Local recurrence following breast conservation therapy in African-American women with invasive breast cancer

Racial and socioeconomic disparities in triple-negative breast cancer treatment

INTRODUCTION

Triple-negative breast cancer (TNBC) continues to be a significant concern, especially among minority populations, where treatment disparities are notably pronounced. Addressing these disparities, especially among African American women and other minorities, is crucial for ensuring equitable healthcare.

AREAS COVERED

This review delves into the continuum of TNBC treatment, noting that the standard of care, previously restricted to chemotherapy, has now expanded due to emerging clinical trial results. With advances like PARP inhibitors, immunotherapy, and antibody-drug conjugates, a more personalized treatment approach is on the horizon. The review highlights innovative interventions tailored for minorities, such as utilizing technology like text messaging, smartphone apps, and targeted radio programming, coupled with church-based behavioral interventions.

EXPERT OPINION

Addressing TNBC treatment disparities demands a multifaceted approach, blending advanced medical treatments with culturally sensitive community outreach. The potential of technology, especially in the realm of promoting health awareness, is yet to be fully harnessed. As the field progresses, understanding and integrating the socio-economic, biological, and access-related challenges faced by minorities will be pivotal for achieving health equity in TNBC care.

Racial and Ethnic Disparities in Locoregional Recurrence Among Patients With Hormone Receptor-Positive, Node-Negative Breast Cancer: A Post Hoc Analysis of the TAILORx Randomized Clinical Trial

Importance

Whether racial and ethnic disparities in locoregional recurrence (LRR) exist among patients with similar access to care treated in randomized clinical trials is unknown.

Objective

To examine racial and ethnic differences in LRR among patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (ERBB2 [formerly HER2 or HER2/neu])-negative, node-negative breast cancer enrolled in the Trial Assigning Individualized Options for Treatment (TAILORx).

Design, Setting, and Participants

This unplanned retrospective post hoc analysis examined a prospective multicenter clinical trial population of women with breast cancer enrolled between 2006 and 2010, with 9 years of follow-up. The TAILORx investigators randomized patients to treatment based on their Oncotype DX recurrence score, including endocrine therapy alone (recurrence score <11), endocrine therapy alone vs chemotherapy followed by endocrine therapy (recurrence score 11-25), or chemotherapy followed by endocrine therapy (recurrence score >25). Patients with unknown race and ethnicity or lack of follow-up were excluded from this analysis. Data analysis was performed between December 2021 and March 2022.

Main Outcome and Measures

Locoregional recurrence was defined as ipsilateral in breast, skin, chest wall, or regional nodal recurrence without concurrent distant recurrence, and was stratified by racial and ethnic group. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards regression models were used for survival analyses.

Results

Of the 10 273 women enrolled in TAILORx, this analysis included 9369 with T1-2N0 HR-positive, ERBB2-negative breast cancer. Of these patients, 428 (4.6%) were Asian, 886 (9.4%) were Hispanic, 676 (7.2%) were non-Hispanic Black (hereinafter Black), and 7406 (78.8%) were non-Hispanic White (hereinafter White). Assigned treatment receipt was high, with a 9.3% (n = 870) crossover of treatment groups and a median endocrine therapy duration of longer than 60 months, ranging from 61.1 to 65.9 months, across racial and ethnic groups. A total of 6818 patients (72.6%) received radiation (6474 [96.1%] after breast-conserving surgery and 344 [13.0%] after mastectomy). At a median follow-up of 94.8 months (range, 1-138 months), 8-year LRR rates were 3.6% (95% CI, 1.6%-5.6%) in Asian patients, 3.9% (95% CI, 2.2%-5.4%) in Black patients, 3.1% in Hispanic patients (95% CI, 1.7%-4.5%), and 1.8% (95% CI, 1.5%-2.3%) in White patients (P < .001). In survival analyses adjusted for patient, tumor, and treatment factors, Asian race (hazard ratio, 1.91 [95% CI, 1.12-3.29]) and Black race (1.78 [1.15-2.77]) were independently associated with LRR. In adjusted survival analyses for breast cancer mortality, LRR was independently associated with increased breast cancer mortality (hazard ratio, 5.71 [95% CI, 3.50-9.31]).

Conclusions and Relevance

In this post hoc analysis, racial and ethnic differences in LRR were observed among patients with T1-2N0 HR-positive, ERBB2-negative breast cancer despite high rates of treatment receipt in this clinical trial population, with the highest LRR rates in Asian and Black patients. Further study is needed to understand whether failure to rescue after LRR may contribute to racial disparities in breast cancer mortality.

Trial Registration

ClinicalTrials.gov Identifier: NCT00310180.

Health and Racial Disparity in Breast Cancer

Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. It currently affects more than one in ten women worldwide. The chance for a female to be diagnosed with breast cancer during her lifetime has significantly increased from 1 in 11 women in 1975 to 1 in 8 women (Altekruse, SEER Cancer Statistics Review, 1975-2007. National Cancer Institute, Bethesda, 2010). This chance for a female of being diagnosed with cancer generally increases with age (Howlader et al, SEER Cancer Statistics Review, 1975-2010. National Cancer Institute, Bethesda, 2013). Fortunately, the mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments in the White population. Although the mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic population has continued to grow. The goal of the work presented in this book chapter is to highlight similarities and differences in breast cancer morbidity and mortality rates among non-Hispanic white and non-Hispanic black populations. This book chapter also provides an overview of breast cancer, racial/ethnic disparities in breast cancer, breast cancer incidence and mortality rate linked to hereditary, major risk factors of breast cancer among minority population, breast cancer treatment, and health disparity. A considerable amount of breast cancer treatment research have been conducted, but with limited success for African Americans compared to other ethnic groups. Therefore, new strategies and approaches are needed to promote breast cancer prevention, improve survival rates, reduce breast cancer mortality, and ultimately improve the health outcomes of racial/ethnic minorities. In addition, it is vital that leaders and medical professionals from minority population groups be represented in decision-making in research so that racial disparity in breast cancer can be well-studied, fully addressed, and ultimately eliminated in breast cancer.

Assessing the Racial and Ethnic Disparities in Breast Cancer Mortality in the United States

Breast cancer is the second leading cause of cancer related deaths among women aged 40-55 in the United States and currently affects more than one in ten women worldwide. It is also one of the most diagnosed cancers in women both in wealthy and poor countries. Fortunately, the mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments in White population. Although the mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic populations has continued to grow. The goal of the present review article was to highlight similarities and differences in breast cancer morbidity and mortality rates primarily among African American women compared to White women in the United States. To reach our goal, we conducted a search of articles in journals with a primary focus on minority health, and authors who had published articles on racial/ethnic disparity related to breast cancer patients. A systematic search of original research was conducted using MEDLINE, PUBMED and Google Scholar databases. We found that racial/ethnic disparities in breast cancer may be attributed to a large number of clinical and non-clinical risk factors including lack of medical coverage, barriers to early detection and screening, more advanced stage of disease at diagnosis among minorities, and unequal access to improvements in cancer treatment. Many African American women have frequent unknown or unstaged breast cancers than White women. These risk factors may explain the differences in breast cancer treatment and survival rate between African American women and White women. New strategies and approaches are needed to promote breast cancer prevention, improve survival rate, reduce breast cancer mortality, and ultimately improve the health outcomes of racial/ethnic minorities.

Independent Prognostic Factors for Overall Survival after Salvage Operation for Ipsilateral Breast Tumor Recurrence Following Breast-Conserving Surgery

PURPOSE

Few studies address independent prognostic factors after ipsilateral breast tumor recurrence (IBTR) following breast-conserving surgery (BCS). Locoregional recurrence is associated with distant metastases and increased mortality rates. Therefore anticipating prognoses after IBTR and evaluating risk factors for overall survival following a second salvage operation are important. We evaluated independent prognostic factors affecting overall survival after a second operation for IBTR.

METHODS

We retrospectively identified 11,073 patients who underwent breast cancer surgery between November 1995 and December 2011. Locoregional recurrence occurred in 787 patients. Among them, IBTR developed in 165 patients selected for analysis. Excluding eight patients who refused further treatment, we analyzed 157 patients who underwent a second operation (partial mastectomy, 28 [17.8%]; total mastectomy, 129 [82.2%]) for IBTR. Excluding 26 patients with incomplete data, we evaluated the clinicopathol-ogical features influencing overall survival at the first and the second operation in the 131 patients who underwent a second operation.

RESULTS

The median age of patients at the first operation was 43.6 years (range, 27-69 years). The median duration from the first to the second operation was 45.0 months (range, 2.5-164.6 months). The 5-year overall survival rate after IBTR was 87.1%. In the multivariable analyses, duration from the first to the second operation, histopathology, lymph node status, and adjuvant chemotherapy, radiotherapy, and endocrine therapy at the first operation were independent prognostic factors for overall survival. Positive estrogen receptor status and endocrine therapy at the second operation were also associated with increased overall survival following salvage operations for IBTR.

CONCLUSION

The time interval to IBTR following BCS is related to overall survival after salvage operation for IBTR and it is important to undergo optimal adjuvant treatments according to risk factors after the first operation because those risk factors affect overall survival for IBTR following BCS.

The 21-gene recurrence score and locoregional recurrence in breast cancer patients

PURPOSE

Although the 21-gene recurrence score (RS) assay has been validated to assess the risk of distant recurrence in hormone receptor-positive breast cancer patients, the relationship between RS and the risk of locoregional recurrence (LRR) remains unclear. The purpose of this study was to determine if RS is associated with LRR in breast cancer patients and whether this relationship varies based on the type of local treatment [mastectomy or breast-conserving therapy (BCT)].

METHODS

163 consecutive estrogen receptor-positive breast cancer patients at our institution had an RS generated from the primary breast tumor between August 2006 and October 2009. Patients were treated with lumpectomy and radiation (BCT) (n = 110) or mastectomy alone (n = 53). Patients were stratified using a pre-determined RS of 25 and then grouped according to local therapy type.

RESULTS

Median follow-up was 68.2 months. Patients who developed an LRR had stage I or IIA disease, >2 mm surgical margins, and received chemotherapy as directed by RS. While an RS > 25 did not predict for a higher rate of LRR, an RS > 24 was associated with LRR in our subjects. Among mastectomy patients, the 5-year LRR rate was 27.3 % in patients with an RS > 24 versus 10.7 % (p = 0.04) in those whose RS was ≤ 24. RS was not associated with LRR in patients who received BCT.

CONCLUSIONS

Breast cancer patients treated with mastectomy for tumors that have an RS > 24 are at high risk of LRR and may benefit from post-mastectomy radiation.

An exploratory analysis of fear of recurrence among African-American breast cancer survivors

BACKGROUND

Fear of recurrence (FOR) is a psychological concern that has been studied extensively in cancer survivors but has not been adequately examined in African-American breast cancer survivors.

PURPOSE

This exploratory study describes the extent and nature of FOR in African-American breast cancer survivors. FOR is examined in relation to socio-demographic characteristics, treatment-related characteristics, psychological distress, and quality of life (QOL).

METHODS

Participants completed questionnaires assessing FOR, psychological distress, QOL, and demographic and treatment characteristics. Pearson r correlations, t tests, and ANOVAs were used to determine the association between FOR and demographic and treatment-related characteristics. Hierarchical multiple regression models were performed to investigate the degree to which FOR dimensions account for the variance in QOL and psychological distress.

RESULTS

Fifty-one African-American breast cancer survivors participated in this study. The mean age of participants was 64.24 (SD = 12.3). Overall fears as well as concerns about death and health were rated as low to moderate. Role worries and womanhood worries were very low. Inverse relationships were observed between age and FOR dimensions. FOR was positively correlated with measures of psychological distress and negatively correlated with QOL. FOR significantly accounted for a portion of the variance in QOL and distress after controlling for other variables.

CONCLUSIONS

This study suggests that African-American women in this sample demonstrated some degree of FOR. Results indicate that FOR among African-American breast cancer survivors decreases with age and time since diagnosis and co-occurs with psychological distress as well as diminished quality of life.

Racial differences and disparities in cancer care and outcomes: where's the rub?

Despite a profusion of studies over the past several years documenting racial differences in cancer outcomes, there is a paucity of data as to the root causes underlying these observations. This article reviews work to date focusing on black-white differences in cancer outcomes, explores potential mechanisms underlying these differences, and identifies patient, physician, and health care system factors that may account for persistent racial disparities in cancer care. Research strategies to elucidate the relative influence of these various factors and policy recommendations to reduce persistent disparities are also discussed.

A longitudinal study of factors associated with perceived risk of recurrence in women with ductal carcinoma in situ and early-stage invasive breast cancer

Breast cancer patients' perceived risk of recurrence has been associated with psychological distress. Little is known about the change of patients' perceived risk of recurrence over time and factors associated with their recurrence-risk perceptions. We prospectively recruited 549 newly diagnosed early-stage breast cancer patients; patients completed interviews at 6 weeks, 6 months, 1 year, and 2 years after definitive surgical treatment. A random-effects regression model with repeated ordinal measurements was used to estimate the relationship between perceived risk of recurrence and demographic, medical, and psychosocial factors. We analyzed data from 535 patients [34% ductal carcinoma in situ (DCIS); 20% non-white] who reported their perceived risk at one or more interviews. At the first interview, 16% reported having no lifetime risk of recurrence, and another 16% reported ≥ 50% risk of recurrence, including 15% of DCIS patients. Patients who were white (OR = 5.88, 95% CI 3.39-10.19) and had greater state anxiety (OR = 1.04, 95% CI 1.02-1.07) were more likely, while patients who received radiotherapy (OR = 0.72, 95% CI 0.54-0.96) and had more social support (OR = 0.59, 95% CI 0.46-0.75) were less likely to report higher risk of recurrence. Cancer stage was not significantly associated with perceived risk of recurrence. Perceived risk of recurrence did not change significantly over time. Educating early-stage breast cancer patients about their actual risk could result in more realistic recurrence-risk perceptions, and increasing social support could help alleviate anxiety associated with exaggerated risk perceptions.

Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer

PURPOSE

Locoregional failure (LRF) after breast-conserving therapy (BCT) is associated with increased risk of distant disease and death. The magnitude of this risk has not been adequately characterized in patients with lymph node-negative disease.

PATIENTS AND METHODS

Our study population included 3,799 women randomly assigned to five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative disease (ie, B-13, B-14, B-19, B-20, and B-23) who underwent lumpectomy and whole breast irradiation with or without adjuvant systemic therapy. Cumulative incidences of ipsilateral breast tumor recurrence (IBTR) and other locoregional recurrence (oLRR) were calculated, along with distant-disease-free interval (DDFI) and overall survival (OS) after these events. Cox models were employed to model mortality by using clinical and pathologic factors jointly with these events.

RESULTS

Four hundred nineteen patients (11.0%) experienced LRF: 342 (9.0%) experienced IBTR, and 77 (2.0%) experienced oLRR. The 12-year cumulative incidences of IBTR and oLRR in patients treated with adjuvant systemic therapy were 6.6% and 1.8%, respectively. Overall, 37.1% of IBTRs and 72.7% of oLRRs occurred within 5 years of diagnosis. Older age, black race, higher body mass index (BMI), larger tumors, and occurrence of IBTR or oLRR were significantly associated with increased mortality. The 5-year OS after IBTR and oLRR were 76.6% and 34.9%, respectively. Adjusted hazard ratios for mortality associated with IBTR and oLRR were significantly higher in estrogen receptor (ER)-negative patients than in ER-positive patients (P = .002 and P < .0001, respectively). Patients with early LRF had worse OS and DDFI than those with later-occurring LRF.

CONCLUSION

Although LRF is uncommon in patients with node-negative breast cancer who are treated with lumpectomy, radiation, and adjuvant systemic therapy, those who do develop LRF have substantially worse OS and DDFI.

Long-term outcomes and clinicopathologic differences of African-American versus white patients treated with breast conservation therapy for early-stage breast cancer

BACKGROUND

African-American (AA) and white patients with early-stage disease who were treated with breast conservation therapy (BCT) were examined to detect differences in clinicopathologic features and outcomes as a function of race.

METHODS

Clinical data from the charts of 2164 white and 207 AA patients treated with BCT, and p53 expression status on 444 patients (from an existing tissue database), were analyzed to detect differences between the 2 cohorts.

RESULTS

The median follow-up was 7 years. There were no differences in the method of tumor detection, lymph nodes excised, surgical margin status, or chemotherapy/radiotherapy delivered, reflecting similar screening and treatment policies for AA women in the study community. Despite this, AA patient presented at a younger age, with higher T and N classifications, and more estrogen and progesterone negative and "triple negative" tumors (all P values < .016). Tumors in AA patients were p53 positive more often than tumors in white patients (P= .0003). At 10 years, AA patients had a higher rate of distant metastasis (20% vs 17%; P= .042), lymph node recurrence (6% vs 2%; P= .004), and breast recurrence (17% vs 13%; P= .036). There was no difference in overall survival between the 2 groups. On multivariate analysis, only lymph node recurrence (risk ratio of 3.140; 95% confidence interval, 1.396-7.063 [P= .0057]) remained significantly higher among AA women.

CONCLUSIONS

In this cohort of uniformly treated patients, the authors found the expected clinicopathologic differences, but race was not found to be an independent predictor of local recurrence for AA patients when other confounding variables were taken into account in the multivariate model. These findings suggest that BCT is a reasonable option for appropriately selected AA patients. To the authors' knowledge, this is the largest study addressing outcomes after BCT for AA women published to date.

Urban/rural residence moderates effect of race on receipt of surgery in patients with nonmetastatic breast cancer: a report from the South Carolina central cancer registry

BACKGROUND

Surgical resection is the cornerstone of therapy in patients with nonmetastatic breast cancer. Previous studies have reported underuse of adjuvant therapy among African Americans (AA). This study explores the independent effect of race on surgical resection in a recent, population-based sample of breast cancer patients.

METHODS

All cases of nonmetastatic breast cancer reported to the our state Cancer Registry between 1996 and 2002 were identified and linked to the state Inpatient/Outpatient Surgery Files and the 2000 Census. Characteristics between Caucasian and AA patients were compared using Student's t and chi-square tests. Odds ratios (OR) of resection and 95% confidence intervals (CI) were calculated using logistic regression.

RESULTS

We identified 12,404 Caucasian and 3,411 AA women. AA patients were more likely to be younger, non-married, have greater comorbidity, reside in rural communities, be less educated, live in poverty, and be uninsured or covered by Medicaid (all P < 0.0001). AA patients were slightly less likely to undergo resection compared to Caucasian patients (94.9% versus 96.4%, P < 0.0001). An interaction effect between race and urban/rural patient residence was observed (P = 0.003). After controlling for other factors, the adjusted OR for resection for urban AA patients was 0.58 (95% CI 0.41-0.82). In contrast, race had no effect on resection among rural patients (OR = 1.02; 95% CI 0.70-1.47).

CONCLUSIONS

AA race is an independent predictor of underuse of surgery among urban patients with breast cancer, while rural residence is associated with underuse of surgery, irrespective of race. Interventions designed to optimize surgical cancer care should target these vulnerable populations.

Barriers to adequate follow-up during adjuvant therapy may be important factors in the worse outcome for Black women after breast cancer treatment

Introduction

Black women appear to have worse outcome after diagnosis and treatment of breast cancer. It is still unclear if this is because Black race is more often associated with known negative prognostic indicators or if it is an independent prognostic factor. To study this, we analyzed a patient cohort from an urban university medical center where these women made up the majority of the patient population.

Methods

We used retrospective analysis of a prospectively collected database of breast cancer patients seen from May 1999 to June 2006. Time to recurrence and survival were analyzed using the Kaplan-Meier method, with statistical analysis by chi-square, log rank testing, and the Cox regression model.

Results

265 female patients were diagnosed with breast cancer during the time period. Fifty patients (19%) had pure DCIS and 215 patients (81%) had invasive disease. Racial and ethnic composition of the entire cohort was as follows: Black (N = 150, 56.6%), Hispanic (N = 83, 31.3%), Caucasian (N = 26, 9.8%), Asian (N = 4, 1.5%), and Arabic (N = 2, 0.8%). For patients with invasive disease, independent predictors of poor disease-free survival included tumor size, node-positivity, incompletion of adjuvant therapy, and Black race. Tumor size, node-positivity, and Black race were independently associated with disease-specific overall survival.

Conclusion

Worse outcome among Black women appears to be independent of the usual predictors of survival. Further investigation is necessary to identify the cause of this survival disparity. Barriers to completion of standard post-operative treatment regimens may be especially important in this regard.

Posttreatment breast cancer surveillance and follow-up care experiences of breast cancer survivors of African descent: an exploratory qualitative study

Breast cancer survivors are at considerable risk for breast cancer recurrence and at higher risk of developing a new breast cancer compared with women never diagnosed. It is recommended that survivors undergo careful breast cancer surveillance as cancers detected early are more treatable. However, data indicate that surveillance among African American survivors, particularly mammography, is lower than that of white survivors. There is little published work focusing on general experiences of posttreatment breast cancer surveillance among survivors of African descent. In the current qualitative pilot study, key informant interviews were conducted in order to explore the following: (1) the extent of posttreatment surveillance information provided to or obtained by survivors of African descent; (2) the actual follow-up care received by survivors in the past year; and (3) factors that are either motivators of or barriers to care. Participants were 10 African American and African Caribbean breast cancer survivors. Survivors reported a number of factors that motivated them in obtaining follow-up care: a desire to maintain good health, concern about recurrence, support from healthcare providers, familial relationships, relationships with other survivors, and religious/spiritual faith. Survivors also reported barriers to care: fear of recurrence, low support from family and friends, lack of information about posttreatment follow-up care, and medical care costs. These results represent formative work that may inform similar studies examining factors in breast cancer surveillance and follow-up care in larger samples of survivors of African descent.

Are there racial differences in breast cancer treatments and clinical outcomes for women treated at M.D. Anderson Cancer Center?

PURPOSE

To determine the influence of race on breast cancer treatment and on recurrence and breast cancer specific death.

PATIENTS AND METHODS

The study population consisted of 6,054 African-American or white women who were diagnosed with breast cancer and received at least one of the treatments including mastectomy or breast conservative surgery, radiation, adjuvant chemotherapy, neo-adjuvant chemotherapy, and adjuvant endocrine therapy at M.D. Anderson Cancer Center between June 1997 and February 2005. The clinical outcomes were disease-free survival and breast-cancer-specific survival. Logistic regression analysis was performed to investigate if race was associated with the selection of each primary treatment while adjusting for tumor characteristics at diagnosis. Cox proportional hazards model was used to determine the effect of race on recurrence-free survival and breast-cancer-specific survival controlling for tumor characteristics, presence of co-morbidity conditions and use of these treatments.

RESULTS

The use of any primary treatment for breast cancer was not significantly different by race after adjusting for tumor characteristics and co-morbidity conditions. Although tumor characteristics at diagnosis explained the major differences in clinical outcomes, race remained an independent prognostic factor for breast-cancer-specific survival (P=0.002), and a marginally significant factor for disease-free survival (P=0.063) in multivariate analyses.

CONCLUSION

Equal treatment may not lead to equal clinical outcomes given similar tumor characteristics at diagnosis. To reduce racial differences in breast cancer recurrence and survival, it is important to have a better understanding of differences in tumor biology by race and to promote the use of early detection programs among African-American women.

Breast Cancer in African‐American Women

African-American women face a lower risk of being diagnosed with breast cancer as compared to Caucasian-American women, yet they paradoxically face an increased breast cancer mortality hazard. An increased incidence rate for early-onset disease has also been documented. This manuscript review summarizes the socioeconomic, environmental, genetic, and possible primary tumor biologic factors that may explain these disparities.

Clinical outcome and cosmesis in African-American patients treated with conservative surgery and radiation therapy

PURPOSE

The purpose of this study was to evaluate the prognostic significance of race in breast cancer patients treated with lumpectomy and radiation therapy.

METHODS AND MATERIALS

Between 1973 and 1997, 1614 patients were treated with lumpectomy and radiation therapy at our institution. All patient data, including race, age, stage, pathology, treatment, and outcome variables, were entered into a computerized database. One hundred and one women were identified as African American, and 1513 were identified as white. A small number (22) of patients of Asian, Hispanic, or other ethnic groups were eliminated from analysis. A detailed cosmetic analysis was performed on a selected subset of 20 African-American patients and 20 white patients from the database. The two groups were intentionally matched by age, follow-up, adjuvant therapy, and breast size and were asked to participate in a detailed cosmetic evaluation.

RESULTS

As of September 2001, median follow-up was 14.5 years. African-American patients presented with an earlier age of onset than white patients (51.1 African-American patients vs 56.5 white). By age groups, 42.5% of African-American patients were older than 50 years, compared with 68.6% of white patients. African-American patients presented with larger tumors (mean pathological size, 1.87 cm in African-American patients vs 1.57 cm in white patients) and were more frequently estrogen receptor negative (51% estrogen receptor-negative African-American patients vs 37% estrogen receptor-negative white patients). However, nodal status was similar in the two populations (27% node-positive African-American patients vs 24% node-positive white patients). Given their younger age and estrogen receptor negativity, African-American patients were more likely to receive chemotherapy, whereas white patients were more likely to receive adjuvant tamoxifen. Despite the earlier age of onset and larger tumor size, there were no significant differences between the African-American and white populations with respect to overall survival (82% in the African-American population vs 79% in the white) or cause-specific survival at 10 years (88% in the African-American population vs 86% in the white). African-American patients had a significantly lower breast relapse-free rate at 10 years (81% in the African-American population vs 87% in the white). Although this may be in part related to the younger age in the African-American patients, a multivariate analysis including age, race, margin status, and treatment parameters revealed young age and African-American race to be significantly associated with local relapse. With respect to overall cosmetic outcome and all specific cosmetic measures (edema, fibrosis, and pigmentation), African-American patients fared more poorly than white patients. Overall cosmesis was good to excellent in 55% of African Americans, compared with 90% of whites.

CONCLUSIONS

Despite a younger age of onset and a larger tumor size, outcome in African-American patients was similar to that of white patients with respect to overall and cause-specific survival. The explanation for a slightly higher local relapse rate and poorer cosmetic result requires further investigation.

Treatment choices and response rates in African-American women with breast carcinoma

BACKGROUND

Breast cancer mortality rates are higher among African-American women compared with white American women, yet little is known regarding ethnicity-related variation in patterns of primary surgical treatment, locoregional recurrence rates, and response to induction chemotherapy.

METHODS

The available literature was reviewed to evaluate outcome from breast-conservation therapy in African-American women and response rates to systemic therapy.

RESULTS

Breast-conservation therapy appears to be underused among African-American women, a pattern that is noted also among white women with breast carcinoma. Higher rates of locoregional recurrence are seen among African-American women regardless of whether they receive breast-conserving treatment or undergo mastectomy, and this appears to be a function of primary tumor biology. Response rates to appropriately delivered systemic therapy are similar for African-American patients and white patients.

CONCLUSIONS

Despite the apparent increased aggressiveness of disease seen in African-American women with breast carcinoma, patterns of response to local and systemic therapy are similar to the patterns seen in white women with breast carcinoma.

Variations in breast carcinoma treatment in older medicare beneficiaries: is it black or white

BACKGROUND

To evaluate associations between race and breast carcinoma treatment.

METHODS

Data from 984 black and 849 white Medicare beneficiaries 67 years or older with local breast carcinoma and a subset of 732 surviving women interviewed 3-4 years posttreatment were used to calculate adjusted odds of treatment, controlling for age, comorbidity, attitudes, region, and area measures of socioeconomic and health care resources.

RESULTS

Sixty-seven percent of women received a mastectomy and 33% received breast-conserving surgery. The odds of radiation omission were 48% higher (95% confidence interval [CI] 1.01-2.19) for blacks than for whites after considering covariates, but the absolute number of women who failed to receive this modality was small (11%). In race-stratified models, the odds of having radiation omitted were significantly higher among blacks living greater distances from a cancer center (vs. lesser) or living in areas with high poverty (vs. low), but these factors did not affect radiation use among whites. Among those interviewed, blacks reported perceiving more ageism and racism in the health care system than whites (P = 0.001). The independent odds of receiving mastectomy (vs. breast conservation and radiation) were 2.72 times higher (95% CI 1.25-5.92) among women reporting the highest quartile of perceived ageism scores, compared with the lowest, and higher perceived ageism tended to be associated with higher odds of radiation omission (P = 0.06).

CONCLUSIONS

Older black women with localized breast carcinoma may have a different experience obtaining treatment than their white counterparts. The absolute number of women receiving nonstandard care was small and the effects were small to moderate. However, if these patterns persist, it will be important to evaluate whether such experiences contribute to within-stage race mortality disparities.

Racial differences in breast cancer survival: the effect of residual disease

BACKGROUND

A survival difference has been seen in numerous studies between African-American (AA) and Caucasian (C) women with breast cancer. The purpose of this study was to elucidate the differences in patient characteristics and outcomes between AA and C women with breast cancer in our population.

METHODS

We performed a retrospective analysis of 1345 women with newly diagnosed breast cancer who were entered into our tumor registry from October 1980 to December 1998.

RESULTS

The association between race and stage at presentation was significant, as was the difference in the overall median survival between C and AA women. The data revealed no significant differences in survival between C and AA women presenting with Stage I or II disease. However, the differences between the median survival times for AA and C women presenting with Stage III and IV disease were both highly significant. A significantly lower percentage of AA women became "disease free" after initial therapy as compared with C women (P < 0.001). Interestingly, when data were stratified by stage, only in Stage III and IV were there significant differences between the races for becoming disease free.

CONCLUSIONS

AA women tend to present at a later stage and have poorer survival from later-stage disease as compared with C women. The poorer survival appears to be related to the decreased ability to achieve disease-free status in AA women with advanced disease. The underlying causes of this difference in treatment outcome need further evaluation.