Racial differences in the use of adjuvant chemotherapy for breast cancer in a large urban integrated health system

Factors affecting delay in the presentation of breast cancer symptoms among women in Gaza, occupied Palestinian territory: a cross-sectional survey

OBJECTIVE

To identify factors related to women's delay in presenting with breast cancer symptoms to improve diagnosis in the occupied Palestinian territory (oPt).

DESIGN

Cross-sectional.

SETTING

Two government cancer hospitals.

PARTICIPANTS

A consecutive sample of 130 Palestinian women living in Gaza with newly diagnosed breast cancer were approached in the waiting rooms of cancer hospitals in Gaza between 1 January 2017 and 31 December 2017. 120 women took part and returned the completed questionnaire.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical information about breast cancer was collected from hospital cancer records. An interval of 3 months or more between women's self-discovery of symptoms and their first presentation to a medical provider was considered as a delay.

RESULTS

94% (122/130) of women attending cancer hospitals in Gaza agreed to take part in the study. Their mean age was 51 years (range: 23-72), 33.6% (31/122) had a family history of breast cancer and 74.5% (41/55) of those whose cancer stage was known had been diagnosed at stage III or IV. Around one-half (62/122) said they had not recognised the seriousness of their breast changes but only 20% (24/122) of women delayed seeking healthcare by 3 months and more. The two only factors associated to late presentation were that the woman considered their symptoms not serious (p<0.001) and lack of pain (p=0.012). Lower socioeconomic status, older age, lower education and negative family history of breast cancer were not statistically associated with women's delay.

CONCLUSIONS

Women's awareness about the seriousness of breast changes and the critical importance of seeking prompt diagnosis needs to be improved using context-relevant and evidence-based awareness campaigns. This should be accompanied with training of female nurses on promoting early detection and improvement in diagnostic facilities to ensure timely diagnosis of cancer in the oPt.

Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum

BACKGROUND

There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies.

METHODS

Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed.

RESULTS

Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index.

CONCLUSIONS

This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Racial disparities in chemotherapy administration for early-stage breast cancer: a systematic review and meta-analysis

PURPOSE

We conducted a systematic review and meta-analysis to measure the extent to which race is associated with delayed initiation or receipt of inadequate chemotherapy among women with early-stage breast cancer.

METHODS

We performed a systematic search of all articles published from January 1987 until June 2017 within four databases: PubMed/Medline, EMBASE, CINAHL, and Cochrane CENTRAL. Eligible studies were US-based and examined the influence of race on chemotherapy delays, cessation, or dose reductions among women with stage I, II, or III breast cancer. Data were pooled using a random effects model.

RESULTS

A total of twelve studies were included in the quantitative analysis. Blacks were significantly more likely than whites to have delays to initiation of adjuvant therapy of 90 days or more (OR 1.41, 95% CI 1.06-1.87; X² = 31.05, p < 0.00001; I² = 90%). There was no significant association between race and chemotherapy dosing. Due to overlap between studies assessing the relationship between race and completion of chemotherapy, we conducted two separate analyses. Black patients were significantly more likely to discontinue chemotherapy, however, this was no longer statistically significant when larger numbers of patients with more advanced (stage III) breast cancer were included.

CONCLUSIONS

These results suggest that black breast cancer patients experience clinically relevant delays in the initiation of adjuvant chemotherapy more often than white patients, which may in part explain the increased mortality observed among black patients.

Influence of clinical, societal, and treatment variables on racial differences in ER-/PR- breast cancer survival

BACKGROUND

African American (AA) women with breast cancer have persistently higher mortality compared to whites. We evaluated racial disparities in mortality among women with estrogen receptor (ER)/progesterone receptor (PR)-negative breast cancer.

METHODS

The study population included 542 women (45% AA) diagnosed with ER/PR-negative Stage I through III breast cancer treated at the Henry Ford Health System (HFHS) between 1996 and 2005. Linked datasets from HFHS, Metropolitan Detroit Cancer Surveillance System, and the U.S. Census Bureau were used to obtain demographic, socioeconomic, and clinical information. Economic deprivation was categorized using a previously validated deprivation index, which included 5 categories based on the quintile of census tract socioeconomic deprivation. Cox proportional hazards models were used to assess the relationship between race and mortality.

RESULTS

AA women were more likely to have larger tumors, have higher Charlson Comorbidity Indices (CCI), and to reside in economically deprived areas. In an unadjusted analysis, AA women demonstrated a significantly higher risk of death compared to whites [hazard ratio (HR) 1.47, 95% confidence interval (CI) 1.09-2.00]. Following adjustment for clinical factors (age, stage, CCI) and treatment (radiation and chemotherapy), AA race continued to have a significant impact on mortality (HR 1.51, CI 1.10-2.08 and HR 1.63, CI 1.20-2.21). Only after adjusting for deprivation was race no longer significant (HR 1.26, CI 0.84-1.87).

CONCLUSIONS

Social determinants of health play a large role in explaining racial disparities in breast cancer outcomes, especially among women with aggressive subtypes.

Safety profiles of non-small cell lung cancer patients treated with pemetrexed plus carboplatin: a real-world retrospective, observational, cohort study

OBJECTIVE

Pemetrexed plus carboplatin (PCb) is a frequently used first-line treatment in advanced non-small cell lung cancer (NSCLC). This study examined the characteristics and safety profile of a NSCLC population treated with PCb area under the concentration-time curve 5 (PCb5) or 6 mg/mL•min (PCb6) under real-world conditions.

RESEARCH DESIGN AND METHODS

A retrospective, observational, cohort study was conducted, utilizing data from the IMS Oncology US clinic-based, longitudinal, patient-level electronic medical records (EMR), including patients with NSCLC on PCb5 or PCb6 regimens initiated concomitantly on or after the diagnosis of lung cancer during 2004-2014. Patient characteristics and incidence of adverse events (AEs) were described for each cohort. Propensity scores were calculated based on baseline demographic and clinical factors. Propensity score stratification was used to further adjust for cohort differences.

RESULTS

In total, 636 NSCLC patients receiving PCb5 (37% aged ≥70 years) and 184 patients receiving PCb6 (34% aged ≥70 years) who met the inclusion criteria were identified in the EMR. Patients with more comorbidities were more likely to have received PCb5. Overall incidence rates (IRs) per 100 person-years were similar for neutropenia in both cohorts, were numerically higher for anemia (IR = 43.6 vs 101.0) and thrombocytopenia (IR = 1.5 vs 17.9), and were numerically lower for nausea (IR = 14.4 vs 9.9) in the PCb6 vs PCb5 cohort. Within the PCb6 cohort, the IR per 100 person-years was higher for neutropenia for ≥70 year-old patients (IR = 41.1) compared to <70 year-old patients (IR = 14.5). After propensity score stratification, adjusted IRs showed similar patterns.

LIMITATIONS

Limitations included lack of power for AEs other than anemia, given the nature of EMR.

CONCLUSIONS

Results from this real-world analysis add to existing evidence from randomized clinical trials about PCb safety profiles in the overall NSCLC population and in elderly patients. These results may guide physicians when making treatment decisions.

Risk factors for delay of adjuvant chemotherapy in non-metastatic breast cancer patients: A systematic review and meta-analysis involving 186982 patients

Purpose

Delay performance of adjuvant chemotherapy (AC) after surgery has been presented to affect survival of breast cancer patients adversely, but the risk factors for delay in initiation remain controversial. Therefore, we conducted this systematic review of the literature and meta-analysis aiming at identifying the risk factors for delay of adjuvant chemotherapy (DAC) in non-metastatic breast cancer patients.

Methods

The search was performed on PubMed, Embase, Chinese National Knowledge Infrastructure and Wanfang Database from inception up to July 2016. DAC was defined as receiving AC beyond 8-week after surgery. Data were combined and analyzed using random-effects model or fixed-effects model for risk factors considered by at least 3 studies. Heterogeneity was analyzed with meta-regression analysis of year of publication and sample size. Publication bias was studied with Egger’s test.

Results

A total of 12 observational studies including 186982 non-metastatic breast cancer patients were eligible and 12 risk factors were analyzed. Combined results demonstrated that black race (vs white; OR, 1.18; 95% CI, 1.01–1.39), rural residents (vs urban; OR, 1.60; 95% CI, 1.27–2.03) and receiving mastectomy (vs breast conserving surgery; OR, 1.35; 95% CI, 1.00–1.83) were significantly associated with DAC, while married patients (vs single; OR, 0.58; 95% CI, 0.38–0.89) was less likely to have a delay in initiation. No significant impact from year of publication or sample size on the heterogeneity across studies was found, and no potential publication bias existed among the included studies.

Conclusions

Risk factors associated with DAC included black race, rural residents, receiving mastectomy and single status. Identifying of these risk factors could further help decisions making in clinical practice.

Racial disparities in overall survival among renal cell carcinoma patients with young age and small tumors

We examined the overall survival of a population‐based cohort of black and white patients with renal cell carcinoma (RCC) to better understand the paradox of poorer RCC survival despite more frequent diagnosis at lower stage among blacks. Renal cell carcinoma patients (699 white, 252 black) diagnosed between 2002 and 2007 in metropolitan Detroit were followed for vital status in the Detroit Surveillance, Epidemiology and End Results (SEER) registry. Hazard ratios (HR) of death for black versus white race and 95% confidence intervals (CIs) were calculated using Cox proportional hazard models stratified by demographic and prognostic factors, and in models successively adjusted for clinical factors, comorbidities, and socioeconomic factors. Mean follow‐up time was 88.4 months for white patients and 89.6 months for black patients (P = 0.49), with 202 white deaths and 89 black deaths (P = 0.06). While black race was weakly associated with poorer overall survival (P = 0.053), black patients <65 years at diagnosis or with tumors <4 cm in size had significantly poorer survival than their white counterparts (HR = 1.46, 95% CI 1.06–2.01 and HR = 2.15, 95% CI 1.51–3.06, respectively). The racial disparities within these two subgroups were minimally affected by adjustment for clinical/treatment factors (HR = 1.49, 95% CI 1.01–2.19 and HR = 1.95, 95% CI 1.27–2.99), but were substantially reduced when renal‐relevant comorbidities were added (HR = 1.30, 95% CI 0.89–1.91 and HR = 1.76, 95% CI 1.16–2.66). After further adjustment for socioeconomic factors, the survival disparities were essentially null (HR = 1.14, 95% CI 0.71–1.85 and HR = 1.15, 95% CI 0.67–1.98). In this population‐based sample of RCC patients, younger black patients and those with small tumors had poorer overall survival than whites. The disparity was explained primarily by racial differences in renal‐relevant comorbidities, particularly chronic renal failure, and socioeconomic deprivation. Future research should focus on younger patients and those with smaller tumors to better understand how these factors may contribute to the survival disparity.

Patient delays and system delays in breast cancer treatment in developed and developing countries

AbstractDelays in treating breast cancer have been associated with a more advanced stage of the disease and a decrease in patient survival rates. The scope of this integrative review was to analyze the main causal factors and types of patient and system delays. The underlying causal factors of delays were compared among studies conducted in developing and developed countries. Of the 53 studies selected, 24 were carried out in developing countries and 29 in developed countries, respectively. Non-attribution of symptoms to cancer, fear of the disease and treatment and low educational level were the most frequent causes of patient delay. Less comprehensive health insurance coverage, older/younger age and false negative diagnosis tests were the three most common causal factors of system delay. The effects of factors such as age were not decisive per se and depended mainly on the social and cultural context. Some factors caused both patient delay and system delay. Studies conducted in developing countries identified more causal factors of patient delay and had a stronger focus on patient delay or the combination of both. Studies conducted in developed countries had a stronger focus on aspects of system delay during treatment and guidance of breast cancer patients in the health care system.

Racial differences in breast cancer survival in a large urban integrated health system

BACKGROUND

African American (AA) women are known to have poorer breast cancer survival than whites, and the differences may be related to underlying disparities in their clinical presentation or access to care. This study evaluated the relationship between demographic, treatment, and socioeconomic factors and breast cancer survival among women in southeast Michigan.

METHODS

The population included 2387 women (34% AA) with American Joint Committee on Cancer stage I to III breast cancer who were treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked data sets from the HFHS, the Metropolitan Detroit Cancer Surveillance System, and the US Census Bureau were used to obtain demographic and clinical information. Comorbidities were classified with the modified Charlson comorbidity index (CCI). Economic deprivation was categorized with a census tract-based deprivation index (DI), which was stratified into 5 quintiles of increasing socioeconomic disadvantage.

RESULTS

Compared with whites, AA women were significantly more likely to have larger, hormone receptor-negative tumors and more comorbidities and to reside in an economically deprived area. In an unadjusted analysis, AAs had a significantly higher risk of death (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.16-1.59); however, after adjustments for clinical (age, stage, hormone receptor, and CCI) and societal factors (DI), the effect of race was not significant (HR, 1.13 [95% CI, 0.96-1.34] , and HR, 0.97 [0.80-1.19] respectively).

CONCLUSIONS

Racial differences in breast cancer survival can be explained by clinical and socioeconomic factors. Nonetheless, AA women with breast cancer remain disproportionately affected by unfavorable tumor characteristics and economic deprivation, which likely contribute to their increased overall mortality.

Race and breast cancer survival by intrinsic subtype based on PAM50 gene expression

To evaluate whether differences in PAM50 breast cancer (BC) intrinsic (Luminal A, Luminal B, Basal-like, and HER2-enriched) subtypes help explain the Black-White BC survival disparity. Utilizing a stratified case-cohort design, this study included 1,635 women from the Pathways and Life After Cancer Epidemiology cohorts, selecting women with tumors based upon IHC classification, recurrences, and deaths.One millimeter punches were obtained from tumor tissue, and expression of the PAM50 genes for molecular subtype was determined by RT-qPCR of extracted RNA. Cox proportional hazards models were used to analyze associations between race and BC outcomes, adjusted for PAM50 BC subtype. All tests of statistical significance were two-sided. Black women had a higher prevalence of the Basal-like BC subtype. Adjusted for potential confounding variables and disease characteristics at diagnosis, Black women had higher risks of recurrence (HR 1.65, 95 % CI 1.06-2.57) and breast cancer-specific mortality (HR 1.71, 95 % CI 1.02-2.86) than White women, but adjusting further for subtype did not attenuate survival disparities. By contrast, Hispanic women had a lower risk of recurrence (HR 0.54, 95 % CI 0.30-0.96) than Whites. Among those with the Basal-like subtype, Black women had a similar recurrence risk as women in other race groups but a higher recurrence risk for all other subtypes. Hispanic women had a lower recurrence risk within each subtype, though associations were not significant, given limited power. Although Black women had a higher risk of the Basal-like subtype, which has poor prognosis, this did not explain the Black-White BC survival disparity.