Race, Menopausal Hormone Therapy, and Invasive Breast Cancer in the Carolina Breast Cancer Study

Racial disparities in menopausal hormone therapy acceptance: a pilot study

OBJECTIVE

Previous studies provide little data on the role of race in acceptance and utilization of hormone therapy. Our primary objective was to examine differences in hormone therapy acceptance between self-reported racial groups, whereas our secondary objective was to assess patient comorbidities and reported symptom frequency at presentation in these cohorts in a menopause-focused care clinic.

METHODS

We conducted a retrospective medical record review of patients presenting to a menopause clinic at an urban university-affiliated academic medical center in the Midsouth between July 2018 and July 2021. Statistical analysis was performed with Student t tests and odds ratios and P values ≤ 0.05 were considered statistically significant. During the 3-year study period, 113 patients presented with menopausal symptoms and were included in the study.

RESULTS

The cohort's self-reported racial composition was 51% Black (58 patients), and 42% White (47), and 7% unknown/declined to answer (8). Of the 42 patients who presented to the clinic with a primary complaint of vasomotor symptoms, 55% (23 patients) accepted lifestyle modification therapy, and 45% (19 patients) accepted hormone therapy. Of 34 patients who presented with a primary complaint of vaginal dryness, 85% (29 patients) accepted the recommendation of moisturizers or lubricants, whereas only 15% (5) accepted vaginal hormone therapy. Of patients with vasomotor symptoms, 10 (25%) were excluded from eligibility for systemic hormone therapy due to medical comorbidities. Thirty-seven individuals were eligible for systemic hormone therapy; 18 (49%) White patients accepted hormone therapy; however, only 9 (24%) Black patients accepted with similar clinical criteria ( P = 0.01). Black patients were 24% less likely to accept hormones for menopausal symptom management. The odds ratio was 0.24 (95% confidence interval, 0.09-0.64).

CONCLUSIONS

Our pilot study suggests a racial disparity in acceptance of both systemic and local hormonal therapy among perimenopausal and postmenopausal patients. The presence of racial disparity in acceptance of these treatment modalities can inform clinicians about patient factors affecting treatment choice for menopausal symptoms and opportunities to explore racial differences in quality of care.

National and Subnational Incidence, Mortality, and Years of Life Lost Due to Breast Cancer in Iran: Trends and Age-Period-Cohort Analysis Since 1990

Breast cancer is the most common cancer among women, causing considerable burden and mortality. Demographic and lifestyle transitions in low and low-middle income countries have given rise to its increased incidence. The successful management of cancer relies on evidence-based policies taking into account national epidemiologic settings. We aimed to report the national and subnational trends of breast cancer incidence, mortality, years of life lost (YLL) and mortality to incidence ratio (MIR) since 1990. As part of the National and Subnational Burden of Diseases project, we estimated incidence, mortality and YLL of breast cancer by sex, age, province, and year using a two-stage spatio-temporal model, based on the primary dataset of national cancer and death registry. MIR was calculated as a quality of care indicator. Age-period-cohort analysis was used to distinguish the effects of these three collinear factors. A significant threefold increase in age-specific incidence at national and subnational levels along with a twofold extension of provincial disparity was observed. Although mortality has slightly decreased since 2000, a positive mortality annual percent change was detected in patients aged 25-34 years, leading to raised YLLs. A significant declining pattern of MIR and lower provincial MIR disparity was observed. We observed a secular increase of breast cancer incidence. Further evaluation of risk factors and developing national screening policies is recommended. A descending pattern of mortality, YLL and MIR at national and subnational levels reflects improved quality of care, even though mortality among younger age groups should be specifically addressed.

National and Subnational Incidence, Mortality, and Years of Life Lost Due to Breast Cancer in Iran: Trends and Age-Period-Cohort Analysis Since 1990

Breast cancer is the most common cancer among women, causing considerable burden and mortality. Demographic and lifestyle transitions in low and low-middle income countries have given rise to its increased incidence. The successful management of cancer relies on evidence-based policies taking into account national epidemiologic settings. We aimed to report the national and subnational trends of breast cancer incidence, mortality, years of life lost (YLL) and mortality to incidence ratio (MIR) since 1990. As part of the National and Subnational Burden of Diseases project, we estimated incidence, mortality and YLL of breast cancer by sex, age, province, and year using a two-stage spatio-temporal model, based on the primary dataset of national cancer and death registry. MIR was calculated as a quality of care indicator. Age-period-cohort analysis was used to distinguish the effects of these three collinear factors. A significant threefold increase in age-specific incidence at national and subnational levels along with a twofold extension of provincial disparity was observed. Although mortality has slightly decreased since 2000, a positive mortality annual percent change was detected in patients aged 25-34 years, leading to raised YLLs. A significant declining pattern of MIR and lower provincial MIR disparity was observed. We observed a secular increase of breast cancer incidence. Further evaluation of risk factors and developing national screening policies is recommended. A descending pattern of mortality, YLL and MIR at national and subnational levels reflects improved quality of care, even though mortality among younger age groups should be specifically addressed.

Premenopausal gynecologic surgery and survival among black and white women with breast cancer

PURPOSE

In the United States, hysterectomies and oophorectomies are frequently performed before menopause for benign conditions. The procedures are associated with reduced breast cancer-specific mortality among White women. The relationship between premenopausal gynecologic surgery and mortality in Black women with breast cancer is unknown.

METHODS

This investigation used incident invasive cases of breast cancer from Phases 1 and 2 of the Carolina Breast Cancer Study a population-based study that recruited Black and White women in North Carolina between 1993 and 2001. Premenopausal gynecologic surgery was operationalized in three categories: no surgery; hysterectomy with bilateral oophorectomy; hysterectomy with conservation of ≥ 1 ovary. Mortality was ascertained using the National Death Index, last updated in 2016. Multivariable-adjusted Cox Proportional Hazard Models were used to estimate the effect of premenopausal surgery on breast cancer-specific and all-cause mortality RESULTS: Hysterectomy with bilateral oophorectomy was associated with reduced breast cancer-specific mortality (HR 0.68; 95% CI 0.49, 0.96). White and Black women had a similar reduction in breast cancer-specific mortality. (HR among white: 0.66; 95% CI 0.43, 1.02), (HR among Black: 0.67; 95% CI 0.37, 1.21).

CONCLUSIONS

There was a similar reduction in breast cancer-specific mortality following premenopausal, pre-diagnosis hysterectomy with bilateral oophorectomy across both Black and White women.

Evaluation of the benefit of post-mastectomy radiotherapy in patients with early-stage breast cancer: A propensity score matching study

The present study aimed to evaluate the significance of post-mastectomy radiotherapy (PMRT) in patients with early stage (T1-2) breast cancer. The Surveillance, Epidemiology, and End Results database was searched, and data on female patients with early stage (T1-2) breast cancer with 1–3 positive axillary lymph nodes (LNs) were extracted. Patients were subdivided into two groups: Those who had received PMRT and those who had not (no PMRT). Data from the two groups were analyzed in order to identify associations between PMRT status, breast cancer-specific survival (BCSS) probability and overall survival (OS) probability using multivariate Cox proportional hazards regression and propensity score matching models. A total of 7,316 patients were included in the analysis. Prior to propensity score matching, outcome probabilities were increased in the PMRT group, compared with the no PMRT group (BCSS probabilities: 92.0 vs. 90.1%, respectively, P=0.015; OS probabilities: 89.8 vs. 86.0%, respectively, P<0.001). In multivariate analyses, tumor location was not identified as being a risk factor for BCSS (hazard ratio, 0.917; 95% confidence interval, 0.772–1.090; P=0.326). Following propensity score matching, differences between the two treatment groups (PMRT and no PMRT) in terms of their BCSS scores remained significant (93.7 vs. 90.1%, respectively; P=0.007). Compared with the no PMRT group, the OS probabilities of the PMRT group were increased (89.4 vs. 86.0%; P=0.025). In conclusion, the present results indicated that PMRT may benefit the prognosis of patients with breast cancer with early stage disease (T1-2), and those with one to three positive axillary LNs.

Epidemiology of Breast Cancer in Women

Epidemiologic studies have contributed importantly to current knowledge of environmental and genetic risk factors for breast cancer. Worldwide, breast cancer is an important cause of human suffering and premature mortality among women. In the United States, breast cancer accounts for more cancer deaths in women than any site other than lung cancer. A variety of risk factors for breast cancer have been well-established by epidemiologic studies including race, ethnicity, family history of cancer, and genetic traits, as well as modifiable exposures such as increased alcohol consumption, physical inactivity, exogenous hormones, and certain female reproductive factors. Younger age at menarche, parity, and older age at first full-term pregnancy may influence breast cancer risk through long-term effects on sex hormone levels or by other biological mechanisms. Recent studies have suggested that triple negative breast cancers may have a distinct etiology. Genetic variants and mutations in genes that code for proteins having a role in DNA repair pathways and the homologous recombination of DNA double stranded breaks (APEX1, BRCA1, BRCA2, XRCC2, XRCC3, ATM, CHEK2, PALB2, RAD51, XPD), have been implicated in some cases of breast cancer.