Breast Cancer Trends Among Black and White Women in the United States

Differences in 21-Gene and PAM50 Recurrence Scores in Younger and Black Women With Breast Cancer

PURPOSE

Genomic tests, such as the Oncotype Dx 21-gene and Prosigna risk of recurrence (ROR-P) assay, are commonly used for breast cancer prognostication. Emerging data suggest variability between assays, but this has not been compared in diverse populations.

MATERIALS AND METHODS

RNA sequencing was performed on 647 previously untreated stage I-III estrogen receptor-positive/human epidermal growth factor receptor 2-negative tumors in the Carolina Breast Cancer Study, which oversampled Black and younger women (age <50 years at diagnosis), using research versions of two common RNA-based prognostic assays: ROR-PR and the 21-gene recurrence score (RSR). Relative frequency differences and 95% CIs were estimated for associations with race and age, and hazards of 5-year local or distant recurrence were modeled with Cox regression. Proliferation and estrogen module scores from each assay, representing broad activity of genes in those pathways, were examined to guide interpretation of differences between tests.

RESULTS

Among both younger and older individuals, Black women had higher frequency of intermediate and high ROR-PR scores than non-Black women. Race was not significantly associated with RSR in either age group. High (hazard ratio [HR], 4.67 [95% CI, 1.73 to 12.70]) and intermediate (HR, 2.12 [95% CI, 0.98 to 4.62]) ROR-PR scores were associated with greater risk of recurrence, but RSR did not predict recurrence. RSR emphasized estrogen over proliferation modules, whereas ROR-PR emphasized proliferation. Higher proliferation scores were associated with younger age and Black race in both assays. Modifications to the RSR algorithm that increased emphasis on proliferation improved prognostication in this diverse population.

CONCLUSION

ROR-PR and the 21-gene RSR differentially emphasize estrogen-related and proliferative biology. The emphasis of 21-gene RS on estrogen-related biology and lower endocrine therapy initiation among Black women may contribute to poorer prognostic ability in heterogeneously treated populations.

Ethnic disparities in breast cancer patterns in Brazil: examining findings from population-based registries

PURPOSE

To investigate breast cancer (BC) incidence and mortality rates among specific racial groups in Brazil.

METHODS

BC incidence was evaluated from 2010 to 2015, using Brazilian Population-Based Cancer Registries, incorporating crude ratios and annual average percentage change (AAPC). Clinical and sociodemographic data from 2000 to 2019 were obtained from Hospital-Based Cancer Registries. Mortality data from 2000 to 2020 were sourced from the National Mortality Information System, comparing White women and Black women.

RESULTS

Across 13 Brazilian registries, 70,896 new BC cases were reported from 2010 to 2015. The median BC incidence rate was notably higher for White women (101.3 per 100,000) compared to Black women (59.7 per 100,000). In the general population, non-significant decrease in annual BC incidence was observed (AAPC = - 1.2; p = 0.474). Black women were more likely to live in underdeveloped areas, have lower education levels, live without a partner, and have higher alcohol consumption as compared to White women. A higher proportion of Black women received advanced-stage diagnoses (60.1% versus 50.6%, p < 0.001). BC-related mortality analysis showed 271,002 recorded deaths, with significant increase in BC-specific mortality rates in both racial groups. Black women displayed an AAPC of 2.3% (p < 0.001), while White women demonstrated a moderately elevated AAPC of 0.6% (p < 0.001).

CONCLUSION

This study underscores the need for targeted policies to address disparities in access to early detection and proper treatment, particularly for Black women in underprivileged regions, aiming to improve the survival rates of Brazilian women grappling with BC.

Characteristics, healthcare utilization, and outcomes of patients with HER2-low breast cancer

PURPOSE

Treatment for HER2-low [defined as ImmunoHistoChemistry (IHC) 1 + or 2 + and negative/normal in Situ Hybridization (ISH)] breast cancer patients is rapidly evolving, yet we lack critical information about the HER2-low population.

METHODS

We conducted a retrospective cohort study of women aged 18 years or older diagnosed with breast cancer between 2010 and 2016 in North Carolina. Analyses were conducted for the overall cohort and a stage IV sub-cohort. We examined demographic and clinical characteristics, and characterized prevalence of HER2-low disease and healthcare utilization. We estimated adjusted rate ratios for the association between HER2 classifications and utilization outcomes, and hazard ratios for 3-year all cause mortality (stage IV only).

RESULTS

The overall and stage IV cohorts included 12,965 and 635 patients, respectively. HER2-low patients represented more than half of both cohorts (59% overall, 53% stage IV). HER2-low patients were more likely than IHC 0 patients to have hormone receptor (HR)-positive disease. In the stage IV cohort, HER2-low patients were more likely to be Black (26% vs. 16% IHC 0, p = 0.0159). In both cohorts, rates of hospitalizations were slightly higher among HER2-low patients. There were no survival differences between HER2-low and IHC 0 among stage IV patients.

CONCLUSION

New treatment options for HER2-low breast cancer may have potential for significant impact at the population level particularly for patients with stage IV disease. In light of racial differences between HER2-low and IHC 0 patients observed in our cohort, research- and practice-based efforts to ensure equitable adoption of new treatment guidelines for patients with HER2-low metastatic breast cancer will be essential.

Racial Disparities in Locoregional Recurrence in Postmenopausal Patients with Stage I-III, Hormone Receptor-Positive Breast Cancer Enrolled in the NSABP B-42 Clinical Trial

BACKGROUND

There are limited data examining racial disparities in locoregional recurrence (LRR) among women with access to high-quality care. We aimed to examine differences in late LRR by race in patients with stage I-IIIA, hormone receptor-positive (HR+) breast cancer enrolled in the National Surgical Adjuvant Breast and Bowel (NSABP) B-42 trial.

METHODS

From 2006 to 2010, 3966 postmenopausal women with stage I-IIIA HR+ breast cancer who were disease-free after 5 years of endocrine therapy were randomized to an additional 5 years of endocrine therapy or placebo. Patients were excluded if multi-racial or if race was unknown. Kaplan-Meier curves were used to estimate 6-year LRR from the time of trial registration and according to race. Cox proportional hazards models were used for adjusted survival analyses.

RESULTS

Overall, 3929 NSABP B-42 patients were included: 3688 (93.9%) White, 151 (3.8%) Black, and 90 (2.3%) Asian patients. Median follow-up was 75.2 months. Overall estimated 6-year LRR from trial registration was 1.8% and differed by race: LRR rates were 1.7% in White women, 4.9% in Black women, and 0% in Asian women (p = 0.046). Adjusted Cox proportional hazards analysis found Black race to be independently associated with LRR (hazard ratio [HzR] 2.36, 95% confidence interval [CI] 1.01-5.49; p = 0.047). Node-positivity was also associated with increased LRR (HzR 1.75, 95% CI 1.07-2.86; p = 0.025). Adjusted Cox analysis found LRR (HzR 2.32, 95% CI 1.33-4.06; p = 0.003) to be associated with increased overall mortality; however, race was not independently associated with mortality.

CONCLUSION

Among postmenopausal patients with stage I-IIIA HR+ breast cancer in the NSABP B-42 trial, racial differences in late LRR were present, with the highest LRR in Black women.

Racial disparities in overall survival after the introduction of cyclin-dependent kinase 4/6 inhibitors for patients with hormone receptor-positive, HER2-negative metastatic breast cancer

PURPOSE

CDK4/6 inhibitors (CDK4/6i) combined with endocrine therapy have improved HR + /HER2- metastatic breast cancer (MBC) outcomes. However, it is still unclear whether the response to CDK4/6i is similar for all races. Therefore, we aimed to assess overall survival (OS) trends stratified by race in patients with HR + /HER2- MBC after the approval of CDK4/6i, as part of the standard of care, in 2015.

METHODS

We performed a population-based study using the SEER database. Patients with HR + /HER2- MBC were divided into two time-based cohorts: 1) pre-CDK4/6i era (diagnosed in 2011-2013) and 2) post-CDK4/6i era (diagnosed in 2015-2017). We used propensity score matching and identified 2,684 patients in each cohort that matched in several characteristics. Kaplan-Meier methods were used to estimate 2-year OS. Association between cohort and OS was evaluated using marginal Cox proportional hazards models with robust sandwich variance estimator. We conducted competing risk analysis to estimate the risk of breast cancer death in both cohorts.

RESULTS

The 2-year OS rate was 65% for the post-CDK4/6i era and 62% for the pre-CDK4/6i era (stratified log-rank p = 0.025). The 2-year OS for non-Hispanic White (NHW) patients improved in the post-CDK4/6i era compared to the pre-CDK4/6i era (67% vs. 63%, p = 0.033). However, OS did not improve for non-Hispanic Black (NHB) (54% vs. 54%, p = 0.876) or Hispanic (67% vs. 65%, p = 0.617) groups. The risk of breast cancer death decreased in the post-CDK4/6i era as compared to the pre-CDK4/6i era (2-year risk of breast cancer death: 33% vs. 30%, p = 0.015); however, this effect was observed only in NHW (sHR 0.84, p = 0.005) women, but not in NHB (sHR 0.94, p = 0.630) or Hispanic (sHR 0.91, p = 0.550) women.

CONCLUSIONS

Our study confirms that outcomes for HR + /HER2- MBC have improved after CDK4/6i were introduced in 2015. However, this effect is primarily driven by the improved OS in NHW patients, without significant improvement in OS in NHB or Hispanics.

Young Black Women May be More Likely to Have First Mammogram Cancers: A New Perspective in Breast Cancer Disparities

INTRODUCTION

Black women are diagnosed with breast cancer at earlier ages and are 42% more likely to die from the disease than White women. Recommendations for commencement of screening mammography remain discordant. This study sought to determine the frequency of first mammogram cancers among Black women versus other self-reported racial groups.

METHODS

In this retrospective cohort study, clinical and mammographic data were obtained from 738 women aged 40-45 years who underwent treatment for breast cancer between 2010 and 2019 within a single hospital system. First mammogram cancers were defined as those with tissue diagnoses within 3 months of baseline mammogram. Multivariate logistic regression was applied to assess variables associated with first mammogram cancer detection.

RESULTS

Black women were significantly more likely to have first mammogram cancer diagnoses (39/82, 47.6%) compared with White women (162/610, 26.6%) and other groups (16/46, 34.8%) [p < 0.001]. Black women were also more likely to have a body mass index > 30 (p < 0.001), higher clinical T categories (p = 0.02), and present with more advanced clinical stages (p = 0.03). Every month delay in mammographic screening beyond age 40 years (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.05-1.07; p < 0.0001), Black race (OR 2.24, 95% CI 1.10-4.53; p = 0.03), and lack of private insurance (OR 2.41, 95% CI 1.22-4.73; p = 0.01) were associated with an increased likelihood of cancer detection on first mammogram.

CONCLUSION

Our findings suggests that Black women aged 40-45 years may be more likely to have cancer detected on their first mammogram and would benefit from starting screening mammography no later than age 40 years, and for those with elevated lifetime risk, even sooner.

The Role of the Quality of Relationship in Couples Facing Treatment for Breast Cancer: A Qualitative Italian Study

INTRODUCTION

Breast cancer is the leading cause of cancer death in women worldwide. Recently, the focus of research has shifted from psychiatric, psychological, and social consequences on the woman who gets sick from breast cancer to the impact on the couple. Indeed, the psychosocial perspective has developed the construct of the Quality of Relationship (QoR) that affects the quality of life of both members of the dyad.

OBJECTIVE

The aim of this study was to extend knowledge in this field by identifying and analyzing what dimensions of QoR may impact couples' psychosocial adjustment to breast cancer and related treatments.

PATIENTS AND METHODS

Semistructured interviews explored couples' experiences of breast cancer diagnosis and treatment. Transcripts were analyzed using inductive thematic analysis.

RESULTS

Twelve couples were interviewed. Results showed how the dimensions of psychosocial support, dyadic coping, communication, and intimacy are associated and define the construct of QoR, thus affecting the couples' adjustment to breast cancer diagnosis and to the disease pathway.

CONCLUSION

Assessment procedures of couple functioning since and after diagnosis could increase the appropriateness and benefits of integrating existing clinical practice in oncological settings.

Construction and validation of a prognostic nomogram in metastatic breast cancer patients of childbearing age: A study based on the SEER database and a Chinese cohort

Introduction

Cancer in patients of childbearing age continues to become increasingly common. The purpose of this study was to explore the impact of metastatic breast cancer (MBC) on overall survival (OS) and cancer-specifific survival (CSS) in patients of childbearing age and to construct prognostic nomograms to predict OS and CSS.

Methods

Data from MBC patients of childbearing age were obtained from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015, and the patients were randomly assigned into the training and validation cohorts. Univariate and multivariate Cox analyses were used to search for independent prognostic factors impacting OS and CSS, and these data were used to construct nomograms. The concordance index (C-index), area under the curve (AUC), and calibration curves were used to determine the predictive accuracy and discriminative ability of the nomograms. Additional data were obtained from patients at the Yunnan Cancer Hospital to further verify the accuracy of the nomograms.

Results

A total of 1,700 MBC patients of childbearing age were identifified from the SEER database, and an additional 92 eligible patients were enrolled at the Yunnan Cancer Hospital. Multivariate Cox analyses identifified 10 prognostic factors for OS and CSS that were used to construct the nomograms. The calibration curve for the probabilities of OS and CSS showed good agreement between nomogram prediction and clinical observations. The C-index of the nomogram for OS was 0.735 (95% CI = 0.725-0.744); the AUC at 3 years was 0.806 and 0.794 at 5 years.The nomogram predicted that the C-index of the CSS was 0.740 (95% CI = 0.730- 0.750); the AUC at 3 years was 0.811 and 0.789 at 5 years. The same results were observed in the validation cohort. Kaplan- Meier curves comparing the low-,medium-, and high-risk groups showed strong prediction results for the prognostic nomogram.

Conclusion

We identifified several independent prognostic factors and constructed nomograms to predict the OS and CSS for MBC patients of childbearing age.These prognostic models should be considered in clinical practice to individualize treatments for this group of patients.

Racial disparity in distant recurrence-free survival in patients with localized breast cancer: A pooled analysis of National Surgical Adjuvant Breast and Bowel Project trials

BACKGROUND

Black race is associated with worse outcome in patients with breast cancer. The distant relapse-free survival (DRFS) between Black and White women with localized breast cancer who participated in National Cancer Institute-sponsored clinical trial was evaluated.

METHODS

Pooled data were analyzed from 8 National Surgical Adjuvant Breast and Bowel Project (NSABP) trials including 9702 women with localized breast cancer treated with adjuvant chemotherapy (AC, n = 7485) or neoadjuvant chemotherapy (NAC, n = 2217), who self-reported as Black (n = 1070) or White (n = 8632) race. The association between race and DRFS was analyzed using log-rank tests and multivariate Cox regression.

RESULTS

After adjustment for covariates including age, tumor size, nodal status, body mass index and taxane use, and treatment (AC vs NAC), Black race was associated with an inferior DRFS in estrogen receptor-positive (ER+; hazard ratio [HR], 1.24; 95% CI, 1.05-1.46; P = .01), but not in ER- disease (HR, 0.97; 95% CI, 0.83-1.14; P = .73), and significant interaction between race and ER status was observed (P = .03). There was no racial disparity in DRFS among patients with pathologic complete response (pCR) (log-rank P = .8). For patients without pCR, Black race was associated with worse DRFS in ER+ (HR, 1.67; 95% CI, 1.14-2.45; P = .01), but not in ER- disease (HR, 0.91; 95% CI, 0.65-1.28; P = .59).

CONCLUSIONS

Black race was associated with significantly inferior DRFS in ER+ localized breast cancer treated with AC or NAC, but not in ER- disease. In the NAC group, racial disparity was also observed in patients with residual ER+ breast cancer at surgery, but not in those who had pCR.

LAY SUMMARY

Black women with breast cancer have worse outcomes compared with White women. We investigated if this held true in the context of clinical trials that provide controlled treatment setting. Black women with cancer expressing estrogen receptors (ERs) had worse outcome than White women. If breast cancers did not express ERs, there was no racial disparity in outcome. We also observed racial disparity in women who received chemotherapy before their cancer was removed, but only if they had cancer expressing ERs and residual disease on completion of treatment. If the cancer disappeared with presurgical chemotherapy, there was no racial disparity.

Construction and Validation of Nomograms Predicting Survival in Triple-Negative Breast Cancer Patients of Childbearing Age

Background

Triple-negative breast cancer (TNBC) is one of the most aggressive subtypes of breast cancer with poorest clinical outcomes. Patients of childbearing age have a higher probability of TNBC diagnosis, with more demands on maintenance and restoration of physical and psychosocial function. This study aimed to design effective and comprehensive nomograms to predict survival in these patients.

Methods

We used the SEER database to identify patients with TNBC aged between 18 and 45 and randomly classified these patients into a training (n=2,296) and a validation (n=2,297) cohort. Nomograms for estimating overall survival (OS) and breast cancer-specific survival (BCSS) were generated based on multivariate Cox proportional hazards models and competing-risk models in the training cohort. The performances of the nomograms were quantified in the validation cohort using calibration curves, time-dependent receiver operating characteristic (ROC) curves and Harrell’s concordance index (C-index).

Results

A total of 4,593 TNBC patients of childbearing age were enrolled. Four prognostic factors for OS and six for BCSS were identified and incorporated to construct nomograms. In the validation cohort, calibration curves showed excellent agreement between nomogram-predicted and actual survival data. The nomograms also achieved relatively high Harrell’s C-indexes and areas under the time-dependent ROC curves for estimating OS and BCSS in both training and validation cohorts.

Conclusions

Independent prognostic factors were identified, and used to develop nomograms to predict OS and BCSS in childbearing-age patients with TNBC. These models could enable individualized risk estimation and risk-adapted treatment for these patients.

Social Determinants of Racial Disparities in Breast Cancer Mortality Among Black and White Women

INTRODUCTION

Mortality from breast cancer among Black women is 60% greater than that of White women in South Carolina (SC). The aim of this study was to assess racial differences in mortality among Black and White breast cancer patients based on variations in social determinants and access to state-based early detection programs.

METHODS

We obtained a retrospective record for breast cancer patients diagnosed between 2002 and 2010 from the SC Central Cancer Registry. Mortality was the main outcome while race-stratified Cox proportional hazard models were performed to assess disparities in mortality. We assessed effect modification, and we used an automated backward elimination process to obtain the best fitting models.

RESULTS

There were 3286 patients of which the majority were White women (2186, 66.52%). Compared with married White women, the adjusted hazard ratio (aHR) for mortality was greatest among Black unmarried women (aHR 2.31, CI 1.83, 2.91). Compared with White women who lived in the Low Country region mortality was greatest among Black women who lived in the Midland (aHR 2.17 CI 1.47, 3.21) and Upstate (aHR 2.96 CI 1.96, 2.49). Mortality was higher among Black women that were not receiving services in the Best Chance Network (BCN) program (aHR 1.70, CI 1.40, 2.04) compared with White women.

CONCLUSIONS

To reduce the racial disparity gap in survival in SC, Black breast cancer patients who live in the Upstate, are unmarried, and those that are not enrolled in the BCN program may benefit from more intense navigation efforts directed at early detection and linkage to breast cancer treatments.

Outcomes of Hormone-Receptor Positive, HER2-Negative Breast Cancers by Race and Tumor Biological Features

Background

Black women have higher hormone receptor positive (HR+) breast cancer mortality than White women. Early recurrence rates differ by race, but little is known about genomic predictors of early recurrence among HR+ women.

Methods

Using data from the Carolina Breast Cancer Study (phase III, 2008-2013), we estimated associations between race and recurrence among nonmetastatic HR+/HER2-negative tumors, overall and by PAM50 Risk of Recurrence score, PAM50 intrinsic subtype, and tumor grade using survival curves and Cox models standardized for age and stage. Relative frequency differences (RFD) were estimated using multivariable linear regression. To assess intervention opportunities, we evaluated treatment patterns by race among patients with high-risk disease.

Results

Black women had higher recurrence risk relative to White women (crude hazard ratio = 1.81, 95% confidence interval [CI] = 1.34 to 2.46), which remained elevated after standardizing for clinical covariates (hazard ratio = 1.42, 95% CI = 1.05 to 1.93). Racial disparities were most pronounced among those with high PAM50 Risk of Recurrence score (5-year standardized recurrence risk = 18.9%, 95% CI = 8.6% to 29.1% in Black women vs 12.5%, 95% CI = 2.0% to 23.0% in White women) and high grade (5-year standardized recurrence risk = 16.6%, 95% CI = 11.7% to 21.5% in Black women vs 12.0%, 95% CI = 7.3% to 16.7% in White women). However, Black women with high-grade tumors were statistically significantly less likely to initiate endocrine therapy (RFD = −8.3%, 95% CI = −15.9% to −0.6%) and experienced treatment delay more often than White women (RFD = +9.0%, 95% CI = 0.3% to 17.8%).

Conclusions

Differences in recurrence by race appear greatest among women with aggressive tumors and may be influenced by treatment differences. Efforts to identify causes of variation in cancer treatment are critical to reducing outcome disparities.

Breast cancer and the black swan

Most current research in cancer is attempting to find ways of preventing patients from dying after metastatic relapse. Driven by data and analysis, this project is an approach to solve the problem upstream, i.e., to prevent relapse. This project started with the unexpected observation of bimodal relapse patterns in breast and a number of other cancers. This was not explainable with the current cancer paradigm that has guided cancer therapy and early detection for many years. After much analysis using computer simulation and input from a number of medical specialties, we eventually came to the conclusion that the surgery to remove the primary tumour produced systemic inflammation for a week after surgery. This systemic inflammation apparently caused exits of cancer cells and micrometastases from dormant states and resulted in relapses in the first 3 years post-surgery. It was determined in a retrospective study that the common inexpensive perioperative non-steroidal anti-inflammatory drug (NSAID) ketorolac could curtail the early relapse events after breast cancer surgery. A second retrospective study strongly confirmed this but an apparently underpowered prospective study showed no advantage. We are analysing these data and are now proposing to test the perioperative NSAID at Beth Israel Deaconess Medical Centre with triple-negative breast cancer (TNBC) patients, the category that could respond best to the perioperative NSAID. If this works as well as we expect, we would then transfer this technology to low- and/or middle-incomes countries (LMICs), starting with Nigeria where early onset type of TNBC is common. There is an unmet need in LMICs, especially in countries like Nigeria (190 million population), for a means to prevent surgery induced relapse that we are attempting to resolve. This work aims, thus, to describe eventual mechanisms, and ways to test a solution addressing an unmet need. But first, we consider the context, including within an historical perspective, important to explain how and why a Kuhnian paradigm shift may be considered.

Risk-Reducing Options for Women with a Hereditary Breast Cancer Predisposition

Genetic testing is now widely utilized to identify women with a hereditary predisposition for breast cancer. Women who carry mutations that increase breast cancer risk may consider three options to reduce risk: screening, chemoprevention, and prophylactic surgery. Yet, no randomized trials have specifically assessed the efficacy of these options in mutation carriers. In many developed countries, mammography is regarded as the optimal means of screening for breast cancer in the general population. However, breast MRI is a more sensitive screening tool, and for mutation carriers, any breast cancer screening strategy should incorporate screening with MRI. In randomized trials of women at high risk for developing breast cancer, chemoprevention reduces that risk, but it has not been shown to reduce mortality. Finally, observational studies suggest that, in mutation carriers, prophylactic surgery may reduce the risk of developing breast cancer by 90-95%. There are several prophylactic mastectomy procedures to choose from, and these are generally done in conjunction with breast reconstruction. In this article, we discuss management of women who carry mutations that have been associated with an increased breast cancer risk. Mutation carriers should be informed of the potential risks and benefits of the three available options to reduce breast cancer risk.

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.

Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013

Purpose

To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer.

Patients and Methods

Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs).

Results

We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor–positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor–negative disease, although the HRs were substantially smaller.

Conclusion

Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.

Understanding Breast Cancer Knowledge and Barriers to Treatment Adherence: A Qualitative Study Among Breast Cancer Survivors

Disparities in breast cancer treatment receipt are common and multifactorial. Data are limited on how knowledge about one's breast cancer and understanding treatment rationales may impact treatment completion. In this qualitative analysis, we explored barriers to care with a focus on knowledge. We conducted 18 in-depth interviews with women from diverse socioeconomic backgrounds who were treated at Dana-Farber Cancer Institute (n = 12; Boston, MA) and Columbia University Medical Center (n = 6; New York, NY) and had undergone neo/adjuvant breast cancer treatment within the prior 3 years. Interviews focused on treatments received, adherence, barriers experienced, and questions related to breast cancer knowledge and treatment rationales. We analyzed transcribed interview recordings in N'Vivo using a two-stage coding process that allowed for both preconfigured and emergent themes. Answers for breast cancer knowledge were confirmed using medical records. In our analysis, over one-third of women reported incomplete therapy, including never initiating treatment, stopping treatment prematurely, or missing/delaying treatments due to logistical reasons (childcare, transportation) or patient preferences. Others reported treatment modifications because of provider recommendations. Nearly all women were able to accurately describe the rationale for recommended treatments. Among 17 women for whom medical records were available, women correctly reported 18–71% of their tumor characteristics; incorrect reporting was not consistently associated with treatment incompletion. In conclusion, logistical issues and patient preferences were the main reasons for incomplete therapy in our study. Understanding of treatment rationale was high, but breast cancer knowledge was variable. Further assessment of how knowledge may impact cancer care is warranted.

Breast Cancer Epidemiology and Risk Factors

Between the years 2010 and 2012, the lifetime probability of developing female breast cancer was 12.3%, or approximately 1 in 8. Worldwide, breast cancer is the most common cancer in women. Survival is increasing. Between 2005 and 2011, the 5-year relative survival was found to be 89%. This is thought to be due to both the increase in utilization of population-wide screening, as well as advances in treatment. Less than 10% of breast cancers can be attributed to an inherited genetic mutation. Breast cancer is more commonly associated with environmental, reproductive, and lifestyle factors, some of which are potentially modifiable.

Distinctions in Breast Tumor Recurrence Patterns Post-Therapy among Racially Distinct Populations

BACKGROUND

Clinical studies have revealed a higher risk of breast tumor recurrence in African-American (AA) patients compared to European-American (EA) patients, contributing to the alarming inequality in clinical outcomes among the ethnic groups. However, distinctions in recurrence patterns upon receiving hormone, radiation, and/or chemotherapy between the races remain poorly characterized.

METHODS

We compared patterns and rates (per 1000 cancer patients per 1 year) of recurrence following each form of treatment between AA (n = 1850) and EA breast cancer patients (n = 7931) from a cohort of patients (n = 10504) treated between 2005-2015 at Northside Hospital in Atlanta, GA.

RESULTS

Among patients who received any combination of adjuvant therapy, AA displayed higher overall rates of recurrence than EA (p = 0.015; HR: 1.699; CI: 1.108-2.606). Furthermore, recurrence rates were higher in AA than EA among stage I (p = 0.031; HR: 1.736; CI: 1.052-2.864) and T1 classified patients (p = 0.003; HR: 2.009; CI: 1.263-3.197). Interestingly, among patients who received neoadjuvant chemotherapy, AA displayed higher rates of local recurrence than EA (p = 0.024; HR: 7.134; CI: 1.295-39.313).

CONCLUSION

Our analysis revealed higher incidence rates of recurrence in AA compared to EA among patients that received any combination of adjuvant therapy. Moreover, our data demonstrates an increased risk of tumor recurrence in AA than EA among patients diagnosed with minimally invasive disease. This is the first clinical study to suggest that neoadjuvant chemotherapy improves breast cancer recurrence rates and patterns in AA.

Epidemiology of breast cancer: retrospective study in the Central African Republic

Background

Breast cancer is recognised as a major public health problem in developing countries; however, there is very limited evidence about its epidemiology in the Central African Republic. The aim of this study was to investigate the epidemiological and histopathological characteristics of breast cancer in Bangui.

Methods

This is a retrospective study based on the data collected from pathological anatomy records from 2003 to 2015 in Bangui. A questionnaire was designed to collect information and data was analysed using descriptive and inferential statistical methods.

Results

The mean age was 45.83 (SD = 13.5) years. The age group of 45–54 years represented the majority of the study population (29.3%). Over 69.5% of the women were housewives with a moderate economic status (56.9%). Less than 14% of the study population had a level of academic degree and 85.6% lived in cities. The breast cancer prevalence was 15.27%. The age-standardized incidence and death by world population (ASW) were 11.19/100,000 and 9.97/100,000 respectively. 50–54 years were most affected. Left breast cancer is mainly common and the time between first symptoms and consultation is more than 48 months. Most (69%) of the samples analysed were lumpectomy. The most common morphology of breast cancer was invasive ductal carcinoma (64.9%). Scarff Bloom Richardson III was the main grade in both common pathological types, but their proportion showed no significant increase along with time (χ2 = 7.06, p = 0.54). Invasion of regional lymph node differed significantly among the pathological type of breast cancer (χ2 = 24.6, p = 0.02). Surgery and chemotherapy were appropriate treatment yet 84.5% of the cases died.

Conclusion

The findings of this study showed that breast cancer is common and mostly affected women. Epidemiological trends are more or less common to those of developing countries with a predominance of invasive ductal carcinoma. However, most of the women studied live in an urban area and developed the disease in advanced stage. The establishment of an appropriate framework will effectively contribute to promoting the early detection and reducing the incidence of this disease in the population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3863-6) contains supplementary material, which is available to authorized users.

Racial/ethnicity disparities in invasive breast cancer among younger and older women: An analysis using multiple measures of population health

INTRODUCTION

Few studies have examined age and racial/ethnic disparities in invasive breast cancer among younger (age 15-44 years) vs. older (age 45-64 years) women. This study estimates disparities in breast cancer among younger compared with older women by race/ethnicity using five measures of population health: life expectancy (LE), expected years of life lost (EYLL), cumulative incidence rate (CIR), and incidence and mortality rate ratios (IRR and MRR).

METHODS

Using Surveillance, Epidemiology, and End Results data, LE and EYLL were estimated from a cohort of 15-44 and 45-64 years, non-Hispanic black (NHB), non-Hispanic white (NHW), and Hispanic women diagnosed with breast cancer, 2000-2013. Survival function was obtained from the study years and then extrapolated to lifetime using the Monte Carlo method. The CIR, IRR and MRR were calculated using 2009-2013 breast cancer incidence and mortality rates from the Centers for Disease Control and Prevention's National Program of Cancer Registries.

RESULTS

The estimated LE ranged from 32.12 to 7.42 years for localized to distant stages among younger NHB women compared to 33.05 to 9.95 years for younger NHW women. The estimated EYLL was 12.78 years for younger women, and 4.99 for older women. By race/ethnicity, it was 15.53 years for NHB, 14.23 years for Hispanic and 11.87 years for NHW (P<0.00025). The CIR for age-group 15-44 years (CIR15-44) indicated a 1 in 86 probability for NHB compared to a 1 in 87 probability for NHW being diagnosed with breast cancer by age 45. The estimated age-adjusted incidence rate for NHB-to-NHW women was IRR=1.10 (95%, CI=1.08-1.11) and the corresponding mortality rate was MRR=2.02 (95%, CI=1.94-2.11).

CONCLUSIONS

The breast cancer disparities between younger NHB compared to NHW women highlight the need for expanded efforts to address these disparities through primary prevention and to improve access to quality healthcare to minority women with breast cancer.

Breast cancer risk and protracted low-to-moderate dose occupational radiation exposure in the US Radiologic Technologists Cohort, 1983-2008

Background:

Although high-dose ionising radiation is associated with increased breast cancer risks, the association with protracted low-dose-rate exposures remains unclear. The US Radiologic Technologist study provides an opportunity to examine the association between low-to-moderate dose radiation and breast cancer incidence and mortality.

Methods:

One thousand nine hundred and twenty-two self-reported first primary cancers were diagnosed during 1983–2005 among 66 915 female technologists, and 586 breast cancer deaths occurred during 1983–2008 among 83 538 female cohort members. Occupational breast dose estimates were based on work histories, historical data, and, after the mid-1970s, individual film badge measurements. Excess relative risks were estimated using Poisson regression with birth cohort stratification and adjustment for menopause, reproductive history, and other risk factors.

Results:

Higher doses were associated with increased breast cancer incidence, with an excess relative risk at 100 mGy of 0.07 (95% confidence interval (CI): -0.005 to 0.19). Associations were strongest for technologists born before 1930 (excess relative risk at 100 mGy=0.16; 95% CI: 0.03–0.39) with similar patterns for mortality among technologists born before 1930.

Conclusions:

Occupational radiation to the breast was positively associated with breast cancer risk. The risk was more pronounced for women born before 1930 who began working before 1950 when mean annual doses (37 mGy) were considerably higher than in later years (1.3 mGy). However, because of the uncertainties and possible systematic errors in the occupational dose estimates before 1960, these findings should be treated with caution.

The Effect of Patient and Contextual Characteristics on Racial/Ethnic Disparity in Breast Cancer Mortality

BACKGROUND

Racial/ethnic disparity in breast cancer-specific mortality in the United States is well documented. We examined whether accounting for racial/ethnic differences in the prevalence of clinical, patient, and lifestyle and contextual factors that are associated with breast cancer-specific mortality can explain this disparity.

METHODS

The California Breast Cancer Survivorship Consortium combined interview data from six California-based breast cancer studies with cancer registry data to create a large, racially diverse cohort of women with primary invasive breast cancer. We examined the contribution of variables in a previously reported Cox regression baseline model plus additional contextual, physical activity, body size, and comorbidity variables to the racial/ethnic disparity in breast cancer-specific mortality.

RESULTS

The cohort comprised 12,098 women. Fifty-four percent were non-Latina Whites, 17% African Americans, 17% Latinas, and 12% Asian Americans. In a model adjusting only for age and study, breast cancer-specific HRs relative to Whites were 1.69 (95% CI, 1.46-1.96), 1.00 (0.84-1.19), and 0.52 (0.33-0.85) for African Americans, Latinas, and Asian Americans, respectively. Adjusting for baseline-model variables decreased disparity primarily by reducing the HR for African Americans to 1.13 (0.96-1.33). The most influential variables were related to disease characteristics, neighborhood socioeconomic status, and smoking status at diagnosis. Other variables had negligible impact on disparity.

CONCLUSIONS

Although contextual, physical activity, body size, and comorbidity variables may influence breast cancer-specific mortality, they do not explain racial/ethnic mortality disparity.

IMPACT

Other factors besides those investigated here may explain the existing racial/ethnic disparity in mortality. Cancer Epidemiol Biomarkers Prev; 25(7); 1064-72. ©2016 AACR.

Racial disparities in breast cancer diagnosis and treatment by hormone receptor and HER2 status

BACKGROUND

African American and Hispanic women are more likely to be diagnosed with aggressive forms of breast cancer. Disparities within each subtype of breast cancer have not been well documented.

METHODS

Using data from 18 SEER cancer registries, we identified 102,064 women aged 20 years or older, diagnosed with invasive breast cancer in 2010-2011, and with known stage, hormone receptor (HR), and HER2 status. Associations between race/ethnicity and cancer stage and receipt of guideline-concordant treatment were evaluated according to HR/HER2 status.

RESULTS

Overall, African American and Hispanic women were 30% to 60% more likely to be diagnosed with stage II-IV breast cancer compared with non-Hispanic whites. African American women had 40% to 70% higher risks of stage IV breast cancer across all four subtypes. American Indian/Alaska Native women had a 3.9-fold higher risk of stage IV triple-negative breast cancer. African American and Hispanic whites were 30% to 40% more likely to receive non-guideline-concordant treatment for breast cancer overall and across subtypes.

CONCLUSIONS

Women in several racial/ethnic groups are more likely to be diagnosed with more advanced stage breast cancer. African American and American Indian/Alaska Native women in particular had the highest risk of being diagnosed with stage IV triple-negative breast cancer. African American and Hispanic women were also consistently at higher risk of not receiving guideline-concordant treatment across subtypes.

IMPACT

These findings provide important characterization of which subtypes of breast cancer racial/ethnic disparities in stage and treatment persist.

Associations among ancestry, geography and breast cancer incidence, mortality, and survival in Trinidad and Tobago

Breast cancer (BC) is the most common newly diagnosed cancer among women in Trinidad and Tobago (TT) and BC mortality rates are among the highest in the world. Globally, racial/ethnic trends in BC incidence, mortality and survival have been reported. However, such investigations have not been conducted in TT, which has been noted for its rich diversity. In this study, we investigated associations among ancestry, geography and BC incidence, mortality and survival in TT. Data on 3767 incident BC cases, reported to the National Cancer Registry of TT, from 1995 to 2007, were analyzed in this study. Women of African ancestry had significantly higher BC incidence and mortality rates (

INCIDENCE

66.96;

MORTALITY

30.82 per 100,000) compared to women of East Indian (

INCIDENCE

41.04, MORTALITY: 14.19 per 100,000) or mixed ancestry (

INCIDENCE

36.72, MORTALITY: 13.80 per 100,000). Geographically, women residing in the North West Regional Health Authority (RHA) catchment area followed by the North Central RHA exhibited the highest incidence and mortality rates. Notable ancestral differences in survival were also observed. Women of East Indian and mixed ancestry experienced significantly longer survival than those of African ancestry. Differences in survival by geography were not observed. In TT, ancestry and geographical residence seem to be strong predictors of BC incidence and mortality rates. Additionally, disparities in survival by ancestry were found. These data should be considered in the design and implementation of strategies to reduce BC incidence and mortality rates in TT.

Race, response to chemotherapy, and outcome within clinical breast cancer subtypes

The effect of race on breast cancer outcome is confounded by tumor and treatment heterogeneity. We examined a cohort of women with stage II-III breast cancer treated uniformly with neoadjuvant chemotherapy to identify factors associated with racial differences in chemotherapeutic response and long-term survival. Using a prospective database, we identified women with stage II-III breast cancer treated with neoadjuvant chemotherapy from 1998 to 2011. Race was categorized as African-American (AA) or non-AA. Preplanned subtype analyses were stratified by hormone receptor (HR) and HER2. Pathologic response to chemotherapy (pCR), time to recurrence (TTR), and overall survival (OS) were assessed using logistic regression, Kaplan-Meier method, and Cox proportional hazards regression analyses. Of 349 women identified, 102 (29 %) were AA, who were younger (p = 0.03), more obese (p < 0.001), and less likely to have HR+/HER2- tumors (p = 0.01). No significant differences in pCR rate by race were found. At median follow-up of 6.5 years, AA had worse TTR (hazard ratio 1.51, 95 % CI 1.02-2.24), which was attenuated in multivariable modeling, and there was no significant difference in OS. When stratified by HR, worse outcomes were limited to HR+AA (TTR hazard ratio 1.85, 95 % CI 1.09-3.14; OS hazard ratio 2.42 95 % CI 1.37-4.28), which remained significant in multivariable analysis including pCR rate and BMI. With long-term follow-up, racial disparity in outcome was limited to HR+ breast cancer, with no apparent contribution of chemotherapy sensitivity. This suggests that disparity root causes may be driven by HR+ factors such as unmeasured molecular differences, endocrine therapy sensitivity, or adherence.

MicroRNAs in endometrial cancers from black and white patients

OBJECTIVE

Previous studies have identified differences in gene mutations among endometrial cancers from whites and blacks suggesting that differences in tumor biology may explain racial disparities in patient outcome. Micro RNAs (miRNAs) have emerged as regulators of transcript expression and their aberrant expression has been discovered in many diseases, including endometrial cancer. We performed quantitative polymerase chain reaction-based analysis in a set of endometrial cancers to identify whether there are racial differences in miRNA expression.

STUDY DESIGN

Tumor cells from 50 stage-I endometrioid endometrial cancer specimens from 41 white and 9 black patients were prepared by laser microdissection and miRNA extracts were analyzed using TaqMan (Life Technologies, Carlsbad, CA) low-density arrays. Statistically significant, differentially expressed miRNAs between blacks and whites were identified using multidimensional scaling, Wilcoxon testing, and analysis of variance.

RESULTS

There were no global differences in miRNA expression between endometrial cancers from 41 white and 9 black patients. To minimize potential bias introduced by unbalanced sample size, we performed a subset analysis with stage- and histology-matched specimens from 9 whites and 9 blacks that identified 18 differentially abundant miRNAs (>2-fold at P < .005). Quantitative polymerase chain reaction validated miRNA-337-3p in an independent set of endometrial cancer specimens from 23 white and 24 black women. There were no racial differences in hsa-miR-337-3p expression in normal endometrium.

CONCLUSION

These data indicate that hsa-mir-337-3p is more frequently down-regulated in endometrial cancers from whites compared to blacks. Future studies are focused on determining the phenotypic impact of miR-337-3p and whether its differential expression is associated with clinical outcome.

Lung cancer incidence trends by histology type among Asian American, Native Hawaiian, and Pacific Islander populations in the United States, 1990-2010

BACKGROUND

Lung cancer is one of the leading cancer sites diagnosed among Asian Americans, Pacific Islanders, and Native Hawaiians (AANHPI). To better understand the patterns of lung cancer incidence among AANHPIs, we examined the incidence trends of five histologic cell types of lung cancer across ten AANHPI populations in comparison with non-Hispanic Whites.

METHODS

Lung cancer incidence data from 1990 through 2010 were obtained from 13 U.S. population-based cancer registries. Age-adjusted histologic cell-type-specific incidence rates and 95% confidence intervals were calculated. Joinpoint regression models and annual percentage change (APC) statistics were used to characterize the magnitude and direction of trends.

RESULTS

From 1990 through 2010, incidence rates of adenocarcinoma increased significantly for Filipino and Korean women with a 2.6% and 3.0% annual percentage increase, respectively. More recently, a significant rise in the incidence of adenocarcinoma was observed for Chinese men (1996-2010; APC = 1.3%). Squamous cell carcinoma (SCC) increased 2.4% per year among Japanese women. For SCC, small cell lung carcinoma, large cell and other specified carcinoma, and unspecified types, stable or decreasing trends were observed in most AANHPI groups and non-Hispanic Whites.

CONCLUSIONS

AANHPIs demonstrate a range in the burden of lung cancer across histologies and specific populations.

IMPACT

These findings illustrate the importance of disaggregating AANHPIs into their specific populations. The rise in incidence of adenocarcinoma and SCC among certain AANHPIs demonstrates the need for research into non-tobacco associated risk factors for these populations and targeted efforts for tobacco prevention.

Trends in 5-year survival rates among breast cancer patients by hormone receptor status and stage

Improvement in breast cancer survival has been observed in recent decades in the U.S., but it is unclear if similar survival gains are consistent across breast cancer subtypes, especially with regards to more advanced stages of the disease. Data were from 13 population-based cancer registries participating in the surveillance, epidemiology, and end results (SEER) program, consisting of women between 20 and 79 years of age diagnosed with invasive breast cancer between 1992 and 2008. 2-year (1992-2008) and 5-year (1992-2006) breast cancer cause-specific survival rates were calculated and stratified by estrogen receptor (ER)/progesterone receptor (PR) status, stage, and race. Annual percent changes in survival rates were assessed. From 1992 through 1998-1999, 5- and 2-year cause-specific survival rates significantly improved across ER+/PR+, ER-/PR-, and ER+/PR- subtypes, with an annual increase ranging from 0.5 to 1.0 % in the 5-year rates. From 1998-1999 to 2006, different patterns were observed by ER/PR subtypes with survival rates slightly improving for ER+/PR+, continuing to improve at a rate of 0.5 % per year for ER-/PR-, and dropping 0.3 % annually for ER+/PR-. No significant survival gains were experienced by patients with ER-/PR+ cancer during the study period. In terms of advanced diseases, greatest annual increases in survival rates were seen for patients with stage III-IV ER+/PR+ and ER-/PR- tumors but less progress was observed for advanced ER+/PR- breast cancers. Steady improvements in survival rates for breast cancer have been achieved over the past several decades. However, 5-year survival rates for stage IV disease remained dismally below 20 % for most ER/PR subtypes.

Prevalence of breast masses and barriers to care: results from a population-based survey in Rwanda and Sierra Leone

BACKGROUND AND OBJECTIVES

Breast cancer incidence may be increasing in low- and middle-income countries (LMIC). This study estimates the prevalence of breast masses in Rwanda (RW) and Sierra Leone (SL) and identifies barriers to care for women with breast masses. only.

METHODS

Data were collected from households in RW and SL using Surgeons Overseas Assessment of Surgical Need (SOSAS), a cross-sectional, randomized, cluster-based population survey designed to identify surgical conditions. Data regarding breast masses and barriers to care in women with breast masses were analyzed.

RESULTS

3,469 households (1,626 RW; 1,843 SL) were surveyed and 6,820 persons (3,175 RW; 3,645 SL) interviewed. Breast mass prevalence was 3.3% (SL) and 4.6% (RW). Overall, 93.8% of masses were in women, with 49.1% (SL) and 86.1% (RW) in women >30 years. 73.7% (SL) and 92.4% (RW) of women reported no disability; this was their primary reason for not seeking medical attention. Overall, 36.8% of women who reported masses consulted traditional healers only.

CONCLUSIONS

For women in RW and SL, minimal education, poverty, and reliance on traditional healers are barriers to medical care for breast masses. Public health programs to increase awareness and decrease barriers are necessary to lower breast cancer mortality rates in low- and middle-income countries (LMIC).

The effect of local therapy on breast cancer mortality: is there an age-interaction?

There are no randomized trials comparing local therapy versus no therapy in patients with primary breast cancer, as such trials would be deemed unethical. Thus, the impact of local therapy on breast cancer mortality is poorly understood. However, an overview of clinical trials comparing various permutations in the local therapy of breast cancer suggests that inadequate local therapy increases the risk of local recurrences, and thereby increases breast cancer mortality. Yet, age-interactions are commonly reported in studies that have examined the etiology, prognosis, and treatment of breast cancer, and might be associated with the effect of local therapy as well. Moreover, the effect of local therapy on breast cancer mortality might be time-dependent. In cohorts of women with high-risk tumors (predominantly younger women) local therapy may adversely (but only transiently) perturb the natural history of breast cancer. In contrast, such an effect is not evident in cohorts of women with low-risk tumors (predominantly older women). For both groups of patients, local therapy appears to ultimately have a beneficial effect in reducing breast cancer mortality, but in patients with low-risk tumors the benefit is immediate, while in patients with high-risk tumors it is delayed. Evidence for such an age-interaction is derived from comparison of the breast cancer hazard curves in women with high-risk and low-risk tumors, and analysis of the mammography screening trials. Neo-adjuvant systemic therapy may eventually prove useful in modulating the effects of local therapy.

Managing the changing burden of cancer in Asia

Asia accounts for 60% of the world population and half the global burden of cancer. The incidence of cancer cases is estimated to increase from 6.1 million in 2008 to 10.6 million in 2030, due to ageing and growing populations, lifestyle and socioeconomic changes. Striking variations in ethnicity, sociocultural practices, human development index, habits and dietary patterns are reflected in the burden and pattern of cancer in different regions. The existing and emerging cancer patterns and burden in different regions of Asia call for political recognition of cancer as an important public health problem and for balanced investments in public and professional awareness. Prevention as well as early detection of cancers leads to both better health outcomes and considerable savings in treatment costs. Cancer health services are still evolving, and require substantial investment to ensure equitable access to cancer care for all sections of the population. In this review, we discuss the changing burden of cancer in Asia, along with appropriate management strategies. Strategies should promote healthy ageing via healthy lifestyles, tobacco and alcohol control measures, hepatitis B virus (HBV) and human papillomavirus (HPV) vaccination, cancer screening services, and vertical investments in strengthening cancer healthcare infrastructure to improve equitable access to services.

Female Body Mass Index and its Relationship With Triple Negative Breast Cancer and Ethnicity

BACKGROUND

Breast cancer in women is a relatively common malignancy in the western hemisphere and is perhaps one of the leading causes of mortality among females. We conducted a retrospect cohort study to investigate the association of body mass index (BMI) with triple negative breast cancer and ethnicity.

METHODS

Tumor Registry Database at the University of Florida, College of Medicine in Jacksonville was utilized for our cohort study. A total of 84 women with triple negative breast cancer, between 2004 and 2008 met our criteria and were selected for this study. For comparison, another 83 women with at least one hormone receptors positive breast cancer were randomly selected in the same time period. Chi-square testing was used to evaluate categorical variables, while the t-test analysis was used to analyze for the continuous variables.

RESULTS

Our data demonstrated that 27.4% of the triple negative group had BMI < 25 compared to the 14.5% of non-triple negative breast cancer, 73.6% of the triple negative group had BMI ≥ 25 compared to 86.5% in the non-triple negative group with a P-value of 0.245. In terms of ethnicity, triple negative breast cancer was found in 56% of African-American and 44% of Caucasian females. Non-triple negative breast cancer was found in 48.2% of African-Americans and 51.8% of Caucasians females with a P-value of 0.354.

CONCLUSIONS

We were not able to show any statistically significant association of body mass index triple with triple negative breast cancer or ethnicity. While our findings are not in agreement with the research published earlier, we do submit that our retrospective cohort study has shortcomings, including the small sample size pooled from a single center, which greatly limits our ability to deduce any definitive conclusions. In light of these shortcomings, we recommend a future multicenter study with a larger sample size.

The California Breast Cancer Survivorship Consortium (CBCSC): prognostic factors associated with racial/ethnic differences in breast cancer survival

Racial/ethnic disparities in mortality among US breast cancer patients are well documented. Our knowledge of the contribution of lifestyle factors to disease prognosis is based primarily on non-Latina Whites and is limited for Latina, African American, and Asian American women. To address this knowledge gap, the California Breast Cancer Survivorship Consortium (CBCSC) harmonized and pooled interview information (e.g., demographics, family history of breast cancer, parity, smoking, alcohol consumption) from six California-based breast cancer studies and assembled corresponding cancer registry data (clinical characteristics, mortality), resulting in 12,210 patients (6,501 non-Latina Whites, 2,060 African Americans, 2,032 Latinas, 1,505 Asian Americans, 112 other race/ethnicity) diagnosed with primary invasive breast cancer between 1993 and 2007. In total, 3,047 deaths (1,570 breast cancer specific) were observed with a mean (SD) follow-up of 8.3 (3.5) years. Cox proportional hazards regression models were fit to data to estimate hazards ratios (HRs) and 95 % confidence intervals (CIs) for overall and breast cancer-specific mortality. Compared with non-Latina Whites, the HR of breast cancer-specific mortality was 1.13 (95 % CI 0.97-1.33) for African Americans, 0.84 (95 % CI 0.70-1.00) for Latinas, and 0.60 (95 % CI 0.37-0.97) for Asian Americans after adjustment for age, tumor characteristics, and select lifestyle factors. The CBCSC represents a large and racially/ethnically diverse cohort of breast cancer patients from California. This cohort will enable analyses to jointly consider a variety of clinical, lifestyle, and contextual factors in attempting to explain the long-standing disparities in breast cancer outcomes.

Cancer incidence trends among Asian American populations in the United States, 1990-2008

BACKGROUND

National cancer incidence trends are presented for eight Asian American groups: Asian Indians/Pakistanis, Chinese, Filipinos, Japanese, Kampucheans, Koreans, Laotians, and Vietnamese.

METHODS

Cancer incidence data from 1990 through 2008 were obtained from 13 Surveillance, Epidemiology, End Results (SEER) registries. Incidence rates from 1990 through 2008 and average percentage change were computed using SEER*Stat and Joinpoint software. The annual percentage change (APC) in incidence rates was estimated with 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates. Rates for non-Hispanic whites are presented for comparison.

RESULTS

Prostate cancer was the most common malignancy among most groups, followed by lung, colorectal, liver, and stomach cancers. Breast cancer was generally the most common cancer in women, followed by colorectal and lung cancers; liver, cervix, thyroid, and stomach cancers also ranked highly. Among men, increasing trends were observed for prostate (Asian Indians and Pakistanis: APC 1990-2003 = 2.2, 95% CI = 0.3 to 4.1; Filipinos: APC 1990-1994 = 19.0, 95% CI = 4.5 to 35.4; Koreans: APC 1990-2008 = 2.9, 95% CI = 1.8 to 4.0), colorectal (Koreans: APC 1990-2008 = 2.2, 95% CI = 0.9 to 3.5), and liver cancers (Filipinos: APC 1990-2008 = 1.6, 95% CI = 0.4 to 2.7; Koreans: APC 1990-2006 = 2.1, 95% CI = 0.4 to 3.7; Vietnamese: APC 1990-2008 = 1.6, 95% CI = 0.3 to 2.8), whereas lung and stomach cancers generally remained stable or decreased. Among women, increases were observed for uterine cancer (Asian Indians: APC 1990-2008 = 3.0, 95% CI = 0.3 to 5.8; Chinese: APC 2004-2008 = 7.0, 95% CI = 1.4 to 12.9; Filipina: APC 1990-2008 = 3.0, 95% CI = 2.4 to 3.7; Japanese: APC 1990-2008 = 1.1, 95% CI = 0.1 to 2.0), colorectal cancer (Koreans: APC 1990-2008 = 2.8, 95% CI = 1.7 to 3.9; Laotians: APC: 1990-2008 = 5.9, 95% CI = 4.0 to 7.7), lung cancer (Filipinas: APC 1990-2008 = 2.1, 95% CI = 1.4 to 2.8; Koreans: APC 1990-2008 = 2.1, 95% CI = 0.6 to 3.6), thyroid cancer (Filipinas: APC 1990-2008 = 2.5, 95% CI = 1.7 to 3.3), and breast cancer in most groups (APC 1990-2008 from 1.2 among Vietnamese and Chinese to 4.7 among Koreans). Decreases were observed for stomach (Chinese and Japanese), colorectal (Chinese), and cervical cancers (Laotians and Vietnamese).

CONCLUSIONS

These data fill a critical knowledge gap concerning the cancer experience of Asian American groups and highlight where increased preventive, screening, and surveillance efforts are needed-in particular, lung cancer among Filipina and Korean women and Asian Indian/Pakistani men, breast cancer among all women, and liver cancer among Vietnamese, Laotian, and Kampuchean women and Filipino, Kampuchean, and Vietnamese men.

Cancer incidence trends among native Hawaiians and other Pacific Islanders in the United States, 1990-2008

BACKGROUND

Lack of annual population estimates for disaggregated Native Hawaiian and Other Pacific Islander (NHOPI) populations limits the ability to examine cancer incidence rates and trends to understand the cancer burdens among NHOPIs.

METHODS

Utilizing 1990 and 2000 population census data, we estimated the annual populations by age and sex for Native Hawaiians, Samoans, and Guamanians/Chamorros for 1990-2008 in regions covered by 13 of the National Cancer Institute's SEER registries. Cancer diagnoses during 1990-2008 from these registries were used to calculate the age-adjusted (2000 US Standard) incidence rates by sex, calendar year/period, and cancer type for each population. The annual percentage change (APC) in incidence rates was estimated with the 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates.

RESULTS

Statistically significant declining trends were found in Native Hawaiians, in men for lung and stomach cancers (APC = -2.3%; 95% CI = -3.3 to -1.3; and APC = -3.8%; 95% CI = -6.0 to -1.6, respectively), and in women for breast cancer (APC = -4.1%; 95% CI = -5.7 to -2.5) since 1998 and lung cancer (APC = -6.4%; 95% CI = -10.7 to -1.8) since 2001. Rising incidence trends were experienced by Samoans, especially by Samoan women for breast (APC = 2.7%; 95% CI = 0.9 to 4.5) and uterus (APC = 7.3%; 95% CI = 6.2 to 8.4) cancers. With limited data, Guamanians/Chamorros demonstrated lower, but increasing, incidence rates than other NHOPIs.

CONCLUSIONS

Population-based cancer incidence rates for disaggregated NHOPI populations help identify disparities in cancer burden and provide valuable information to improve cancer control efforts among NHOPIs.

Mortality risk of black women and white women with invasive breast cancer by hormone receptors, HER2, and p53 status

Background

Black women are more likely than white women to have an aggressive subtype of breast cancer that is associated with higher mortality and this may contribute to the observed black-white difference in mortality. However, few studies have investigated the black-white disparity in mortality risk stratified by breast cancer subtype, defined by estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status. Furthermore, it is not known whether additional consideration of p53 protein status influences black-white differences in mortality risk observed when considering subtypes defined by ER, PR and HER2 status.

Methods

Four biomarkers were assessed by immunohistochemistry in paraffin-embedded breast tumor tissue from 1,204 (523 black, 681 white) women with invasive breast cancer, aged 35–64 years at diagnosis, who accrued a median of 10 years’ follow-up. Multivariable Cox proportional hazards regression models were fit to assess subtype-specific black-white differences in mortality risk.

Results

No black-white differences in mortality risk were observed for women with triple negative (ER-negative [ER-], PR-, and HER2-) subtype. However, older (50–64 years) black women had greater overall mortality risk than older white women if they had been diagnosed with luminal A (ER-positive [ER+] or PR+ plus HER2-) breast cancer (all-cause hazard ratio, HR, 1.88; 95% confidence interval, CI, 1.18 to 2.99; breast cancer-specific HR, 1.51; 95% CI, 0.83 to 2.74). This black-white difference among older women was further confined to those with luminal A/p53- tumors (all-cause HR, 2.22; 95% CI, 1.30 to 3.79; breast cancer-specific HR, 1.89; 95% CI, 0.93 to 3.86). Tests for homogeneity of race-specific HRs comparing luminal A to triple negative subtype and luminal A/p53- to luminal A/p53+ subtype did not achieve statistical significance, although statistical power was limited.

Conclusions

Our findings suggest that the subtype-specific black-white difference in mortality risk occurs mainly among older women diagnosed with luminal A/p53- breast cancer, which is most likely treatable. These results further suggest that factors other than subtype may be relatively more important in explaining the increased mortality risk seen in older black women.

Correlates of depressive symptomatology in African-American breast cancer patients

PURPOSE

This study assessed the levels of depressive symptomatology in African-American women with breast cancer compared to those of women without breast cancer and examined demographic, psychosocial, and clinical factors correlated with depression.

METHODS

A total of 152 African-American women were recruited from Washington, DC and surrounding suburbs. Breast cancer patients (n = 76 cases) were recruited from a health care center and women without cancer were recruited from health fairs (n = 76 comparison). We assessed depression, psychosocial variables (ego strength and social support), and sociodemographic factors from in-person interviews. Stage and clinical factors were abstracted from medical records. Independent sample t test, chi square test, analyses of variance, and multiple regression models were used to identify differences in depression and correlates of depression among the cases and comparison groups.

RESULTS

Women with breast cancer reported significantly greater levels of depression (m = 11.5, SD = 5.0) than women without breast cancer (m = 3.9, SD = 3.8) (p < 0.001). Higher cancer stage (beta = 0.91) and higher age (beta = 0.11) were associated with depression in the breast patients, explaining 84 % of the variance. In the comparison group, ego strength and tangible support were inversely associated with depressive symptoms, accounting for 32 % of the variance.

CONCLUSIONS

Women with more advanced disease may require interdisciplinary approaches to cancer care (i.e., caring for the whole person).

IMPLICATIONS FOR CANCER SURVIVORS

Depression is often underrecognized and undertreated in African-American breast cancer patients. Understanding the factors related to depression is necessary to integrate psychosocial needs to routine cancer care to improve survivors' quality of life.

Use of adjuvant trastuzumab in women with human epidermal growth factor receptor 2 (HER2)-positive breast cancer by race/ethnicity and education within the National Comprehensive Cancer Network

BACKGROUND

Trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive breast cancer is highly efficacious yet costly and time-intensive, and few data are available about its use. The authors of this report examined receipt and completion of adjuvant trastuzumab by race/ethnicity and education for women with HER2-positive disease.

METHODS

The National Comprehensive Cancer Network Breast Cancer Outcomes Database was used to identify 1109 women who were diagnosed with stage I through III, HER2-positive breast cancer during September 2005 through December 2008 and were followed for ≥1 year. The authors used multivariable logistic regression to assess the association of race/ethnicity and education with the receipt of trastuzumab and, among those women who initiated trastuzumab, with the completion of > 270 days of therapy.

RESULTS

The cohort was 75% white, 8% black, and 9% Hispanic; and 20% of women had attained a high school degree or less. Most women (83%) received trastuzumab, and no significant differences were observed according to race/ethnicity or socioeconomic status. Among the women who initiated trastuzumab, 73% of black women versus 87% of white women (P = .007) and 70% of women with less than a high school education versus 90% of women with a college degree completed > 270 days of therapy (P = .006). In adjusted analyses, black women (vs white women) and women without a high school degree (vs those with a college degree) had lower odds of completing therapy (black women: odds ratio, 0.45; 95% confidence interval, 0.27-074; white women: odds ratio, 0.27, 95% confidence interval, 0.14-0.51).

CONCLUSIONS

Differences in completing trastuzumab therapy were observed according to race and educational attainment among women who received treatment at National Comprehensive Cancer Network centers. Efforts to assure the appropriate use of trastuzumab and to understand treatment barriers are needed and may lead to improved outcomes. The authors report differences in the rate at which patients complete treatment with trastuzumab according to race and education among women who receive treatment at National Comprehensive Cancer Network centers. Efforts to assure the appropriate use of trastuzumab and to understand treatment barriers are needed and may lead to improved outcomes.

Pathological and epidemiological factors associated with advanced stage at diagnosis of breast cancer

BACKGROUND

Breast cancer is a highly heterogeneous disease, but the stage at presentation significantly influences outcome. It is important to dissect the pathobiological and epidemiological factors that influence the stage at presentation in order to develop effective strategies to improve clinical outcome.

SOURCES OF DATA

PubMed references relating to breast cancer subtypes, molecular classification of breast cancer, genetic susceptibility, young women and breast cancer.

AREAS OF AGREEMENT

HER-2 positive, basal-like tumours and inflammatory breast cancers (IBC) more frequently present as late stage disease. Socioeconomic, cultural and ethnic background also influence stage at presentation.

AREAS OF CONTROVERSY

The biology of IBC is poorly understood. Relative contribution of social and genetic factors in certain ethnic groups. GROWING POINTS Molecular determinants of breast cancer behaviour. Genetic and biological factors influencing disease phenotype in different ethnic groups.

AREAS TIMELY FOR DEVELOPING RESEARCH

Biology of basal-like tumours and IBC. Role of predisposition of genetic variants in determining breast cancer phenotypes. Biological differences in breast cancer from different ethnic groups.

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample

PURPOSE

Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample.

PATIENTS AND METHODS

Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt.

RESULTS

The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt.

CONCLUSION

In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Racial differences and disparities in cancer care and outcomes: where's the rub?

Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.