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

Differences in Breast Cancer Presentation at Time of Diagnosis for Black and White Women in High Resource Settings

This paper provides a narrative review of the existing literature on differences in demographic and biological features of breast cancer at time of diagnosis between Black and White women in Canada, the United Kingdom and the United States. Electronic database searches for published peer-reviewed articles on this topic were conducted, and 78 articles were included in the final narrative review. Differences between Black and White women were compared for eight categories including age, tumour stage, size, grade, lymph node involvement, and hormone status. Black women were significantly more likely to present with less favourable tumour features at the time of diagnosis than White women. Significant differences were reported in age at diagnosis, tumour stage, size, grade and hormone status, particularly triple negative breast cancer. Limitations on the generalizability of the review findings are discussed, as well as the implications of these findings on future research, especially within the Canadian context.

Overcoming disparities: Multidisciplinary breast cancer care at a public safety net hospital

PURPOSE

Public safety net hospitals (SNH) serve a disparate patient population; however, little is known about long-term oncologic outcomes of patients receiving care at these facilities. This study is the first to examine overall survival (OS) and the initiation of treatment in breast cancer patients treated at a SNH.

METHODS

Patients presenting to a SNH with stage I-IV breast cancer from 2005 to 2017 were identified from the local tumor registry. The hospital has a weekly breast tumor board and a multidisciplinary approach to breast cancer care. Kaplan-Meier survival analysis was performed to identify patient, tumor, and treatment characteristics associated with OS. Factors with a p < 0.1 were included in the Cox proportional hazards model.

RESULTS

2709 breast cancer patients were evaluated from 2005 to 2017. The patient demographics, tumor characteristics, and treatments received were analyzed. Five-year OS was 78.4% (93.9%, 87.4%, 70.9%, and 23.5% for stages I, II, III, and IV, respectively). On multivariable analysis, higher stage, age > 70 years, higher grade, and non-Hispanic ethnicity were associated with worse OS. Patients receiving surgery (HR = 0.33, p < 0.0001), chemotherapy (HR = 0.71, p = 0.006), and endocrine therapy (HR = 0.61, p < 0.0001) had better OS compared to those who did not receive these treatments.

CONCLUSION

Despite serving a vulnerable minority population that is largely poor, uninsured, and presenting with more advanced disease, OS at our SNH approaches national averages. This novel finding indicates that in the setting of multidisciplinary cancer care and with appropriate initiation of treatment, SNHs can overcome socioeconomic barriers to achieve equitable outcomes in breast cancer care.

Elucidating Determinants of Survival Disparities Among a Real-world Cohort of Metastatic Breast Cancer Patients: A National Cancer Database Analysis

BACKGROUND

Disparities in breast cancer survival by race/ethnicity and socioeconomic status have been reported. However, it is unclear if these findings are reproducible among subpopulations. This study aimed to assess if socially oriented factors are predictive of overall survival (OS) among patients with hormone receptor-positive (HR+), human epidermal growth factor 2-positive (HER2+) metastatic breast cancer (MBC).

PATIENTS AND METHODS

We analyzed patients with MBC included in the National Cancer Database diagnosed with HR+ and HER2+ disease treated between 2010 and 2015. Multivariate analyses describe the association between non-clinical prognostic factors and OS. A matched analysis, which balanced prognostic factors between whites and African Americans (AA), was also conducted.

RESULTS

Of the 6200 patients analyzed, the majority were 50 years or older, white, and treated with hormonal therapy. Disparities in OS were observed; multivariate analysis revealed diminished survival was associated with low income (< $38K vs. ≥ $63K, hazard ratio [HR], 1.30; P < .001), having government insurance (government vs. private, HR, 1.55; P < .001), living closer to one's treatment facility (< 4 miles vs. ≥ 18 miles, HR, 1.16; P = .04), and being AA (AA vs. white, HR, 1.20; P = .006). The mortality disparity attributed to race was insignificant in the matched analysis (AA vs. white, HR, 1.13; 95% confidence interval, 0.98-1.30; P = .09).

CONCLUSIONS

This study confirms that the known sociodemographic disparities in OS among patients with MBC are similar within the HR+/HER2+ subpopulation. The discordance of outcomes between matched and unmatched analysis demonstrate that there is a highly vulnerable subgroup of AAs. Further investigation is required to determine if the identified associations are independently causal of poor prognosis.

A Step toward Understanding Diet Quality in Urban African-American Breast Cancer Survivors: A Cross-sectional Analysis of Baseline Data from the Moving Forward Study

PURPOSE

Little is known about the dietary behaviors of African-American breast cancer survivors (AABCS). We sought to describe dietary intake and quality in AABCS and examine associations with demographic, social, lifestyle, and body composition factors to potentially inform the development of effective dietary interventions.

METHODS

Baseline data from a prospective weight loss trial of 210 AABCS were assessed. A food frequency questionnaire was used to evaluate dietary intake and diet quality via the Healthy Eating Index 2010 (HEI-2010) and Alternative Healthy Eating Index 2010 (AHEI-2010). Linear regression analysis was conducted to determine the most influential variables on diet quality.

RESULTS

Mean HEI- and AHEI-2010 total scores were 65.11 and 56.83 indicating that diet quality needs improvement. Women were the least adherent to recommendations for intake of whole grains, dairy, sodium, empty calories, sugary beverages, red/processed meats, and trans-fat. Increased self-efficacy for healthy eating behaviors, more years of education (AHEI only), negative smoking status, smaller waist circumference, and increased physical activity (HEI only) were significantly associated with higher diet quality scores.

CONCLUSION

Our findings suggest the diet quality of AABCS needs improvement. Intervention programs may achieve higher diet quality in AABCS by focusing on increasing self-efficacy for healthy eating behaviors.

Literature review of data-based models for identification of factors associated with racial disparities in breast cancer mortality

In the United States, early detection methods have contributed to the reduction of overall breast cancer mortality but this pattern has not been observed uniformly across all racial groups. A vast body of research literature shows a set of health care, socio-economic, biological, physical, and behavioural factors influencing the mortality disparity. In this paper, we review the modelling frameworks, statistical tests, and databases used in understanding influential factors, and we discuss the factors documented in the modelling literature. Our findings suggest that disparities research relies on conventional modelling and statistical tools for quantitative analysis, and there exist opportunities to implement data-based modelling frameworks for (1) exploring mechanisms triggering disparities, (2) increasing the collection of behavioural data, and (3) monitoring factors associated with the mortality disparity across time.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Mediation of the effects of living in extremely poor neighborhoods by health insurance: breast cancer care and survival in California, 1996 to 2011

BACKGROUND

We examined the mediating effect of health insurance on poverty-breast cancer care and survival relationships and the moderating effect of poverty on health insurance-breast cancer care and survival relationships in California.

METHODS

Registry data for 6,300 women with breast cancer diagnosed between 1996 and 2000 and followed until 2011 on stage at diagnosis, surgeries, adjuvant treatments and survival were analyzed. Socioeconomic data were obtained for residences from the 2000 census to categorize neighborhoods: high poverty (30% or more poor), middle poverty (5%-29% poor) and low poverty (less than 5% poor). Primary payers or health insurers were Medicaid, Medicare, private or uninsured.

RESULTS

Evidence of survival mediation was observed for women with node negative breast cancer. The apparent effect of poverty disappeared in the presence of Medicare or private health insurance. Women who were so insured were advantaged on 8-year survival compared to the uninsured or those insured by Medicaid (OR = 1.89). Evidence of payer moderation by poverty was also observed for women with node negative breast cancer. The survival advantaging effect of Medicare or private insurance was stronger in low poverty (OR = 1.81) than it was in middle poverty (OR = 1.57) or in high poverty neighborhoods (OR = 1.16). This same pattern of mediated and moderated effects was also observed for early stage at diagnosis, shorter waits for adjuvant radiation therapy and for the receipt of sentinel lymph node biopsies. These findings are consistent with the theory that more facilitative social and economic capital is available in low poverty neighborhoods, where women with breast cancer may be better able to absorb the indirect and direct, but uncovered, costs of care. As for treatments, main protective effects as well as moderator effects indicative of protection, particularly in high poverty neighborhoods were observed for women with private health insurance.

CONCLUSIONS

America's multi-tiered health insurance system mediates the quality of breast cancer care. The system is inequitable and unjust as it advantages the well insured and the well to do. Recent health care reforms ought to be enacted in ways that are consistent with their federal legislative intent, that high quality health care be truly available to all.

Diagnosis delay in Libyan female breast cancer

AIMS

To study the diagnosis delay and its impact on stage of disease among women with breast cancer on Libya.

METHODS

200 women, aged 22 to 75 years with breast cancer diagnosed during 2008-2009 were interviewed about the period from the first symptoms to the final histological diagnosis of breast cancer. This period (diagnosis time) was categorized into 3 periods: <3 months, 3-6 months, and >6 months. If diagnosis time was longer than 3 months, the diagnosis was considered delayed (diagnosis delay). Consultation time was the time taken to visit the general practitioner after the first symptoms. Retrospective preclinical and clinical data were collected on a form (questionnaire) during an interview with each patient and from medical records.

RESULTS

The median of diagnosis time was 7.5 months. Only 30.0% of patients were diagnosed within 3 months after symptoms. 14% of patients were diagnosed within 3-6 months and 56% within a period longer than 6 months. A number of factors predicted diagnosis delay: Symptoms were not considered serious in 27% of patients. Alternative therapy (therapy not associated with cancer) was applied in 13.0% of the patients. Fear and shame prevented the visit to the doctor in 10% and 4.5% of patients, respectively. Inappropriate reassurance that the lump was benign was an important reason for prolongation of the diagnosis time. Diagnosis delay was associated with initial breast symptom(s) that did not include a lump (p < 0.0001), with women who did not report monthly self examination (p < 0.0001), with old age (p = 0.004), with illiteracy (p = 0.009), with history of benign fibrocystic disease (p = 0.029) and with women who had used oral contraceptive pills longer than 5 years (p = 0.043). At the time of diagnosis, the clinical stage distribution was as follows: 9.0% stage I, 25.5% stage II, 54.0% stage III and 11.5% stage IV.Diagnosis delay was associated with bigger tumour size (p <0.0001), with positive lymph nodes (N2, N3; p < 0.0001), with high incidence of late clinical stages (p < 0.0001), and with metastatic disease (p < 0.0001).

CONCLUSIONS

Diagnosis delay is very serious problem in Libya. Diagnosis delay was associated with complex interactions between several factors and with advanced stages. There is a need for improving breast cancer awareness and training of general practitioners to reduce breast cancer mortality by promoting early detection. The treatment guidelines should pay more attention to the early phases of breast cancer. Especially, guidelines for good practices in managing detectable of tumors are necessary.