Race, anthropometric factors, and stage at diagnosis of breast cancer

The Relationship Between Death Anxiety and COVID-19 Fear and Anxiety in Women With Breast Cancer

This study determined the relationship between death anxiety and COVID-19 related fear and anxiety in women with breast cancer. This is a descriptive correlation-seeking study. The research included 140 women with breast cancer who visit the day treatment unit of the oncology department of a state university hospital. Personal Information Form, Fear of COVID-19 Scale (FCV-19S), Coronavirus Anxiety Scale (CAS), and Death Anxiety Scale (DAS) were used to collect data. A significant difference was found between the DAS score and body mass index (p = .019) and between FCV-19S score and COVID-19 vaccination status (p = .007). As the fear of COVID-19 and coronavirus anxiety of women with breast cancer increase, death anxiety also increases. In conclusion, death anxiety should be taken into consideration for this patient group while maintaining the continuity of care for these patients now and in future pandemics.

Disparities in the Use of Sentinel Lymph Node Dissection for Early Stage Breast Cancer

BACKGROUND

Clinical trials have long established the long-term safety of omitting axillary lymph node dissection (ALND) after sentinel lymph node dissection (SLND) in patients with clinically node-negative early stage breast cancer. The variations in utilization of SLND and ALND in this patient population, however, are currently unknown.

METHODS

Adult female patients (40 years and older) within the National Cancer Database diagnosed with breast cancer between January 2013 and December 2015, who had clinical T1-T2 and N0 disease, and who underwent either SLND (with or without subsequent ALND) or ALND were included. Differences in utilization across race, ethnicity, insurance type, facility, and residential characteristics were assessed using multivariable logistic regression.

RESULTS

Overall, 271,689 patients were included, of which 26,527 (10%) received ALND and 245,162 (90%) underwent SLND. After adjusting for demographics and cancer characteristics, black (odds ratio [OR], 1.11; 95% confidence interval [95% CI], 1.06-1.17) and Hispanic women (OR, 1.16; 95% CI, 1.10-1.24) were more likely to receive ALND. Patients without health insurance (OR, 1.33; 95% CI, 1.19-1.47), compared with private health insurance, and those receiving treatment at community cancer centers (OR, 1.60; 95% CI, 1.53-1.67), compared with academic/research centers, were also more likely to receive ALND.

CONCLUSIONS

Although the vast majority of women undergo SLND, significant disparities exist in its utilization for early stage breast cancer, with traditionally underserved patients receiving unwarranted extensive axillary surgery. Increased patient and surgeon education is needed to decrease variations in care that can affect patient's quality of life.

Social Determinants of Racial Disparities in Breast Cancer Mortality Among Black and White Women

INTRODUCTION

Mortality from breast cancer among Black women is 60% greater than that of White women in South Carolina (SC). The aim of this study was to assess racial differences in mortality among Black and White breast cancer patients based on variations in social determinants and access to state-based early detection programs.

METHODS

We obtained a retrospective record for breast cancer patients diagnosed between 2002 and 2010 from the SC Central Cancer Registry. Mortality was the main outcome while race-stratified Cox proportional hazard models were performed to assess disparities in mortality. We assessed effect modification, and we used an automated backward elimination process to obtain the best fitting models.

RESULTS

There were 3286 patients of which the majority were White women (2186, 66.52%). Compared with married White women, the adjusted hazard ratio (aHR) for mortality was greatest among Black unmarried women (aHR 2.31, CI 1.83, 2.91). Compared with White women who lived in the Low Country region mortality was greatest among Black women who lived in the Midland (aHR 2.17 CI 1.47, 3.21) and Upstate (aHR 2.96 CI 1.96, 2.49). Mortality was higher among Black women that were not receiving services in the Best Chance Network (BCN) program (aHR 1.70, CI 1.40, 2.04) compared with White women.

CONCLUSIONS

To reduce the racial disparity gap in survival in SC, Black breast cancer patients who live in the Upstate, are unmarried, and those that are not enrolled in the BCN program may benefit from more intense navigation efforts directed at early detection and linkage to breast cancer treatments.

Assessment of total fatness and fatty tissue distribution in young active and physically inactive women

Study aim: The aim of the study was to evaluate the total fat and fat distribution in young active and physically inactive women. Material and methods: The study group consisted of a total of 300 students from Warsaw aged 20 to 25 years. The weekly physical activity level expressed in metabolic equivalent task was assessed using the International Physical Activity Question­naire. The distribution of adipose tissue was assessed on the basis of anthropometric measurements by somatometry. The waist and hip circumference, body mass and height were measured. Body mass index and waist to hip ratio were calculated. General fat was evaluated by bioelectric impedance. Results: Physically active students had significantly lower (p < 0.001) body mass, waist and hip circumference, lower body fat content and lower BMI and WHR compared to inactive students. Weight loss and the gynoidal type of adipose tissue distribu­tion were more frequent among physically active subjects. In inactive women the androidal-abdominal type of distribution dominated. A healthy somatic profile characterized by BMI in the normal range, gynoid type of adipose tissue distribution and normal or slightly lower body fat was significantly more frequent in physically active subjects (36% vs. 15%). Conclusions: Lack of physical activity was associated with larger waist and hip circumference, higher BMI and unfavorable adipose tissue distribution (androidal), which increases the risk of metabolic diseases in women. The study indicates the need for education and implementation of disease prevention programs regarding abdominal fat distribution and overweight among young women.

Racial Differences in Utilization of Breast Conservation Surgery: Results from the National Cancer Data Base (NCDB)

BACKGROUND

Whether rates of breast-conservation surgery (BCS) vary based on race and ethnicity has not been clearly elucidated on a national leve.

METHODS

The National Cancer Data Base (NCDB) was used to identify women who underwent surgery for invasive breast cancer during 2010 and 2011. The effect of race and ethnicity on BCS rates was determined, independent of patient demographics, tumor-related variables, and geographic region.

RESULTS

There were 299,827 patients with known race and ethnicity who underwent definitive breast surgery. BCS rates by race were as follows: 135,065/241,236 (56.0 %) for whites, 17,819/33,301 (53.5 %) for blacks, 4,722/9,508 (49.7 %) for Asian/Pacific Islanders, and 7,919/15,782 (50.2 %) for Hispanics (p < 0.001). Mean tumor size differed among the racial groups: 2.07 cm in whites, 2.54 cm in blacks, 2.23 cm in Asians, and 2.48 cm in Hispanics (p < 0.001). When stratified by tumor size, BCS was most common in blacks and least common in Asians for all tumors >2 cm (p < 0.001). On multivariable analysis adjusted for age, tumor size, nodal status, grade, molecular type, geographic area, urban/rural residence, insurance status, and census-derived median income and education for the patient's zip code, the odds ratio for BCS for blacks compared to whites was 1.23 (95 % confidence interval [CI] 1.20-1.27, p < 0.001), for Asians was 0.84 (95 % CI 0.80-0.88, p < 0.001), and for Hispanics was 1.00 (95 % CI 0.96-1.05, p = 0.885).

CONCLUSIONS

When adjusted for patient demographics, tumor-related variables, and geographic area, BCS rates are higher in blacks and lower in Asians compared to whites.

Effect of obesity on molecular characteristics of invasive breast tumors: gene expression analysis in a large cohort of female patients

Background

Obesity is a risk factor for breast cancer in postmenopausal women and is associated with decreased survival and less favorable clinical characteristics such as greater tumor burden, higher grade, and poor prognosis, regardless of menopausal status. Despite the negative impact of obesity on clinical outcome, molecular mechanisms through which excess adiposity influences breast cancer etiology are not well-defined.

Methods

Affymetrix U133 2.0 gene expression data were generated for 405 primary breast tumors using RNA isolated from laser microdissected tissues. Patients were classified as normal-weight (BMI < 25), overweight (BMI 25–29.9) or obese (BMI ≥ 30). Statistical analysis was performed by ANOVA using Partek Genomics Suite version 6.6 using a false discovery rate <0.05 to define significance.

Results

Obese patients were significantly more likely to be diagnosed ≥50 years or with African American ancestry compared to lean or overweight women. Pathological characteristics including tumor stage, size or grade, lymph node status, intrinsic subtype, and breast cancer mortality did not differ significantly between groups. No significant gene expression differences were detected by BMI in a non-stratified analysis which included all subtypes or within luminal B, HER2-enriched or basal-like subtypes. Within luminal A tumors, however, 44 probes representing 42 genes from pathways such as cell cycle, p53 and mTOR signaling, DNA repair, and transcriptional misregulation were differentially expressed.

Conclusions

Identification of transcriptome differences in luminal A tumors from normal-weight compared to obese women suggests that obesity alters gene expression within ER+ tumor epithelial cells. Alterations of pathways involved in cell cycle control, tumorigenesis and metabolism may promote cellular proliferation and provide a molecular explanation for less favorable outcome of obese women with breast cancer. Targeted treatments, such as mTOR inhibitors, may allow for improved treatment and survival of obese women, especially African American women, who are more likely to be obese and suffer outcome disparities.

Assessing the Key Attributes of Low Utilization of Mammography Screening and Breast-self Exam among African-American Women

PURPOSE

African-American (AA) women living in four Black Belt Counties (BBC) of Alabama; consisting of Barbour, Macon, Green and Wilcox are known to have lower mammogram utilization and breast self-exam rates when compared to their white female counterparts. The influence of socioeconomic and demographic factors on these disparities has not been clearly defined so far. Our study was designed to determine whether these observed disparities can be predicted with the socioeconomic and other demographic attributes.

METHODS

Health Disparity Questionnaires data (n = 516) for BBC of Alabama was analyzed using a logistic regression model to examine the association of breast cancer screening rates and breast self-exam with income, the level of education, family doctor, type of health insurance, obesity, and age.

RESULTS

Income, education, family doctor, age and health insurance were independent predictors for the low utilization rate of mammography and breast self-exam (BSE).

CONCLUSION

Improving socioeconomic conditions such as level of education and availability of health care are essential to increase the rates of breast cancer screening test and breast self-exam in the BBC of Alabama.

What Predicts an Advanced-Stage Diagnosis of Breast Cancer? Sorting Out the Influence of Method of Detection, Access to Care, and Biologic Factors

BACKGROUND

Multiple studies have yielded important findings regarding the determinants of an advanced-stage diagnosis of breast cancer. We seek to advance this line of inquiry through a broadened conceptual framework and accompanying statistical modeling strategy that recognize the dual importance of access-to-care and biologic factors on stage.

METHODS

The Centers for Disease Control and Prevention-sponsored Breast and Prostate Cancer Data Quality and Patterns of Care Study yielded a seven-state, cancer registry-derived population-based sample of 9,142 women diagnosed with a first primary in situ or invasive breast cancer in 2004. The likelihood of advanced-stage cancer (American Joint Committee on Cancer IIIB, IIIC, or IV) was investigated through multivariable regression modeling, with base-case analyses using the method of instrumental variables (IV) to detect and correct for possible selection bias. The robustness of base-case findings was examined through extensive sensitivity analyses.

RESULTS

Advanced-stage disease was negatively associated with detection by mammography (P < 0.001) and with age < 50 (P < 0.001), and positively related to black race (P = 0.07), not being privately insured [Medicaid (P = 0.01), Medicare (P = 0.04), uninsured (P = 0.07)], being single (P = 0.06), body mass index > 40 (P = 0.001), a HER2 type tumor (P < 0.001), and tumor grade not well differentiated (P < 0.001). This IV model detected and adjusted for significant selection effects associated with method of detection (P = 0.02). Sensitivity analyses generally supported these base-case results.

CONCLUSIONS

Through our comprehensive modeling strategy and sensitivity analyses, we provide new estimates of the magnitude and robustness of the determinants of advanced-stage breast cancer.

IMPACT

Statistical approaches frequently used to address observational data biases in treatment-outcome studies can be applied similarly in analyses of the determinants of stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 25(4); 613-23. ©2016 AACR.

Are There Differences in Treatment and Survival Between Poor, Older Black and White Women with Breast Cancer?

OBJECTIVES

To explore differences in treatment and survival outcome between poor, older black and white women with breast cancer.

DESIGN

Retrospective cohort study.

SETTING

Public safety net hospital.

PARTICIPANTS

Women aged 65 and older diagnosed with breast cancer from 1999 to 2008 (n = 1,000).

MEASUREMENTS

Breast cancer treatments that black and white women sought were compared using the Pearson chi-square test. All-cause mortality of black and white women was compared using hazard ratios derived from a multivariate Cox proportional hazards model.

RESULTS

There was no significant difference between older black and white women in surgical treatment, radiation therapy, chemotherapy, or hormone therapy over the study period. Race was not a significant predictor of survival in the Cox proportional hazards model that controlled for stage of cancer, age at diagnosis, dual-eligibility status, comorbid conditions, body mass index, smoking history, mammogram screening, and treatment for breast cancer.

CONCLUSION

Race did not appear to affect treatment or mortality in a cohort of older women with low socioeconomic status. This may be associated with similar healthcare delivery and equivalent access to health care for the older black and white women in this study.

Racial and ethnic disparities in the diagnosis of breast cancer: changes in presenting stage in minority populations in Florida during 1981-2009

We assessed whether presenting breast cancer stage has changed over time in Florida, and whether there is variation in this change with respect to race, ethnicity, and socioeconomic status (SES). Data were obtained from the Florida Cancer Data System. We included females with invasive breast cancer and complete information on race, ethnicity, and SES during 1981-2009 (n = 226,651). Associations between categorical variables were examined using Chi-square tests. Predictors of SEER stage at diagnosis (local, regional, and distant) were modeled with multinomial ordinal logistic regression models. There was a significant increase in local disease and a decrease in regional and distant disease at presentation (p < 0.0001) over the time period assessed. Compared to whites, black patients continue to have lower odds of local presentation (OR 0.73, 95% CI 0.63, 0.85), as do Hispanic patients (OR 0.80, 95% CI 0.76, 0.84) compared to non-Hispanics. The increase in local stage at diagnosis was greater for black than white patients, as was the decrease in regional and distant disease (p < 0.001). Hispanic women also had significant increase in localized disease and decrease in regional and distant disease (p < 0.001), but there was little difference in the change compared to non-Hispanic women. Localized breast cancer stage at diagnosis has become more common over time in all groups. Significant disparity persists, with black and Hispanic patients being less likely to present with localized disease than white patients overall. There was a greater change for black versus white patients, resulting in a narrowing in the racial gap in stage at diagnosis.

The impact of overweight and obesity on breast cancer: data from Switzerland, so far a country little affected by the current global obesity epidemic

This review presents results from the project "The Impact of Overweight/Obesity on Breast Cancer: data from Switzerland". Swiss data is interesting because the general female population is distinctive in two areas when compared to that of most other industrialized countries: Switzerland has comparatively low rates of overweight (22-23%) and obesity (7-8%) and has rather stable rates of overweight and obesity. The entire project comprised three major issues: (I) etiology of breast cancer (BC). There is a consistently shown association between obesity and postmenopausal BC risk in countries with high obesity prevalence rates in the literature. In our Swiss study group, however, we did not find higher rates of overweight and obesity in postmenopausal BC cases than in the general population. A possible explanation for this observation may be a curvilinear dose-response relationship between BMI and postmenopausal BC risk, so that an increased risk may only be observed in populations with a high prevalence of obese/very obese women; (II) tumor characteristics. BMI was significantly associated with tumor size; this applied not only to the cases where the tumor was found by self-detection, but also to lesions detected by radiological breast examinations. In addition, a higher BMI was positively correlated with advanced TNM stage, unfavorable grading and a higher St. Gallen risk score. No associations were observed between BMI and histological subtype, estrogen receptor status, HER2 status and triple negative BC; (III) patient compliance and persistence towards adjuvant BC therapy. Many studies found that the prognosis of overweight/obese BC patients was significantly lower than that of normal weight patients. However, failure of compliance and persistence towards therapy on the part of the patient is not a contributing factor for this observed unfavorable prognosis. In most therapy modes, patients with increasing BMI demonstrated greater motivation and perseverance towards the recommended treatment.

Impact of body mass index on prognostically relevant breast cancer tumor characteristics

BACKGROUND

This study analyzes the association of body mass index (BMI) and prognostically relevant breast cancer (BC) characteristics in a country that has been rather spared of the global obesity epidemic.

PATIENTS AND METHODS

Based on 20-year data (1999-2009, n = 1,414) of the prospective relational BC database of the University Hospital Basel, Switzerland, the associations between BMI, tumor size and stage, histological subtype, grading, hormonal receptor status, HER2 status and 'triple-negative' status were evaluated. Multivariate analysis considered BMI and patient's age.

RESULTS

The association between increasing BMI and the above-mentioned variables were as follows (results described in each case: Beta-coefficient or odds ratio, 95% confidence interval, p value): tumor size, (1) entire cohort: 0.03 (0.01-0.05), p < 0.001, (2) tumor found by self-palpation: 0.05 (0.03-0.07), p < 0.001, (3) tumor found by radiological examination: 0.03 (0-0.07), p = 0.044; advanced TNM stage: 1.16 (1.02-1.31), p = 0.022; histological subtype: 1.04 (0.89-1.22), p = 0.602; unfavorable grading: 1.11 (1.00-1.25), p = 0.057; positive estrogen receptor status: 0.95 (0.83-1.09), p = 0.459; positive HER2 status: 0.92 (0.74-1.15), p = 0.467; presence of a 'triple-negative' carcinoma: 1.19 (0.93-1.52), p = 0.165. Consideration of only postmenopausal BC patients (n = 1,063) did attenuate the results, but did not change the direction of the associations with BMI.

CONCLUSION

BMI was positively associated with TNM stage, grading and tumor size for tumors that were found by self-detection, as well as for those lesions detected by radiological breast examinations.

Adiponectin pathway polymorphisms and risk of breast cancer in African Americans and Hispanics in the Women's Health Initiative

Adiponectin, a protein secreted by the adipose tissue, is an endogenous insulin sensitizer with circulating levels that are decreased in obese and diabetic subjects. Recently, circulating levels of adiponectin have been correlated with breast cancer risk. Our previous work showed that polymorphisms of the adiponectin pathway are associated with breast cancer risk. We conducted the first study of adiponectin pathways in African Americans and Hispanics in the Women's Health Initiative SNP Health Association Resource cohort of 3,642 self-identified Hispanic women and 8,515 self-identified African American women who provided consent for DNA analysis. Single nucleotide polymorphisms (SNPs) from three genes were included in this analysis: ADIPOQ, ADIPOR1, and ADIPOR2. The genome-wide human SNP array 6.0 (909,622 SNPs) ( www.affymetrix.com ) was used. We found that rs1501299, a functional SNP of ADIPOQ that we previously reported was associated with breast cancer risk in a mostly Caucasian population, was also significantly associated with breast cancer incidence (HR for the GG/TG genotype: 1.23; 95 % CI 1.059-1.43) in African American women. We did not find any other SNPs in these genes to be associated with breast cancer incidence. This is the first study assessing the role of adiponectin pathway SNPs in breast cancer risk in African Americans and Hispanics. RS1501299 is significantly associated with breast cancer risk in African American women. As the rates of obesity and diabetes increase in African Americans and Hispanics, adiponectin and its functional SNPs may aid in breast cancer risk assessment.

Associations between body size and serum estradiol and sex hormone-binding globulin levels in premenopausal African American women

CONTEXT

African American (AA) women have the highest rates of premenopausal breast cancer; however, it is unclear whether body size contributes to the hormonal patterns potentially associated with increased breast cancer risk in these women.

OBJECTIVE

To characterize the association between body size and serum levels of estradiol and sex hormone-binding globulin (SHBG) levels in a sample of premenopausal AA women.

DESIGN

A total of 164 premenopausal AA women who were not pregnant or breastfeeding were recruited for this study. Serum samples were collected during the early follicular phase, and trained staff collected body size measurements. Multiple linear regression models were performed to assess potential associations.

MAIN OUTCOME MEASURES

Serum estradiol and SHBG levels.

RESULTS

Many (81%) of the women enrolled were overweight or obese. Both waist-to-hip ratio (WHR) (β = 2.68, P = .008) and waist circumference (WC) (β = 2.02, P = .046) were positively associated with higher levels of estradiol. All measures of body was significantly and inversely associated with SHBG levels (all P < .05).

CONCLUSIONS

Premenopausal AA women with higher WHR or larger WC may have higher levels of estradiol and lower levels of SHBG. Thus, WHR or WC may be better indicators for assessing hormonal patterns implicated in breast cancer pathogenesis in these women.

Racial differences in breast cancer stage at diagnosis in the mammography era

OBJECTIVES

We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.

METHODS

We calculated adjusted odds of distant (versus local or regional) tumors for 143,249 White and 13,571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.

RESULTS

Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black-White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).

CONCLUSIONS

In the mammography era, racial disparities remain in stage at diagnosis.

Racial disparities in breast cancer mortality in a multiethnic cohort in the Southeast

BACKGROUND

Although much has been done to examine those factors associated with higher mortality among African American women, there is a paucity of literature that examines disparities among rural African Americans in South Carolina. The purpose of this investigation was to examine the association of race and mortality among breast cancer patients in a large cohort residing in South Carolina for which treatment regimens are standardized for all patients.

METHODS

Subjects included 1209 women diagnosed with breast cancer between 2000 and 2002 at a large, local hospital containing a comprehensive breast center. Kaplan-Meier survival curves were calculated to determine survival rates among African American and European American women, stratified by disease stage or other prognostic characteristics. Adjusting for various characteristics, Cox multivariate survival models were used to estimate the hazard ratio (HR).

RESULTS

The 5-year overall all-cause mortality survival proportion was ∼78% for African American women and ∼89% for European American women, P < 0.01. In analyses of subpopulations of women with identical disease characteristics, African American women had significantly higher mortality than European American women for the same type of breast cancer disease. In multivariate models, African American women had significantly higher mortality than European American women for both breast cancer-specific death (HR, 2.41; 95% confidence interval [CI], 1.21-4.79) and all-cause mortality (HR, 1.42; 95% CI, 1.06-1.89).

CONCLUSIONS

African American women residing in rural South Carolina had lower survival for breast cancer even after adjustment for disease-related prognostic characteristics. These findings support health interventions among African American breast cancer patients aimed at tertiary prevention strategies or further down-staging of disease at diagnosis.

Which patients pursue fertility preservation treatments? A multicenter analysis of the predictors of fertility preservation in women with breast cancer

OBJECTIVE

To evaluate predictors of undergoing fertility preservation treatment (FPT) in women with breast cancer.

DESIGN

Secondary analysis of a clinical database.

SETTING

Three academic fertility preservation centers.

PATIENT(S)

One hundred eight patients with breast cancer undergoing FPT and 77 patients with breast cancer not undergoing FPT from 2005 to 2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Patients' demographic and medical information.

RESULT(S)

Women who had FPT were older, wealthier, and had lower cancer stage compared with women who did not have FPT. The rate of the administration of neoadjuvant chemotherapy (NAC) was significantly lower in women who underwent FPT. After adjusting for age, body mass index (BMI), income, cancer stage, and center, a negative correlation persisted between NAC and FPT (odds ratio 0.091, 95% confidence interval 0.009-0.904). When we stratified the women by center, women at center 1 had a significantly lower FPT rate, lower parity, higher BMI, more advanced cancer stage, and lower income compared with centers 2 and 3. The rates of NAC were significantly higher in center 1.

CONCLUSION(S)

Although age, BMI, income, cancer stage, center, and NAC seem to be associated with undergoing FPT, NAC is the only modifiable variable. Because NAC restricts the time available for FPT, oncologists may consider offering adjuvant chemotherapy, except in cases in which NAC clearly improves survival, in women who are interested in FPT.

The role of anthropometric and nutritional factors on breast cancer risk in African-American women

OBJECTIVE

While the role of nutrition, physical activity and body size on breast cancer risk has been extensively investigated, most of these studies were conducted in Caucasian populations. However, there are well-known differences in tumour biology and the prevalence of these factors between African-American and Caucasian women. The objective of the present paper was to conduct a review of the role of dietary factors, anthropometry and physical activity on breast cancer risk in African-American women.

DESIGN

Twenty-six research articles that presented risk estimates on these factors in African-American women and five articles involving non-US black women were included in the current review.

SETTING

Racial disparities in the impact of anthropometric and nutritional factors on breast cancer risk.

SUBJECTS

African-American and non-US black women.

RESULTS

Based on the few studies that presented findings in African-American women, an inverse association with physical activity was found for pre- and postmenopausal African-American women, while the association for anthropometric and other dietary factors, such as alcohol, was unclear. Studies assessing the effect by molecular subtypes in African-American women were too few and based on sample sizes too small to provide definitive conclusions.

CONCLUSIONS

The effect of certain nutrition and lifestyle factors on breast cancer in African-American women is not starkly distinct from those observed in white women. However, there is an enormous need for further research on this minority group to obtain more confirmatory findings.

Obesity and survival among black women and white women 35 to 64 years of age at diagnosis with invasive breast cancer

PURPOSE

To evaluate the effect of obesity on survival among black women and white women with invasive breast cancer and to determine whether obesity explains the poorer survival of black women relative to white women.

PATIENTS AND METHODS

We observed 4,538 (1,604 black, 2,934 white) women who were 35 to 64 years of age when diagnosed with incident invasive breast cancer between 1994 and 1998. Multivariate Cox regression models were used to examine the effect of body mass index (BMI, in kilograms per square meter) 5 years before diagnosis on risk of death from any cause and from breast cancer.

RESULTS

During a median of 8.6 years of follow-up, 1,053 women died (519 black, 534 white), 828 as a result of breast cancer (412 black, 416 white). Black women were more likely to die than white women (multivariate-adjusted relative risk [RR], 1.33; 95% CI, 1.16 to 1.53). Compared with women with BMI of 20 to 24.9 kg/m(2), those who were obese (BMI ≥ 30 kg/m(2)) had a greater risk of all-cause mortality (RR, 1.23; 95% CI, 1.04 to 1.47) and breast cancer-specific mortality (RR, 1.20; 95% CI, 0.99 to 1.46). These associations were observed among white women (all-cause RR, 1.54; 95% CI, 1.21 to 1.96; breast cancer RR, 1.46; 95% CI, 1.11 to 1.92), but not among black women (all-cause RR, 1.03; 95% CI, 0.81 to 1.29; breast cancer RR, 1.02; 95% CI, 0.79 to 1.33).

CONCLUSION

Obesity may play an important role in mortality among white but not black patients with breast cancer. It is unlikely that differences in obesity distributions between black women and white women account for the poorer survival of black women.

A review of body size and breast cancer risk in Hispanic and African American women

Obesity is an epidemic in the United States, especially among Hispanics and African Americans. Studies of obesity and breast cancer risk have been conducted primarily in non-Hispanic whites. There have been few studies of the association between body mass index (BMI) or weight gain and the risk of breast cancer in minorities, and the results have been inconsistent. Because most studies are conducted primarily in non-Hispanic whites, the etiology of breast cancer in minorities is not well understood. The authors of the current report reviewed the literature on the association between obesity, weight, and weight gain and breast cancer in minorities using a combination of the Medical Subject Heading (MeSH) terms "obesity," "body mass index," "weight," "weight gain," "Hispanic," and "African American." Only publications in English and with both risk estimates and 95% confidence intervals were considered. Forty-five studies of body size and breast cancer risk in non-Hispanic whites were identified. After an exhaustive search of the literature, only 3 studies of body size and breast cancer were conducted in Hispanic women were identified, and only 8 such studies in African American women were identified. The results were inconsistent in both race/ethnicity groups, with studies reporting positive, inverse, and null results. Thus, as obesity rates among Hispanics and African Americans continue to rise, there is an urgent need to identify the roles that both obesity and adult weight gain play in the development of breast cancer in these minorities. Additional studies are needed to provide more understanding of the etiology of this disease and to explain some of the disparities in incidence and mortality.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Obesity and breast cancer: status of leptin and adiponectin in pathological processes

It is well recognized that obesity increases the risk of various cancers, including breast malignancies in postmenopausal women. Furthermore, obesity may adversely affect tumor progression, metastasis, and overall prognosis in both pre- and postmenopausal women with breast cancer. However, the precise mechanism(s) through which obesity acts is/are still elusive and this relationship has been the subject of much investigation and speculation. Recently, adipose tissue and its associated cytokine-like proteins, adipokines, particularly leptin and adiponectin, have been investigated as mediators for the association of obesity with breast cancer. Higher circulating levels of leptin found in obese subjects could be a growth-enhancing factor as supported by in vitro and preclinical studies, whereas low adiponectin levels in obese women may be permissive for leptin's growth-promoting effects. These speculations are supported by in vitro studies which indicate that leptin promotes human breast cancer cell proliferation while adiponectin exhibits anti-proliferative actions. Further, estrogen and its receptors have a definite impact on the response of human breast cancer cell lines to leptin and adiponectin. More in-depth studies are needed to provide additional and precise links between the in vivo development of breast cancer and the balance of adiponectin and leptin.

The impact of obesity on gynecologic cancer screening: an integrative literature review

INTRODUCTION

Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening.

METHODS

A literature search of standard computerized databases was conducted for peer-reviewed articles published between 1950 and January 2009.

RESULTS

Twenty-three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient-provider communication.

DISCUSSION

Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women.

WITHDRAWN: Effect of obesity at the pathologic response to neoadjuvant chemotherapy among premenopausal Tunisian women with breast cancer

In this article, we evaluated BMI and response to neoadjuvant chemotherapy (NC) in premenopausal Tunisian women with operable breast cancer. From May 2006 to July 2009, 800 patients were diagnosed and received NC from CHU Farhat Hached (Sousse, Tunisia). Patients were categorized as obese (BMI >/=30 kg/m(2)), overweight (25 </= BMI < 30 kg/m(2)), or normal/underweight (BMI <25 kg/m(2)). Logistic regression was used to examine associations between BMI and pathologic complete response (pCR). Breast cancer-specific, progression-free, and overall survival times were examined using the Kaplan-Meier method and Cox proportional hazards regression analysis. Median age was 42 years; 27% of patients were obese, 25% were overweight, and 48% were normal or underweight. In the univariate model, there was a significant difference in pCR to NC for obese compared with normal/underweight patients. In multivariate analysis, there was no significant difference in pCR for obese compared to normal weight patients. Overweight and the combination of overweight and obese patients were significantly less likely to have a pCR (odds ratio (OR) = 0.59; 95% confidence interval (CI), 0.37-0.95; and OR = 0.67; 95% CI, 0.45-0.99, respectively). Higher BMI was associated with worse pCR to NC. So, its association with worse overall survival suggests that greater attention should be focused on this risk factor to optimize the care of breast cancer patients.

Disparities in medical care among commercially insured patients with newly diagnosed breast cancer: opportunities for intervention

BACKGROUND

African-American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity.

METHODS

In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n = 476) and African-American women (n = 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]-positive status), treatment (breast-conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and all-cause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/treatment.

RESULTS

White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African-American women. More white women had positive ER/PR status (75% vs 56% African-American; P = .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African-American; P < .001). White women received slightly more breast-conserving surgery and chemotherapy dose modification than African-American women (P value nonsignificant). African-American women had a higher mortality rate (8.1%) than white women (3.6%; P = .06). In adjusted analyses, African-American women were diagnosed at later stages (odds ratio, 1.71; P = .02), and white women received more antiestrogen therapy (odds ratio, 2.1; P = .03).

CONCLUSIONS

Disparities in medical care among patients with newly diagnosed breast cancer were evident between African-American women and white women despite health plan insurance coverage. Interventions that address the gaps identified are needed.

Racial differences in follow-up of abnormal mammography findings among economically disadvantaged women

BACKGROUND

In the United States, and particularly in South Carolina, African-American women suffer disproportionately higher mortality rates from breast cancer than European-American women. The timeliness of patient adherence to the follow-up of mammographic abnormalities may influence prognosis and survival. The objective of the current investigation was to examine racial differences in the completion and completion time of a diagnostic workup after the finding of a suspicious breast abnormality.

METHODS

Study participants of the Best Chance Network, a statewide service program that provides free mammography screening to economically disadvantaged and medically underserved women, were included in the study. Racial differences in tumor characteristics and adherence to recommended workup were tested using chi-square tests and t tests. Logistic and Cox regression modeling was used to assess the relation between workup completion and other factors among African-American women and European-American women.

RESULTS

Completion of the workup was associated with the number of previous procedures and income, and no significant differences were noted by race. The amount of time to completion of the workup was influenced by previous procedures, income, and race. After accounting for completion time, African-American women were 12% less likely than European-American women to complete the recommended workup (hazard ratio, 0.88; P=.01).

CONCLUSIONS

The results from this study established a racial disparity in the time to completion of a diagnostic workup among Best Chance Network participants. These findings highlight the importance of understanding the factors associated with delays in and adherence to completing the recommended workup when breast abnormalities are detected in mammograms.

Obesity and mammography: a systematic review and meta-analysis

BACKGROUND

Obese women experience higher postmenopausal breast cancer risk, morbidity, and mortality and may be less likely to undergo mammography.

OBJECTIVES

To quantify the relationship between body weight and mammography in white and black women.

DATA SOURCES AND REVIEW METHODS

We identified original articles evaluating the relationship between weight and mammography in the United States through electronic and manual searching using terms for breast cancer screening, breast cancer, and body weight. We excluded studies in special populations (e.g., HIV-positive patients) or not written in English. Citations and abstracts were reviewed independently. We abstracted data sequentially and quality information independently.

RESULTS

Of 5,047 citations, we included 17 studies in our systematic review. Sixteen studies used self-reported body mass index (BMI) and excluded women <40 years of age. Using random-effects models for the six nationally representative studies using standard BMI categories, the combined odds ratios (95% CI) for mammography in the past 2 years were 1.01 (0.95 to 1.08), 0.93 (0.83 to 1.05), 0.90 (0.78 to 1.04), and 0.79 (0.68 to 0.92) for overweight (25-29.9 kg/m(2)), class I (30-34.9 kg/m(2)), class II (35-39.9 kg/m(2)), and class III (> or =40 kg/m(2)) obese women, respectively, compared to normal-weight women. Results were consistent when all available studies were included. The inverse association was found in white, but not black, women in the three studies with results stratified by race.

CONCLUSIONS

Morbidly obese women are significantly less likely to report recent mammography. This relationship appears stronger in white women. Lower screening rates may partly explain the higher breast cancer mortality in morbidly obese women.

Relationship between obesity and pathologic response to neoadjuvant chemotherapy among women with operable breast cancer

PURPOSE

To understand the mechanism through which obesity in breast cancer patients is associated with poorer outcome, we evaluated body mass index (BMI) and response to neoadjuvant chemotherapy (NC) in women with operable breast cancer.

PATIENTS AND METHODS

From May 1990 to July 2004, 1,169 patients were diagnosed with invasive breast cancer at M. D. Anderson Cancer Center and received NC before surgery. Patients were categorized as obese (BMI >or= 30 kg/m(2)), overweight (BMI of 25 to < 30 kg/m(2)), or normal/underweight (BMI < 25 kg/m(2)). Logistic regression was used to examine associations between BMI and pathologic complete response (pCR). Breast cancer-specific, progression-free, and overall survival times were examined using the Kaplan-Meier method and Cox proportional hazards regression analysis. All statistical tests were two-sided.

RESULTS

Median age was 50 years; 30% of patients were obese, 32% were overweight, and 38% were normal or underweight. In multivariate analysis, there was no significant difference in pCR for obese compared with normal weight patients (odds ratio [OR] = 0.78; 95% CI, 0.49 to 1.26). Overweight and the combination of overweight and obese patients were significantly less likely to have a pCR (OR = 0.59; 95% CI, 0.37 to 0.95; and OR = 0.67; 95% CI, 0.45 to 0.99, respectively). Obese patients were more likely to have hormone-negative tumors (P < .01), stage III tumors (P < .01), and worse overall survival (P = .006) at a median follow-up time of 4.1 years.

CONCLUSION

Higher BMI was associated with worse pCR to NC. In addition, its association with worse overall survival suggests that greater attention should be focused on this risk factor to optimize the care of breast cancer patients.

Adiposity, the metabolic syndrome, and breast cancer in African-American and white American women

Breast cancer, the second most common cause of cancer-related deaths in American women, varies substantially in incidence and mortality according to race and ethnicity in the United States. Although the overall incidence of breast cancer among African-American (AA) women is lower than in white American women, this cancer is more common in young premenopausal AA women, and AA breast cancer patients of all ages are more likely to have advanced disease at diagnosis, higher risk of recurrence, and poorer overall prognosis. Epidemiological studies indicate that these differences may be attributable in part to variation in obesity and body fat distribution. Additionally, AA women more frequently exhibit breast cancer with an aggressive and metastatic phenotype that may also be attributable to the endocrine and metabolic changes associated with upper body obesity. These changes include both elevated estrogen and androgen bioactivity, hyperinsulinemia, and perturbations of the adipokines. Type 2 diabetes and the metabolic syndrome, which are more common in AA women, have also been associated with breast cancer risk. Moreover, each of the individual components of the syndrome has been associated with increased breast cancer risk, including low levels of the adipocytokine, adiponectin. This review explores the specific roles of obesity, body fat distribution (particularly visceral and sc adipose tissue), type 2 diabetes, metabolic syndrome, and adipocytokines in explaining the differential patterns of breast cancer risk and prognosis between AA and white American women.

Combination of physical activity, nutrition, or other metabolic factors and vaccine response

A number of lifestyle factors that reduce cancer risk in the primary prevention setting may be potential new targets for use in combination with cancer vaccines. This review discusses the modulation of energy balance (physical activity, calorie restriction, and obesity prevention), and the supplementation with natural and synthetic analogs of vitamins A and E, as potential interventions for use in combination with cancer vaccines. Additionally, the pharmacologic manipulation of nutrient metabolism in the tumor microenvironment (e.g., arachidonic acid, arginine, tryptophan, and glucose metabolism) is discussed. This review includes a brief overview of the role of each agent in primary cancer prevention; outlines the effects of these agents on immune function, specifically adaptive and/or anti-tumor immune mechanisms, when known; and discusses the potential use of these interventions in combination with therapeutic cancer vaccines. Modulation of energy balance through exercise and strategies targeting nutrient metabolism in the tumor microenvironment represent the most promising interventions to partner with therapeutic cancer vaccines. Additionally, the use of vitamin E succinate and the retinoid X receptor-directed rexinoids in combination with cancer vaccines offer promise. In summary, a number of energy balance- and nutrition-related interventions are viable candidates for further study in combination with cancer vaccines.

Investigating the phenotypes and genotypes of breast cancer in women with African ancestry: the need for more genetic epidemiology

Disparities in incidence, mortality, and age of onset of breast cancer between women of African ancestry and women of other racial/ethnic backgrounds are poorly understood. A more comprehensive elaboration of genetic variants that occur in African women may facilitate a better understanding of the disease in African American women and explain the role of genetic admixture on the variation in the expression of the disease. Large-scale, population-based databases that document the cancer burden of Africa are lacking because of financial and infrastructural limitations. The development of such programs would represent an important cancer control and research strategy.

Cancer screening in women: body mass index and adherence to physician recommendations

BACKGROUND

The reasons that obese women are less likely to obtain mammograms and Papanicolaou tests (Pap smears) are poorly understood. This study evaluated associations between body mass index (BMI) and receipt of and adherence to physician recommendations for mammography and Pap smear.

METHODS

Data from the 2000 National Health Interview Survey (8289 women aged 40 to 74 years) were analyzed in 2006 using logistic regression. Women with previous hysterectomy were excluded from Pap smear analyses (n=5521). Outcome measures were being up-to-date with screening, receipt of physician recommendations, and women's adherence to physician recommendations for mammography and Pap smear.

RESULTS

After adjusting for sociodemographic variables, healthcare access, health behaviors, and comorbidity, severely obese women (BMI > 40 kg/m(2)) were less likely to have had mammography within 2 years (odds ratio [OR]=0.50, 95% confidence interval [CI]=0.37-0.68) and a Pap smear within 3 years (OR=0.43, 95% CI=0.27-0.70). Obese women were as likely as normal-weight women to receive physician recommendations for mammography and Pap smear. Severely obese women were less likely to adhere to physician recommendations for mammography (OR=0.49, 95% CI=0.32-0.76). Women in all obese categories (BMI > 30 kg/m(2)) were less likely to adhere to physician recommendations for Pap smear (ORs ranged from 0.17 to 0.28, p<0.001).

CONCLUSIONS

Obese women are less likely to adhere to physician recommendations for breast and cervical cancer screening. Interventions focusing solely on increasing physician recommendations for mammography and Pap smears will probably be insufficient for obese women. Additional strategies are needed to make cancer screening more acceptable for this high-risk group.

Body Mass Index Influences Palpability but not Stage of Breast Cancer at Diagnosis

Body mass index (BMI) is associated with breast cancer risk, but its relationship with stage at diagnosis is unclear. BMI was calculated for patients in the North American Fareston and Tamoxifen Adjuvant trial, and was correlated with clinicopathologic factors, including stage at diagnosis. One thousand eight hundred fourteen patients were enrolled in the North American Fareston and Tamoxifen Adjuvant study; height and weight were recorded in 1451 (80%) of them. The median BMI was 27.1 kg/m2 (range, 14.7–60.7). The median patient age was 68 years (range, 42–100); median tumor size was 1.3 cm (range, 0.1–14 cm). One thousand seven hundred ninety-three (99.0%) patients were estrogen receptor positive, and 1519 (84.7%) were progesterone receptor positive. There was no significant relationship between BMI (as a continuous variable) and nodal status ( P = 0.469), tumor size ( P = 0.497), American Joint Committee on Cancer stage ( P = 0.167), grade ( P = 0.675), histologic subtype ( P = 0.179), or estrogen receptor status ( P = 0.962). Patients with palpable tumors, however, had a lower BMI than those with nonpalpable tumors (median 26.4 kg/m2 vs 27.5 kg/m2, P < 0.001). Similar results were found when BMI was classified as a categorical variable (<25 vs 25–29.9 vs ≥30). Increased BMI does not lead to a worse stage at presentation. Obese patients, however, tend to have nonpalpable tumors. Mammography in this population is especially important.

Achieving healthy weight in African-American communities: research perspectives and priorities

The longstanding high burden of obesity in African-American women and the more recent, steeper than average rise in obesity prevalence among African-American children constitute a mandate for an increased focus on obesity prevention and treatment research in African-American communities. The African-American Collaborative Obesity Research Network (AACORN) was formed to stimulate and support greater participation in framing and implementing the obesity research agenda by investigators who have both social and cultural grounding in African-American life experiences and obesity-related scientific expertise. AACORN's examination of obesity research agenda issues began in 2003 in conjunction with the Think Tank on Enhancing Obesity Research at the National Heart, Lung, and Blood Institute (NHLBI). The assessment was subsequently expanded to take into account the overall NIH strategic plan for obesity research, literature reviews, and descriptions of ongoing studies. In identifying priorities, AACORN members considered the quality, quantity, focus, and contextual relevance of published research relevant to obesity prevention and treatment in African-American adults or children. Fifteen recommended research priorities are presented in five categories adapted from the NHLBI Think Tank proceedings: health effects, social and environmental context, prevention and treatment, research methods, and research training and funding. These recommendations from an African-American perspective build on and reinforce certain aspects of the NHLBI and overall NIH research agendas by providing more specific rationale and directions on areas for enhancement in the type of research being done or in the conceptualization and implementation of that research.

Breast and cervical cancer screening in obese minority women

PURPOSE

Studies using survey data from mostly white women showed that obese women are less likely than nonobese women to undergo breast and cervical cancer screening. It is unclear if these findings are true in nonwhite women. Using chart audit data, we examined the relationship between obesity and mammography and Pap smear screening among minority women.

METHODS

Data from retrospective chart review of women in three urban New Jersey academic family medicine practices were analyzed (n = 1809) using hierarchical logistic regression models. Outcome measures were being up-to-date in mammography and Pap smears among obese and nonobese women.

RESULTS

There was no difference in mammography rates among obese and nonobese women. Independent risk factors for not being up-to-date in mammography included age 40-49, smoking, and comorbidity. Obese women were less likely than nonobese women to be upto- date in Pap smears (69% vs. 77%, p = 0.001). In multivariate analysis, obesity was associated with 25% decreased odds of being up-to-date on Pap smears (OR, 0.75, 95% CI, 0.58-0.99, p = 0.041). Age >or=65 years was also associated with decreased odds of being up-to-date in Pap smears. Hispanic women had increased odds of being up-to-date in mammography (OR 2.43, 95% CI 1.63-3.63) and Pap smears (OR 1.94, 95% CI 1.24-3.03) compared with white women.

CONCLUSIONS

Obesity was associated with decreased Pap smear screening but not with decreased mammography. Further studies are needed to determine barriers and effective interventions to improve screening in obese minority women.

Differential expression of HER-2/NEU receptor of invasive mammary carcinoma between Caucasian and African American patients in the Detroit metropolitan area. Correlation with overall survival and other prognostic factors

GOALS

HER-2/neu overexpression in invasive mammary carcinoma is associated with more aggressive biologic behavior. Breast cancer in African American (AA) women has been associated with a shorter survival rate than that seen in Caucasians (C). This study evaluated the frequency of HER-2/neu overexpression in C compared to AA patients and the association of HER-2/neu expression with overall survival and other prognostic factors.

METHODS

A retrospective review of the SEER data of Karmanos Cancer Institute for patients with invasive mammary carcinoma was conducted between 1998 and 2001. Pathology reports and pathology slides were obtained for those patients with missing data. Available data and material on 608 patients were found. The median follow-up interval was 35 months with a range of 1-91 months. 46.7% of the study population was C while 53.3% was AA. The differential of HER-2/neu expression in C and AA was evaluated. The association of HER-2/neu expression and other prognostic factors with overall survival was carried out by univariate and multivariable analyses using Cox's proportional hazards regression model.

PRINCIPLE RESULTS

No statistically significant difference was found in HER-2/neu expression between C and AA patients. Overexpression of HER-2/neu did not correlate with decreased overall survival in this analysis.

MAJOR CONCLUSIONS

Breast cancer HER-2/neu expression in AA patients is not statistically different from that of Caucasians. HER-2/neu expression is not associated with overall survival. Among the other prognostic factors analyzed, ER status and histologic grade were not statistically significant.

Obesity and prognosis of breast cancer

Obesity has a complicated relationship to both breast cancer risk and the clinical behaviour of the established disease. It is suggested that obesity is associated with both an increased risk of developing breast cancer risk and worse prognosis after disease onset. In post-menopausal women, various measures of obesity such as body mass index, weight, weight gain and waist : hip ratio have all been positively associated with risk of developing breast cancer. In most but not all case-control and prospective cohort studies, an inverse relationship has been found between weight and breast cancer among pre-menopausal women. Some data suggest that adult weight gain and central obesity increase the risk of pre-menopausal breast cancer. Obesity at the time of diagnosis is thought to be significant as a poor prognostic factor. Obesity is associated with adverse outcomes in both pre- and post-menopausal women with breast cancer. Many cancer survivors seek ways to minimize the risk of recurrence and death because of breast cancer. Despite complex and at times controversial data, enough evidence is available at present to suggest that weight management should be a part of the strategy to prevent the occurrence, recurrence and death because of breast cancer. In this review the effect of obesity on the prognosis of breast cancer is examined in detail.

Reducing racial/ethnic disparities in female breast cancer: screening rates and stage at diagnosis

OBJECTIVES

We assessed whether population rates of mammography screening, and their changes over time, were associated with improvements in breast cancer stage at diagnosis and whether the strength of this association varied by race/ethnicity.

METHODS

We analyzed state cancer registry data linked to socioeconomic characteristics of patients' areas of residence for 1990-1998 time trends in the likelihood of early stage diagnosis. We appended each cancer registry record with matching subgroup estimates of self-reported mammography screening.

RESULTS

Trends in screening and stage at diagnosis were consistent within groups, but African American women had a significantly lower proportion of early stage cancers despite an advantage in screening. Population screening rates were significantly associated with early diagnosis, with a weaker association in African American women than White women (odds ratio [OR] = 1.70; P<.0001 vs OR=2.02; P<.0001, respectively).

CONCLUSIONS

Improvements in screening rates during the 1990s across racial/ethnic groups appear to have contributed significantly to earlier diagnosis within each group, but a smaller effect in African American women should raise concerns. A key health policy challenge is to ensure that screening effectively translates into earlier diagnosis.

Association of overweight with breast cancer survival

The authors investigated the association between overweight at the time of or soon after cancer diagnosis and survival in a cohort of 1,455 breast cancer patients aged 25-64 years. The patients were recruited into the Shanghai Breast Cancer Study (Shanghai, China), a population-based case-control study, between August 1996 and March 1998. The median follow-up time for this cohort was 5.1 years (1996-2002) after breast cancer diagnosis, and 240 deaths were identified. Being overweight at cancer diagnosis or soon afterward, as measured by body mass index (BMI; weight (kg)/height (m)(2)), was associated with poorer overall survival and disease-free survival. Five-year survival rates were 86.5%, 83.8%, and 80.1% for subjects whose BMIs were <23.0, 23.0-24.9, and >or=25.0, respectively (p = 0.02); the corresponding 5-year disease-free survival rates were 81.9%, 78.1%, and 76.6% (p = 0.05). The inverse association between BMI and survival persisted after adjustment for age at diagnosis and other known prognostic factors for breast cancer, including disease stage. The authors found neither waist:hip ratio nor waist circumference to be independently associated with overall survival or disease-free survival. These results suggest that excess weight may be an independent predictor of breast cancer survival among Chinese women.

Perceptions of changes in weight among African American breast cancer survivors

BACKGROUND

Although African American breast cancer survivors are most likely to gain weight following diagnosis and treatment compared to women from other ethnic groups, limited information is available on psychological and behavioral reactions to weight change in this population.

OBJECTIVES

To explore perceptions and reactions to weight change in African American breast cancer survivors.

METHODOLOGY

A parallel mixed methods approach was used to explore experiences with and reactions to weight change following breast cancer diagnosis and treatment. Participants were 16 short- and long-term African American breast cancer survivors.

RESULTS

Nine out of 16 participants gained weight following diagnosis and treatment and most participants were concerned about these changes. Most participants were also interested in diet and exercise programs; however, a holistic and common sense approach to diet and physical activity emerged as key themes.

CONCLUSIONS

Although prior reports have found that African American women in the general population report a greater tolerance for larger body sizes, most participants in this study were concerned about changes in their weight and were actively trying to minimize weight gain. Several themes emerged regarding physical activity and dietary behaviors; overall, participants described a holistic and practical approach to these behaviors.

Adult weight gain and histopathologic characteristics of breast cancer among postmenopausal women

BACKGROUND

Although the link between postmenopausal breast cancer and adiposity is well established, the association between weight gain and specific histopathologic characteristics of breast carcinoma has not been studied carefully.

METHODS

Using 1200 incident invasive breast cancers among 44,161 postmenopausal women who were not taking hormone therapy in the American Cancer Society's Cancer Prevention Study II Nutrition Cohort, the authors computed age-adjusted rates and rate ratios (RR) for breast cancer by histology, stage, grade, and estrogen receptor (ER) and progesterone receptor (PR) status by categories of adult weight gain.

RESULTS

Age-adjusted rates of breast cancer were highest for women who reported the most weight gain, regardless of histologic type. For weight gain >60 pounds, compared with weight gain < or =20 pounds the RR for ductal carcinoma was 1.89 (95% confidence interval [95%CI], 1.53-2.34), and the RR for lobular carcinoma was 1.54 (95%CI. 1.01-2.33). Weight gain was associated with increased risk at every tumor stage and grade. The risk for regional or distant stage was elevated significantly in every category of weight gain and was 3 times higher among women who had the greatest weight gain (RR, 3.15; 95%CI, 2.21-4.48). Weight gain was associated with increased risk of ER-positive/PR-positive tumors (P for trend <.0001) but not ER-negative/PR-negative tumors (P for trend = .09). The results essentially remained unchanged when the analysis was restricted to women who had regular screening mammograms.

CONCLUSIONS

Excess adiposity is an important contributor to breast cancer risk among postmenopausal women, regardless of histologic type, and especially for tumors of advanced stage and high grade.

Effects of obesity and race on prognosis in lymph node-negative, estrogen receptor-negative breast cancer

BACKGROUND

Several factors may contribute to poorer prognosis for obese breast cancer patients, including unfavorable disease features, the influence of fat on estrogen availability, co-morbidity, and socio-demographic factors. Both obesity and estrogen receptor negative (ER-) tumors are more prevalent in black women than in whites in North America. We evaluated obesity and race in relation to outcomes in women with ER-breast cancer.

METHODS

Among 4,077 women from National Surgical Adjuvant Breast and Bowel Project clinical trials for node-negative, ER-breast cancer, we evaluated disease-free survival (DFS) and its constituents (tumor recurrence, contralateral breast cancer (CBC), second primary cancers, deaths prior to these events) and mortality in relation to body mass index (BMI) and race, using statistical modeling to account for other prognostic factors.

RESULTS

Compared to those of normal weight (BMI< or =24.9), DFS hazard was greater for obese (BMI > or = 30) women [hazard ratio (HR)=1.16, 95% confidence interval (CI)=1.01-1.33]. Obesity did not increase recurrence hazard, but did influence CBC (HR=2.08, 95% CI=1.22-3.55 in postmenopausal women) and second cancers (HR=1.49, 95% CI=1.06-2.10). Mortality increased with obesity; when partitioned by likely cause, those with BMI > or = 35.0 had greater risk of non-breast cancer mortality (HR=1.86, 95% CI=1.21-2.84). Relative to whites and adjusted for BMI, black women had greater hazard for DFS (HR=1.17, 95% CI=1.00-1.38), CBC (HR=1.37, 95% CI=0.94-1.99), and non-breast cancer deaths (HR=2.10, 95% CI=1.45-3.03); risk for deaths likely due to breast cancer was closer to that in whites (HR=1.18; 95% CI=0.93-1.50).

CONCLUSIONS

For women with node-negative, ER-breast cancer from clinical trials, obesity did not increase recurrence risk, but was associated with greater risk for second cancers, CBC, and mortality, particularly non-breast cancer deaths. Less favorable prognosis for black women persists in clinical trials, and is in part attributable to non-breast cancer outcomes.

Disparities across the breast cancer continuum

OBJECTIVE

We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality.

METHODS

We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum.

RESULTS

Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact.

CONCLUSION

A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.

Body mass index and breast cancer risk in African American women

PURPOSE

Studies of the relationship between body mass index (BMI) and breast cancer in African American women have been few. We conducted a case-control study to examine whether BMI is associated with risk of breast cancer in this population.

METHODS

Cases were 304 women diagnosed with breast cancer at the ages of 20 to 64 years. Controls were 305 women without a history of breast cancer. Telephone interviews were conducted to collect data on history of exposure to various factors at or before the date of diagnosis in cases or equivalent date in controls (reference date). Using logistic regression, we compared cases and controls in BMI at age 18, BMI at the reference date, and change in BMI between the two dates.

RESULTS

Using BMI at reference date, we found an odds ratio (OR) of 1.75 (95% confidence interval [CI], 1.02-3.02) and 2.32 (95% CI, 1.33-4.03) for women with BMI of 25 to 29.9 and 30 or higher, respectively, compared with women having BMI lower than 25. The corresponding OR estimates for BMI at age 18 were not significantly different from the unity. The average annual change in BMI between age 18 and date of diagnosis or reference date was associated with breast cancer risk, as shown that more BMI change tended to increase breast cancer risk compared with the baseline quartile of change. When data were analyzed by menopausal status, the association was found for both post-menopausal and pre-menopausal tumors for BMI at reference date but not for BMI at age 18. There was a higher risk for more annual BMI change compared with the baseline for both pre-menopausal and post-menopausal women.

CONCLUSION

Our results suggest that BMI at reference date and change in BMI were associated with increased risk of breast cancer in African American women, and the association might be found for both post-menopausal and pre-menopausal tumors.

Improving multiple behaviors for colorectal cancer prevention among african american church members

The WATCH (Wellness for African Americans Through Churches) Project was a randomized trial comparing the effectiveness of 2 strategies to promote colorectal cancer preventive behaviors among 587 African American members of 12 rural North Carolina churches. Using a 2 X 2 factorial research design, the authors compared a tailored print and video (TPV) intervention, consisting of 4 individually tailored newsletters and targeted videotapes, with a lay health advisor (LHA) intervention. Results showed that the TPV intervention significantly improved (p <.05) fruit and vegetable consumption (0.6 servings) and recreational physical activity (2.5 metabolic task equivalents per hour) and, among those 50 and older (n = 287), achieved a 15% increase in fecal occult blood testing screening (p =.08). The LHA intervention did not prove effective, possibly because of suboptimal reach and diffusion.

Racial disparities in female breast cancer in South Carolina: clinical evidence for a biological basis

OBJECTIVE

Racial disparities in breast cancer outcomes are well documented: African-American (AA) women have markedly poorer survival than do European-American (EA) women. A growing literature suggests that AA women have, on average, tumors of more aggressive histopathology, even if discovered early. We investigated this in our South Carolina population.

METHODS

Tumor registry data for 1687 AA and EA women with breast cancers newly diagnosed during 2000-2002 at the two Palmetto Health hospitals in Columbia, SC, were reviewed.

RESULTS

Corresponding to our regional population, 31% of cancers were in AA women. In both racial groups, 19% were in situ. Among women with invasive cancers, AA women had significantly earlier age at diagnosis than did EA women. Fewer AA women had lobular carcinoma (p = 0.001) or Her-2 over-expressing disease (7 versus 19%, p = 0.001). Significantly more AA women had high-grade cancer, larger tumors, axillary metastases and ER negative/PR negative tumors. After controlling for T-stage, AA women were significantly more likely to have high-grade and/or ER negative disease. Detection of invasive cancers by screening mammogram was less frequent in AA women (40 versus 53%, p < 0.000), and in small ER negative cancers.

CONCLUSIONS

At diagnosis, breast cancers in AA women tend to have the hallmarks of more aggressive and less treatable disease, even in small tumors, a pattern resembling that of breast cancers in younger EA women. Whatever the causes, these observations suggest breast cancer is biologically different in AA women. This may contribute substantially to the poorer outcomes in African-American women.

Racial Differences in Enrolment in a Cancer Genetics Registry

Background: Lower enrolment of minorities into research studies has been reported frequently. Most studies have little information about nonparticipants, making it difficult to identify characteristics associated with enrolment and how they might vary by race. Methods: Women who had previously participated in a population-based, case-control study of breast cancer in North Carolina were invited to enrol in a cancer genetics registry. Detailed questionnaire data on sociodemographic characteristics and cancer risk factors were available for all women. We compared characteristics of women who agreed to be in the registry with those who were deceased, were unlocatable, or declined enrolment. Unconditional logistic regression analyses were done to identify predictors of enrolment. Results: Enrolment rates were markedly lower among African Americans than Whites (15% and 36%, respectively) due to both lower contact rates (41% versus 63%) and lower enrolment rates among those contacted (37% versus 58%). Logistic regression models suggested that racial differences in enrolment were not due to socioeconomic characteristics or other cancer risk factors; race was the only significant predictor of enrolment in multivariable models (odds ratio 0.41, 95% confidence interval 0.23-0.72). Conclusions: Although all women had previously taken part in a research study, African American women were less likely to enrol in the cancer genetics registry than White women. A possible explanation of these findings is that studies of genetics may present particular concerns for African Americans. Further research is needed to identify attitudes and issues that present barriers to participation among minorities.

Breast cancer and obesity: an update

Obesity has a complicated relationship to both breast cancer risk and the clinical behavior of the established disease. In postmenopausal women, particularly the elderly, various measures of obesity have been positively associated with risk. However, before menopause increased body weight is inversely related to breast cancer risk. In both premenopausal and postmenopausal breast cancer, the mechanisms by which body weight and obesity affect risk have been related to estrogenic activity. Obesity has also been related to advanced disease at diagnosis and with a poor prognosis in both premenopausal and postmenopausal breast cancer. Breast cancer in African-American women, considering its relationship to obesity, exhibits some important differences from those described in white women, although the high prevalence of obesity in African-American women may contribute to the relatively poor prognosis compared with white American women. Despite the emphasis on estrogens to explain the effects of obesity on breast cancer, other factors may prove to be equally or more important, particularly as they relate to expression of an aggressive tumor phenotype. Among these, this review serves to stress insulin, insulin-like growth factor-I, and leptin, and their relationship to angiogenesis, and transcriptional factors.