Breast cancer incidence in young women by estrogen receptor status and race

Mammography: review of the controversy, health disparities, and impact on young african american women

BACKGROUND

Ongoing debate about mammography screening for women in their 40s has brought awareness to the opportunities and challenges for achieving optimal breast health in young African American women and in battling health inequities that place them at greater risk for mortality from breast cancer. Despite the screening controversy, a need exists to understand the complex issues related to mammography knowledge, attitudes, and behaviors of young minority women, while empowering them to take an active role in their breast health care.

OBJECTIVES

The purpose of this article is to describe the complicated issues related to screening in young African American women within the context of the uncertainty about the evidence surrounding screening practices.

METHODS

Literature was reviewed to garner a comprehensive update of the mammography screening controversy and its impact on mammography practices.

FINDINGS

Nurses should be aware of the mammography screening controversy and breast cancer risk assessment and how they affect young women's participation in mammography screening. Mammography screening should be a shared decision between the patient and healthcare provider. A better understanding of breast health and its effect on young minority women is needed. Nurses have a prominent role to advocate for, empower, and educate patients as they face the task of deciding whether to begin or continue mammography in their 40s.

Dietary intake of folate, B-vitamins and methionine and breast cancer risk among Hispanic and non-Hispanic white women

Background

Low dietary folate intake is associated with several neoplasias, but reports are inconsistent for breast cancer. Additionally, the association of folate with breast cancer estrogen receptor (ER) status is not well established.

Objective

To determine if dietary intakes of folate, B-vitamins (B₂, B₆, B₁₂) and methionine are associated with breast cancer risk and ER status in Hispanic, and non-Hispanic White women in the southwestern US.

Materials and Methods

Primary breast cancer cases (n = 2,325) in the 4-Corners region (Arizona, Colorado, New Mexico and Utah), diagnosed between October 1999 and May 2004, were identified through state cancer registries. Controls (n = 2,525) were frequency-matched by ethnicity and age (±5 years). Dietary intake, physical activity and other exposures were assessed using in-person interviews. Risk was assessed through multivariable and multinomial logistic regression with adjustment for relevant covariates.

Result

While there was no overall association with breast cancer, the highest quartile of folate intake was marginally inversely associated with ER− breast cancer (Odds Ratio (OR) = 0.50, 95%CI 0.25–1.00, p for trend = 0.07). Vitamin B₁₂ intake was inversely associated with breast cancer also (OR = 0.73, 95%CI 0.53–1.00, p for trend = 0.06), particularly for the highest quartile of ER+ breast cancer (OR = 0.67, 95%CI 0.46–0.99, p for trend = 0.06), among NHW women (OR = 0.49, 95%CI 0.29–0.81, p for trend = 0.01) and invasive breast cancer (OR = 0.63; 95%CI: 0.42, 0.93, P_trend = 0.01). Methionine intake was also inversely associated with ER+ breast cancer (OR for 4^th quartile = 0.83, 95%CI 0.66–1.03, p for trend = 0.04), primarily among Hispanic women (OR = 0.71, 95%CI 0.47–1.06, and P for trend = 0.02).

Conclusion

Higher intake of folate is marginally associated with a lower risk for ER− breast cancer, and higher intakes of vitamin B-12 and methionine are marginally associated with a lower risk of ER+ breast cancer.

Fruit and vegetable intake and risk of breast cancer by hormone receptor status

BACKGROUND

Estrogen receptor-negative (ER(-)) breast cancer has few known or modifiable risk factors. Because ER(-) tumors account for only 15% to 20% of breast cancers, large pooled analyses are necessary to evaluate precisely the suspected inverse association between fruit and vegetable intake and risk of ER(-) breast cancer.

METHODS

Among 993 466 women followed for 11 to 20 years in 20 cohort studies, we documented 19 869 estrogen receptor positive (ER(+)) and 4821 ER(-) breast cancers. We calculated study-specific multivariable relative risks (RRs) and 95% confidence intervals (CIs) using Cox proportional hazards regression analyses and then combined them using a random-effects model. All statistical tests were two-sided.

RESULTS

Total fruit and vegetable intake was statistically significantly inversely associated with risk of ER(-) breast cancer but not with risk of breast cancer overall or of ER(+) tumors. The inverse association for ER(-) tumors was observed primarily for vegetable consumption. The pooled relative risks comparing the highest vs lowest quintile of total vegetable consumption were 0.82 (95% CI = 0.74 to 0.90) for ER(-) breast cancer and 1.04 (95% CI = 0.97 to 1.11) for ER(+) breast cancer (P (common-effects) by ER status < .001). Total fruit consumption was non-statistically significantly associated with risk of ER(-) breast cancer (pooled multivariable RR comparing the highest vs lowest quintile = 0.94, 95% CI = 0.85 to 1.04).

CONCLUSIONS

We observed no association between total fruit and vegetable intake and risk of overall breast cancer. However, vegetable consumption was inversely associated with risk of ER(-) breast cancer in our large pooled analyses.

Socioeconomic disparities and breast cancer hormone receptor status

PURPOSE

Recent research, although inconsistent, indicates that socioeconomic status (SES) may be associated with hormone receptor (HR) status. This study aims to examine the association between SES and breast cancer HR status within and across racial/ethnic groups stratified by age at diagnosis and tumor stage.

METHODS

The study subjects were 184,602 women with incident breast cancer diagnosed during 2004-2007 and identified from the National Cancer Institute's Surveillance, Epidemiology and End Results program. Log-binomial regression assessed the risk of having breast tumors that were (1) HR-negative versus HR-positive and (2) HR-unknown versus HR-known between women who, at the time of diagnosis, were residing in high or medium poverty areas compared to low poverty areas.

RESULTS

High poverty areas tended to have a greater prevalence of HR-negative tumors compared to more affluent areas. Although not always significant, this was observed among non-Hispanic white and Hispanic women regardless of age-tumor stage category, and only among young, non-Hispanic black women and non-Hispanic Asian/Pacific Islander women with regional and distant stage. High poverty areas also tended to have a greater prevalence of HR-unknown tumors compared to more affluent areas. Furthermore, significant trends between HR status and poverty level varied by race/ethnicity, age, and tumor stage.

CONCLUSIONS

Poverty may be related to breast cancer negative and unknown HR status. These findings suggest the effects of non-genetic factors on biochemical features of breast cancer, as well as imply a clinical importance to improve HR measurement or recording for low socioeconomic breast cancer patients.

Synchronous breast invasive ductal carcinoma and endometrial endometrioid adenocarcinoma: case report

Diagnosis of synchronous primary cancers in one patient is a relatively rare event. The well-known synchronous primary cancers of women are combined ovarian and endometrial cancers, especially when both are the endometrioid cell type. Although breast cancer and endometrial cancer are two common female malignancies, they often occur during the postmenopausal period. Therefore, the possibility of concomitant breast cancer and endometrial cancer in a younger woman (premenopausal) is often neglected. The reported case is an example of this situation. A 37-year-old woman was diagnosed with synchronous breast invasive ductal carcinoma and endometrial endometrioid adenocarcinoma. Since this condition is rarely reported, the correlated risk factors are worthy of our attention and the strategy for prevention is highlighted.

Personal history of breast cancer as a significant risk factor for endometrial serous carcinoma in women aged 55 years old or younger

A comparative study between endometrial serous carcinoma (ESC) and endometrial endometrioid carcinoma (EEC) was performed to determine whether a personal history of breast cancer is a risk factor for ESC in women aged ≤ 55 yr. Study subjects consisted of 348 women who were diagnosed with ESC and 830 comparison subjects who had EEC. Variables studied included age at diagnosis, a history of breast cancer, tamoxifen therapy, hormonal replacement therapy and smoking history. Overall, 19.4% of women with ESC had a history of breast cancer, which was significantly higher than that of 3% in comparison subjects. Among the study subjects, the incidence of a prior breast cancer was significantly higher in patients who were 55 yr of age or younger (41.5%) than those who were older than 55 yr (16%). The statistical significance of both of the aforementioned comparisons was independent of tamoxifen usage on multivariate analyses. The mean time interval between prior breast cancer and endometrial cancer was 92.5 mo (range 7-240 mo) in the study group and 79 mo (range 7-192 mo) in the comparison group. For the whole cohort and individual subgroups (ESC, EEC, ≤ 55 yr and >55 yr), a personal history of breast cancer did not adversely affect the patient outcomes, which was largely dependent on standard clinicopathologic parameters such as International Federation of Gynecology and Obstetrics stage, as has previously been demonstrated. These findings suggest that a personal history of breast cancer may be a significant risk factor for the development of ESC in women aged ≤ 55 yr. Further studies are needed to clarify the relationship between these two cancers in this age group and whether this increased risk is reflective of a genetic predisposition.

Activity of ixabepilone in oestrogen receptor-negative and oestrogen receptor-progesterone receptor-human epidermal growth factor receptor 2-negative metastatic breast cancer

Oestrogen receptor (ER)-negative breast cancer, including oestrogen receptor-, progesterone receptor- and human epidermal growth factor receptor 2-negative (ER/PR/HER2-negative) breast cancer, is more aggressive than ER-positive disease. A major limitation in the treatment of ER-negative disease subtypes is the inherent insensitivity to hormonal agents (tamoxifen, aromatase inhibitors) that are widely used in the treatment of breast cancer. Thus, therapeutic options for poor prognosis patients with ER-negative breast cancer are limited to a handful of chemotherapeutic agents, and new agents are needed to improve the treatment of this disease. Ixabepilone, a novel epothilone B analogue with low susceptibility to cellular mechanisms that confer resistance to taxanes and other chemotherapeutic agents, has demonstrated potent preclinical antitumour activity in multiple models, including those with primary or acquired drug resistance. This review summarises the results of a prospective subset analysis from a phase III clinical trial evaluating ixabepilone for the treatment of metastatic breast cancer (MBC), in which efficacy and safety were evaluated in patients with ER-negative and ER/PR/HER2-negative disease.

Race/ethnicity and breast cancer estrogen receptor status: impact of class, missing data, and modeling assumptions

OBJECTIVE

To test whether reported associations between race/ethnicity and breast cancer estrogen receptor (ER) status are inflated due to missing ER data, lack of socioeconomic data, and use of the odds ratio (OR) rather than the prevalence ratio (PR).

METHODS

We geocoded and added census tract socioeconomic data to all cases of primary invasive breast cancer (n = 42,420) among women diagnosed between 1998 and 2002 in two California cancer registries (San Francisco Bay Area; Los Angeles County) and analyzed the data using log binomial regression.

RESULTS

Adjusting for socioeconomic position and tumor characteristics, in models using the imputed data, reduced the PR for the black versus white excess risk of being ER--from 1.76 (95% CI: 1.66, 1.86; adjusted for age and catchment area) to 1.47 (95% CI: 1.38, 1.56). The latter parameter estimate was 16% greater (i.e., 1.56) in models excluding women with missing ER data, and was 43% greater when estimated using the OR (i.e., 1.82).

CONCLUSION(S)

Studies on race/ethnicity and ER status that fail to account for missing data and socioeconomic data and report the OR are likely to yield inflated estimates of racial/ethnic disparities in ER status.

Estrogen and progesterone receptor status in breast cancer: Effect of oral contraceptive pills and hormone replacement therapy

BACKGROUND

Higher incidence of hormone receptor positive breast cancer (BC) in White women compared to Blacks and Asians is attributed to different inherent biology. Many of our patients have estrogen receptor (ER) and progesterone receptor (PR) negative tumors. We tried to explore if this is related to low frequency of oral contraceptive pills (OCP) and hormone replacement therapy (HRT) intake.

SETTING

Breast Unit, Department of Surgical Oncology, Tertiary Care Hospital, India.

METHODS

Records of female BC patients classified as 'Users' of OCP/HRT for minimum of 1 year and age, stage, histopathology matched 'Non-users' were reviewed retrospectively from January 1990 to October 2006.

RESULTS

Analysis of 150 evaluable 'Users' (58/122 premenopausal, 92/178 postmenopausal) and 150 matched 'Non-users' revealed 128 (42.67%) patients had ER and PR-negative, 157 (52.33%) ER and PR-positive, 12(4%) ER-positive/PR-negative, 3(1%) ER-negative/PR-positive tumor. Significantly more ER-positive tumor was found in both premenopausal [62.07% versus 39.06%, p=0.0184, odd's ratio (OR) 2.5527 and 95% confidence interval (CI) 1.2297-5.2993] and postmenopausal (63.04% versus 40.7%, p=0.0046, OR 2.4857 and 95% CI 1.3593-4.5455) 'Users' compared to 'Non-users', respectively. Grade III tumors were significantly less in premenopausal (p=0.0041) and postmenopausal (p=0.0012) 'Users'.

CONCLUSIONS

These observations suggest that a low incidence of hormone receptor positivity in our patients could be partly due to low prevalence of OCP/HRT intake.

Hormone-related risk factors for breast cancer in women under age 50 years by estrogen and progesterone receptor status: results from a case-control and a case-case comparison

INTRODUCTION

It has been suggested that hormonal risk factors act predominantly on estrogen receptor and progesterone receptor (ER/PR)-positive breast cancers. However, the data have been inconsistent, especially in younger women.

METHODS

We evaluated the impact of age at menarche, pregnancy history, duration of breastfeeding, body mass index, combined oral contraceptive use, and alcohol consumption on breast cancer risk by ER/PR status in 1,725 population-based case patients and 440 control subjects aged 20 to 49 years identified within neighborhoods of case patients. We used multivariable unconditional logistic regression methods to conduct case-control comparisons overall as well as by ER/PR status of the cases, and to compare ER+PR+ with ER-PR- case patients.

RESULTS

The number of full-term pregnancies was inversely associated with the risk of ER+PR+ breast cancer (ptrend = 0.005), whereas recent average alcohol consumption was associated with an increased risk of ER+PR+ breast cancer (ptrend = 0.03). Neither of these two factors was associated with the risk of ER- PR- breast cancer. Late age at menarche and a longer duration of breastfeeding were both associated with decreased breast cancer risk, irrespective of receptor status (all ptrend< or = 0.03).

CONCLUSION

Our results suggest that the number of full-term pregnancies and recent alcohol consumption affect breast cancer risk in younger women predominantly through estrogen and progesterone mediated by their respective receptors. Late age at menarche and breastfeeding may act through different hormonal mechanisms.

Racial Inequities in the Timing of Breast Cancer Detection, Diagnosis, and Initiation of Treatment

BACKGROUND

Recent studies suggest differences in quality and timeliness of care received may be major contributing sources to the racial disparity in breast cancer detection and related outcomes.

METHODS

Female patients with breast cancer diagnosed during 1985-1993 (n=400) and followed through June 20, 2001, were included in this retrospective cohort study. Three white patients were selected randomly and matched to each black patient by year of diagnosis. Method and timing of diagnosis and timing of treatment were abstracted from medical records. Initial staging and subsequent breast cancer recurrence and vital status were obtained from the Hospital and Connecticut State Tumor Registry.

RESULTS

Black women were more likely than white women to be diagnosed after a patient-noted abnormality. Black women were less likely than white women to have completed a diagnostic evaluation within 30 days after a patient-noted abnormality (P <0.01) or after having an abnormality noted on screening mammogram (P=0.0001) and were less likely to have initiated treatment within 30 days of diagnosis (P=0.0001). Women diagnosed after a patient-noted abnormality were more likely to have subsequent breast cancer recurrence and/or death due to breast cancer compared with women diagnosed after a screening mammogram (56% versus 24%, respectively, P <0.05).

CONCLUSIONS

Racial differences were identified at each step in the evaluation and treatment clinical pathway, including method of detection, timing from first symptoms of cancer to pathologic diagnosis, and timing from diagnosis to initiation of treatment. The findings highlight the need to provide equal opportunity for timely medical care and treatment.

A comparison of five immunohistochemical biomarkers and HER-2/neu gene amplification by fluorescence in situ hybridization in white and Korean patients with early-onset breast carcinoma

BACKGROUND

The objective of this article was to compare five tumor markers between white women in the U.S. and native Korean women with early-onset breast carcinoma.

METHODS

Sixty Korean women who were diagnosed with breast carcinoma at age 45 years or younger and 60 white women with breast carcinoma who were matched by age were selected for this study. The median age of both groups was 37 years. Paraffin embedded blocks of the primary tumor were processed for immunohistochemical staining of estrogen receptor (ER), progesterone receptor (PR), p53, cyclin D1, and HER-2/neu.

RESULTS

The proportion of tumors that stained positive for ER, PR, p53, and cyclin D1 in the Korean women were 47.5%, 42.4%, 28.8%, and 40.9%, respectively; in the white women, the proportions were 43.9%, 52.6%, 21.1%, and 59.1%, respectively. The differences between the white patients and the Korean patients were not statistically significant with respect to any of those variables. A significant difference was found in the expression of HER-2/neu. Specifically, positive HER-2/neu status was observed in 47.5% of Korean women, compared with overexpression in only 15.8% of white women (P < 0.001). Fluorescence in situ hybridization analysis for HER-2/neu gene amplification on all HER-2/neu positive samples that scored 2 + and 3 + demonstrated a significant difference (P = 0.007) in gene amplification between the two populations. Differences in HER-2/neu positivity were observed for the entire cohort as well as among the subsets of patients with negative and positive lymph node status. No association was found between immunoreactivity for the five markers and axillary lymph node metastasis.

CONCLUSIONS

The findings of high positivity of HER-2/neu expression and gene amplification in Korean women with early-onset breast carcinoma may have potential implications for local and systemic management of breast carcinoma, especially anti-HER-2/neu therapy for patients with hormone receptor negativity. Further research will be needed to identify biologic and genetic factors and their effects on the survival between different racial groups.

Racial differences in mammographic breast density

BACKGROUND

African American women have a lower incidence but a higher mortality from breast carcinoma than Caucasians. A proposed explanation for this discrepancy is the decreased efficacy of screening among African American women. Increased breast density in African American women may result in decreased sensitivity of mammography. The purpose of this article is to determine whether there is a difference in mammographic breast density between African American and Caucasian women.

METHODS

A series of 769 women were recruited from 5 sites. Mammograms were reviewed centrally by seven reviewers using Breast Imaging Reporting and Data System categories converted to numeric values. The mean mammographic densities for Caucasian, African American, and Latina patients were compared using a two-way analysis of covariance. The mean values for each race were estimated adjusting for the reader as well as for each patient's age and body mass index (BMI).

RESULTS

African American women had the lowest mean breast density. The reported density in this group was 2.43, compared with 2.69 among Caucasians and 2.65 among Latina patients. After adjusting for age and BMI as well as the reader, there was still an independent racial effect on breast density (P = 0.0050).

CONCLUSIONS

Mammographic breast density was lower in African American women than in Caucasians and Latinas. This discrepancy may be an intrinsic racial difference due to undetermined causes. Factors, such as the growth rate of tumors and the incidence of calcifications, must be studied to confirm that other forces do not have a negative impact on the efficacy of screening mammograms in African American women.

Race, socioeconomic status, and breast carcinoma in the U.S: what have we learned from clinical studies

BACKGROUND

Whether African-American women have biologically more aggressive breast carcinoma compared with white women and whether race acts as a significant independent prognostic factor for survival have not been determined. Alternatively, race merely may be a surrogate for socioeconomic status (SES).

METHODS

A literature review was performed of clinical trials and retrospective studies in the U.S. that compared survival between white women and black women with breast carcinoma after adjustment for known prognostic factors (patient age, disease stage, lymph node status, and estrogen receptor status) to assess the impact of race and SES.

RESULTS

Single institutional and clinical studies suggest that, when black patients are treated appropriately and other prognostic variables are controlled, their survival is similar to the survival of white patients. Twelve retrospective studies and 1 analysis of a clinical trial included SES and race as variables for survival. Only three of those studies revealed race as a significant prognostic factor for survival after adjusting for SES.

CONCLUSIONS

SES replaces race as a predictor of worse outcome after women are diagnosed with breast carcinoma in many studies. However, black women present with more advanced disease that appear more aggressive biologically, and they present at a younger age compared with white women. Further research should be conducted concerning the precise elements of SES that account for the incidence of breast carcinoma, age at diagnosis, hormone receptor status, and survival to devise better strategies to improve outcome.

Breast cancer-race, ethnicity, and survival: a literature review

A review of the literature on breast cancer was conducted to identify gaps in knowledge as it relates breast cancer risk, race, and survival. The discussion has been divided into three broad categories: (1) breast cancer basics and the relationships between risks, race, and survival; (2) influence of race and socioeconomic status on breast cancer morbidity and mortality; and (3) relationship between age and mammography screening. All of the cited studies reveal evidence of a linkage between race and breast cancer survival, however, the effects of socioeconomic factors and race needs to be examined. Results suggest that African-American women and lower income women need to be targeted for early detection. Many of the analyses among younger women (20-39 years) reported that very little disease occurrence in young black women was associated with the socioeconomic factors studied. Conclusions from all studies indicate that more aggressive screening and public education programs directed toward younger black women is warranted. The gaps in knowledge identified included the lack of an explanation of early onset breast cancer with high penetrance as well as an explanation of African-American women's resistance to self-examination and mammography screening and other barriers to diagnostic treatment. Future studies should also examine the link between familial breast cancer and genetic mutations.

Hormone receptors in breast cancer: racial differences in distribution and survival

The purpose of this study was to describe hormone receptor status and analyze the effect of receptors on survival from breast cancer. Comparisons were made between African-American and Caucasian racial categories. Breast cancer data from 1990 through 1997 collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program were analyzed. Subjects were 993 Caucasian men, 12,303 African-American women, and 141,045 Caucasian women. The number of African-American men was too small to analyze separately (n = 93). In addition to analysis of estrogen and progesterone receptor status by sex and race, tumor and patient characteristics included age, stage at time of diagnosis, and tumor histology. The proportion of Caucasian men with hormone receptor positive tumors remained relatively high and stable for all ages. In women, the proportion of hormone receptor positive tumors increased with age, with African-American women having the highest proportion of hormone receptor negative tumors. Caucasian men had highest proportions of hormone receptor positive tumors in all histology and stage groups, while African-American women had lowest proportions of hormone receptor positive tumors in all stage and histologic categories. Survival for African-American women was significantly worse for each hormone receptor category. In multivariate analyses, race was a significant independent predictor of survival, but sex was not. Although reasons for differences in hormone receptor status by sex and race are unknown, several hypotheses are discussed with respect to differences in tumor histopathology and risk factors.

Dietary soy isoflavones and bone mineral density: results from the study of women's health across the nation

Isoflavones are naturally occurring selective estrogen receptor modulators, with potential bone protective effects. To study the relation between soy isoflavone intake and bone mineral density (BMD), the authors analyzed baseline data from the Study of Women's Health Across the Nation, a US community-based cohort study of women aged 42-52 years. Their 1996-1997 analysis included African-American (n = 497), Caucasian (n = 1,003), Chinese (n = 200), and Japanese (n = 227) participants. Genistein and daidzein intakes were highly correlated (r = 0.98); therefore, analyses were conducted by using genistein. Median intakes of genistein (measured in micrograms/day) by African Americans and Caucasians were too low to pursue relational analyses further. For Chinese and Japanese women, median genistein intakes were 3,511 and 7,151 microg/day, respectively. Ethnic-specific, linear models were used to predict BMD as a function of energy-adjusted tertile of intake, controlled for relevant covariates. For Chinese women, no association between genistein and BMD was found. Premenopausal, but not perimenopausal, Japanese women whose intakes were greater had higher spine and femoral neck BMD. Adjusted mean spinal BMD of those in the highest tertile of intake was 7.7% greater than that of women in the lowest tertile (p = 0.02); femoral neck BMD was 12% greater in the highest versus the lowest tertile (p < 0.0001).

Tumor variants by hormone receptor expression in white patients with node-negative breast cancer from the surveillance, epidemiology, and end results database

PURPOSE

Hormone receptor expression (presence-positive or absence-negative) may reflect different stages of one disease or different breast cancer types. Determining whether hormone receptor expression represents one or more breast cancer phenotypes would have important paradigmatic and practical implications.

METHODS

Breast cancer records were obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. The study included 19,541 non-Hispanic white women with node-negative breast cancer. Standard tumor cell characteristics and breast cancer-specific survival were analyzed by independent estrogen receptor (ER+ and ER-), independent progesterone receptor (PR+ and PR-), and joint ERPR expression (ER+PR+, ER+PR-, ER-PR+, and ER-PR-).

RESULTS

Age frequency density plots by hormone receptor expression showed two overlapping breast cancer populations with early-onset and/or late-onset etiologies. Independent ER+ and PR+ phenotype were associated with smaller tumor sizes, better grade, and better cancer-specific survival than ER- and PR- breast cancer types. Joint ERPR phenotype exhibited biologic gradients for tumor size, grade, and cancer-specific survival, which ranked from good to worse for ER+PR+ to ER+PR- to ER-PR+ to ER-PR-.

CONCLUSION

Variations of standard tumor cell characteristics and breast cancer-specific survival by hormone receptor expression in white patients with node-negative breast cancer suggested two breast cancer phenotypes with overlapping etiologies and distinct clinical features.

Racial differences in breast carcinoma survival

BACKGROUND

Survival after breast carcinoma diagnosis is significantly worse among African American women for reasons unknown. The purpose of this study was to update reports on the National Surveillance, Epidemiology, and End Results Program and to examine the effect of race on breast carcinoma survival.

METHODS

Subjects were 135,424 women diagnosed with primary breast carcinoma between 1988-1995. Patient age, tumor stage at the time of diagnosis, hormone receptor status, tumor histology, menopausal status, and survival were compared by race category.

RESULTS

African American women diagnosed with breast carcinoma (n = 11,159) had a significantly increased risk of death from breast carcinoma and from all cancers compared with white women (n = 124,265), independent of the effects of other predictor variables. African American women were significantly younger at the time of diagnosis, with approximately 33% of the population age </= 50 years, compared with slightly <25% of the white women belonging to that younger age group. African American women were significantly more likely to present with advanced stages of breast carcinoma and, within each stage category, had significantly poorer survival compared with white women. African American women were significantly less likely to have tumors positive for estrogen or progesterone receptors, as well as histologically confirmed lobular and tubular carcinomas, whereas they were more likely to have inflammatory, medullary, and papillary histology compared with white women.

CONCLUSIONS

The results of the current study show that race is an independent predictor of survival from breast carcinoma. These findings are consistent with other large, population-based studies of racial differences in breast carcinoma survival and have been comported by studies of racial differences in the molecular biology of breast carcinoma, thus providing support for the epidemiologic credibility of the independence of the association.

Estrogen and progesterone receptor concentrations and prevalence of tumor hormonal phenotypes in older breast cancer patients

We examined the concentrations of estrogen (ER) and progesterone receptors (PR) and the distribution of tumor phenotypes as a function of age in breast cancer patients. ER and PR concentrations were determined in tissue biopsies from 1739 patients with primary breast cancer, using ligand binding assays. Tumors were classified as estrogen receptor positive (ER+) or negative (ER-) and progesterone receptor positive (PR+) or negative (PR-) based on the presence or absence of receptor binding activity. Tumors were stratified into four phenotypes: ER+PR+; ER+PR-; ER-PR+; and ER-PR-. Significant positive associations were found between ER concentration and age (p = 0.0001) and between PR concentration and age (p = 0.0002). The median ER concentrations were statistically different by age groups, with the greatest levels in older versus younger patients. The prevalence of ER+PR+ tumor phenotype increased with age. In contrast, the prevalence of ER-PR- and ER-PR+ tumor phenotypes decreased with age. The median PR-to-ER ratio decreased with age (p = 0.0001), and this trend was attributed to increased ER concentration with age. The prevalence of ER-PR- and ER-PR+ tumor phenotypes is greater in younger patients suggesting that hormonal regulation of ER gene expression may be responsible for the observed age disparity of tumor phenotypes in breast cancer.

Breast carcinoma tumor characteristics in black and white women

BACKGROUND

A significant disparity in mortality rates exists between black and white patients with breast carcinoma. This study was designed to compare breast carcinoma tumor characteristics by race and to examine the possible reasons for these differences.

METHODS

Female patients with an initial diagnosis of breast carcinoma between January 1, 1985 and December 31, 1993 were selected from the Yale-New Haven Hospital Tumor Registry for this retrospective cohort study. All black patients were eligible and white patients were selected randomly and matched to each black patient by year of diagnosis. Data were gathered from multiple sources including the hospital, the Connecticut Tumor Registry, and the U. S. Census. All pathology specimens were reviewed at Yale-New Haven Hospital.

RESULTS

The final cohort had 100 black and 300 white patients. The black patients tended to be younger than white patients at the time of diagnosis (mean age 55 years vs. 60 years; P = 0.001). A significant racial difference was noted in eight tumor characteristics: stage, size of the tumor, lymph node status, presence of necrosis, vascular/lymphatic invasion, ductal carcinoma in situ, perineural invasion, and progesterone receptor status. Although income, medical insurance coverage, and method of tumor detection explained some pathology differences, black patients still were more likely to have necrosis and a larger tumor size, even after adjustment.

CONCLUSIONS

Black patients with breast carcinoma tend to be diagnosed at a younger age and in a few important respects have different tumor characteristics compared with white patients, even after controlling for income, medical insurance coverage, and method of tumor detection after screening mammography. These differences may have etiologic and clinical implications.

Breast carcinoma survival analysis for African American and white women in an equal-access health care system

BACKGROUND

This retrospective review of breast carcinoma cases in the Department of Defense (DoD) Central Tumor Registry evaluated differences in survival patterns between African American and white women treated in U.S. military health care facilities. The study examined the effects of age, stage of cancer, tumor size, grade, lymph node involvement, waiting time between diagnosis and first treatment, marital status, military dependent status, alcohol usage, tobacco usage, and family history of cancer.

METHODS

Researchers reviewed the tumor registry records of 6577 women (5879 whites and 698 African Americans) diagnosed with breast carcinoma. The patients, ages 19-97 years, were diagnosed between 1975 and 1994. A hazard ratio (relative risk of mortality) model compared African American and white patients, adjusting for various combinations of covariates; impact of independent variables on the risk of death; prognostic factors significantly associated with survival; disease free and overall survival times; effects of ethnicity, stage, and age on survival; and trends in stage at diagnosis. A P value (2-sided) of less than 0.05 was considered statistically significant.

RESULTS

After adjustment for age, the risk of death was 1.45 (95% confidence interval [CI], 1.20-1.76) times greater for African American women than for white women. Adjustment for stage reduced the risk to 1.41 (95% CI, 1.16-1.70); further adjustment for demographic variables and most clinical variables had no effect. Still, African American women treated in the military health care facilities had a better survival rate than African American women represented in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. In our study, the 5-year risk of death, from any cause, was 1.37 for African American women with breast carcinoma; in other words, the mortality rate for African American women was 24.77% compared with 18.08% for white women. In the latest SEER data, the 5-year relative risk of death for African American women compared with white women is 1.86. The mortality rate in SEER is 34.2% for African American women and 18.4% for white women. The survival rate for white DoD beneficiaries is comparable to that for white women in SEER.

CONCLUSIONS

These observations suggest that ready access to medical facilities and the full complement of treatment options that are standard for all DoD patients improve survival rates for African American women. However, a significant unexplained difference in survival still exists between African American and white military beneficiaries.

Prognosis among African-American women and white women with lymph node negative breast carcinoma: findings from two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP)

BACKGROUND

A disparity in breast carcinoma survival between African-American and white women has been noted over the past several decades. A major factor implicated in this disparity is stage of disease at diagnosis. In this study, survival and related endpoints were examined among African-American women and white women with lymph node negative breast carcinoma who participated in two randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP).

METHODS

Patients from two studies, one conducted among patients with estrogen receptor (ER) negative tumors and the other among patients with ER positive tumors, were included. Study goals were to determine whether African-Americans and whites had comparable outcomes, accounting for ER status and differences in patient characteristics at diagnosis, and to determine whether treatment response was similar for African-Americans and whites.

RESULTS

Five-year survival rates were 83% for African-Americans and 85% for whites among ER negative patients, and 93% for African-Americans and 92% for whites among ER positive patients. Rates of disease free survival (DFS) (i.e., time to disease recurrence, second primary cancer, or death) were 71% for African-Americans and 74% for whites at 5 years among ER negative patients, and 81% for African-Americans and 80% for whites among ER positive patients. African-Americans tended to have less favorable baseline prognostic characteristics. Adjusted relative risk (RR) estimates indicated similar prognosis for African-Americans compared with whites for mortality (African-American/white RR = 1.02 with 95% confidence interval [CI], 0.66-1.56 among ER negative patients; RR = 1.14 with 95% CI, 0.84-1.54 among ER positive patients) and DFS (RR = 0.98 with 95% CI, 0.70-1.37 for ER negative patients; RR = 0.96 with 95% CI, 0.75-1.22 for ER positive patients). Estimated percent reductions in DFS events for patients receiving adjuvant therapy were 32% for ER negative African-Americans, 36% for ER negative whites, 20% for ER positive African-Americans, and 39% for ER positive whites.

CONCLUSIONS

African-American and white patients with localized breast carcinoma had similar outcomes and benefited equally from systemic therapy. These results suggest that early detection and appropriate therapy among African-American patients could result in a reduction in the current disparity in breast carcinoma mortality between African-Americans and whites.

Racial differences in breast cancer survival: the interaction of socioeconomic status and tumor biology

OBJECTIVE

Our purpose was to evaluate the effect of sociodemographic and clinical variables on survival rates of African-American and white women with breast cancer.

STUDY DESIGN

Between 1988 and 1992 the Metropolitan Detroit Cancer Surveillance System Identified 10,502 women (82% white and 18% African-American) in whom invasive breast cancer was diagnosed. Cox proportional hazards regression was used to estimate the relative risk of death for African-Americans compared with whites after controlling for variables believed to influence survival.

RESULTS

African-American women were more likely than white women to have tumors that were of a more advanced stage, a higher grade, and hormone receptor-negative. After controlling for age, tumor size, stage, histologic grade, census-derived socioeconomic status, and the presence of a residency training program at the treatment hospital, the relative risk of dying for African-Americans compared with whites was 1.68 (95% confidence interval, 1.27-2.23) for women less than 50 years of age, and 1.33 (95% confidence interval, 1.13-1.56) for women older than 50 years of age.

CONCLUSIONS

Known factors that predict survival differences between African-Americans and whites are more prevalent among women less than 50 years of age, emphasizing the need to focus more attention on public health efforts directed toward younger women.

Breast cancer in African American women: epidemiology and tumor biology

This review of published data on the epidemiology, pathology, and molecular biology of breast cancer in African American women seeks to identify how the etiology and presentation of the disease differ from those in white women. The crossover from higher to lower age-specific incidence rates in African American women at age 45 cannot be explained by current data on the distribution of risk factors. Data from six case-control studies suggest that the relative risks associated with both established and probable breast cancer risk factors are similar in African American and white women. Lower survival in African American compared to white women is primarily attributable to diagnosis at a later stage. However, evidence from a number of studies suggests that tumors in African American women may exhibit a more aggressive phenotype, which could also contribute to the survival disparity. Tumors in African American women are more likely to occur at a younger age, to be poorly differentiated and estrogen receptor negative, and to exhibit high grade nuclear atypia, more aggressive histology (more medullary and less lobular), and higher S-phase. Overexpression of p53 and erbB-2 occurs with similar frequency in African American and white women, although limited data suggest the former may exhibit different p53 mutation spectra. One study found high risk associated with a specific CYP1A1 polymorphism in African American but not white women. Additional studies of molecular differences in African American and white women are needed, with multifactorial assessment of the independent effects of molecular and conventional risk attributes.

Racial differences in survival of female breast cancer in the Detroit metropolitan area

BACKGROUND

In the United States, breast cancer survival is worse among African-American women compared with white women. This difference in survival is likely due to several factors, including tumor biology and/or access to care. In this analysis, we evaluated the effects of sociodemographic and clinical variables on differences in breast cancer survival among African-American and white women.

METHODS

The study population included 10,502 women (82% white, 18% African-American), diagnosed between 1988 and 1992 and identified through the Metropolitan Detroit Cancer Surveillance System, a member of the Surveillance, Epidemiology and End-Results (SEER) Program. Cox proportional hazards regression was used to estimate the relative risk of death comparing African-American women with white women after controlling for variables believed to influence survival.

RESULTS

The mean age at diagnosis was 61 years and average length of follow-up was 34 months (range, 1-78 months). African-American women were more likely to present with regional or distant disease (45%) than were white women (37%). Although white women had better survival than African-American women during the first 4 years postdiagnosis (P < 0.0001), there were no significant differences in survival by race for women who lived longer than 4 years (P = 0.64). There was a significant interaction between age and race. The unadjusted relative risk of dying for African-American women compared with white women was 2.35 (95% confidence interval [CI], 1.88-2.93) for women younger than 50 years of age, and was 1.66 (95% CI, 1.46-1.88) for women age 50 years or older. After controlling for age, tumor size, stage, histologic grade, census-derived socioeconomic status, and residency training status, the relative risk was 1.68 (95% CI, 1.27-2.24) for women younger than 50 years of age and 1.33 (95% CI, 1.13-1.56) for women age 50 years and older. Adjustment for marital status, hospital size, and the proportion of Medicaid or Medicare discharges had no further effect on the relative risk.

CONCLUSIONS

Known factors that predict survival differences between African-American and white women are more prevalent among women younger than age 50.

Breast cancer in young patients

BACKGROUND

Breast cancer in a young person is considered by many to be a rare and very aggressive disease. Theories regarding the aggressiveness of the disease are varied. This study was undertaken in an attempt to help formulate guidelines regarding screening for and treatment of breast cancer in the young patient.

PATIENTS AND METHODS

A retrospective review was undertaken of 81 breast cancer patients aged < or = 35 years who underwent definitive surgical treatment. All patients were treated at a single institution.

RESULTS

Overall 5- and 10-year survival rates were 65% and 49%, respectively. In patients with disease localized to the breast, 5- and 10-year rates were 89% and 78%, respectively. There was no significant difference in survival with respect to age or date of diagnosis, nor was there a difference in cancer stage distribution. The only major determinant of survival was stage at the time of diagnosis.

CONCLUSIONS

We conclude that young age does not seem to be directly related to the "aggressiveness" or "virulence" of breast cancer, especially among patients with localized disease. These results underscore the need for aggressive and early treatment of these patients. The improved survival with early detection is a valid argument for careful screening, even among very young patients.

Breast cancer risk factors in African-American women: the Howard University Tumor Registry experience

This retrospective case-control study examines risk factors for breast cancer in African-American women, who recently have shown an increase in the incidence of this malignancy, especially in younger women. Our study involves 503 cases from the Howard University Hospital and 539 controls from the same hospital, seen from 1978 to 1987. Using information culled from medical charts, an analysis of various factors for their effect on breast cancer risk was made. The source of data necessarily meant that some known risk factors were missing. Increases in risk were found for known risk factors such as decreased age at menarche and a family history of breast cancer. No change in risk was observed with single marital status, nulliparity, premenopausal status, or lactation. An increased odds ratio was found for induced abortions, which was significant in women diagnosed after 50 years of age. Spontaneous abortions had a small but significant protective effect in the same subgroup of women. Birth control pill usage conferred a significantly increased risk. It is of note that abortions and oral contraceptive usage, not yet studied in African Americans, have been suggested as possibly contributing to the recent increase in breast cancer in young African-American women.

Conservative surgery and radiation therapy in black women with early stage breast cancer. Patterns of failure and analysis of outcome

Between 1977 and 1986, 75 black and 615 white women with American Joint Committee (AJC) Stages I and II breast cancer were treated with excisional biopsy, axillary dissection, and radiation therapy for breast conservation. Cyclophosphamide, methotrexate, and 5-fluorouracil, with and without prednisone and tamoxifen, was given to 92% of premenopausal, 83% of perimenopausal, and 63% of postmenopausal node-positive women; 20 of 106 (19%) postmenopausal node-positive women received tamoxifen only. The clinical characteristics of the similarly treated patients were compared. The 5-year actuarial local only first failure rate was 5% for black women and 6% for white women (P = 0.53). Regional only failure as the first site of failure was 9% for blacks versus 1% for whites (P = 0.002), with regional recurrence as any component of first failure being 16% for blacks and 4% for whites (P = 0.001). The supraclavicular fossa was identified as the primary site of regional recurrence in black patients with either pathologically positive or negative axillae. Distant metastases as the only site of first failure were significantly greater in the black population with a 20% 5-year actuarial failure rate versus 11% in white patients (P = 0.01). The 5-year actuarial overall survival for the black patients was 82% versus 91% for the white patients (P = 0.01), with no-evidence-of-disease (NED) survival being 64% and 83% (P = 0.0002) and relapse-free survival (RFS) being 61% and 77% (P = 0.01), respectively. Black patients younger than 40 years of age or with pathologically positive axillary nodes had significantly worse NED, RFS, and overall survival compared with similarly staged white patients. Cosmetic results were analyzed at 3 and 5 years after completion of therapy. Although significantly fewer black patients had an excellent-to-good cosmetic result at 3 years compared with white patients, the results were not significantly different at 5 years. These results show that appropriately selected black patients with early stage breast cancer have excellent local control after conservative surgery and radiation therapy and should continue to be offered breast preservation as an alternative to mastectomy. Patterns of failure, however, demonstrated higher regional and distant recurrence rates and lower NED, RFS, and overall survival rates in most subsets of black patients reviewed.