivors. Impact was: i) costs: -$557.5 Blacks (p < .001), -$813.4 Whites (p < .001); ii) ER: Incidence Rate Ratio (IRR) 0.97 Blacks (NS), 0.93 Whites (p < .001); iii) hospitalizations: IRR 0.97 Blacks (NS), 0.91 Whites (p < .001). There was no significant difference in impact across minority groups. No significant differences were found in high distress (29% Black, 25.1% White), ≥1 distress cause (61.6% Black, 57.8% White), or ≥ 1 assistance request (64.5% Black, 59.1% White). Blacks were more likely to have ≥1 distress cause in the Practical domain.

CONCLUSION

The PCCP may benefit both Black and White older cancer survivors. Programs should consider the proportion of older survivors with high distress, and the specific needs of minorities.

Upstaging papillary lesions to carcinoma on surgical excision is not impacted by patient race

BACKGROUND

The management of papillary lesions is controversial with studies showing different rates of upstaging to malignancy. There is a paucity of research into race as an independent risk factor. The aim of this study is to identify if race is correlated with upstaging to malignancy with a secondary focus of analyzing for other personal and tumor specific risk factors for upstaging.

METHODS

We performed a retrospective review of 123 papillary lesions with univariate analysis to identify risk factors for upstaging.

RESULTS

The incidence of papillary lesions found on core needle biopsy was 6%. Atypical papillary lesions were most likely to be upstaged to malignancy at a rate of 27.7%. Papillary lesions and papillary lesions with hyperplasia were also upstaged to cancer at a lower rate of 8.3% and 12.5%, respectively. A univariate analysis of all papillary lesions and a separate analysis of atypical lesions demonstrated a higher likelihood of upstage based on BIRADS classification. Race, age, size of tumor and other radiographic features were not associated with an increased risk for upstaging to malignancy.

CONCLUSIONS

Atypia remains the most significant contributor to the risk of upstaging papillary lesions to malignancy. Our research supports the practice of excising all atypical papillary lesions with selected excision of those without atypia. In our cohort, there was no association between race and risk of upstaging to malignacy.

"For lack of knowledge, our people will perish": Using focus group methodology to explore African-American communities' perceptions of breast cancer and the environment

Among women living in the United States, breast cancer is the second leading cause of cancer death. Disproportionate racial disparities in breast cancer exist, with African American (AA) women consistently having the highest rates of breast cancer related mortality despite lower incidence. This study attends to the Institute of Medicine's (IOM) call to action recommending the identification of effective strategies for communicating accurate and reliable breast cancer risk information to diverse audiences. Using focus group methodology, this study explores how AAs perceive and decipher information related to breast cancer and its relationship to their environment. Six focus groups were conducted. The sample (n = 50) was African American, 98% female, with an average age of 50.1 years. The focus group protocol consisted of open-ended questions designed to elicit information about participants' perceptions of their environment and its link to breast cancer. Focus groups were audio recorded and professionally transcribed. Analysis of the focus group transcripts revealed themes pertaining to these categories: (1) general knowledge and beliefs about breast cancer, (2) perceived environmental risks factors for breast cancer, (3) importance of seeking knowledge about breast cancer and the environment, and (4) recommended communication strategies. The emergent themes reflect the knowledge participants possessed about breast cancer and environmental risk factors, in addition to concerns about the importance of possessing accurate information, and how culturally appropriate health communication strategies can be used to disseminate breast cancer knowledge in the community. Findings from this study can be used for culturally appropriate communication about breast cancer and the environment with AA communities.

Racial and Socioeconomic Disparities Are More Pronounced in Inflammatory Breast Cancer Than Other Breast Cancers

Inflammatory breast cancer (IBC) is a rare yet aggressive form of breast cancer. We examined differences in patient demographics and outcomes in IBC compared to locally advanced breast cancer (LABC) and all other breast cancer patients from the Breast and Prostate Cancer Data Quality and Patterns of Care Study (POC-BP), containing information from cancer registries in seven states. Out of 7,624 cases of invasive carcinoma, IBC and LABC accounted for 2.2% (N = 170) and 4.9% (N = 375), respectively. IBC patients were more likely to have a higher number (P = 0.03) and severity (P = 0.01) of comorbidities than other breast cancer patients. Among IBC patients, a higher percentage of patients with metastatic disease versus nonmetastatic disease were black, on Medicaid, and from areas of higher poverty and more urban areas. Black and Hispanic IBC patients had worse overall and breast cancer-specific survival than white patients; moreover, IBC patients with Medicaid, patients from urban areas, and patients from areas of higher poverty and lower education had worse outcomes. These data highlight the effects of disparities in race and socioeconomic status on the incidence of IBC as well as IBC outcomes. Further work is needed to reveal the causes behind these disparities and methods to improve IBC outcomes.

The American Cancer Society challenge goal to reduce US cancer mortality by 50% between 1990 and 2015: Results and reflections

In 1996, the Board of Directors of the American Cancer Society (ACS) challenged the United States to reduce what looked to be possible peak cancer mortality in 1990 by 50% by the year 2015. This analysis examines the trends in cancer mortality across this 25-year challenge period from 1990 to 2015. In 2015, cancer death rates were 26% lower than in 1990 (32% lower among men and 22% lower among women). The 50% reduction goal was more fully met for the cancer sites for which there was enactment of effective approaches for prevention, early detection, and/or treatment. Among men, mortality rates dropped for lung cancer by 45%, for colorectal cancer by 47%, and for prostate cancer by 53%. Among women, mortality rates dropped for lung cancer by 8%, for colorectal cancer by 44%, and for breast cancer by 39%. Declines in the death rates of all other cancer sites were substantially smaller (13% among men and 17% among women). The major factors that accounted for these favorable trends were progress in tobacco control and improvements in early detection and treatment. As we embark on new national cancer goals, this recent past experience should teach us that curing the cancer problem will require 2 sets of actions: making new discoveries in cancer therapeutics and more completely applying those discoveries in cancer prevention we have already made. CA Cancer J Clin 2016;66:359-369. © 2016 American Cancer Society.

Genetic variations in the Hippo signaling pathway and breast cancer risk in African American women in the AMBER Consortium

The Hippo signaling pathway regulates cellular proliferation and survival, thus exerting profound effects on normal cell fate and tumorigenesis. Dysfunction of the Hippo pathway components has been linked with breast cancer stem cell regulation, as well as breast tumor progression and metastasis. TAZ, a key component of the Hippo pathway, is highly expressed in triple negative breast cancer; however, the associations of genetic variations in this important pathway with breast cancer risk remain largely unexplored. Here, we analyzed 8309 germline variants in 15 genes from the Hippo pathway with a total of 3663 cases and 4687 controls from the African American Breast Cancer Epidemiology and Risk Consortium. Odds ratios (ORs) were estimated using logistic regression for overall breast cancer, by estrogen receptor (ER) status (1983 ER positive and 1098 ER negative), and for case-only analyses by ER status. The Hippo signaling pathway was significantly associated with ER-negative breast cancer (pathway level P = 0.02). Gene-based analyses revealed that CDH1 was responsible for the pathway association (P < 0.01), with rs4783673 in CDH1 statistically significant after gene-level adjustment for multiple comparisons (P = 9.2×10(-5), corrected P = 0.02). rs142697907 in PTPN14 was associated with ER-positive breast cancer and rs2456773 in CDK1 with ER-negativity in case-only analysis after gene-level correction for multiple comparisons (corrected P < 0.05). In conclusion, common genetic variations in the Hippo signaling pathway may contribute to both ER-negative and ER+ breast cancer risk in AA women.

Understanding and effectively addressing breast cancer in African American women: Unpacking the social context

Black women have a higher incidence of breast cancer before the age of 40 years, more severe disease at all ages, and an elevated mortality risk in comparison with white women. There is limited understanding of the contribution of social factors to these patterns. Elucidating the role of the social determinants of health in breast cancer disparities requires greater attention to how risk factors for breast cancer unfold over the lifecourse and to the complex ways in which socioeconomic status and racism shape exposure to psychosocial, physical, chemical, and other individual and community-level assaults that increase the risk of breast cancer. Research that takes seriously the social context in which black women live is also needed to maximize the opportunities to prevent breast cancer in this underserved group. Cancer 2016;122:2138-49. © 2016 American Cancer Society.

Obesity, weight gain, and ovarian cancer risk in African American women

Although there is growing evidence that higher adiposity increases ovarian cancer risk, little is known about its impact in African American (AA) women, the racial/ethnic group with the highest prevalence of obesity. We evaluated the impact of body mass index (BMI) 1 year before diagnosis and weight gain since age 18 years on ovarian cancer risk in a population-based case-control study in AA women in 11 geographical areas in the US. Cases (n = 492) and age and site matched controls (n = 696) were identified through rapid case ascertainment and random-digit-dialing, respectively. Information was collected on demographic and lifestyle factors, including self-reported height, weight at age 18 and weight 1 year before diagnosis/interview. Multivariable logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CI), adjusting for potential covariates. Obese women had elevated ovarian cancer risk, particularly for BMI ≥ 40 kg/m(2) compared to BMI <25 (OR = 1.72, 95% CI: 1.12-2.66; p for trend: 0.03). There was also a strong association with weight gain since age 18 (OR: 1.52; 95% CI: 1.07-2.16; p for trend: 0.02) comparing the highest to lowest quartile. In stratified analyses by menopausal status, the association with BMI and weight gain was limited to postmenopausal women, with a 15% (95% CI: 1.05-1.23) increase in risk per 5 kg/m(2) of BMI and 6% (95% CI: 1.01-1.10) increase in risk per 5 kg of weight gain. Excluding hormone therapy users essentially did not change results. Obesity and excessive adult weight gain may increase ovarian cancer risk in post-menopausal AA women.

Testing the effects of narrative and play on physical activity among breast cancer survivors using mobile apps: study protocol for a randomized controlled trial

Background

Physical activity reduces risk for numerous negative health outcomes, but postmenopausal breast cancer survivors do not reach recommended levels. Many interventions encourage self-monitoring of steps, which can increase physical activity in the short term. However, these interventions appear insufficient to increase motivation for sustained change. There is a need for innovative strategies to increase physical activity motivation in this population. Narratives are uniquely persuasive, and video games show promise for increasing motivation. This study will determine the effectiveness of an intervention that combines narrative and gaming to encourage sustained physical activity.

Methods/Design

SMARTGOAL (Self-Monitoring Activity: a Randomized Trial of Game-Oriented AppLications) is a randomized controlled intervention trial. The intervention period is six months, followed by a six month maintenance period. Participants (overweight, sedentary postmenopausal breast cancer survivors aged 45–75) will be randomized to a self-monitoring group or an enhanced narrative game group. The self-monitoring group will be encouraged to use a mobile application for self-monitoring and feedback and will receive 15 counseling phone calls emphasizing self-regulation. The narrative game group will be encouraged to use a mobile application that includes self-monitoring and feedback as well as a narrative-based active video game. The 15 calls for this group will emphasize concepts related to the game storyline. Counseling calls in both groups will occur weekly in months 1 – 3 and monthly in months 4 – 6. No counseling calls will occur after month 6, but both groups will be encouraged to continue using their apps. The primary outcome of the study is minutes of moderate to vigorous physical activity at six months. Other objectively measured outcomes include fitness and physical function. Self-reported outcomes include quality of life, depression, and motivation.

Discussion

This protocol will result in implementation and evaluation of two technology-based physical activity interventions among breast cancer survivors. Both interventions hold promise for broad dissemination. Understanding the potential benefit of adding narrative and game elements to interventions will provide critical information to interventionists, researchers, clinicians, and policymakers. This study is uniquely suited to investigate not just whether but how and why game elements may improve breast cancer survivors’ health.

Trial registration

clinicaltrials.gov NCT02341235 (January 9, 2015)

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2244-y) contains supplementary material, which is available to authorized users.

Analyzing historical trends in breast cancer biomarker expression: a feasibility study (1947-2009)

Background/Objectives:

Determining long-term trends in tumor biomarker expression is essential for understanding aspects of tumor biology amenable to change. Limiting the availability of such data, currently used assays for biomarkers are relatively new. For example, assays for the estrogen receptor (ER), which are the oldest, extend back only to the 1970s.

Methods:

To extend scant knowledge about the feasibility of obtaining long-term data on tumor biomarkers, we randomly selected 60 breast cancer cases (10 per decade) diagnosed between 1947–2009 among women members of the Kaiser Permanente Northern California health plan to obtain and analyze their formalin-fixed paraffin-embedded (FFPE) tumor specimens. For each tumor specimen, we created duplicate tissue microarrays for analysis.

Results:

We located tumor blocks and pathology reports for 50 of the 60 cases (83%), from which we randomly sampled 5 cases per decade for biomarker analysis (n=30). All 30 cases displayed excellent morphology and exhibited biomarkers compatible with histologic type and grade. Test–retest reliability was also excellent: 100% for ER; 97% for human epidermal growth factor receptor 2 and epidermal growth factor receptor; 93% for progesterone receptor and cytokeratin 5/6; and 90% for Ki67 and molecular phenotype; the kappa statistic was excellent (>0.9) for 4 of the 7 biomarkers, strong (0.6–0.8) for 2, and fair for only 1 (owing to low prevalence).

Conclusions:

These results indicate immunostaining for biomarkers commonly used to evaluate breast cancer biology and assign surrogate molecular phenotypes can reliably be employed on archival FFPE specimens up to 60 years old.

African-American Cancer Survivors' Use of Religious Beliefs to Positively Influence the Utilization of Cancer Care

Among African-Americans, religion impacts health-seeking behaviors. This qualitative study used criterion purposeful sampling and thematic analysis in analysis of data from 31 African-American cancer patients to understand the influence of religion on the utilization of cancer care services. Our findings suggest that religious beliefs and practices positively influenced attitudes toward their illness and ability to endure treatment. God's ability to heal and cure, God's control over survival, God's will over their lives, and God's promise for health and prosperity were examples of survivor's religious beliefs. Religious practices such as prayer promoted a trusting relationship with healthcare providers and were a source of strength and encouragement.

The Influence of Socioeconomic Status on Racial/Ethnic Disparities among the ER/PR/HER2 Breast Cancer Subtypes

Background. The eight ER/PR/HER2 breast cancer subtypes vary widely in demographic and clinicopathologic characteristics and survival. This study assesses the contribution of SES to the risk of mortality for blacks, Hispanics, Asian/Pacific Islanders, and American Indians when compared with white women for each ER/PR/HER2 subtype. Methods. We identified 143,184 cases of first primary female invasive breast cancer from the California Cancer Registry between 2000 and 2012. The risk of mortality was computed for each race/ethnicity within each ER/PR/HER2 subtype. Models were adjusted for tumor grade, year of diagnosis, and age. SES was added to a second set of models. Analyses were conducted separately for each stage. Results. Race/ethnicity did not contribute to the risk of mortality for any subtype in stage 1 when adjusted for SES. In stages 2, 3, and 4, race/ethnicity was associated with risk of mortality and adjustment for SES changed the risk only in some subtypes. SES reduced the risk of mortality by over 45% for American Indians with stage 2 ER+/PR+/HER2− cancer, but it decreased the risk of mortality for blacks with stage 2 triple negative cancer by less than 4%. Conclusions. Racial/ethnic disparities do not exist in all ER/PR/HER2 subtypes and, in general, SES modestly alters these disparities.

Genetic variants in one-carbon metabolism genes and breast cancer risk in European American and African American women

Folate-mediated one-carbon metabolism plays critical roles in DNA synthesis, repair and DNA methylation. The impact of single nucleotide polymorphisms (SNPs) in folate-metabolizing enzymes has been investigated in risk of breast cancer among European or Asian populations, but not among women of African ancestry. We conducted a comprehensive analysis of SNPs in eleven genes involved in one-carbon metabolism and risk of breast cancer in 1,275 European-American (EA) and 1,299 African-American (AA) women who participated in the Women's Circle of Health Study. Allele frequencies varied significantly between EA and AA populations. A number of these SNPs, specifically in genes including MTR, MTRR, SHMT1, TYMS and SLC19A1, were associated with overall breast cancer risk, as well as risk by estrogen receptor (ER) status, in either EA or AA women. Associations appeared to be modified by dietary folate intake. Although single-SNP associations were not statistically significant after correcting for multiple comparisons, polygenetic score analyses revealed significant associations with breast cancer risk. Per unit increase of the risk score was associated with a modest 19 to 50% increase in risk of breast cancer overall, ER positive or ER negative cancer (all p < 0.0005) in EAs or AAs. In summary, our data suggest that one-carbon metabolizing gene polymorphisms could play a role in breast cancer and that may differ between EA and AA women.

Racial disparity in breast cancer survival: the impact of pre-treatment hematologic variables

PURPOSE

A survival disparity of black versus white breast cancer patients has been extensively documented but not adequately explained. Blacks and whites also have significant differences in hematologic traits including hemoglobin (HGB). However, a link between survival disparity and hematologic differences has not been reported. We aimed to explore the effect of pre-treatment hematologic variables on this survival disparity.

METHODS

We sequentially matched 443 black patients, using a minimum distance approach, to four different sets of 443 whites on demographics (age, year of diagnosis, smoking, and drinking status), tumor presentation (all demographic variables plus tumor stage, grade, and hormone receptor status), treatment (all presentation variables plus surgery, chemotherapy, radiation therapy, and hormone therapy), and presentation plus pre-treatment hematologic variables. Racial survival for each matched dataset was analyzed by Cox proportional hazards model.

RESULTS

We found that white patients matched on demographic characteristics had more favorable survival than blacks [hazard ratio (HR) 0.57, 95 % confidence interval (CI) 0.42-0.77, p log-rank = 0.0002]. Presentation match diminished this disparity [HR 0.72 (0.54-0.95), p log-rank = 0.0199], which was not further reduced in treatment match [HR 0.73 (0.55-0.96), p log-rank = 0.0249]. However, the survival disparity was largely reduced when pre-treatment level of HGB or red blood cell distribution width was further matched in addition to presentation match [HR 0.83 (0.64-1.09), p log-rank = 0.1819 and HR 0.83 (0.64-1.09), p log-rank = 0.1760, respectively].

CONCLUSIONS

We found that in our patient population, differences in tumor presentation and certain pre-treatment hematologic traits, but not treatment, were associated with the survival disparity between black and white breast cancer patients.

Quality measurement in breast cancer

Variation in the quality of breast care affects outcomes. Objective measurement tools are central to this effort. Most quality measures are process measures. Application of these improves quality. Many national organizations are promoting them for purposes ranging from feedback to providers to public reporting and directing payment. Surgeons should evaluate their own practices and should be involved in local, regional and national efforts to assess and improve breast care.

Follow-up of breast papillary lesion on core needle biopsy: experience in African-American population

Background

The optimal course of clinical follow-up after a diagnosis of breast papillary lesion on a core needle biopsy (CNB) remains elusive. In particular, no reports in literature have addressed this question in African-American population. We describe our experience with breast papillary lesions in a primarily African-American population.

Methods

A search of our database for breast papillary lesions diagnosed on CNB between September 2002 and September 2012 was conducted. Cases were categorized into benign, atypical, and malignant. CK5/6 and CK903 stains were performed when necessary.

Results

A total of 64 breast papillary lesions were diagnosed on CNB, including 55 (86%) benign papillary lesions, 6 (9%) atypical lesions, and 3 (5%) intraductal papillary carcinomas. Of these 64 patients, 29 patients (25 African-Americans, 3 Hispanics, 1 Asian American) underwent lumpectomy within 6 months after CNB. Pathology of the lumpectomy showed: five of the 25 (20%) benign papillary lesions on needle biopsy were upgraded to intraductal or invasive papillary carcinoma; 2 of the 3 atypical papillary lesion cases on core biopsy were upgraded (67%), one into intraductal papillary carcinoma, the other invasive papillary carcinoma; the only case of malignant papillary lesion on CNB remained as intraductal papillary carcinoma on lumpectomy. The rate of upgrade in lumpectomy/mastectomy was 25%. CK5/6 and CK903 immunostains were performed on all seven core needle biopsies that were later upgraded.

Conclusions

In our predominantly African-American urban population, 25% of benign or atypical papillary lesions diagnosed on CNB was upgraded in the final excisional examination. Early excision of all papillary lesions diagnosed on CNB may be justified in this patient population.

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