Racial/ethnic differences in early detection of breast cancer: a study of 250,985 cases from the California Cancer Registry

Racial and ethnic disparities in cancer survival by neighborhood socioeconomic status in Surveillance, Epidemiology, and End Results (SEER) Registries

INTRODUCTION

Reducing cancer disparities is a major public health objective. Disparities often are discussed in terms of either race and ethnicity or socioeconomic status (SES), without examining interactions between these variables.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-18 data, excluding Alaska Native and Louisiana registries, from 2002 to 2008, were used to estimate five-year, cause-specific survival by race/ethnicity and census tract SES. Differences in survival between groups were used to assess absolute disparities. Hazard ratios were examined as a measure of relative disparity. Interactions between race/ethnicity and neighborhood SES were evaluated using proportional hazard models.

RESULTS

Survival increased with higher SES for all racial/ethnic groups and generally was higher among non-Hispanic white and Asian/Pacific Islander (API) than non-Hispanic black and Hispanic cases. Absolute disparity in breast cancer survival among non-Hispanic black vs non-Hispanic white cases was slightly larger in low-SES areas than in high-SES areas (7.1% and 6.8%, respectively). In contrast, after adjusting for stage, age, and treatment, risk of mortality among non-Hispanic black cases compared with non-Hispanic white cases was 21% higher in low-SES areas and 64% higher in high-SES areas. Similarly, patterns of absolute and relative disparity compared with non-Hispanic whites differed by SES for Hispanic breast cancer, non-Hispanic black colorectal cancer, and prostate cancer cases. Statistically significant interactions existed between race/ethnicity and SES for colorectal and female breast cancers.

DISCUSSION

In health disparities research, both relative and absolute measures provide context. A better understanding of the interactions between race/ethnicity and SES may be useful in directing screening and treatment resources toward at-risk populations.

Mother-Daughter Dyad Recruitment and Cancer Intervention Challenges in an African American Sample

Developing an effective youth-based health messaging intervention for African American women, who remain disparately impacted by cancer, presents unique challenges. This paper reports on the challenges with recruiting familial dyads from predominantly low-income, African American neighborhoods, as well as the challenges associated with designing and implementing an upward-directed cancer screening intervention. We developed and pilot tested an educational workshop that provided adolescents with cancer screening information to share with their mother or female relative. Data from follow-up interviews and focus groups, as well as observation records regarding implementation obstacles highlight important lessons learned. The use of familial dyads as well as issues of access posed challenges for recruitment and follow-up. Workshop-related challenges stemmed from the approach, content and length. Finally, personal and environmental factors presented barriers to adolescent message delivery and adult follow-through. By identifying these challenges, we hope to influence and enable the future development of effective adolescent-initiated health messaging interventions.

African American women's perspectives on breast cancer: implications for communicating risk of basal-like breast cancer

African American women suffer a disproportionately high burden of basal-like breast cancer, an aggressive subtype that has no targeted therapy. While epidemiologic research has identified key prevention strategies, little is known about how best to communicate risk to this population. This study explored women's knowledge, beliefs, and attitudes about breast cancer to learn about risk perceptions. Six focus groups were conducted in North Carolina with 57 women (ages 18-49). Age, race (especially perceptions of cancer as a "White disease"), and lack of family history of breast cancer were all shown to contribute to women's perceptions of low breast cancer susceptibility. Perceptions of low risk were also attributed to conflicting risk information from family, media, and health providers. Women had little to no knowledge of breast cancer subtypes, and emphasized that health communications should be personally relevant, culturally appropriate, and convenient. These findings will assist in developing health communication tools that encourage prevention.

Facilitators and barriers to help-seeking for breast and cervical cancer symptoms: a qualitative study with an ethnically diverse sample in London

Objective

Earlier diagnosis of cancer has become a policy priority. There is evidence that minority ethnic groups are more likely to delay help-seeking for cancer symptoms, but few studies have explored reasons for delay in these groups. The present study explored facilitators and barriers to help-seeking for breast and cervical cancer in an ethnically diverse sample of women.

Methods

Semi-structured interviews were carried out with 54 healthy women from a range of ethnic backgrounds; Indian, Pakistani, Bangladeshi, Caribbean, African, Black British, Black other, White British and White other. Framework analysis was used to identify themes.

Results

Appraising a symptom as possibly due to cancer was an important facilitator of help-seeking, although for some the prospect of a cancer diagnosis was a deterrent. Women believed that earlier diagnosis improved the chance of survival, and this facilitated prompt help-seeking. A sympathetic GP facilitated help-seeking, and an unsympathetic GP was a deterrent. Some ethnic minority women described the use of alternative medicine and prayer as a first-line strategy that might delay help-seeking. Language barriers, racism and a tendency to ‘soldier on’ were also mentioned by these women.

Conclusions

Models of delay in presentation for early cancer symptoms are likely to transfer across different ethnic groups. Encouraging open discussion about cancer among minority communities could help raise awareness about the importance of early detection and promote help-seeking as a priority response to a possible cancer symptom. © 2013 The Authors. Psycho-Oncology published by John Wiley & Sons, Ltd.

Neighborhood socio-economic disadvantage and race/ethnicity as predictors of breast cancer stage at diagnosis

BACKGROUND

This study investigated the role of key individual- and community-level determinants to explore persisting racial/ethnic disparities in breast cancer stage at diagnosis in California during 1990 and 2000.

METHODS

We examined socio-demographic determinants and changes in breast cancer stage at diagnosis in California during 1990 and 2000. In situ, local, regional, and distant diagnoses were examined by individual (age, race/ethnicity, and marital status) and community (income and education by zip code) characteristics. Community variables were constructed using the California Cancer Registry 1990-2000 and the 1990 and 2000 U.S. Census.

RESULTS

From 1990 to 2000, there was an overall increase in the percent of in situ diagnoses and a significant decrease in regional and distant diagnoses. Among white and Asian/Pacific Islander women, a significant percent increase was observed for in situ diagnoses, and significant decreases in regional and distant diagnoses. Black women had a significant decrease in distant -stage diagnoses, and Hispanic women showed no significant changes in any diagnosis during this time period. The percent increase of in situ cases diagnosed between 1990 and 2000 was observed even among zip codes with low income and education levels. We also found a significant percent decrease in distant cases for the quartiles with the most poverty and least education.

CONCLUSIONS

Hispanic women showed the least improvement in breast cancer stage at diagnosis from 1990 to 2000. Breast cancer screening and education programs that target under-served communities, such as the rapidly growing Hispanic population, are needed in California.

Understanding the limits of large datasets

Many health professionals use large datasets to answer behavioral, translational, or clinical questions. Understanding the impact of missing data in large databases, such as disease registries, can avoid erroneous interpretations of these data. Using the California Cancer Registry, the authors selected seven common cancers, seven sociodemographic and clinical variables, and the top three reporting sources, as examples of the type of data that would be deemed critical to most studies. The gender variable had no missing data, followed by age (<0.1 % missing), ethnicity (1.7 %), stage (9.8 %), differentiation (39.1 %), and birthplace (41.1 %). Reports from hospitals and clinics had the lowest percentages of missing data. Users of large datasets should anticipate the limitations of missing data to prevent methodological flaws and misinterpretations of research findings. Knowledge of what and how much data may be missing in large datasets can help prevent errors in research conclusions, while better guiding treatment modalities and public health policies and programs.

Psychosocial concerns of young African American breast cancer survivors

Thirty-three African American breast cancer survivors age 45 or younger participated in semistructured phone interviews about psychosocial concerns. Twenty-six percent believed treatment interfered with employment. One third wanted additional emotional support at and after diagnosis. One half felt cancer negatively influenced romantic relationships. Forty-five percent wanted children at diagnosis, but one half these women never received fertility information. One third reported sexual problems, but 73% never discussed sexuality with providers. Fifty-two percent lacked information about cancer-related sexual dysfunction. The strength and spirituality of African American women may facilitate cancer adjustment, but cultural taboos surrounding women's health issues may interfere with successful coping.

Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women

OBJECTIVE

This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women.

METHODS

The study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40-86 years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (n = 67), bilingual (n = 173), and Spanish-dominant (n = 148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression.

RESULTS

In age-adjusted models, mammography use was non-significantly lower among English-dominant (OR = 0.84; 95% CI: 0.45-1.59) and bilingual (OR = 0.86; 95% CI: 0.55-1.35) MAs and significantly lower among Spanish-dominant MAs (OR = 0.53; 95% CI: 0.34-0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90 days (17%).

CONCLUSIONS

These findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional.

Early developments in gene-expression profiling of breast tumors: potential for increasing black-white patient disparities in breast cancer outcomes?

New prognostic tests, such as gene-expression profiling (GEP) of breast tumors, are expected to prolong survival and improve the quality of life for many breast cancer patients. In this article, we argue that GEP has not been adequately validated in minority populations, and that both biological and social factors might affect the broad utility of these tests in diverse populations. We suggest that the widespread use of this technology could potentially lead to suboptimal treatment for black women, resulting in a further increase in black-white patient disparities in treatment response, morbidity and mortality rates. We argue for the need to build a large and diverse evidence base for GEP and other emerging technologies in personalized medicine.

Contextualizing the survivorship experiences of Haitian immigrant women with breast cancer: opportunities for health promotion

PURPOSE/OBJECTIVES

To examine challenges faced by Haitian immigrant women managing a breast cancer diagnosis.

RESEARCH APPROACH

Trained community health workers conducted focus groups with Haitian women who were breast cancer survivors. A grounded theory approach guided analysis of transcripts.

SETTING

A large community-based organization in Miami, FL.

PARTICIPANTS

18 women took part in three focus groups. Participants were 40 years or older, were ethnically Haitian, and had been diagnosed with breast cancer 6-12 months prior to the study.

METHODOLOGIC APPROACH

Data were collected as part of an ongoing community-based participatory research initiative in Little Haiti, the largest enclave of Haitian settlement in Miami, FL. Community health workers, integral to the initiative, recruited participants through their extensive social networks and community contacts.

MAIN RESEARCH VARIABLES

Screening knowledge, illness beliefs, social and economic consequences of a breast cancer diagnosis, and advice for breast health education.

FINDINGS

Emergent themes suggest that Haitian breast cancer survivors face multiple challenges, including misperceptions about screening guidelines, disease etiology, and risk; a reduced capacity to earn a living because of physical debility; and diminished social support.

CONCLUSIONS

Future research must continue to examine the impact of breast cancer on Haitian immigrant women and identify key strategies, such as community outreach and support programs, to improve their quality of life.

INTERPRETATION

Nurses can play an essential role in such strategies by providing culturally relevant clinical care and partnering with community stakeholders to define the scope and focus of public health intervention.

Sisters Peer Counseling in Reproductive Issues After Treatment (SPIRIT): a peer counseling program to improve reproductive health among African American breast cancer survivors

BACKGROUND

African American breast cancer survivors may be at high risk for reproductive health problems, including menopause symptoms, sexual dysfunction, and distress about cancer-related infertility. The authors partnered with Sisters Network Inc. to create the Sisters Peer Counseling in Reproductive Issues After Treatment (SPIRIT) program, a culturally sensitive intervention program that combined a written workbook and peer counseling.

METHODS

Three hundred women were randomized to receive either the workbook plus 3 in-person sessions with a trained peer counselor or the workbook plus ≤ 30 minutes of telephone counseling to be initiated by the participant. Questionnaires at baseline, post-treatment, and at 6-month and 12-month follow-up assessed emotional distress, sexual function, relationship satisfaction, spirituality, menopause symptoms, and knowledge. Satisfaction with the program and the use of medical care also were assessed.

RESULTS

Both groups of women improved significantly in knowledge, decreased in distress, and had decreased hot flashes. Sexually active women had improved sexual function at 6-month follow-up but not at 1 year. However, peer counseling had little incremental benefit over the telephone counseling.

CONCLUSIONS

The SPIRIT program was rated very useful by 66% of women. Outcomes justify continued use of the workbook and further research to optimize the impact of peer counseling.

Effectiveness of mammography screening in reducing breast cancer mortality in women aged 39-49 years: a meta-analysis

BACKGROUND

Mammography screening of women >50 years of age significantly reduces breast cancer mortality in randomized controlled trials (RCTs). We sought to evaluate the effectiveness of mammography screening in women aged 39-49 years in reducing breast cancer mortality and to discuss previously published meta-analyses.

METHODS

PubMed/MEDLINE, OVID, COCHRANE, and Educational Resources Information Center (ERIC) databases were searched, and extracted references were reviewed. Dissertation abstracts and clinical trials databases available online were assessed to identify unpublished works. All assessments were independently done by two reviewers. All trials included were RCTs, published in English, included data on women aged 39-49, and reported relative risk (RR)/odds ratio (OR) or frequency data.

RESULTS

Nine studies were identified: the Kopparberg, Ostergotland (The Two-County study), Health Insurance Plan (HIP), Canada, Stockholm, Gothenburg, Edinburgh, Age, and Malmo trials. The individual trials were quality assessed, and the data were extracted using predefined forms. Using the DerSimonian and Laird random effects model, the results from the seven RCTs with the highest quality score were combined, and a significant pooled RR estimate of 0.83 (95% confidence interval [CI] 0.72-0.97) was calculated. Post hoc sensitivity analyses excluding studies with randomization before 1980 caused a loss of statistical significance (RR 0.87, 95% CI: 0.56, 1.13).

CONCLUSIONS

Mammography screenings are effective and generate a 17% reduction in breast cancer mortality in women 39-49 years of age. The quality of the trials varies, and providers should inform women in this age group about the positive and negative aspects of mammography screenings.

Then and now: comparison of baseline breast cancer screening rates at 2 time intervals

BACKGROUND

Breast cancer is Asian American women's most frequently occurring cancer.

METHODS

Asian American women completed breast cancer-related baseline surveys for 2 studies 5 years apart.

RESULTS

Statistically significant and rapid improvements in knowledge and screening practices were seen between the 948 participants in the first study (1995) and the 1540 participants in the second study. This increase paralleled the reported climb in early detection rates among Asian American women.

CONCLUSIONS

The data document the achievement of a tipping point in breast cancer screening rates with culturally and linguistically focused education programs and increased access to screening among disadvantaged women.