Racial differences in the early detection of breast cancer in metropolitan Detroit, 1978 to 1987

Neonatal outcomes of pregnancy-associated breast cancer: Population-based study on 11 million births

BACKGROUND

As the age at first pregnancy continues to rise in the United States so does the incidence of breast cancer diagnosed during pregnancy. Our objective was to evaluate temporal trends in the incidence of pregnancy-associated breast cancer (PABC) and to measure neonatal outcomes associated with PABC.

METHODS

We conducted a population-based cohort study using the 1999-2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from the United States. Logistic regression models, adjusted for maternal baseline characteristics, examined the effect of PABC on neonatal outcomes.

RESULTS

There were 11 846 300 deliveries between 1999 and 2012, of which 772 cases of PABC were identified, resulting in an overall incidence of 6.5 cases/100 000 pregnancies. There was a significant increase in the incidence of PABC during the study period (P < 0.05). Women with PABC tended to be older, of white ethnicity, belong to a higher income quartile and to be treated in an urban teaching hospital. In pregnancies complicated by breast cancer, there was a greater risk of preterm delivery (OR 4.84, 95% CI 4.05-5.79) and preterm premature rupture of membranes (OR 1.79, 95% CI 1.06-3.05). No associations were observed between PABC and intrauterine growth restriction, congenital anomalies or intrauterine fetal demise.

CONCLUSION

There is an uptrend in the incidence of PABC and therefore, the need for counseling these patients is also increasing. Although pregnancies with the diagnosis of maternal breast cancer are more prone to premature births, it is encouraging that these babies do not appear to be at increased risk for congenital anomalies, growth restriction, or fetal demise.

Increased racial differences on breast cancer care and survival in America: historical evidence consistent with a health insurance hypothesis, 1975-2001

PURPOSE

This study examined whether race/ethnicity had differential effects on breast cancer care and survival across age strata and cohorts within stages of disease.

METHODS

The Detroit Cancer Registry provided 25,997 breast cancer cases. African American and non-Hispanic white, older Medicare-eligible and younger non-eligible women were compared. Successive historical cohorts (1975-1980 and 1990-1995) were, respectively, followed until 1986 and 2001.

RESULTS

African American disadvantages on survival and treatments increased significantly, particularly among younger women who were much more likely to be uninsured. Within node positive disease all treatment disadvantages among younger African American women disappeared with socioeconomic adjustment.

CONCLUSIONS

Growth of this racial divide implicates social, rather than biological, forces. Its elimination will require high quality health care for all.

Impacting cultural attitudes in African-American women to decrease breast cancer mortality

BACKGROUND

Over the past decade breast cancer mortality has decreased 1% or 2% per year in white women, but not in African-American women. The resulting "mortality gap" is a serious national problem, and it must be a high priority to understand the reasons for it and develop solutions.

METHODS

The literature is reviewed to elucidate reasons for the mortality gap and the current status of possible solutions to the problem. In addition, new results of large population-based surveys in North Carolina are presented that may shed light on the problem.

RESULTS

The most important reason for the mortality gap is that African-American women tend to be diagnosed with more advanced stage breast cancer than white women. This is due both to lower utilization of screening mammography and to delayed presentation for women with palpable lumps. This is related both to socioeconomic factors that influence access to medical care and to cultural factors that tend to discourage women from seeking care early for breast problems.

CONCLUSIONS

Understanding the cultural beliefs that influence patient behavior will greatly aid physicians in caring for their African-American patients, and ultimately may help reduce the racial gap in breast cancer mortality.

Impact of breast carcinoma on African-American women: the Detroit experience

BACKGROUND

National and regional population-based data have demonstrated substantially worse outcome in African-American patients with breast carcinoma when compared with white patients, as well as a younger age distribution among African-American patients with breast carcinoma. The extent to which various socioeconomic, environmental, lifestyle, and genetic factors interact to account for this ethnicity-related disparity in survival is poorly understood. Greater than one-half of the inner-city population of Detroit, Michigan is African American, and greater metropolitan Detroit has been one of the contributing registries for the Surveillance, Epidemiology, and End Results (SEER) program since its inception in 1973. The impact of breast carcinoma on African Americans in the Detroit area is therefore well documented and provides significant insight into the history, epidemiology, and biology of this major public health care problem.

METHODS

A review of the medical literature published over the past 20 years regarding African-American patients with breast carcinoma was performed. The pertinent findings were summarized in the context of advances made in breast carcinoma screening, treatment, and risk reduction during that period.

RESULTS

The large African-American population of Detroit is a major factor contributing to the excessive breast carcinoma mortality rate reported for this city, which is one of the highest in the United States. Improvements in early detection of breast carcinoma by using screening mammography have been apparent in the earlier stage distributions of breast carcinoma observed in both white and African-American patients; however, progress has lagged substantially for the latter group. Detroit SEER registry data also have shown a younger age distribution of African-American patients with breast carcinoma and higher rates of estrogen receptor negative tumors. Finally, preliminary data from health maintenance organizations have suggested improved breast carcinoma outcome for African Americans who possess greater socioeconomic benefits, but disparities in disease stage at presentation persist.

CONCLUSIONS

The diverse Detroit community is ideally suited for breast carcinoma screening programs and clinical investigations that seek to address and overcome ethnicity-related survival disparities and barriers to health care. Findings from these studies can be correlated with results from similar projects in other geographic areas.

Age at presentation of African-American and Caucasian breast cancer patients

BACKGROUND

The purpose of this study was to compare the age at presentation of Black-American (Caribbean-American and African-American) and Caucasian breast cancer patients.

STUDY DESIGN

We reviewed the records of all breast cancer patients seen at King's County Hospital Center and SUNY Health Science Center at Brooklyn between 1982 and 1995. The patients were stratified based on ethnicity. Age distribution, median, and mean ages are compared for Black-American and Caucasian patients.

RESULTS

The median age, mean age, and standard deviation for 1,632 African-American patients was 54, 54.17, and 13.11 years, respectively, whereas for 671 Caucasians patients it was 62, 60.35, and 13.85 years, respectively. Using the Student's t-test for equality of means there is a statistically significant difference in the mean age of presentation for the 2 ethnic groups with a p < 0.001 and a 95% confidence interval for difference (4.960, 7.405). More than one-third (37.7%) of Black-American breast cancer patients present younger than 50 years of age compared with 24.7% for Caucasians.

CONCLUSIONS

The younger age at presentation of Black-American breast cancer patients ought to be considered while setting screening guidelines for that group of women.

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study

BACKGROUND

Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis.

METHODS

The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance.

RESULTS

Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven.

CONCLUSION

A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.

Age-specific patterns of association between breast cancer and risk factors in black women, ages 20 to 39 and 40 to 54

Data from the 1980 to 1982 population-based Cancer and Steroid Hormone case-control study of women 20 to 54 years old afforded the opportunity to investigate risk factors for breast cancer among black women younger than 40 years (177 patients and 137 control subjects) and to compare the results to black women 40 to 54 years old (313 patients and 348 control subjects). Information on exposure variables was obtained by in-person interviews. The logistic regression results indicated that the risk of breast cancer among black women younger than 40 years was nearly three times greater for those who used oral contraceptives for more than 10 years relative to never-users (odds ratio, 2.8; 95% confidence interval, 1.2 to 6.8) and more than four times greater for severely obese women (body mass index > or = 32.30 kg/m2) relative to women whose relative weights were less than 24.90 kg/m2. Patterns of association for the two age groups were similar for surgical menopausal, age at first full-term pregnancy, and multiple births, but differed for age at menarche.

Breast cancer among black and white women in the 1980s. Changing patterns in the United States by race, age, and extent of disease

BACKGROUND

This national study of breast cancer incidence and mortality was conducted to determine whether patterns of change differ for black and white women, to evaluate patterns by extent of disease, and to determine whether recent patterns of breast cancer are consistent with results that one would expect due to increases in use of screening examinations by women.

METHODS

The study included 104,351 cases of in situ or invasive breast cancer diagnosed between 1983 and 1989 among women from the nine geographic areas participating in the National Cancer Institute Surveillance, Epidemiology, and End Results program. Breast cancer incidence patterns were examined by extent of disease for black and white women and by age at diagnosis.

RESULTS

Significant increases occurred in the incidence of all early-stage breast cancers. Concomitantly, significant decreases occurred in the incidence of the most advanced-stage breast cancers. Although both white and black women experienced significant increases in early-stage breast cancer, black women have substantially lower rates of the least extensive breast cancers.

CONCLUSIONS

These results strongly suggest that a major explanation for the increase in breast cancer incidence in the 1980s may well be the increased prevalence of breast cancer screening among women in the United States. They also suggest a consistent benefit of screening across all age groups from 40 to 49 years through 70 years and older.

Recent trends in the incidence of in situ and invasive breast cancer in the Detroit metropolitan area (1975-1988)

BACKGROUND

Over the past two decades, breast cancer incidence rates have increased dramatically for women in all age groups.

METHODS

Breast cancer incidence trends were evaluated in a population-based study of data from the Metropolitan Detroit Cancer Surveillance System, a participant in the Surveillance Epidemiology and End Results Program of the National Cancer Institute. Incidence rates from 1975 through 1988 were evaluated, based on tumor size, age at diagnosis, and race.

RESULTS

Age-adjusted rates for all breast cancers have increased since 1975, with the largest change occurring since 1983. Age-adjusted incidence rates for ductal carcinoma in situ (DCIS) and cancers smaller than 2.0 cm were higher in white women than black women, whereas age-adjusted incidence rates for larger tumors (> or = 2.0 cm) have been higher in black women since 1985. The rate of increase in incidence as measured by the average interval percentage change was highest for DCIS and small invasive tumors (< 1.0 cm) for all age groups of women.

CONCLUSIONS

The more rapid increase in incidence of early breast cancer in the population suggests that the observed increase in breast cancer incidence over the last 2 decades may have resulted, at least in part, from a screening effect.

Effects of cognitive style and maintenance strategies on breast self-examination (BSE) practice by African American women

A convenience sample of 159 African American women, 18-45 years old, was trained to perform breast self-examination (BSE) and was categorized according to the participants' cognitive style (monitors/blunters). Participants were then randomly assigned to one of four groups differing in BSE maintenance strategy (self-management, positive reinforcement, both, or neither). Self-reported monthly compliance with BSE was subsequently assessed during a 9-month period. A significant interaction between maintenance strategies and cognitive style was found. For blunters, the highest compliance rates and the highest competency scores occurred in the group with no maintenance strategy, whereas for monitors, the highest compliance rates and competency scores were found in the groups receiving positive reinforcement and/or self-management strategies. Additional results indicate that high levels of BSE competency were achieved across conditions and that competency improved over time.

Cellulitis after axillary lymph node dissection for carcinoma of the breast

We present a series of patients who developed cellulitis following axillary lymph node dissection for carcinoma of the breast. Bacterial cultures were not helpful in making a diagnosis for the majority of the cases. The clinical scenario of upper extremity cellulitis after axillary dissection mimics the presentation of cellulitis in the lower extremity. Until diagnostic methods or treatment advances can eliminate the indications for axillary lymphadenectomy, many women treated for breast cancer will be at long-term risk for the development of cellulitis due to localized immune impairment. Patient and physician awareness of this syndrome is the best available tool to prevent secondary exacerbation of lymphedema. Prompt treatment with appropriate antibiotics appears universally successful. Antistreptococcal antibiotics should not be withheld pending results of blood or tissue cultures, since in only a few cases will a pathogen be isolated. Although there are no studies confirming the concept, it is likely that appropriate treatment for lymphedema may reduce the risk of infection.

Stage and delay in breast cancer diagnosis by race, socioeconomic status, age and year

Information on 23,567 Non-Hispanic White, 2,539 Black, and 2,380 Hispanic breast cancer cases diagnosed between 1977 and 1985 was used to evaluate the risk of late stage diagnosis and long duration of symptoms prior to diagnosis in relation to ethnicity, socioeconomic status, age and year of diagnosis. All data were collected by the University of Southern California Cancer Surveillance Program, the comprehensive population-based incidence registry of Los Angeles County. The results indicate that lower socioeconomic status, Black or Hispanic ethnicity, younger age, and earlier year of diagnosis are risk factors for late stage diagnosis and long duration of symptoms. The effect of ethnicity was not explained by lower SES levels among Black or Hispanic women. After controlling for duration of symptoms, race and SES remained significantly predictive of more advanced stage. More recent diagnosis across the 9 year time frame was not associated with improved stage for those of low SES. These results suggest that increased efforts are needed to reach low SES and Black and Hispanic women with campaigns to improve the stage at which breast cancer is detected.

Racial differences in cancer of the male breast--15 year experience in the Detroit metropolitan area

Characteristics of cancer of the male breast were evaluated in a population based review of 244 cases identified retrospectively through the Metropolitan Detroit Cancer Surveillance System (MDCSS) between 1973 and 1987. The mean age at diagnosis was 65 years and median survival time, 44 months. There were no apparent time trends in incidence for either white or black men from 1973 through 1987. Modified radical mastectomy was the most common surgical procedure, while simple and radical mastectomy declined in popularity over time. Cox's proportional hazards regression model was used to test the simultaneous effects of age, race, stage, and treatment on survival. Men older than 65 at diagnosis had a greater risk of dying than men under 65 (RR 1.52, 95% confidence interval, 1.01-2.28). Survival was significantly worse for men who presented at a more advanced stage; regional versus localized (RR 2.19, 95% confidence interval, 1.39-3.45) and remote versus localized (RR 4.31, 95% confidence interval 2.26-8.23). Race had no significant effect on survival in men with breast cancer in the Detroit Metropolitan Area.

Trends in the diagnosis of in situ breast cancer in the Detroit metropolitan area, 1973 to 1987

The recent increase in incidence in situ breast cancer has been marked by a higher detection rate among white women. Although the increase in incidence may reflect the concomitant uptrend in mammographic screening, the lower proportion of cases among black women is of major public health concern. Time trends in the diagnosis of in situ breast cancer were evaluated in a population-based analysis of data accrued from the Metropolitan Detroit Cancer Surveillance System. The proportions of in situ cases detected among all women with breast cancer were measured annually between 1973 and 1987, and the average interval percentage changes were calculated for eight subgroups of women stratified by race and age at diagnosis. Although the proportions of in situ cancers were generally higher among white than black women, the greatest increase in average interval percentage change was observed in the oldest age category of black women. The disparity seen in younger black and white women suggests possible implications for breast cancer screening. From 1973 through 1987, the largest increase in diagnosis of in situ breast cancer occurred in black women older than 70.