A comparative study of breast cancer in the black and white populations of two inner-city hospitals

Histopathology of breast cancer among African-American women

Although the overall incidence of breast cancer in African-American women is lower than in white women, African-American women younger than 50 years old have a higher incidence of breast cancer than white women. African-American women with breast cancer have a poorer survival rate than white women and are more likely to die of breast cancer in almost every age group. To explain this disparity, we studied a substantial body of literature that reported a biologic difference in the tumors found in African-American and white women. Specifically, more aggressive histopathologic patterns have been described among African-American patients with breast cancer when compared with white women. In addition, there are data that support an ethnicity-related variation in the expression of breast tumor hormonal markers. The objective of this study was to critically evaluate the existing published data on the histologic features of breast cancer to determine whether breast cancer in African-American women is a histologically more aggressive disease than in white women. We conclude that the aggressive tumor histology reported in African-American women has not been analyzed carefully with respect to the age of the patient at the time of diagnosis and the stage of disease at presentation. Furthermore, there is a need for central pathology review using accepted, published criteria for diagnosis of uncommon and controversial histologic subtypes of breast cancer.

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.

Local recurrence and survival among black women with early-stage breast cancer treated with breast-conservation therapy or mastectomy

BACKGROUND

Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer.

METHODS

The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed.

RESULTS

Fifty-eight percent of patients (n = 211) had tumors < or = 5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P < .01) and the mastectomy group (43% vs. 76%, P < .01). LR and 5-year disease-specific survival rates were similar for patients <50 years of age and patients > or = 50 years of age, regardless of treatment.

CONCLUSIONS

LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.

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.

Relationship between breast histopathology and family history of breast cancer

BACKGROUND

The relationship between breast cancer histology and a number of epidemiologic risk factors associated with breast cancer was examined in 4071 histologically confirmed breast cancer cases aged 20 to 54 years from the Cancer and Steroid Hormone Study.

METHODS

The distribution of risk factors, which included a family history of breast cancer, age at onset of breast cancer, laterality, race, age at menarche, age at menopause, history of benign breast disease, parity, number of livebirths and number of stillbirths, and age at first childbirth, were examined by histologic subgroup. To determine whether histology is associated with familial risk of breast cancer, a Cox proportional hazards model was used, modeling time to onset of breast cancer among mothers and sisters.

RESULTS

Cases with medullary carcinoma were found to be significantly younger than cases with other tumor types in these data. In addition, medullary carcinoma was reported more frequently among black cases than among white cases. Cases with lobular carcinoma in situ were significantly more likely to have a mother and/or sister affected with breast cancer than cases with other tumor types and were also more likely to be bilateral, although few of these cases were both bilateral and reported a family history of breast cancer. The highest reported rates of benign breast disease occurred in cases with carcinoma in situ (both ductal and lobular) and tubular carcinoma. The remaining risk factors showed no association with histology.

CONCLUSIONS

The current study clarifies the extent and nature of the relationship between breast cancer histology and epidemiologic risk factors including a family history of breast cancer.

Ethnic variation in breast cancer survival: a review

Intercountry, as well as intracountry, survival comparisons have revealed some differences in breast cancer survival among various ethnic populations. Most of these differences are probably explained by factors related to socioeconomic status. However, the well documented survival advantage of Japanese patients compared to Caucasian patients remains unexplained. Some recent studies suggest an adverse prognostic effect for obesity. Although still inconclusive, these findings raise the possibility that the better survival of Japanese patients may be in part related to their lower mean body weight. An effect of the lower fat intake of the Japanese in explaining their breast cancer survival advantage has little support at present, but, like the obesity hypothesis, deserves further study.

Histologic types of breast carcinoma in relation to international variation and breast cancer risk factors. WHO Collaborative Study of Neoplasia and Steroid Contraceptives

Associations between breast cancer risk factors and histologic types of invasive breast carcinoma were studied in 2,728 patients. Lobular and tubular carcinomas occurred with increased relative frequency in most high-risk groups. The proportion of these types increased with age to a maximum at 45-49 years and decreased in the following decade. Significantly increased proportions of lobular and tubular carcinomas were also associated with high-risk countries, prior benign breast biopsy, bilateral breast cancer, concurrent mammary dysplasia, high age at first live birth, never-pregnant patients compared to those with a first live birth before age 20, private pay status, and length of education. Nonsignificant increases were associated with family history of breast cancer, less than 5 live births, less than 25 months total of breast feeding, use of oral contraceptives or IUD, and high occupational class. As a general trend, the higher the overall relative risk, the higher the proportion of lobular and tubular carcinomas. The occurrence of other histologic types also increased with increased breast cancer risk, but to a smaller degree than for lobular/tubular carcinomas. It is suggested that all hormonally related, socio-economic and geographic risk factors exert their effect by selectively increasing number of lobular cells at risk. Family history of breast carcinoma and age over 49 years did not follow the general trend parallel increases in the proportion of lobular/tubular carcinomas and breast cancer risk, and may operate through other mechanisms.

Cancer of the breast in poor black women

The authors carried out a retrospective analysis of 708 patients (94% blacks) with breast cancer who were diagnosed, treated and/or followed at Harlem Hospital Center (New York) between 1964 and 1986: nearly all patients were of low economic status with almost 50% having no medical coverage. Surgical treatment was implemented in 512 patients (72%). Radiotherapy and/or chemotherapy alone were used in 94 patients (13%); 102 patients (14%) refused treatment or died before its initiation. The 5-year and 10-year survival rates for those treated surgically were 39% and 27%, respectively. For those patients undergoing surgery (47% of whom were in Stages III and IV), 5-year and 10-year survival rates were analyzed according to stage of the disease. They were 54% and 54%, respectively, for Stage I; 56% and 35%, respectively, for Stage II; 41% and 18%, respectively, for Stage III; and 11% and 0%, respectively, for Stage IV. There was significant difference in the 5-year survival rates between patients with pathologically negative lymph nodes (64%) and a single positive lymph node (71%), compared to those with multiple positive lymph nodes (33%; P = 0.001). The 10-year survival rates were 39%, 34%, and 15% (P = 0.001), respectively. The authors conclude that breast cancer survival in this population of poor black women is low compared to the survival rate of black women nationally and very low compared to white women.

Influence of age on the metastatic behavior of breast carcinoma

The effects of aging on the biologic behavior of malignant neoplasms are poorly understood. To examine the question of a possible age effect on the metastatic behavior of tumors, we reviewed the clinical histories, autopsy protocols, and histologic slides of 187 patients with metastatic breast carcinoma who were subjected to complete autopsy at The Johns Hopkins Hospital. Patients were categorized in four groups according to the age of onset of breast carcinoma: group I had 12 young patients (less than 40 years old); group II had 41 patients, 40 to 46 years old, considered to be premenopausal; group II had 89 patients, 47 to 60 years old, considered to be early postmenopausal; and group IV had 45 patients over 60 years old, considered to be late postmenopausal. Group II patients survived about 50% longer than group III or IV patients (p less than 0.05), and groups I, II, and III patients had significantly greater numbers of metastases than group IV patients (p less than 0.05). There was a progressive decline in the frequencies of metastases in several locations as a function of age, such that group I and II patients had significantly more frequent metastases to the central nervous system (p less than 0.05), endocrine organs (p less than 0.01), ovary (p less than 0.05), pancreas (p less than 0.01), and gastrointestinal tract (p less than 0.05) than patients in group III or IV. These differences in number and distribution of metastases were not explainable on the basis of survival, therapy, or initial stage of disease. The results suggest that the process of aging may influence the metastatic behavior of breast carcinoma; hormonal and metabolic factors may be implicated.

Social and biological factors in relation to survival among black vs. white women with breast cancer

Longer survival for white women than black women with breast cancer has been observed even when relative survival rates are used and stage at diagnosis is controlled. This study compared prognostic factors in relation to survival for 144 white women and 67 black women with breast cancer diagnosed 1969 to 1979 and identified through the tumor registry. Data were obtained from medical records, the registry, death certificates, and pathology files. Median survival was 7.5 years for whites, vs. 5.6 years for blacks. Significant differences between races were also observed for histological type and grade of tumor, presenting symptoms, and health status at diagnosis. Although Cox multiple regression analyses showed pathological stage at diagnosis and number of positive nodes to be the best predictors of survival in both whites and blacks, the differences in histological type observed in this sample merits further research; blacks have fewer well-differentiated tumors, the type associated with positive estrogen receptors and with better survival.

Race-related differences in breast cancer patients. Results of the 1982 national survey of breast cancer by the American College of Surgeons

Data from the 1982 breast cancer survey of the American College of Surgeons were used to evaluate factors related to clinical, epidemiologic, and survival differences between black and white patients. Breast cancer in blacks was not discovered as early as in whites. Distribution of pathologic types of tumors were similar for both races with the exception of medullary carcinoma, which was more frequent in blacks than in whites. Estrogen receptor-positive tumors were found significantly less frequently in blacks compared with whites. Survival was better for whites compared with blacks within each axillary nodes group 0, 1 to 3, and 4+. Black women with negative or positive estrogen receptors had lower survival rates than white women of the same receptor status. A regression analysis using Cox's proportional hazards model showed race, clinical stage or axillary nodal status, age at diagnosis, and estrogen receptor status as significant predictors of survival. Significant differences between black and white patients were also observed with respect to the report of family history of breast cancer, age at first pregnancy, number of pregnancies, and age at cessation of menses.

Genetics, biomarkers, and control of breast cancer: a review

More has been written about the epidemiology of breast cancer than possibly any other form of cancer affecting mankind. However, in the face of this intense interest, only a paucity of attention has been given to the role of genetics in its etiology. This review represents an attempt by the investigators to provide a comprehensive coverage of hereditary breast cancer. Included are pertinent endogeneous and exogeneous risk factors, which in certain circumstances, may significantly influence the role of primary genetic factors. Hereditary breast cancer is heterogeneous. When discussing the subject, therefore, one must be precise relevant to the particular heterogeneous form of concern, based on differing tumor associations. It is probably not appropriate to discuss "hereditary breast cancer" without qualification of the specific hereditary breast cancer syndrome of concern; i.e., the SBLA syndrome, breast/ovarian cancer syndrome, and others. This reasoning also applies to attempts at linking biomarkers to hereditary breast cancer. Finally, in addition to ongoing discussions on the cardinal principles that associate with hereditary forms of breast cancer, its frequency, and new developments in biomarkers, we have provided surveillance/management programs that embrace those facets of the natural history of this disease.

Epidemiology of breast carcinoma IV: age and histologic tumor type

The purpose of this study was to correlate major chronologic events known to have a bearing on the risk for developing breast carcinoma with histologic tumor type. Data were obtained for 1024 consecutively treated patients with the seven most common forms of mammary carcinoma. The age of occurrence of the following events was determined: menarche; first marriage; first pregnancy and first childbirth; last pregnancy and last childhood; diagnosis. The interval between each of these events and diagnosis of breast cancer was also calculated. Patients with medullary carcinoma had a significantly lower mean age at diagnosis than those with any of the other tumor types. Because of the lower mean age at diagnosis, medullary carcinoma patients were found to have significantly shorter intervals between age at diagnosis and the following: menarche, first pregnancy or first childbirth, and last pregnancy or last childbirth. Intervals between age at diagnosis and these other events were not significantly different among patients with other types of carcinoma. The ages of menarche, marriage, or pregnancy were not related independently to any tumor type. These data indicate that except for current age, the age of occurrence of major risk factors for developing breast cancer is unrelated to the histological type of tumor a patient develops.