Racial and ethnic disparities in breast cancer mortality: are we doing enough to address the root causes?

Effects of super-enhancers in cancer metastasis: mechanisms and therapeutic targets

Metastasis remains the principal cause of cancer-related lethality despite advancements in cancer treatment. Dysfunctional epigenetic alterations are crucial in the metastatic cascade. Among these, super-enhancers (SEs), emerging as new epigenetic regulators, consist of large clusters of regulatory elements that drive the high-level expression of genes essential for the oncogenic process, upon which cancer cells develop a profound dependency. These SE-driven oncogenes play an important role in regulating various facets of metastasis, including the promotion of tumor proliferation in primary and distal metastatic organs, facilitating cellular migration and invasion into the vasculature, triggering epithelial-mesenchymal transition, enhancing cancer stem cell-like properties, circumventing immune detection, and adapting to the heterogeneity of metastatic niches. This heavy reliance on SE-mediated transcription delineates a vulnerable target for therapeutic intervention in cancer cells. In this article, we review current insights into the characteristics, identification methodologies, formation, and activation mechanisms of SEs. We also elaborate the oncogenic roles and regulatory functions of SEs in the context of cancer metastasis. Ultimately, we discuss the potential of SEs as novel therapeutic targets and their implications in clinical oncology, offering insights into future directions for innovative cancer treatment strategies.

Study Protocol for the Social Interventions for Support During Treatment for Endometrial Cancer and Recurrence (SISTER) study: a community engaged national randomized trial

Aim: Social isolation in cancer patients is correlated with prognosis and is a potential mediator of treatment completion. Black women with endometrial cancer (EC) are at increased risk for social isolation when compared with White patients. We developed the Social Interventions for Support during Treatment for Endometrial Cancer and Recurrence (SISTER) study to compare and evaluate interventions to address social isolation among Black women with high-risk EC in USA. The primary objective of the SISTER study is to determine whether virtual support interventions improve treatment completion compared with Enhanced Usual Care. Secondary objectives include comparing effectiveness virtual evidence-based interventions and evaluating barriers and facilitators to social support delivery. Patients & methods: This is a multi-site prospective, open-label, community-engaged randomized controlled trial, consisting of three intervention arms: enhanced usual care, facilitated support group and one-to-one peer support. Primary outcome will be measured using relative dose. Qualitative semi-structured interviews will be conducted with a subset of participants to contextualize the relative degree or lack thereof of social isolation, over time. Data analysis: Primary analysis will be based on an intent-to-treat analysis. Multivariable analysis will be performed to determine the effect of the intervention on the primary and secondary outcomes of interest, relative dose and social isolation score. Semi-structured interviews will be qualitatively analyzed using inductive and deductive approaches of content analysis. Discussion/conclusion: Endometrial cancer mortality disproportionately affects Black women, and social isolation contributes to this disparity. The SISTER study aims to identify whether and to what extent differing social support vehicles improve key outcomes for Black women in the United States with high-risk EC. Clinical Trial Registration: NCT04930159 (ClinicalTrials.gov).

Health insurance and neighborhood poverty as mediators of racial disparities in advanced disease stage at diagnosis and nonreceipt of surgery for women with breast cancer

BACKGROUND

In our recent study, advanced disease stage and nonreceipt of surgery were the most important mediators of the racial disparity in breast cancer survival. The purpose of this study was to quantify the racial disparity in these two intermediate outcomes and investigate mediation by the more proximal mediators of insurance status and neighborhood poverty.

METHODS

This was a cross-sectional study of non-Hispanic Black and non-Hispanic White women diagnosed with first primary invasive breast cancer in Florida between 2004 and 2015. Log-binomial regression was used to obtain prevalence ratios (PR) with 95% confidence intervals (CIs). Multiple mediation analysis was used to assess the role of having Medicaid/being uninsured and living in high-poverty neighborhoods on the race effect.

RESULTS

There were 101,872 women in the study (87.0% White, 13.0% Black). Black women were 55% more likely to be diagnosed with advanced disease stage at diagnosis (PR, 1.55; 95% CI, 1.50-1.60) and nearly twofold more likely to not receive surgery (PR, 1.97; 95% CI, 1.90-2.04). Insurance status and neighborhood poverty explained 17.6% and 5.3% of the racial disparity in advanced disease stage at diagnosis, respectively; 64.3% remained unexplained. For nonreceipt of surgery, insurance status explained 6.8% while neighborhood poverty explained 3.2%; 52.1% was unexplained.

CONCLUSIONS

Insurance status and neighborhood poverty were significant mediators of the racial disparity in advanced disease stage at diagnosis with a smaller impact on nonreceipt of surgery. However, interventions designed to improve breast cancer screening and receipt of high-quality cancer treatment must address additional barriers for Black women with breast cancer.

Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia

PURPOSE

Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system.

MATERIALS AND METHODS

A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model.

RESULTS

A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26).

CONCLUSION

Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Age and Racial Disparities in the Utilization of Anticancer, Antihypertension, and Anti-diabetes Therapies, and in Mortality in a Large Population-Based Cohort of Older Women with Breast Cancer

OBJECTIVE

This study examined the receipt of therapies for cancer, hypertension, and diabetes in association with age and racial disparities in mortality among women with breast cancer.

METHODS

This study identified 92,829 women diagnosed with breast cancer at age ≥ 65 years in 2007-2015 with follow-up to 2016 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.

RESULTS

There were substantial age and racial disparities in the prevalence of hypertension and diabetes, which was higher in women ≥ 75 (86.3% and 32.0%) than younger women 65-74 (72.8% and 29.3%), and the highest in Black women (91.1% and 49.1%), followed by Asian women (80.2% and 40.5%), and White women (77.6 and 27.8%). Black women were significantly less likely to receive chemotherapy (odds ratio: 0.70, 95% CI: 0.64-0.75), radiation therapy (0.87, 0.83-0.92), and hormone therapy (0.80, 0.76-0.85), but significantly more likely to receive antihypertensive (1.26, 1.19-1.33) and antidiabetic (1.19, 1.10-1.28) drugs than White women, after adjusting for sociodemographic and tumor factors. As compared to White women, Black women had a significantly higher risk of all-cause mortality (1.46, 1.41-1.52), but it became insignificant after adjusting for treatment factors (1.01, 0.97-1.06), whereas the adjusted risk of breast cancer-specific mortality remained significantly higher (1.08, 1.01-1.15) in Black women; Asian and other ethnic women had a significantly lower risk of all-cause and breast cancer-specific mortality.

CONCLUSIONS

There were substantial age and racial disparities in the prevalence of hypertension and diabetes and in the receipt of medications. Black women did not have a significantly higher risk of all-cause mortality but had a significantly higher risk of breast cancer-specific mortality as compared to White women.

Diagnostic Mammography Performance across Racial and Ethnic Groups in a National Network of Community-Based Breast Imaging Facilities

BACKGROUND

We evaluated differences in diagnostic mammography performance based on women's race/ethnicity.

METHODS

This cohort study included 267,868 diagnostic mammograms performed to evaluate screening mammogram findings at 98 facilities in the Breast Cancer Surveillance Consortium between 2005 and 2017. Mammogram assessments were recorded prospectively and breast cancers occurring within one year were ascertained. Performance statistics were calculated with 95% confidence intervals (CI) for each racial/ethnic group. Multivariable regression was used to control for personal characteristics and imaging facility.

RESULTS

Among non-Hispanic White (70%), non-Hispanic Black (13%), Asian/Pacific Islander (10%), and Hispanic (7%) women, the invasive cancer detection rate (iCDR, per 1,000 mammograms) and positive predictive value (PPV2) were highest among non-Hispanic White women (iCDR, 35.8; 95% CI, 35.0-36.7; PPV2, 27.8; 95% CI, 27.3-28.3) and lowest among Hispanic women (iCDR, 22.3; 95% CI, 20.2-24.6; PPV2, 19.4; 95% CI, 18.0-20.9). Short interval follow-up recommendations were most common among non-Hispanic Black women [(31.0%; 95% CI, 30.6%-31.5%) vs. other groups, range, 16.6%-23.6%]. False-positive biopsy recommendations were most common among Asian/Pacific Islander women [per 1,000 mammograms: 169.2; 95% CI, 164.8-173.7) vs. other groups, range, 126.5-136.1]. Some differences were explained by adjusting for receipt of diagnostic ultrasound or MRI for iCDR and imaging facility for short-interval follow-up. Other differences changed little after adjustment.

CONCLUSIONS

Diagnostic mammography performance varied across racial/ethnic groups. Addressing characteristics related to imaging facility and access, rather than personal characteristics, may help reduce some of these disparities.

IMPACT

Diagnostic mammography performance studies should include racially and ethnically diverse populations to provide an accurate view of the population-level effects.

Everyday discrimination and telomere length in a multiethnic cohort of breast cancer survivors

Objectives: Racial/ethnic minority women have disproportionately lower breast cancer survival rates compared to white women. As minorities in the US are exposed to higher levels of discrimination, and exposure to discrimination has been associated with shorter telomere lengths (TLs), we investigated the association between perceived everyday discrimination and TL in a multiethnic sample of breast cancer survivors.Design: We examined a cohort of 58 breast cancer survivors who participated in a pilot study to investigate biological stress. Participants were drawn from the Equality in Breast Cancer Care (EBCC) study and were asked to provide saliva samples for DNA extraction. Ordinary least squares linear regression was used to derive regression coefficients (β) and 95% confidence intervals (CI).Results: Higher levels of everyday discrimination were associated with longer TLs (e^β = 1.04, CI: 1.01-1.07), adjusting for age, race/ethnicity, breast cancer stage, and breast cancer subtype. Luminal B subtypes were associated with longer telomeres relative to luminal A, while African Americans were less likely than Whites to have longer telomeres.Conclusions: Further research, particularly longitudinal studies, is needed to understand how discrimination, and other social stressors, impact biological stress and health outcomes.

Socioeconomic and Racial Disparities in Cancer Stage at Diagnosis, Tumor Size, and Clinical Outcomes in a Large Cohort of Women with Breast Cancer, 2007-2016

BACKGROUND

Socioeconomic and treatment factors contribute to diagnosis of early-stage (local-stage) breast cancer, as well as excess deaths among African American women.

OBJECTIVES

We evaluated socioeconomic and treatment predictive factors for early-stage breast cancer among African American women compared to Caucasian women. A secondary aim evaluated predictors and overall risks associated with all-cause and breast cancer-specific mortality.

METHODS

We used retrospective cohort population-based study data from the Surveillance, Epidemiology, and End Results (SEER) Program on 547,703 women aged ≥ 20 years diagnosed with breast cancer primary tumors from 2007 to 2016. Statistical analysis used logistic regression to assess predictors of early-stage breast cancer and Cox proportional hazards regression for mortality risks.

RESULTS

African American women were more likely to be diagnosed at advanced-stage, had larger tumor size at diagnosis, and received less cancer-directed surgery, but more chemotherapy than Caucasian women. Insured women (> 50%) were more likely to be diagnosed at early-stage and to have smaller tumors (p < 0.05). Education level, poverty level, and household income had no impact on racial disparities or socioeconomic disparities in women diagnosed at early stage. We found increased risks for all-cause mortality (hazard ratio = 1.18; 95% confidence interval, 1.16-1.21) and breast cancer-specific mortality (HR = 1.22; 95% CI, 1.19-1.25) among African American women compared to Caucasian women after adjusting for demographic, socioeconomic, and treatment factors.

CONCLUSIONS

In this population-based study using the most recent SEER data, African American women with breast cancer continued to exhibit higher all-cause mortality and breast cancer-specific mortality compared to Caucasian women.

Multilevel determinants of financial toxicity in breast cancer care: perspectives of healthcare professionals and Latina survivors

PURPOSE

Financial toxicity is a multidimensional side effect of cancer treatment. Yet, most relevant research has focused on individual-level determinants of financial toxicity and characterized only patient perspectives. This study examined the multilevel determinants of financial toxicity from the perspectives of Latina breast cancer survivors and healthcare professionals.

METHODS

We analyzed qualitative data from focus groups with 19 Latina breast cancer survivors and interviews with 10 healthcare professionals recruited through community partners and venues in Chicago.

RESULTS

At the individual-level, the lack of knowledge and prioritization regarding financial aspects of care (e.g., costs of treatment, insurance coverage) was identified as important determinants of financial toxicity. However, healthcare professionals emphasized the need for early financial planning, while survivors prioritized survival over financial concerns immediately after diagnosis. At the interpersonal-level, social networks were identified as important platforms for disseminating information on financial resources. At the community-level, community norms and dynamics were identified as important barriers to seeking financial assistance. Access to culturally astute community-based organizations was considered one potential solution to eliminate these barriers. At the organizational/healthcare policy-level, financial assistance programs' restrictive eligibility criteria, lack of coverage post-treatment, limited availability, and instability were identified as major determinants of financial toxicity.

CONCLUSION

Our findings suggest that multilevel interventions at the individual-, interpersonal-, community-, and organizational/healthcare policy-levels are needed to adequately address financial toxicity among Latina and other survivors from disadvantaged communities.

Engaging young African American women breast cancer survivors: A novel storytelling approach to identify patient-centred research priorities

Background

Patient‐centredness is considered an essential aspiration of a high‐quality health‐care system, and patient engagement is a critical precursor to patient‐centred care.

Objectives

To engage patients, health‐care providers and stakeholders in identifying recommendations to address research and practice gaps that impact young African American breast cancer survivors.

Methods

This paper reported an approach for research priority setting. This approach applies an engagement process (January‐September 2018) of using patient and stakeholder groups, patient storytelling workshops and a culminating storytelling conference in Wisconsin to generate relevant research topics and recommendations. Topics were prioritized using an iterative engagement process. Research priorities and recommendation were ranked over the conference by counting participants’ anonymous votes.

Results

One hundred attendees (43 patients/family members, 20 providers/researchers and 37 community members) participated in the conference. Five topics were identified as priorities. The results showed that three priority areas received the most votes, specifically community outreach and education, providing affordable health care and engaging in complementary care practice. Stakeholders also agreed it is critical to ‘include youth in the conversation’ when planning for cancer support and educational programmes for caregivers, friends and family members.

Conclusion

Storytelling as a patient engagement approach can build trust in the patient‐research partnership, ensure that patients are meaningfully engaged throughout the process and capture the diversity of patient experiences and perspectives.

Protocol for a cross sectional study of cancer risk, environmental exposures and lifestyle behaviors in a diverse community sample: the Community of Mine study

Background

Physical inactivity and unhealthy diet are modifiable behaviors that lead to several cancers. Biologically, these behaviors are linked to cancer through obesity-related insulin resistance, inflammation, and oxidative stress. Individual strategies to change physical activity and diet are often short lived with limited effects. Interventions are expected to be more successful when guided by multi-level frameworks that include environmental components for supporting lifestyle changes. Understanding the role of environment in the pathways between behavior and cancer can help identify what environmental conditions are needed for individual behavioral change approaches to be successful, and better recognize how environments may be fueling underlying racial and ethnic cancer disparities.

Methods

This cross-sectional study was designed to select participants (n = 602 adults, 40% Hispanic, in San Diego County) from a range of neighborhoods ensuring environmental variability in walkability and food access. Biomarkers measuring cancer risk were measured with fasting blood draw including insulin resistance (fasting plasma insulin and glucose levels), systemic inflammation (levels of CRP), and oxidative stress measured from urine samples. Objective physical activity, sedentary behavior, and sleep were measured by participants wearing a GT3X+ ActiGraph on the hip and wrist. Objective measures of locations were obtained through participants wearing a Qstarz Global Positioning System (GPS) device on the waist. Dietary measures were based on a 24-h food recall collected on two days (weekday and weekend). Environmental exposure will be calculated using static measures around the home and work, and dynamic measures of mobility derived from GPS traces. Associations of environment with physical activity, obesity, diet, and biomarkers will be measured using generalized estimating equation models.

Discussion

Our study is the largest study of objectively measured physical activity, dietary behaviors, environmental context/exposure, and cancer-related biomarkers in a Hispanic population. It is the first to perform high quality measures of physical activity, sedentary behavior, sleep, diet and locations in which these behaviors occur in relation to cancer-associated biomarkers including insulin resistance, inflammation, impaired lipid metabolism, and oxidative stress. Results will add to the evidence-base of how behaviors and the built environment interact to influence biomarkers that increase cancer risk.

Trial registration

ClinicalTrials.gov NCT02094170, 03/21/2014.

Predictors of breast cancer mortality among white and black women in large United States cities: an ecologic study

PURPOSE

We employed a city-level ecologic analysis to assess predictors of race-specific (black and white) breast cancer mortality rates.

METHODS

We used data from the National Center for Health Statistics and the US Census Bureau to calculate 2010-2014 race-specific breast cancer mortality rates (BCMR) for 47 of the largest US cities. Data on potential city-level predictors (e.g., socioeconomic factors, health care resources) of race-specific BCMR were obtained from various publicly available datasets. We constructed race-specific multivariable negative binomial regression models to estimate rate ratios (RR) and 95% confidence intervals (CIs).

RESULTS

Predictors of the white BCMR included white/black differences in education (RR 0.95; CI 0.91-0.99), number of religious congregations (RR 0.87; CI 0.77-0.97), and number of Medicare primary care physicians (RR 1.15; CI 1.04-1.28). Predictors of the black rate included white/black differences in household income (RR 1.03; CI 1.01-1.05), number of mammography facilities (RR 1.07; CI 1.03-1.12), and mammogram use (RR 0.93; CI 0.89-0.97).

CONCLUSIONS

Our ecologic analysis found that predictors of breast cancer mortality differ for the black and white rate. The results of this analysis could help inform interventions at the local level.

Evaluation of Mammogram Parties as an Effective Community Navigation Method

Women of color do not have the same level of access to mammography services as their White counterparts, and this inequity may be one of the contributing factors to the documented racial disparity in breast cancer mortality in the US. The present study sought to assess the effectiveness of the mammogram party, a promising, but under-studied approach to increasing mammography uptake, particularly among under-served populations. The program targeted mammogram-eligible women in community settings on the west and southwest sides of Chicago, gathering basic demographic information, mammography history, and interest in assistance obtaining a mammogram. Women were navigated either through traditional one-on-one navigation or to a mammogram party. Seven outcome metrics were calculated for each type of navigation. We compared navigation outcomes for those who attended to those who did not attend a mammogram party using two-tailed t tests and chi-square tests. We found that the mammography completion rate for mammogram parties was comparable to that for standard one-on-one navigation (65.8 vs. 63.7%), which is more labor-intensive as evidenced by the number of contacts needed to successfully navigate a woman to mammography (10.9 vs. 15.0). Mammogram parties offer a unique opportunity for fellowship and support for clients who are particularly fearful of mammograms or identifying breast cancer. Programmatically, mammogram parties are an efficient way to complete several mammograms in 1 day. Having the option to both navigate women to mammogram parties or one-on-one navigation allows for more flexibility for scheduling and may ensure a completed a mammogram.

Proposed outcomes measures for state public health genomic programs

PURPOSE

To assess the implementation of evidence-based genomic medicine and its population-level impact on health outcomes and to promote public health genetics interventions, in 2015 the Roundtable on Genomics and Precision Health of the National Academies of Sciences, Engineering, and Medicine formed an action collaborative, the Genomics and Public Health Action Collaborative (GPHAC). This group engaged key stakeholders from public/population health agencies, along with experts in the fields of health disparities, health literacy, implementation science, medical genetics, and patient advocacy.

METHODS

In this paper, we present the efforts to identify performance objectives and outcome metrics. Specific attention is placed on measures related to hereditary breast ovarian cancer (HBOC) syndrome and Lynch syndrome (LS), two conditions with existing evidence-based genomic applications that can have immediate impact on morbidity and mortality.

RESULTS

Our assessment revealed few existing outcome measures. Therefore, using an implementation research framework, 38 outcome measures were crafted.

CONCLUSION

Evidence-based public health requires outcome metrics, yet few exist for genomics. Therefore, we have proposed performance objectives that states might use and provided examples of a few state-level activities already under way, which are designed to collect outcome measures for HBOC and LS.

What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata

Background

Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata.

Methods

We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions’ sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed.

Discussion

Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality.

Trial registration

NCT03136367 at ClinicalTrials.gov

Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5109-2) contains supplementary material, which is available to authorized users.

Barriers to early presentation of breast cancer among women in Soweto, South Africa

PURPOSE

Reported breast cancer incidence is rising in South Africa, where some women are diagnosed late and have poor outcomes. We studied patient and provider factors associated with clinical stage at diagnosis among women diagnosed at the Chris Hani Baragwanath Academic Hospital in Soweto, Johannesburg in 2015-2016.

METHODS

From face-to-face interviewer-administered questionnaires we compared self-reported socioeconomics, demographics, comorbidities, risk factors, personal and health system barriers, and from patient clinical records, clinical staging, receptor subtype, and tumor grade among 499 consecutive women newly diagnosed with advanced stage (III/IV) breast cancer versus those diagnosed early (stage 0/I/II). Logistic regression models were used to identify factors associated with advanced stage at diagnosis.

RESULTS

Among the women, 243 (49%) were diagnosed at early and 256 (51%) at advanced stages. In the multiple logistic regression adjusted model, completion of high school or beyond (odds ratio (OR) 0.59, and greater breast cancer knowledge and awareness (OR 0.86) were associated with lower stage of breast cancer at presentation. Advanced stage was associated with Luminal B (OR 2.25) and triple-negative subtypes (OR 3.17) compared to luminal A, with delays >3 months from first breast symptoms to accessing the health system (OR 2.79) and with having more than 1 visit within the referral health system (OR 3.19) for 2 visits; OR 2.73 for ≥3 visits).

CONCLUSIONS

Limited patient education, breast cancer knowledge and awareness, and health system inefficiencies were associated with advanced stage at diagnosis. Sustained community and healthcare worker education may down-stage disease and improve cancer outcomes.

A Community-Driven Intervention for Improving Biospecimen Donation in African American Communities

INTRODUCTION

Human biospecimens are an invaluable resource for addressing cancers and other chronic diseases. The purpose of this study was to assess the impact of an educational intervention on biospecimen knowledge and attitudes.

METHODS

The participants consisted of 112 African Americans, 18 years and older, and who had not provided biospecimens for any health-related research in the past. A total of 55 participants received the educational brochure, and 57 received the educational video. The main outcomes of the study were knowledge and attitudes for biospecimen donation. This information was collected pre- and post-intervention.

RESULTS

The average knowledge scores increased (p < 0.0001) and the average attitude scores for biospecimen donation improved (p < 0.0001) post-intervention for both the video and brochure conditions. There was an interaction between the intervention condition and knowledge where the participants who received the educational video showed a greater increase in knowledge pre-to-post compared to those who received the educational brochure (p = 0.0061). There were no significant interactions between the two intervention conditions for attitudes toward biospecimen donation.

DISCUSSION

The results of this study demonstrated the feasibility and efficacy of an academic institution collaborating with the African American community in developing educational tools for biospecimen donation.

Racial Disparities in Breast Cancer Survival: The Mediating Effects of Macro-Social Context and Social Network Factors

This study attempts to clarify the associations between macro-social and social network factors and the continuing racial disparities in breast cancer survival. The study improves on prior methodologies by using a neighborhood disadvantage measure that assesses both economic and social disadvantage and an ego-network measurement tool that assesses key social network characteristics. Our population-based sample included 786 breast cancer patients (nHWhite=388; nHBlack=398) diagnosed during 2005-2008 in Chicago, IL. The data included census-derived macro-social context, self-reported social network, self-reported demographic and medically abstracted health measures. Mortality data from the National Death Index (NDI) were used to determine 5-year survival. Based on our findings, neighborhood concentrated disadvantage was negatively associated with survival among nHBlack and nHWhite breast cancer patients. In unadjusted models, social network size, network density, practical support, and financial support were positively associated with 5-year survival. However, in adjusted models only practical support was associated with 5-year survival. Our findings suggested that the association between network size and breast cancer survival is sensitive to scaling of the network measure, which helps to explain inconsistencies in past findings. Social networks of nHWhites and nHBlacks differed in size, social support dimensions, network density, and geographic proximity. Among social factors, residence in disadvantaged neighborhoods and unmet practical support explained some of the racial disparity in survival. Differences in late stage diagnosis and comorbidities between nHWhites and nHBlacks also explained some of the racial disparity in survival. Our findings highlight the relevance of social factors, both macro and inter-personal in the racial disparity in breast cancer survival. Findings suggest that reduced survival of nHBlack women is in part due to low social network resources and residence in socially and economically deprived neighborhoods. To improve survival among breast cancer patients social policies need to continue improving health care access as well as racially patterned social and economic disadvantage.

The impact of health insurance on cancer care in disadvantaged communities

BACKGROUND

Individuals from disadvantaged communities are among the millions of uninsured Americans gaining insurance under the Affordable Care Act. The extent to which health insurance can mitigate the effects of the social determinants of health on cancer care is unknown.

METHODS

This study linked the Surveillance, Epidemiology, and End Results registries to US Census data to study patients diagnosed with the 4 leading causes of cancer deaths between 2007 and 2011. A county-level social determinant score was developed with 5 measures of wealth, education, and employment. Patients were stratified into quintiles, with the lowest quintile representing the most disadvantaged communities. Logistic regression and Cox proportional hazards models were used to estimate associations and cancer-specific survival.

RESULTS

A total of 364,507 patients aged 18 to 64 years were identified (134,105 with breast cancer, 106,914 with prostate cancer, 62,606 with lung cancer, and 60,882 with colorectal cancer). Overall, patients from the most disadvantaged communities (median household income, $42,885; patients below the poverty level, 22%; patients completing college, 17%) were more likely to present with distant disease (odds ratio, 1.6; P < .001) and were less likely to receive cancer-directed surgery (odds ratio, 0.8; P < .001) than the least disadvantaged communities (median income, $78,249; patients below the poverty level, 9%; patients completing college, 42%). The differences persisted across quintiles regardless of the insurance status. The effect of having insurance on cancer-specific survival was more pronounced in disadvantaged communities (relative benefit at 3 years, 40% vs 31%). However, it did not fully mitigate the effect of social determinants on mortality (hazard ratio, 0.75 vs 0.68; P < .001).

CONCLUSIONS

Cancer patients from disadvantaged communities benefit most from health insurance, and there is a reduction in disparities in outcome. However, the gap produced by social determinants of health cannot be bridged by insurance alone. Cancer 2017;123:1219-1227. © 2016 American Cancer Society.

Understanding how low-socioeconomic status households cope with health shocks: An analysis of multi-sector linked data

Low-socioeconomic status (SES) households have little income or wealth to buffer against the negative impacts of an adverse health event (health shock) among adult household members. However, these households may employ a variety of other coping strategies such as receiving help from family, friends, and social services. Administrative data from a non-profit food distribution center, electronic medical record (EMR) data from a safety-net healthcare system, and publicly available residential appraisal data were linked to provide insight into these coping strategies. Three broad types of coping strategies were examined: changes in household structure, residential mobility, and utilization of social services. Of 3,235 households, 20.2% had at least one adult member who experienced a health shock. These households were more likely to gain additional adult household members and employed household members, were more likely to move residence and to move distances greater than one mile, and were less likely to visit the food distribution center after the shock.

A Community-Based Partnership to Successfully Implement and Maintain a Breast Health Navigation Program

Breast cancer screening combined with follow-up and treatment reduces breast cancer mortality. However, in the study clinic, only 12 % of eligible women ≥40 years received a mammogram in the previous year. The objective of this project was to implement patient navigation, in our partner health clinic to (1) identify women overdue for a mammogram; and (2) increase mammography utilization in this population over a 2-year period. Women overdue for a mammogram were identified. One patient navigator made navigation attempts over a 2-year period (2009-2011). Navigation included working around systems- and individual-level barriers to receive a mammogram as well as the appropriate follow-up post screening. Women were contacted up to three times to initiate navigation. The proportion of women navigated and who received a mammogram during the study period were compared to women who did not receive a mammogram using Chi square tests for categorical variables and t tests for continuous variables with an α = 0.05. Barriers to previous mammography were also assessed. With 94.8 % of eligible women navigated and 94 % of these women completing mammography, the implementation project reached 89 % of the target population. This project was a successful implementation of an evidence-based patient navigation program that continues to provide significant impact in a high-need area. Cost was the most commonly cite barrier to mammography. Increasing awareness of resources in the community for mammography and follow-up care remains a necessary adjunct to removing structural and financial barriers to accessing preventive services.

Fear of Treatments Surpasses Demographic and Socioeconomic Factors in Affecting Patients With Breast Cancer in Urban South Africa

Purpose

Breast cancer is the most common cause of cancer in women in South Africa, and often patients present late. There is little understanding of the psychosocial stresses affecting women with breast cancer in Africa.

Methods

A questionnaire was distributed to 263 patients with breast cancer at two sites (one government and one private facility) in Johannesburg. Self-reported levels of fear were recorded on summative scales and their relationship to demographic variables assessed through univariable and multivariable modified Poisson regression.

Results

Fears related to treatments and prognosis, particularly radiation, loss of hair, and loss of breast, were far stronger than those related to socioeconomic barriers. Relative risk (RR) of most fears was higher in women younger than age 40 years, including treatment affordability (RR, 1.80; 95% CI, 1.26 to 2.56), hair loss (RR, 1.48; 95% CI, 1.12 to 2.95), and surgery (RR, 1.31; 95% CI, 1.02 to 1.68). Difficulty taking time off work predicted fear of job loss (RR, 2.59; 95% CI, 1.59 to 4.21) and missing appointments because of transport (RR, 2.46; 95% CI, 1.52 to 3.96) or family commitments (RR, 2.46; 95% CI, 1.52 to 3.96). Women with dependents and black women were more afraid of dying (RR, 1.73; 95% CI, 1.03 to 2.90; and RR, 1.79; 95% CI, 1.33 to 2.24, respectively); however, socioeconomic status in this sample was a strong confounder of race and explained most of the racial differences in levels of fear.

Conclusion

The most significant fears around breast cancer were related to treatment modalities and adverse effects rather than transport, financial, or work concerns. Young age and job insecurity were predictive of increased fears. Education about treatments has a key role to play in improving access to breast cancer care in South Africa.

Mortality risk from comorbidities independent of triple-negative breast cancer status: NCI-SEER-based cohort analysis

PURPOSE

A comparatively high prevalence of comorbidities among African-American/Blacks (AA/B) has been implicated in disparate survival in breast cancer. There is a scarcity of data, however, if this effect persists when accounting for the adverse triple-negative breast cancer (TNBC) subtype which occurs at threefold the rate in AA/B compared to white breast cancer patients.

METHODS

We reviewed charts of 214 white and 202 AA/B breast cancer patients in the NCI-SEER Connecticut Tumor Registry who were diagnosed in 2000-2007. We employed the Charlson Co-Morbidity Index (CCI), a weighted 17-item tool to predict risk of death in cancer populations. Cox survival analyses estimated hazard ratios (HRs) for all-cause mortality in relation to TNBC and CCI adjusting for clinicopathological factors.

RESULTS

Among patients with SEER local stage, TNBC increased the risk of death (HR 2.18, 95 % CI 1.14-4.16), which was attenuated when the CCI score was added to the model (Adj. HR 1.50, 95 % CI 0.74-3.01). Conversely, the adverse impact of the CCI score persisted when controlling for TNBC (Adj. HR 1.49, 95 % CI 1.29-1.71; per one point increase). Similar patterns were observed in SEER regional stage, but estimated HRs were lower. AA/B patients with a CCI score of ≥3 had a significantly higher risk of death compared to AA/B patients without comorbidities (Adj. HR 5.65, 95 % CI 2.90-11.02). A lower and nonsignificant effect was observed for whites with a CCI of ≥3 (Adj. HR 1.90, 95 % CI 0.68-5.29).

CONCLUSIONS

comorbidities at diagnosis increase risk of death independent of TNBC, and AA/B patients may be disproportionately at risk.

The impact of health information technology on cancer care across the continuum: a systematic review and meta-analysis

INTRODUCTION

Health information technology (HIT) has the potential to play a significant role in the management of cancer. The purpose of this review is to identify and examine empirical studies that investigate the impact of HIT in cancer care on different levels of the care continuum.

METHODS

Electronic searches were performed in four academic databases. The authors used a three-step search process to identify 122 studies that met specific inclusion criteria. Next, a coding sheet was used to extract information from each included article to use in an analysis. Logistic regression was used to determine study-specific characteristics that were associated with positive findings.

RESULTS

Overall, 72.4% of published analyses reported a beneficial effect of HIT. Multivariate analysis found that the impact of HIT differs across the cancer continuum with studies targeting diagnosis and treatment being, respectively, 77 (P = .001) and 39 (P = .039) percentage points less likely to report a beneficial effect when compared to those targeting prevention. In addition, studies targeting HIT to patients were 31 percentage points less likely to find a beneficial effect than those targeting providers (P = .030). Lastly, studies assessing behavior change as an outcome were 41 percentage points less likely to find a beneficial effect (P = .006), while studies targeting decision making were 27 percentage points more likely to find a beneficial effect (P = .034).

CONCLUSION

Based on current evidence, HIT interventions seem to be more successful when targeting physicians, care in the prevention phase of the cancer continuum, and/or decision making. An agenda for future research is discussed.

Medical advocacy among African-American women diagnosed with breast cancer: from recipient to resource

PURPOSE

Medical advocacy at multiple levels (self, community/interpersonal, national/public health interest) may be helpful to address the disproportionate burden of breast cancer African-American women encounter. Little, however, is known about the interplay of medical advocacy at different levels.

METHODS

We analyzed qualitative data from two studies focused on the psychosocial experiences of breast cancer among 38 African-American women living in Western Washington State.

RESULTS

Emergent themes suggested that survivors received community/interpersonal advocacy from different members of social networks in the form of social support (appraisal, emotional, informational, instrumental). Survivors indicated that receiving this support was associated with greater self-advocacy in terms of their own care experiences, as well as greater community/interpersonal advocacy on their part as resources to other women diagnosed with breast cancer, their family, friends, and larger communities.

CONCLUSION

Our findings suggest that community/interpersonal advocacy, including providing different types of support, may lead to improved self-advocacy as well as health-protective impacts for the networks in which survivors are embedded. Future quantitative research is warranted to support these findings and assess how this interplay is associated with improved outcomes among this marginalized and resilient population.

Demographic and other characteristics of nodal non-Hodgkin's lymphoma managed in academic versus non-academic centers

BACKGROUND

Cancer therapy and outcomes are known to be affected by various demographic features and hospital types. We aimed to identify the characteristics of non-Hodgkin's lymphoma (NHL) patients associated with receipt of care at academic centers.

METHOD

This is a retrospective study of all patients diagnosed with nodal NHL between 2000 and 2011 in the National Cancer Database (NCDB), who received the diagnosis, and all or part of their initial therapy in the reporting hospital (n = 243,436). Characteristics of patients receiving care in academic versus nonacademic centers were compared using the Chi-square test.

RESULTS

Approximately 27% received care in academic centers. Patients receiving care in nonacademic centers, compared with academic centers, were more likely to be ⩾60 years (69% versus 58%, p < .0001), White (89% versus 80%, p < .0001) and have lower educational attainment (>12% without high school diploma: 72% versus 69%, p < .0001) and economic status (household income <$49,000: 66% versus 61%, p < 0.0001). Patients receiving care in nonacademic centers were less likely to travel ⩾25 miles (21% versus 26%, p < 0.0001). White patients, compared with non-Whites, were more likely to be ⩾60 years (70% versus <50%, p < 0.0001), which probably explains less care in academic centers.

CONCLUSIONS

Patients ⩾60 years and those with poorer educational attainment and economic status were less likely to receive care in academic centers. Care in academic centers required a longer commute. Elderly patients frequently have inferior outcomes and may benefit from clinical trials with novel agents and expertise at academic centers.

Diagnosis and surgical delays in African American and white women with early-stage breast cancer

BACKGROUND

Delays in diagnosis and treatment for breast cancer may contribute to excess deaths among African Americans. We examined racial differences in delays in diagnosis and surgical treatment for early-stage breast cancer and evaluated race-specific predictors associated with delay.

METHODS

A retrospective cohort study was conducted among 634 African American and white women diagnosed with invasive breast cancer between 2005 and 2010 in New Jersey. Detailed medical-chart abstraction and patient interviews were undertaken. Time intervals were calculated from symptom recognition to diagnosis (diagnosis delay) and from diagnosis to first operation (surgical delay). Binomial regression models were used to examine racial differences in delay and factors associated with ≥2 months delay in the overall population and stratified by race. Reasons responsible for diagnosis delay were also examined by race.

RESULTS

Compared to white women, African American women experienced significantly higher risk of ≥2 months delay in diagnosis and surgical treatment (adjusted relative risks=1.44 (1.12-1.86) and 3.08 (1.88-5.04), respectively). For the African Americans, predictors of diagnosis delay included mode of detection, insurance, and tumor size; for whites, mode of detection and tumor grade. Surgical delay was associated with operation type and education among African Americans but with operation type and tumor size for whites. Patient-related factors were commonly noted as reasons for diagnosis delay.

CONCLUSIONS

These findings emphasize the need to raise further awareness, especially among African American patients and their providers, of the importance of prompt evaluation and treatment of breast abnormalities. Research on effective ways to accomplish this is needed.

Provider-based research networks may improve early access to innovative colon cancer treatment for African Americans treated in the community

BACKGROUND

African American (AA) patients with colon cancer (CC) experience worse outcomes than whites partly due to differential treatment. The National Cancer Institute's Community Clinical Oncology Program (CCOP), a provider-based research network, adopts and diffuses innovative CC treatments quickly. The authors hypothesized that CCOP participation would lessen racial differences in the receipt of oxaliplatin, an innovative treatment for CC, among patients with stage III CC in the community.

METHODS

Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, the authors performed a population-based retrospective cohort study of AA and white individuals aged ≥66 years who were diagnosed with AJCC stage III CC from 2003 through 2005. Generalized estimating equations were used to calculate the odds of receiving an oxaliplatin-containing regimen. Predicted probabilities of oxaliplatin receipt for race-CCOP combinations were calculated. The absolute difference in oxaliplatin receipt between races was estimated using the interaction contrast ratio.

RESULTS

Of 2971 included individuals, 36% received oxaliplatin, 29.5% were CCOP-affiliated, and 7.6% were AA. On multivariate analysis, early diffusion of oxaliplatin was not found to be associated with race or CCOP participation. The probability of receiving oxaliplatin for AAs participating in a CCOP (0.46) was nearly double that of AAs who were not participating in a CCOP (0.25; P <.05). For white individuals, the probabilities of receiving oxaliplatin did not differ by CCOP participation. For oxaliplatin receipt, the joint effects assessment suggested a greater benefit of CCOP participation among AAs (interaction contrast ratio, 1.7).

CONCLUSIONS

Among older patients with stage III CC, there is a differential impact of race on oxaliplatin receipt depending on CCOP participation. AAs treated by CCOPs were more likely to receive oxaliplatin than AAs treated elsewhere. Provider-based research networks may facilitate early access to innovative treatment for AAs with stage III CC.

Socioeconomic and racial disparities in the selection of chest wall boost radiation therapy in californian women after mastectomy

To better elucidate the socioeconomic and racial differences in women who received postmastectomy radiation therapy with or without a chest wall boost, the records from 4747 women included in the California Cancer Registry were reviewed. Poor and Hispanic women were more likely to receive a chest wall boost than were more affluent and non-Hispanic women.

INTRODUCTION

Healthcare disparities in breast cancer treatment have been well documented. We investigated the socioeconomic status (SES) and racial factors in women with locally advanced breast cancer from the California Cancer Registry who had received postmastectomy radiation therapy (PMRT) with or without a chest wall boost (CWB).

PATIENTS AND METHODS

The records of 4747 women with invasive breast cancer, diagnosed from 2005 to 2009, who had undergone PMRT, were reviewed and stratified by treatment with (n = 2686 [57%]) or without (n = 2061 [43%]) a CWB. Various patient demographic and biologic factors were analyzed using univariate and multivariate analysis.

RESULTS

Receipt of a CWB was associated with race/ethnicity (P < .001), SES (P < .001), tumor size (P = .038), tumor grade (P = .033), human epidermal growth factor 2 (HER2) status (P = .015), American Joint Committee on Cancer stage (P = .001), number of nodes examined (P = .001), and number of positive nodes (P = .037) on univariate analysis. After controlling for confounding factors, race/ethnicity and SES remained independently predictive of a CWB. Hispanic women were more likely to receive a CWB than Asian (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.60-0.90), black (HR, 0.63; 95% CI, 0.48-0.83), or white (HR, 0.81; 95% CI, 0.69-0.95) women. Also, women of low SES were more likely to receive a CWB than women of high SES (HR, 0.74; 95% CI, 0.64-0.86).

CONCLUSION

We found that poor and Hispanic women were more commonly treated with a CWB than were more affluent and non-Hispanic women with a similar cancer stage, cancer biology, and treatment paradigm.

Variations in Guideline-Concordant Breast Cancer Adjuvant Therapy in Rural Georgia

OBJECTIVE

To examine factors associated with guideline-concordant adjuvant therapy among breast cancer patients in a rural region of the United States and to present an advancement in quality-of-care assessment in the context of multiple treatments.

DATA SOURCES

Chart abstraction on initial therapy received by 868 women diagnosed with primary, invasive, early-stage breast cancer in a largely rural region of southwest Georgia.

STUDY DESIGN

Using multivariable logistic regression, we examined predictors of adjuvant chemo-, radiation, and hormonal therapy regimens defined as guideline-concordant according to the 2000 National Institutes of Health Consensus Development Conference Statement.

PRINCIPAL FINDINGS

Overall, 35.2 percent of women received guideline-concordant care for all three adjuvant therapies. Higher socioeconomic status was associated with receiving guideline-concordant care for all three adjuvant therapies jointly, and for chemotherapy. Compared with private insurance, having Medicaid was associated with guideline-concordant chemotherapy. Unmarried women were more likely to be nonconcordant for chemotherapy and radiation therapy. Increased age predicted nonconcordance for adjuvant therapies jointly, for chemotherapy, and for hormonal therapy.

CONCLUSIONS

A number of factors were independently associated with receiving guideline-concordant adjuvant therapy. Identifying and addressing factors that lead to nonconcordance may reduce disparities in treatment and survival.

"Trust in the Lord": religious and spiritual practices of African American breast cancer survivors

Few studies have examined the role of religion and spirituality among African American breast cancer patients. This study explored how African American women cope with breast cancer through religious and spiritual practices. Forty-seven African American women who had completed treatment for breast cancer participated in in-depth interviews about their experiences. The majority of the women mentioned using both individual and communal religious and spiritual practices to cope with their breast cancer diagnosis and treatment. The main themes that emerged in terms of the types of religious and spiritual practices included: (1) attendance at religious services, (2) comfort through prayers of others, and (3) encouragement through reading Biblical scriptures. These practices helped women "trust in the Lord" throughout the many challenges of cancer from diagnosis through survivorship. Although this study is exploratory, the findings illustrate how African American women with breast cancer use religious and spiritual practices to cope with their diagnosis and treatment. For clinicians, the findings provides an understanding of spiritual and religious needs in diverse populations and the importance of referring patients onto spiritual and religious resources and support.

Aberrant allele-switch imprinting of a novel IGF1R intragenic antisense non-coding RNA in breast cancers

The insulin-like growth factor type I receptor (IGF1R) is frequently dysregulated in breast cancers, yet the molecular mechanisms are unknown. A novel intragenic long non-coding RNA (lncRNA) IRAIN within the IGF1R locus has been recently identified in haematopoietic malignancies using RNA-guided chromatin conformation capture (R3C). In breast cancer tissues, we found that IRAIN lncRNA was transcribed from an intronic promoter in an antisense direction as compared to the IGF1R coding mRNA. Unlike the IGF1R coding RNA, this non-coding RNA was imprinted, with monoallelic expression from the paternal allele. In breast cancer tissues that were informative for single nucleotide polymorphism (SNP) rs8034564, there was an imbalanced expression of the two parental alleles, where the 'G' genotype was favorably imprinted over the 'A' genotype. In breast cancer patients, IRAIN was aberrantly imprinted in both tumours and peripheral blood leucocytes, exhibiting a pattern of allele-switch: the allele expressed in normal tissues was inactivated and the normally imprinted allele was expressed. Epigenetic analysis revealed that there was extensive DNA demethylation of CpG islands in the gene promoter. These data identify IRAIN lncRNA as a novel imprinted gene that is aberrantly regulated in breast cancer.

Mobile Mammography, Race, and Insurance: Use Trends Over a Decade at a Comprehensive Urban Cancer Center

PURPOSE

To assess the use of a mobile mammography unit (MMU) as it relates to race and insurance status in the largest county in Kentucky.

METHODS

We retrospectively reviewed 48,324 screening mammograms of 21,857 patients conducted over a 10-year period. Descriptive statistics for patient age, race, and insurance status were computed by entire cohort and within subsets of cohorts. This analysis was limited to trends in use by race and insurance status. To study the patterns of frequency distributions, indiscrete variables were performed using the Pearson χ(2) test. For continuous variable range, a 95% CI of mean was estimated. Comparisons with a P value less than .05 were considered statistically significant.

RESULTS

Self-reported blacks constituted significant use of the MMU (29% v census data demographic reports of 19%). Race significantly correlated with likelihood to screen ≥ three times, with blacks (30.5%) more likely, and whites (27.8%) and Hispanics (20.2%) less likely (P < .001). Insurance status also affected frequency of use (P < .001).

CONCLUSION

In this data set, blacks were more likely to repeat use of the MMU. Although preliminary, these data suggest outreach efforts of mobile mammography are appropriately reaching certain targeted populations.

Symptom monitoring, alleviation, and self-care among Mexican Americans during cancer treatment

Monitoring the occurrence and severity of symptoms among Mexican American adults undergoing cancer treatments, along with their self-care to alleviate symptoms, are understudied; the current study aimed to fill this gap in the literature. A total of 67 Mexican Americans receiving outpatient oncology treatments in the southwestern United States participated. Instruments included a patient-report checklist, the Therapy-Related Symptom Checklist (TRSC), the Symptom Alleviation: Self-Care Methods tool, and a demographic and health information form. At least 40% of participants reported the occurrence of 12 symptoms: hair loss, feeling sluggish, nausea, taste change, loss of appetite, depression, difficulty sleeping, weight loss, difficulty concentrating, constipation, skin changes, and numb fingers and toes. More than a third also reported pain, vomiting, decreased interest in sexual activity, cough, and sore throat. The helpful self-care strategies reported included diet and nutrition changes; lifestyle changes; and mind, body control, and spiritual activities. Patient report of symptoms during cancer treatments was facilitated by the use of the TRSC. Patients use symptom alleviation strategies to help relieve symptoms during their cancer treatment. The ability to perform appropriate, effective self-care methods to alleviate the symptoms may influence adherence to the treatment regimen.

Patients' cultural beliefs in patient-provider communication with African American women and Latinas diagnosed with breast cancer

African American women and Latinas often experience suboptimal breast cancer care. This article describes providers' self-rated skills in communication practices when working with African American women and Latinas diagnosed with breast cancer. Current literature reveals how providers are lacking in the ability to communicate with these patients and often fail to incorporate cultural beliefs into breast cancer care and treatment. This poor communication and failure to acknowledge cultural beliefs can be correlated with poor patient outcomes. In a study of providers' perceptions of how they address the cultural beliefs of African American women and Latinas diagnosed with breast cancer, interviews with physicians, inpatient nurses, cancer clinic nurses, mammography technicians, and ultrasound technicians showed that they used the same approach for all patients, regardless of race, ethnicity, or culture but felt they practiced culturally sensitive care. Increased and improved cultural competence education is recommended for providers at all levels as a first step toward increasing culturally competent communications.

Psychosocial interventions addressing the needs of Black women diagnosed with breast cancer: a review of the current landscape

BACKGROUND

Poorer health outcomes and lower survival rates have been well documented among African American/Black (Black) women diagnosed with breast cancer. Black women are 41% more likely to die from breast cancer than White women despite a lower incidence rate. Apart from pharmacotherapy, psychosocial interventions are recommended by the Institute of Medicine as standard medical care for breast cancer patients at all phases of treatment. The current review is the first attempt to systematically evaluate the literature on the influence of psychosocial interventions for Black women diagnosed with breast cancer.

METHODS

This systematic review aimed to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comprehensive computerized literature search of CINAHL, PsycINFO, PubMed, and Web of Science was conducted to obtain relevant studies.

RESULTS

Interventions demonstrated improved mood, decreased distress, increased ability to cope with intrusive thoughts and cancer-related stress, personal growth, and improved social well-being. However, aspects unique to this population require additional scientific inquiry. Over 80% of empirical interventions focused on Black women diagnosed with breast cancer have been concentrated on the posttreatment phase. There is a paucity of work at the time of diagnosis and during treatment.

CONCLUSIONS

To address gaps in the scientific literature, more work is needed to better understand how psychosocial interventions can improve the health trajectory for Black women diagnosed with breast cancer particularly in the areas of seeking help and support, identifying culturally acceptable methods for engaging support networks, and identifying best practices for enhancing coping skills.

The dragon and the snake: health practices among Chinese in the UK from an inter-disciplinary perspective

OBJECTIVES

This paper explores how ethnicity has been represented in research on the health practices of Chinese populations in the UK and suggests ways in which such research might be enriched by adopting an interdisciplinary approach.

DESIGN

A systematic literature review of studies was conducted on research with 'Chinese' in the UK.

RESULTS

The review highlighted that research with Chinese populations is frequently grounded in assumptions about the homogeneity of Chinese ethnic and cultural identities, and health practices, which undermines the generalizability of findings and conclusions.

CONCLUSIONS

There was a lack of clarity surrounding the term 'Chinese' as an ethnic and national label that can lead to racialised constructions of ethnicity. An interdisciplinary approach is a valuable tool for enriching understandings of culturally-specific accounts of health and illness, and to address ways in which Chinese populations negotiate different health care systems and models of health.

Breast cancer and coping among women of color: a systematic review of the literature

Breast cancer is the most commonly diagnosed form of cancer for women regardless of race/ethnicity. Women of color are diagnosed at later stages and experience greater mortality than their White counterparts. However, there has been comparatively little research on coping with breast among racial/ethnic minorities at time of diagnosis, during treatment, or in the course of survivorship. This is despite the fact that research has repeatedly shown that distress can impact disease progression and survival. The questions asked of this systematic literature review include: (1) What is known about coping with breast cancer among major racial/ethnic groups? (2) What are the strengths and gaps in research to date? Over 120 peer-reviewed published studies (1980-2012) were reviewed. A total of 33 met criteria for inclusion including 15 quantitative, 17 qualitative, and 1 mixed methods study. The majority of studies were small sample cross-sectional studies. Only five studies were longitudinal, and two randomized-controlled intervention trials sought to improve coping among survivors. The most common topic in both quantitative and qualitative studies was spirituality and coping among African American breast cancer patients. Thirteen studies included Latinas only or in combination with other groups. Only one quantitative and one qualitative study solely addressed the Asian American population exploring coping and adjustment. In the course of this systematic literature review, we elucidate what is known about coping with breast cancer among racial/ethnic minority women and identify priorities for future research.

Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study

Time delay after an abnormal screening mammogram may have a critical impact on tumor size, stage at diagnosis, treatment, prognosis, and survival of subsequent breast cancer. This study was undertaken to evaluate disparities between Latina and non-Hispanic white (NHW) women in time to definitive diagnosis of breast cancer after an abnormal screening mammogram, as well as factors contributing to such disparities. As part of the activities of the National Cancer Institute (NCI)-funded Redes En Acción research network, clinical records of 186 Latinas and 74 NHWs who received abnormal screening mammogram results were reviewed to determine the time to obtain a definitive diagnosis. Data was obtained from participating clinics in six U.S. cities and included demographics, clinical history, and mammogram characteristics. Kaplan-Meier estimates and Cox proportional hazards models were used to test differences in median time to definitive diagnosis by ethnicity after adjusting for clinic site, demographics, and clinical characteristics. Time-to-event analysis showed that Latinas took 2.2 times longer to reach 50% definitively diagnosed with breast cancer relative to NHWs, and three times longer to reach 80% diagnosed (p=0.001). Latinas' median time to definitive diagnosis was 60 days compared to 27 for NHWs, a 59% gap in diagnosis rates (adjusted Hazard Ratio [aHR] = 1.59, 95% CI = 1.09, 2.31; p=0.015). BI-RADS-4/5 women's diagnosis rate was more than twice that of BI-RADS-3 (aHR = 2.11, 95% CI = 1.18, 3.78; p=0.011). Disparities in time between receipt of abnormal screening result and definitive diagnosis adversely affect Latinas compared to NHWs, and remain significant after adjusting for demographic and clinical variables. With cancer now the leading cause of mortality among Latinos, a greater need exists for ethnically and culturally appropriate interventions like patient navigation to facilitate Latinas' successful entry into, and progression through, the cancer care system.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Breast cancer interventions serving US-based Latinas: current approaches and directions

Despite efforts to reduce morbidity and mortality in breast cancer, Latinas continue to have lower 5-year survival rates than their non-Latina white counterparts. All along the cancer continuum from screening to follow-up of abnormal screening to diagnosis and treatment to survivorship, Latinas fare poorer than non-Latina whites. To close this gap, a number of research projects across the continuum have attempted to improve breast cancer outcomes. In this review, we examine studies that have been carried out in breast cancer along the cancer continuum. We focus not only on randomized, controlled trials, but also on quasi-experimental, and pre- and post-test studies that provided interventions for positive breast cancer outcomes. We examine not only the intervention outcomes, but also the type of intervention targets and type of intervention implementation. In future breast cancer research among Latinas, more emphasis should be placed on the steps in detection and treatment that occur after screening.

Use of Web-based training for quality improvement between a field immunohistochemistry laboratory in Nigeria and its United States-based partner institution

The importance of hormone receptor status in assigning treatment and the potential use of human epidermal growth factor receptor 2 (HER2)-targeted therapy have made it beneficial for laboratories to improve detection techniques. Because interlaboratory variability in immunohistochemistry (IHC) tests may also affect studies of breast cancer subtypes in different countries, we undertook a Web-based quality improvement training and a comparative study of accuracy of immunohistochemical tests of breast cancer biomarkers between a well-established laboratory in the United States (University of Chicago) and a field laboratory in Ibadan, Nigeria. Two hundred and thirty-two breast tumor blocks were evaluated for estrogen receptors (ERs), progesterone receptors (PRs), and HER2 status at both laboratories using tissue microarray technique. Initially, concordance analysis revealed κ scores of 0.42 (moderate agreement) for ER, 0.41 (moderate agreement) for PR, and 0.39 (fair agreement) for HER2 between the 2 laboratories. Antigen retrieval techniques and scoring methods were identified as important reasons for discrepancy. Web-based conferences using Web conferencing tools such as Skype and WebEx were then held periodically to discuss IHC staining protocols and standard scoring systems and to resolve discrepant cases. After quality assurance and training, the agreement improved to 0.64 (substantial agreement) for ER, 0.60 (moderate agreement) for PR, and 0.75 (substantial agreement) for HER2. We found Web-based conferences and digital microscopy useful and cost-effective tools for quality assurance of IHC, consultation, and collaboration between distant laboratories. Quality improvement exercises in testing of tumor biomarkers will reduce misclassification in epidemiologic studies of breast cancer subtypes and provide much needed capacity building in resource-poor countries.

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.

Disparities in breast cancer treatment and outcomes: biological, social, and health system determinants and opportunities for research

Racial disparities in breast cancer mortality have been widely documented for several decades and persist despite advances in receipt of mammography across racial groups. This persistence leads to questions about the roles of biological, social, and health system determinants of poor outcomes. Cancer outcomes are a function not only of innate biological factors but also of modifiable characteristics of individual behavior and decision making as well as characteristics of patient-health system interaction and the health system itself. Attempts to explain persistent racial disparities have mostly been limited to discussion of differences in insurance coverage, socioeconomic status, tumor stage at diagnosis, comorbidity, and molecular subtype of the tumor. This article summarizes existing literature exploring reasons for racial disparities in breast cancer mortality, with an emphasis on treatment disparities and opportunities for future research. Because breast cancer care requires a high degree of multidisciplinary team collaboration, ensuring that guideline recommended treatment (such as endocrine therapy for hormone receptor positive patients) is received by all racial/ethnic groups is critical and requires coordination across multiple providers and health care settings. Recognition that variation in cancer care quality may be correlated with race (and socioeconomic and health system factors) may assist policy makers in identifying strategies to more equally distribute clinical expertise and health infrastructure across multiple user populations.

Racial disparities in clinical presentation, surgical treatment and in-hospital outcomes of women with breast cancer: analysis of nationwide inpatient sample database

To examine racial/ethnic disparities in stage of disease and comorbidity (pre-treatment), surgical treatment allocation (breast-conserving surgery versus mastectomy), and in-hospital outcomes after surgery (post-treatment) among women with breast cancer. Nationwide inpatient sample is a nationwide clinical and administrative database compiled from 44 states representing 95 % of all hospital discharges in the Unites States. Discharges of adult women who underwent surgery for breast cancer from 2005 to 2009 were identified. Information about patients and hospitals characteristics was obtained. Multivariate logistic regression analyses were used to examine the risk adjusted association between race/ethnicity and the aforementioned outcomes (pre-treatment, treatment, and post-treatment). We identified 75,100 patient discharges. Compared to Whites, African-Americans (1.17, p < 0.001), and Hispanics (1.20, p < 0.001) were more likely to present with regional or metastatic disease. Similarly, African-American (1.58, p < 0.001) and Hispanics (1.11, p 0.003) were more likely to have comorbidity. Compared to Whites, African-Americans (0.71, p < 0.001), and Hispanics (0.77, p < 0.001) were less likely to receive mastectomy. Compared to Whites, African-Americans were more likely to develop post-operative complications (1.35, p < 0.001) and in-hospital mortality (1.87, p 0.13). Other racial groups showed no statistically significant difference compared to Whites. After controlling for potential confounders, we found racial/ethnic disparities in stage, comorbidity, surgical treatment allocation, and in-hospital outcomes among women with breast cancer. Future researches should examine the underlying factors of these disparities.

Expression and sub-cellular localization of an epigenetic regulator, co-activator arginine methyltransferase 1 (CARM1), is associated with specific breast cancer subtypes and ethnicity

BACKGROUND

Co-Activator Arginine Methyltransferase 1(CARM1) is an Estrogen Receptor (ER) cofactor that remodels chromatin for gene regulation via methylation of Histone3. We investigated CARM1 levels and localization across breast cancer tumors in a cohort of patients of either European or African ancestry.

METHODS

We analyzed CARM1 levels using tissue microarrays with over 800 histological samples from 549 female cancer patients from the US and Nigeria, Africa. We assessed associations between CARM1 expression localized to the nucleus and cytoplasm for 11 distinct variables, including; ER status, Progesterone Receptor status, molecular subtypes, ethnicity, HER2+ status, other clinical variables and survival.

RESULTS

We found that levels of cytoplasmic CARM1 are distinct among tumor sub-types and increased levels are associated with ER-negative (ER-) status. Higher nuclear CARM1 levels are associated with HER2 receptor status. EGFR expression also correlates with localization of CARM1 into the cytoplasm. This suggests there are distinct functions of CARM1 among molecular tumor types. Our data reveals a basal-like subtype association with CARM1, possibly due to expression of Epidermal Growth Factor Receptor (EGFR). Lastly, increased cytoplasmic CARM1, relative to nuclear levels, appear to be associated with self-identified African ethnicity and this result is being further investigated using quantified genetic ancestry measures.

CONCLUSIONS

Although it is known to be an ER cofactor in breast cancer, CARM1 expression levels are independent of ER. CARM1 has distinct functions among molecular subtypes, as is indicative of its sub-cellular localization and it may function in subtype etiology. These sub-cellular localization patterns, indicate a novel role beyond its ER cofactor function in breast cancer. Differential localization among ethnic groups may be due to ancestry-specific polymorphisms which alter the gene product.