Breast Cancer and Obesity: a Qualitative Analysis of a Diverse Population of Breast Cancer Patients' Perspectives on Weight Management

PURPOSE

Obesity and weight gain in breast cancer survivors leads to a greater risk of recurrence and a decreased chance of survival. A paucity of data exists regarding strengths, weaknesses, and barriers for implementing culturally sensitive, patient-centered interventions for weight management among minority communities. The objective of this study was to evaluate breast cancer patients' experience and perspectives regarding weight management in a racially diverse population.

METHODS

Semi-structured qualitative interviews were conducted with breast cancer patients with a body mass index ≥ 25 kg/m2 regarding their experience with weight management. Interviews were transcribed verbatim, and a thematic analysis was conducted.

RESULTS

Participants (n = 17) most commonly self-identified as non-Hispanic Black (70.6%). Nearly all participants felt comfortable being approached about weight management, yet less than half (41.2%) reported that they knew about the link between breast cancer and body weight prior to the interview. Four themes emerged: (1) lack of knowledge regarding the link between body weight and breast cancer risk, (2) barriers to weight management including family stressors, high cost, mental health issues, and chronic medical conditions, (3) previous attempts at weight loss including bariatric surgery, and (4) best practices for approaching weight management including discussion of weight management prior to survivorship.

CONCLUSION

There is a need for a multidisciplinary, patient-centered weight management program for minority breast cancer patients that improves awareness of the link between weight and breast cancer risk. Weight management should be introduced early on as an element of the treatment plan for breast cancer.

Mammography screening beliefs and barriers through the lens of Black women during the COVID-19 pandemic

BACKGROUND

Mammography is an effective screening tool that leads to decreased breast cancer mortality, yet minority women continue to experience barriers. The coronavirus disease 2019 (COVID-19) pandemic has been proven to have negatively affected minority communities, yet its effect on mammography screening habits in Black women is uncertain. The purpose of this study was to evaluate breast cancer mammography screening habits and barriers for Black women in two northeast communities amid the COVID-19 pandemic.

METHODS

The study participants were Black women aged 40 years or older who were recruited from community outreach initiatives. Study coordinators conducted telephone surveys to determine mammography screening behaviors, perceptions, and psychosocial factors.

RESULTS

Two hundred seventy-seven surveys were completed. Two hundred fifty-six patients who reported ever having a mammogram became the study population of interest. One hundred seventy-four of these patients (68%) reported having a mammogram within the past year (nondelayed), and 82 (32%) had a mammogram more than a year ago (delayed). Only thirty-one of the delayed participants (37.8%) had private insurance. There was a significant difference in the mean score for mammography screening perceived barriers for nondelayed participants (mean = 9.9, standard deviation [SD] = 3.6) versus delayed participants (mean = 11.2, SD = 4.3, p = .03). There was also a significant difference in the mean score when they were asked, "How likely is it that 'other health problems would keep you from having a mammogram'?" (p = .002).

CONCLUSIONS

Barriers to mammography screening for Black women during the COVID-19 era include insurance, competing health issues, and perceptions of screening. Community outreach efforts should concentrate on building trust and collaborating with organizations to improve screening despite the COVID-19 pandemic.

The Landmark Series-Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women

Randomized, clinical trials have established the efficacy of screening mammography in improving survival from breast cancer for women through detection of early, asymptomatic disease. However, disparities in survival rates between black women and women from other racial and ethnic groups following breast cancer diagnosis persist. Various professional groups have different, somewhat conflicting, guidelines with regards to recommended age for commencing screening as well as recommended frequency of screening exams, but the trials upon which these recommendations are based were not specifically designed to examine benefit among black women. Furthermore, these recommendations do not appear to incorporate the unique epidemiological circumstances of breast cancer among black women, including higher rates of diagnosis before age 40 years and greater likelihood of advanced stage at diagnosis, into their formulation. In this review, we examined the epidemiologic and socioeconomic factors that are associated with breast cancer among black women and assess the implications of these factors for screening in this population. Specifically, we recommend that by no later than age 25 years, all black women should undergo baseline assessment for future risk of breast cancer utilizing a model that incorporates race (e.g., Breast Cancer Risk Assessment Tool [BCRAT], formerly the Gail model) and that this assessment should be conducted by a breast specialist or a healthcare provider (e.g., primary care physician or gynecologist) who is trained to assess breast cancer risk and is aware of the increased risks of early (i.e., premenopausal) and biologically aggressive (e.g., late-stage, triple-negative) breast cancer among black women.

Postmastectomy Breast Reconstruction Patterns at an Urban Academic Hospital and the Impact of Surgeon Gender

Background

Postmastectomy breast reconstruction is an essential element of multidisciplinary breast cancer care but may be underutilized.

Methods

This retrospective study analyzed mastectomy patients (2018–2021) at an urban hospital. Multivariable logistic regression was performed, and a mixed-effects logistic regression model was constructed to determine patient-level factors (age, race, body mass index, comorbidities, smoking status, insurance, type of surgery) and provider-level factors (breast surgeon gender, participation in multidisciplinary breast clinic) that influence reconstruction.

Results

Overall, 167 patients underwent mastectomy. The reconstruction rate was 35%. In multivariable analysis, increasing age (odds ratio [OR] 0.95; 95% confidence interval [CI] 0.91–0.99) and Medicaid insurance (OR 0.18; 95% CI 0.06–0.53) relative to private insurance were negative predictors, whereas bilateral mastectomy was a positive predictor (OR 7.07; 95% CI 2.95–17.9) of reconstruction. After adjustment for patent age, race, insurance, and type of surgery, female breast surgeons had 3.7 times greater odds of operating on patients who had reconstruction than males (95% CI 1.20–11.42).

Conclusion

Both patient- and provider-level factors have an impact on postmastectomy reconstruction. Female breast surgeons had nearly four times the odds of caring for patients who underwent reconstruction, suggesting that a more standardized process for plastic surgery referral is needed.

Breast Cancer Disparities and the COVID-19 Pandemic

Purpose of Review

The COVID-19 pandemic has placed unprecedented challenges on breast cancer patients and health care providers. The impact of the pandemic on preexisting breast cancer disparities remains unknown but is projected to have adverse outcomes.

Recent Findings

Early work has demonstrated that pandemic-related temporary suspensions in breast cancer screening, interruption of clinical trials, and treatment delays have an adverse impact on breast cancer patient outcomes and may worsen disparities.

Summary

In this review, we highlight existing knowledge regarding breast cancer disparities and the impact of the COVID-19 pandemic. Strategies for mitigating disparities moving forward include targeted research evaluating race-specific outcomes, targeted education for providers regarding breast health disparities, improved access to telehealth, maintenance of patient navigation programs, and patient education regarding the safety and necessity of enrollment in clinical trials.

Alcohol and Tobacco Use in an Ethnically Diverse Sample of Breast Cancer Patients, Including Sea Island African Americans: Implications for Survivorship

Background/Objective: Data suggest that modifiable risk factors such as alcohol and tobacco use may increase the risk of breast cancer (BC) recurrence and reduce survival. Female BC mortality in South Carolina is 40% higher among African Americans (AAs) than European Americans (EAs). Given this substantial racial disparity, using a cross-sectional survey design we examined alcohol and tobacco use in an ethnically diverse statewide study of women with recently diagnosed invasive breast cancer. This included a unique South Carolina AA subpopulation, the Sea Islanders (SI), culturally isolated and with the lowest European American genetic admixture of any AA group.

Methods: Participants (42 EAs, 66 non-SI AAs, 29 SIs), diagnosed between August 2011 and December 2012, were identified through the South Carolina Central Cancer Registry and interviewed by telephone within 21 months of diagnosis. Self-reported educational status, alcohol consumption and tobacco use were obtained using elements of the Behavior and Risk Factor Surveillance System questionnaire.

Results:Alcohol: EAs were approximately twice as likely to consume alcohol (40%) and to be moderate drinkers (29%) than either AA group (consumers: 24% of non-SI AAs, 21% of SIs; moderate drinkers 15 and 10% respectively). Users tended to be younger, significantly among EAs and non-SI AAs, but not SIs, and to have attained more education. Heavy drinking was rare (≤1%) and binge drinking uncommon (≤10%) with no differences by race/ethnicity. Among both AA subgroups but not EAs, alcohol users were six to nine times more likely to have late stage disease (Regional or Distant), statistically significant but with wide confidence intervals. Tobacco: Current cigarette smoking (daily or occasional) was reported by 14% of EAs, 14% of non-SI AAs and 7% of SIs. Smoking was inversely associated with educational attainment. Use of both alcohol and cigarettes was reported by 3–6% of cases.

Conclusions: Prevalences of alcohol and cigarette use were similar to those in the general population, with alcohol consumption more common among EAs. Up to half of cases used alcohol and/or tobacco. Given the risks from alcohol for disease recurrence, and implications of smoking for various health outcomes, these utilization rates are of concern.

How Does MR Imaging Help Care for My Breast Cancer Patient? Perspective of a Surgical Oncologist

MR imaging is now readily available for surgeons to incorporate into their practice, thus, begging the question, is this new modality clinically useful? Current literature and expert opinion are reviewed concerning the implementation of breast MR imaging to clinical management of breast cancer. Although breast MR imaging is acknowledged to be highly sensitive in detection of breast cancer, its routine application to surgical practice remains controversial because these gains in sensitivity have not been demonstrated to translate into improved long-term patient outcomes. Current clinical trials and the future of breast MR imaging are also discussed.

Abstract B27: Overweight/obesity and physical activity rates in an ethnically diverse sample of breast cancer survivors

Background: High body mass index (BMI) is linked to poorer survival after breast cancer diagnosis. Physical activity (PA) could moderate this association.

Objectives/Hypothesis: Prevalence of high BMI (overweight/obesity) and level of PA were evaluated in a statewide sample of women within 18 months of breast cancer diagnosis.

Methods: In an ongoing study, 73 women (35 EA and 38 AA) were identified through the SC Central Cancer Registry, and were interviewed to obtain their self-reported body weight, height, PA and other data.

Results: Age: Age ranged from 26 to 90 years (mean 61 years, SD 13.0), with AAs 2.1 years younger than EAs (p=0.49). Education: 62% had more than a high school (HS) diploma (58% of AAs and 66% of EAs, p=0.49). BMI: 77% were overweight/obese; 42% of AAs and 31% of EAs were overweight, 45% of AAs and 34% of EAs were obese (p=0.03). PA: 23% reported no PA (29% of AAs and 17% of EAs, p=0.23). Only 38% met CDC PA guidelines of at least 150 min/week of moderate PA (29% of AAs and 47% of EAs; p=0.11). PA and BMI: PA <90 min/week was associated with 4-fold higher risk of overweight/ obesity (p=0.023). No significant associations were seen by race. PA and Education: No significant association was observed between >HS education and meeting PA guidelines (p=0.15), or between >HS education and greater PA per week (p=0.57). Education and BMI: No significant association was seen (p=0.77).

Conclusions: Prevalence of overweight/obesity was high, especially among AAs.

Future Recommendations: It is imperative to identify strategies to reduce obesity/overweight in BRCA survivors.

Citation Format: Joan E. Cunningham, Colleen E. Bauza, Erika T. Brown, Alberg J. Anthony, Emily Kistner-Griffin, Ida J. Spruill, Debbie C. Bryant, Nestor F. Esnaola, Melanie S. Jefferson, Keith Whitfield, Rita M. Kramer, Susan Bolick, Deborah Hurley, Catishia Mosley, Tonya R. Hazelton, Vivian J. Bea, Dana R. Burshell, Kendrea D. Knight, Marvella E. Ford. Overweight/obesity and physical activity rates in an ethnically diverse sample of breast cancer survivors. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B27.

Abstract P1-09-20: Evaluating alcohol and tobacco use in an ethnically diverse sample of breast cancer patients: Implications for survivorship

Background/Objective: Data suggest that modifiable risk factors such as alcohol and tobacco use may increase the risk of breast cancer (BC) recurrence and reduce survival. According to 2012 data from the Centers for Disease Control (CDC) and Prevention Behavioral Risk Factor Surveillance System (BRFSS), 4.8% of women in South Carolina (SC) are heavy drinkers (>1 drink/day) with 9.6% having ≥4 drinks at least once in the past month (US state medians are 5.2% and 11.4%); 19.1% are current smokers (US state median 17.4%). Female BC mortality in SC is almost 50% higher in African Americans (AAs) than in European Americans (EAs; 27.5/100,000 and 19.1%, respectively). In SC, there is an AA subpopulation, the Sea Islanders, who carry the lowest AA rate of European genetic admixture. Given the substantial racial survival disparity we examined the patterns of alcohol and tobacco use in an on-going, ethnically diverse statewide study of women with recently diagnosed breast cancer.

Methods: Participants were identified within 18 months post-diagnosis through the SC Central Cancer Registry (SCCCR). Women who opted into the study were interviewed via telephone, self-reporting data including race/ethnicity, educational status, alcohol consumption and tobacco use during the past 30 days. Published CDC guidelines were used to categorize alcohol and tobacco use.

Results: During the first 24 months of recruitment, 172 women ages 38 to 90 years have opted into our study; 139 were interviewed (43 EAs and 96 AAs) and results analyzed. AAs were slightly younger (p=0.066) and tended to have less education (statistically not significant: p=0.114)

Alcohol: The minority of participants self-identified consuming alcohol (29.0%). Heavy use was infrequent: two (1.4%) reported consuming on average >1 drink/day,and six (4.4%) consumed ≥4 drinks on any day. Alcohol consumption was less prevalent among AAs than EAs (p=0.025). Among those who consumed alcohol, usage did not differ between AAs and EAs.

Tobacco: Smoking (daily or occasional) was reported by 7.5% of participants (AA vs EA: p=1.00).

Alcohol and/or Tobacco: Use of alcohol and/or tobacco was 1.7 times as prevalent among EAs compared to AAs (47.6% vs 28.7%; p=0.032).

Conclusions: Compared to self-reported state data few participants reported heavy alcohol consumption or current tobacco use, particularly AAs, but 34.6% of participants do use alcohol or tobacco. While these findings suggest that alcohol and tobacco may not contribute to the racial disparities in breast cancer mortality observed in SC, it is nonetheless imperative to reduce these modifiable risk factors and improve breast cancer outcomes for all breast cancer survivors, regardless of race and ethnicity.

Table 1 African American (AA) N=96European American (EA) N=43p-valueAge (years): mean (±st dev*)58.8 (±11.6)62.9 (±13.2)0.066Education: more than high school51 (53.1%)29 (67.4%)0.114Alcohol in past 30 daysYes (vs No)22 (23.2%)18 (41.9%)0.025Among those who drink:Heavy: average >1 drink/day1 (4.6%)1 (5.6%)1.000Current tobacco useYes (vs No)7 (7.6%)3 (7.1%)1.000Among smokers: Daily use:4 (57.1%)3 (100%)0.475Alcohol and/or Tobacco27 (28.7%)20 (47.6%)0.032Both Alcohol and Tobacco2 (2.2%)1 (2.4%)1.000*standard deviation

Citation Format: Vivian J Bea, Joan E Cunningham, Dana R Burshell, Marvella E Ford. Evaluating alcohol and tobacco use in an ethnically diverse sample of breast cancer patients: Implications for survivorship [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-20.

Abstract P5-12-11: Evaluating overweight/obesity and physical activity rates in an ethnically diverse sample of breast cancer survivors

Introduction: Overweight/obesity are associated with higher risk of recurrence and poorer survival after a breast cancer diagnosis. According to The Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) data for 2011, in South Carolina, 74.6% of African American (AA) and 62.5% of European American (EA) adult women are overweight/obese.

Methods: Prevalence of overweight/obesity and level of physical activity (PA) are evaluated in an ongoing, ethnically-diverse statewide study of adult women with recently-diagnosed invasive breast cancer. Participants are identified within 18 months post-diagnosis through the South Carolina Central Cancer Registry (SCCCR). Participants who opt in to the study are interviewed via telephone and self-report their body weight, height and physical activities. Published CDC body mass index (BMI) categories and 2008 PA guidelines are used to characterize BMI and PA guideline adherence.

Results: During the first 10 months of the study, 98 women (56 AA, 42 EA) were interviewed and results analyzed. Age: Participants ranged in age from 26 to 90 years (mean 60.2 years, SD 12.8), with AAs 3.7 years younger than EAs (p = 0.16). Education: Almost two-thirds of participants (61%) had more than a high school diploma (55% of AAs and 69% of EAs, p = 0.29). BMI: The BMI mean was 30.1 (SD 6.6, median 26.6) which was significantly higher in AAs (31.3 compared to 28.6 in EAs, p = 0.04). Among all women combined, 79% were overweight/obese, with no statistically significant difference by race (p = 0.15). Overweight was equally frequent among AAs (34%) and EAs (33%). However, obesity was more frequent among AAs (50%) than EAs (38%). Physical Activity (PA): CDC guideline adherence of ≥150 minutes/week of moderate PA was reported by only 32% of participants (25% of AAs, 41% of EAs; p = 0.10). A total of 28% reported no physical activity (30% of AAs and 24% of EAs, p = 0.47). Meeting CDC PA guidelines was associated with lower risk of being overweight/obese (OR = 0.41, p = 0.080), but this was statistically significant only among EAs (OR = 0.21, p = 0.035).

Conclusions: Prevalence of overweight/obesity is high, regardless of ethnicity, and physical activity is low in this group of breast cancer survivors. It is imperative to identify effective strategies to reduce overweight and obesity, and to increase PA, in order to reduce the risk of recurrence and improve survival. In this regard, the study team is developing an National Institutes of Health R01 grant application to evaluate the effectiveness of an intervention, which combines a reduced-energy diet with increased PA, in reducing levels of cancer-related inflammatory biomarkers linked to breast cancer recurrence. Updated results of our on-going study, including associations of BMI and PA with breast cancer stage and phenotype, will be presented.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-12-11.

Abstract B48: Design of a feasibility study of breast cancer candidate genes in three ethnic groups

The purpose of this presentation is to highlight the design and preliminary recruitment outcomes of a translational feasibility study to investigate the impacts of selected genetic single nucleotide polymorphisms (SNPs) on ethnic disparities in breast cancer subtypes, defined by ER, PR, and Her2 expression, associated with higher breast cancer mortality rates. The study will investigate the frequencies of five SNPs in the 19p13 locus of BRCA1 and two SNPs on chr 5p12 in three ethnic groups: African Americans with Sea Island ancestry (SI; all four grandparents were born in SI geographic regions), African Americans without known Sea Island ancestry (AA; 0 grandparents were born in SI geographic regions), and European Americans (EA). The SI population is an AA subpopulation indigenous to the coastal southeast that has the lowest rates of European genetic admixture of AA tested.(1,2) Comparing risk alleles across these three ethnic groups provides a novel paradigm to assess the extent to which SI ancestry and social processes such as acculturation may be linked to breast cancer subtypes associated with poor prognosis.

A protocol has been developed to identify, contact and recruit women recently diagnosed with breast cancer within each ethnic group. Breast cancer cases are initially ascertained through the South Carolina Central Cancer Registry (SCCCR). Recruitment methods encompass steps taken at the SCCCR that include passive consent from the physician of record to contact identified patients, followed by active consent from the identified patients prior to contact by study staff. An investigator-developed algorithm developed to determine SI ancestry of patients, based on geographic ancestry, is administered and eligible participants are asked to complete a telephone-administered survey and to provide a saliva sample for genetic analysis. Recruitment began in June 2012. To date, 23 participants have been recruited, of whom 6 are AA (26%) and 17 are EA (74%), with a mean age of 57.5 years (range =39-77 years). Recruitment will continue until 30 women in each ethnic group are enrolled (total 90 participants). The recruitment process is monitored using a CONSORT diagram. This work will ultimately identify loci for further investigation of breast cancer disparities in other groups and for future development of targeted clinical therapies.

References:

1. Divers, J, Sale MM, Lu L, et al. The genetic architecture of lipoprotein subclasses in Gullah-speaking African American families enriched for Type 2 diabetes: the Sea Islands Genetic African American Registry (Project SuGAR). Journal of Lipid Research 2009;51:586-597. PubMed PMID: 9783527; PubMed Central PMCID: PMC2817588.

2. McLean DC, Jr., Spruill I, Argyropoulos G, et al. Mitochondrial DNA (mtDNA haplotypes reveal maternal population genetic affinities of Sea Island Gullah-speaking African Americans. American Journal of Physical Anthropology 2005;127:427-438.

Citation Format: Marvella E. Ford, Joan E. Cunningham, Erika T. Brown, Ida J. Spruill, Anthony J. Alberg, Debbie C. Bryant, Karen D. Charles, Nestor F. Esnaola, Melanie S. Jefferson, Keith Whitfield, Rita M. Kramer, Susan Bolick, Deborah Hurley, Catishia Mosley, Tonya R. Hazelton, Vivian J. Bea, Dana R. Burshell, Shweta Singh, Emily Kistner-Griffin. Design of a feasibility study of breast cancer candidate genes in three ethnic groups. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr B48.