Breast cancer among Hispanics, American Indians and non-Hispanic whites in New Mexico

The fluctuating incidence, improved survival of patients with breast cancer, and disparities by age, race, and socioeconomic status by decade, 1981-2010

Purpose

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related deaths among women worldwide. However, the data on breast cancer incidence and survival over a long period, especially the dynamic changes in the role of race and socioeconomic status (SES), are scant.

Materials and methods

To evaluate treatment outcomes of patients with breast cancer over the past 3 decades, the data from the Surveillance, Epidemiology, and End Results (SEER) registries were used to assess the survival of patients with breast cancer. Period analysis was used to analyze the incidence and survival trend; survival was evaluated by the relative survival rates (RSRs) and Kaplan-Meier analyses. The HRs for age, race, stage, and SES were assessed by Cox regression.

Results

A total of 433,366 patients diagnosed with breast cancer between 1981 and 2010 were identified from the original nine SEER registries. The incidences of breast cancer in each decade were 107.1 per 100,000, 117.5 per 100,000, and 109.8 per 100,000. The 10-year RSRs improved each decade, from 70.8% to 81.5% to 85.6% (P<0.0001). The lower survival in black race and high-poverty group is confirmed by Kaplan-Meier analyses and RSRs. Furthermore, Cox regression analyses demonstrated that age, race, SES, and stage are independent risk factors for patients with breast cancer in each decade.

Conclusion

The current data demonstrated a fluctuating incidence trend with improving survival rates of patients with breast cancer over the past 3 decades. In addition, the survival disparity exists among different races, ages, SESs, and stages.

Acceptance and adherence to treatment among breast cancer patients in Eastern Nigeria

This study reports on the acceptance and adherence behaviors of patients presenting with a clinical suspicion of breast cancer at a breast clinic in Nigeria during a 5-year period (2004-2008). Of the 275 study patients, 28.7% (79 patients) refused a biopsy needed for a definitive diagnosis. Of those who agreed to a biopsy, 10.2% (28 patients) did not return for a follow-up visit. Mastectomy was offered to 140 patients, 47.9% (67 patients) refused the surgery. Of the 53 patients diagnosed with locally advanced lesions offered neo-adjuvant chemotherapy, 28.3% (15 patients) completed the recommended therapy. Of the 44 patients offered adjuvant chemotherapy, 38.6% (17 patients) completed the recommended therapy. Only 23 of the patients advised to go for radiotherapy complied. Barriers to patient adherence to diagnostic and treatment recommendations included both patient barriers and system barriers.

Breast cancer incidence patterns among California Hispanic women: differences by nativity and residence in an enclave

BACKGROUND

Breast cancer incidence is higher in U.S.-born Hispanic women than foreign-born Hispanics, but no studies have examined how these rates have changed over time. To better inform cancer control efforts, we examined incidence trends by nativity and incidence patterns by neighborhood socioeconomic status (SES) and Hispanic enclave (neighborhoods with high proportions of Hispanics or Hispanic immigrants).

METHODS

Information about all Hispanic women diagnosed with invasive breast cancer between 1988 and 2004 was obtained from the California Cancer Registry. Nativity was imputed from Social Security number for the 27% of cases with missing birthplace information. Neighborhood variables were developed from Census data.

RESULTS

From 1988 to 2004, incidence rates for U.S.-born Hispanics were parallel but lower than those of non-Hispanic whites, showing an annual 6% decline from 2002 to 2004. Foreign-born Hispanics had an annual 4% increase in incidence rates from 1995 to 1998 and a 1.4% decline thereafter. Rates were 38% higher for U.S.- than foreign-born Hispanics, with elevations more pronounced for localized than regional/distant disease, and for women>50 years of age. Residence in higher SES and lower Hispanic enclave neighborhoods were independently associated with higher incidence, with Hispanic enclave having a stronger association than SES.

CONCLUSIONS

Compared with foreign-born, U.S.-born Hispanic women in California had higher prevalence of breast cancer risk factors, suggesting that incidence patterns largely reflect these differences in risk factors.

IMPACT

Further research is needed to separate the effects of individual- and neighborhood-level factors that affect incidence in this large and growing population.

Native Hawaiian Women and the Experience of Breast Cancer

This article describes a qualitative inquiry into the experiences of Native Hawaiian women living through and beyond a diagnosis of breast cancer. Native Hawaiian women have increased incidence and mortality breast cancer rates compared with other ethnic groups in Hawaii. Health promotion programs targeted at Native Hawaiians have often failed because of cultural inappropriateness. A lack of knowledge about the culture is frequently a part of this failure. Therefore, the specific purpose of this study was to examine the lived experience of a selected group of Native Hawaiian breast cancer survivors, uncover the connections between their narratives and their personal and cultural milieux, and generate knowledge about the Native Hawaiian woman's breast cancer experience that would be useful in planning future health promotion outreach efforts. The study consisted of interview data collected from 11 Native Hawaiian female participants, ranging from 44 to 82 years of age. An interpretive phenomenological analysis of the data identified recurrent contexts and themes. The three major contexts in their stories were discovery, transformation (physical, emotional and spiritual), and life realignment. Themes included the importance of spiritual connection, an altruistic desire to reach out and assist others in a similar situation, and a context of familial silence about cancer history. These elements can assist in formulating health promotion and intervention activities for this population. Interwoven with these themes was the Native Hawaiian concept of pono--a sense of rightness and balance, and the crucial importance of the participants' Native Hawaiian identity and cultural heritage.

Temporal trends in breast cancer presentation in the third world

BACKGROUND

Third world breast cancer is characterized by late presentation, occurrence at relatively young ages and dismal mortality. This poor outcome has encouraged patients to patronize quacks and alternative healers. Public control measures have targeted mainly public education and provision of screening facilities. Recent reports from the developed world indicate a high association with obesity, tobacco and alcohol, habits which though not currently very popular in the third world are nevertheless increasingly accepted.

METHODS

A prospective study initiated in 1985 for all breast cancer patients attending 4 hospitals located in the Eastern Nigeria heartland where the author practiced. On attendance to hospital detailed epidemiological data including social habits were collected from patients.

RESULTS

Reports from our first series [1987-97] showed some improvement in terms of earlier presentation compared to a historical control of earlier reports from the sub-region. Reports from the present study showed that this improvement has not been maintained probably as a result of diversion of public health campaign finances to HIV/AIDS. However there is an increasing mean age of presentation due to a higher representation of above 70 years age group and a significant reduction in parity. Alcohol intake and smoking have remained at low levels among the patients.

CONCLUSION

There is need to take another look at cancer public health campaign mechanisms in the face of competing demands from HIV. Public control measures should include among others teaching of Breast Self Examination [BSE] to patients, Clinical Breast Examination [CBE] to health workers and opportunistic CBE to all patients. Strenuous efforts should be made to break the vicious cycle of late presentation, poor treatment outcome and reluctance of patients to present to health facilities because of poor outcome.

Population differences in breast cancer severity

Breast cancer incidence and mortality vary among different populations. African-American, Hispanic, Asian and Native American women have lower incidence but higher mortality compared with non-Hispanic white women. Explanations for the observed variation include social and economic factors such as education, income level, health insurance coverage, use of mammography, parity, breastfeeding and diet. Breast cancer may be a heterogeneous disease with different subtypes of tumors having different genetic and environmental risk factors. The difference in frequency of particular tumor subtypes between populations may explain some of the differences in incidence and mortality. Known genetic variants explain a small fraction of breast cancer cases, and so far there are no susceptibility genes that explain population differences in incidence and mortality. Studies evaluating the risk for particular tumor subtypes combining genetic and environmental variables and analyzing cases from different populations are needed to understand population differences in the severity of breast cancer.

Body size, weight change, fat distribution and breast cancer risk in Hispanic and non-Hispanic white women

INTRODUCTION

The incidence of breast cancer varies among women living in the Southwestern part of the US. We evaluate how body size influences breast cancer risk among these women.

METHODS

Cases (n = 2,325) diagnosed with breast cancer between October 1, 1999 and May 2004 residing in Arizona, Colorado, New Mexico, or Utah were matched to controls (n = 2,525). Participants were interviewed; height, weight, waist, and hip circumference were measured at the time of interview; blood was drawn.

RESULTS

A large body mass index (BMI) at age 15 was inversely associated with pre-menopausal breast cancer risk in both non-Hispanic white (NHW) and Hispanic women (Odds ratio, ORs 0.68 95% CI 0.44, 1.04, and 0.65 95% CI 0.39, 1.08, respectively); BMI at age 15 also had an impact on subsequent breast cancer associated with obesity after menopause. Among post-menopausal women, recent exposure to hormones was an important modifier of risk associated with body size. Among women not recently exposed to hormones risk associated with obesity was 1.61 (95% CI 1.05, 2.45) for NHW women; gaining > or = 25 kg between 15 and age 50 was inversely associated with breast cancer among Hispanic women (OR 0.51, 95% CI 0.23, 1.14). A large weight gain and a large waist-to-hip ratio (WHR) was associated with an increased odds of having an estrogen receptor negative tumor among NHW only (OR 1.81, 95% CI 1.07, 3.08, and 2.04 95% CI 1.20,3.50).

CONCLUSIONS

These findings suggest that the metabolic consequences of obesity on breast cancer risk differ between NHW and Hispanic women living in the Southwest.

Differences in cancer incidence among Indians in Alaska and New Mexico and U.S. Whites, 1993-2002

Cancer incidence for American Indians and Alaska Natives is typically reported as a single rate for all U.S. indigenous populations combined. Previously reported combined rates suggest that American Indians and Alaska Natives have lower cancer incidence rates compared with the U.S. population. Alaska Native people comprise three major ethnic groups: Eskimo, Indian, and Aleut people. We examined cancer incidence from only Alaska Indians and compared incidence rates with an American Indian population living in New Mexico. These data indicate striking differences in cancer patterns between two American Indian populations. Cancer data for the years 1993 to 2002 for American Indians of New Mexico and U.S. Whites are from the National Cancer Institute Surveillance, Epidemiology, and End Results Program Public-use data set. Data for Alaska Indians are from the Alaska Native Tumor Registry, which is also a Surveillance Epidemiology and End Results Program participant. Overall, cancer incidence rates for all sites combined in New Mexico Indian men and women were lower than U.S. White rates, whereas Alaska Indian men and women exceeded U.S. rates. In comparing Alaska and New Mexico Indians, we observed a 2.5-fold higher incidence of cancer among Alaska Indians. The largest differences between the two Indian populations were noted primarily in cancers associated with tobacco use, including cancers of the oral cavity/pharynx, esophagus (only in men), colon and rectum, pancreas, larynx (men), lung, prostate, and urinary bladder (men). Lung cancer rates in Alaska Indian men and women were 7 and 10 times those of New Mexico Indian men and women.

Annual report to the nation on the status of cancer, 1975–2003, featuring cancer among U.S. Hispanic/Latino populations

BACKGROUND

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate annually to provide U.S. cancer information, this year featuring the first comprehensive compilation of cancer information for U.S. Latinos.

METHODS

Cancer incidence was obtained from 90% of the Hispanic/Latino and 82% of the U.S. populations. Cancer deaths were obtained for the entire U.S. population. Cancer screening, risk factor, incidence, and mortality data were compiled for Latino and non-Latino adults and children (incidence only). Long-term (1975-2003) and fixed-interval (1995-2003) trends and comparative analyses by disease stage, urbanicity, and area poverty were evaluated.

RESULTS

The long-term trend in overall cancer death rates, declining since the early 1990s, continued through 2003 for all races and both sexes combined. However, female lung cancer incidence rates increased from 1975 to 2003, decelerating since 1991 and breast cancer incidence rates stabilized from 2001 to 2003. Latinos had lower incidence rates in 1999-2003 for most cancers, but higher rates for stomach, liver, cervix, and myeloma (females) than did non-Latino white populations. Latino children have higher incidence of leukemia, retinoblastoma, osteosarcoma, and germ-cell tumors than do non-Latino white children. For several common cancers, Latinos were less likely than non-Latinos to be diagnosed at localized stages.

CONCLUSIONS

The lower cancer rates observed in Latino immigrants could be sustained by maintenance of healthy behaviors. Some infection-related cancers in Latinos could be controlled by evidence-based interventions. Affordable, culturally sensitive, linguistically appropriate, and timely access to cancer information, prevention, screening, and treatment are important in Latino outreach and community networks.

Can the Gail model be useful in American Indian and Alaska Native populations?

BACKGROUND

Very little is known about breast carcinoma risk factors for American Indian/Alaska Native (AI/AN) women undergoing screening. The Gail model has been a useful tool for predicting the risk of breast carcinoma in several populations. It has not been applied systematically to AI/AN women.

METHODS

The current study was a retrospective review of 1458 screening mammograms performed for AI/AN women. The authors applied the Gail model to estimate both absolute risk and relative risk for breast carcinoma for AI/AN women screened in South Dakota, Arizona, and Alaska.

RESULTS

The mean age of the women was 52.4 years. The onset of menses was not significantly different than expected. The average age at first birth was 20 years, very few women were nulliparous, and few women were age > 30 years at first live birth. The proportion of women reporting a first- or second-degree relative with breast carcinoma was similar to the proportion in the general population. The results of the model indicated an overall average relative risk that ranged from 1.42 to 2.69 compared with white American women, depending on the model assumptions used. Using a modified Gail model and calculating an imputed absolute risk, the expected incidence of breast carcinoma in this population increased to rates of 170-180 per 100,000 in the next 10 years, a significant increase over the Surveillance, Epidemiology and End Results-derived incidence rates from 1988 to 1992 of 31.6 per 100,000 for AI women in New Mexico and 78.9 per 100,000 for AN women.

CONCLUSIONS

The model indicated a likelihood of increasing rates of breast carcinoma in the study population. The data obtained were useful in generating preliminary estimates of breast carcinoma risk in the study population, for which no prospective population survey has been completed. The inherent weaknesses in the current retrospective study indicated the need for a large-scale prospective data collection to confirm these exploratory findings.

Conservation Therapy in T1-T2 Breast Cancer

PURPOSE

To assess the significance of patient age, race, tumor-related prognostic parameters, status of surgical excision margins, and irradiation boost on incidence of ipsilateral breast relapse, and to review current issues in the management of T1-T2 breast cancer patients with conservation therapy.

MATERIALS AND METHODS

Records of 1037 patients with histologically confirmed stage T1 and 308 patients with T2 carcinoma of the breast treated with breast conservation therapy from January 1970 through December 1997 were prospectively registered and evaluated. The mean follow-up for surviving patients was 6.6 years (range, 4-30 years), with a minimum follow up of 4 years for all patients.

RESULTS

There were 78 ipsilateral breast relapses (IBRs); the actuarial 10-year incidence of IBR was 7% for T1 and 11% for T2 tumors. In patients 40 years of age or younger, four of 24 (17%) with extensive intraductal component developed an ipsilateral breast relapse, compared with six of 80 (8%) without extensive intraductal component, in contrast to eight of 159 (5%) and 33 of 776 (4%) in postmenopausal patients with or without extensive intraductal component, respectively. In patients with T2 tumors, two of eight (25%) women 40 years or younger with extensive intraductal component, and seven of 50 (14%) without extensive intraductal component developed ipsilateral breast relapse. The corresponding values for the patients older than 40 years were five of 48 (10%) and 13 of 202 (6%), respectively. The incidences of ipsilateral breast relapses, correlated with status of surgical margins after re-excision in T1 tumors, were one of 30 (3.3%) for positive, no relapses in 40 patients with close margins, 16 of 438 (3.6%) for negative, and 18 of 196 (9%) for undetermined margins. In the patients with T2 tumors, ipsilateral breast relapses occurred in two of 16 patients (12.5%) with positive margins, one of 16 (6%) with close, seven of 105 (6.6%)with negative, and four of 68 (5.9%) with undetermined margins (differences not statistically significant). In patients with T1 tumors, negative margins, the 10-year relapse rate was the same (8%) in 559 to whom a boost was administered and in 66 without a boost. In patients with positive margins, the relapse rate was 4% in 215 receiving a boost (18-20 Gy) and 33% (two of six) without a boost. In patients with T2 tumors and negative margins, the rate of ipsilateral breast relapses in 16 patients to whom no boost was given was 12%, as opposed to 10% in 143 patients who received a boost. However, with T2 tumors and close or positive margins, the IBR rate at 10 years was 12% in 81 given a boost, in contrast to 40% (2 of 5) without a boost. In T1 tumors, the breast failure rate was two of 53 (3.7%) in women < or = 40 years receiving chemotherapy and eight of 51 (15.6%) without chemotherapy. For T2 tumors, the corresponding values were seven of 39 (17%) and two of 19 (10.5%), respectively. In women 40 years or younger with T1 tumors receiving hormones or not, the ipsilateral breast relapse rate was two of 19 (10.5%) and eight of 85 (9.4%), respectively; in the older than 40 years group, the corresponding values were six of 377 (1.6%) and 35 of 558 (6.2%). In the patients with T2 tumors, ipsilateral breast relapse rates were not statistically different in the various groups. On multivariate analysis, only age and adjuvant therapy were significant factors predictive of ipsilateral breast relapse.

CONCLUSIONS

Surgical excision margins status following adequate doses of radiation therapy was not a predictor of ipsilateral breast relapse. In patients younger than 40 years of age with extensive intraductal component, a somewhat higher breast relapse rate was noted but not enough to preclude breast conservation therapy. A boost of irradiation did not have a significant impact in the incidence of ipsilateral breast relapse in patients with negative margins, but it was of benefit to those with close or positive margins. Close attention to surgical margin status and delivery of higher doses of irradiation to the tumor excision site in patients with close or positive surgical margins will decrease the probability of breast relapses.

Effects of dietary intervention on IGF-I and IGF-binding proteins, and related alterations in sex steroid metabolism: the Diet and Androgens (DIANA) Randomised Trial

OBJECTIVE

To assess the effects of a comprehensive change in dietary composition on endogenous hormone metabolism. The specific aim was to examine whether this intervention could lead to favourable changes in insulin sensitivity, levels of IGF-I and IGF-binding proteins (IGFBPs), and total and bioavailable testosterone and estradiol, that would be expected to reduce breast cancer risk.

DESIGN

Randomised dietary intervention study; duration of 5 months.

SUBJECTS

From a total of 99 postmenopausal women, who had elevated baseline plasma testosterone levels, 49 women were randomly assigned to the dietary intervention arm and the other 50 to a control group.

INTERVENTIONS

Main aspects of the dietary intervention were reductions in the intake of total fat and refined carbohydrates, an increase in the ratio of n-3 over n-6 plus saturated fatty acids, and increased intakes of foods rich in dietary fibre and phytooestrogens.

RESULTS

Relative to the control group, women of the intervention group showed a significant reduction of body weight, waist circumference, fasting serum levels of testosterone, C peptide, glucose, and insulin area after glucose tolerance test, and a significant increase of serum levels of sex hormone-binding globulin, IGFBP-1, -2, and growth hormone-binding protein. Serum levels of IGF-I did not change.

CONCLUSION

This comprehensive dietary intervention strategy proved to be successful in inducing changes in endogenous hormone metabolism that might eventually result in reduced breast cancer risk. Additional studies are needed to show whether the dietary intervention and related hormonal changes can be both maintained over longer periods, of at least several years.

Chronic disease coverage in Canadian aboriginal newspapers

PURPOSE

To determine the volume and focus of articles on four chronic diseases in newspapers targeting First Nations, Métis, and Inuit in Canada.

METHODS

From a sampling frame of 31 Aboriginal newspapers published in English from 1996-2000, 14 newspapers were randomly selected allowing for national and regional representation. Newspaper archives were searched at the National Library of Canada and articles selected if the disease terms cancer, cardiovascular disease, diabetes, or HIV/AIDS appeared in the headline, or in the first or last paragraph of the article. Articles were coded for inclusion of mobilizing information (local, distant, unrestricted, not specified, none) and content focus (scientific, human interest, commercial, other). Cancer articles were categorized by tumor site specificity. Data were analyzed by frequency, cross tabulations, and chi-square analysis.

RESULTS

Of 400 chronic disease articles, there were significantly more articles on HIV/AIDS (167 or 41.8%) and diabetes (135 or 33.8%) and few articles on cancer (56 or 14%) and cardiovascular disease (30 articles or 7.5%) (p<0.001). Slightly more than one third (36.5%) of the articles contained mobilizing information to enable readers to take further health action. Mobilizing information was virtually absent from cardiovascular (7/30 or 23%) and diabetes (29/135 or 21.5%) articles. Site specific cancer coverage differed significantly from chance (p<0.001) with 41% of the articles on breast cancer and no articles on lung or colorectal cancers.

INTERPRETATION

Given the burden of tobacco-related cardiovascular disease and cancer in Canadian Aboriginal people, the lack of coverage and limited mobilizing information in ethnic newspapers are a missed opportunity for health promotion.

Prevalence and Spectrum of p53 Mutations in White Hispanic and Non-Hispanic Women with Breast Cancer

Hispanic women differ from non-Hispanics in breast cancer incidence, stage at diagnosis, and survival. Ethnic differences in genetic makeup, reproductive patterns, diet, socioeconomic status, physical activity, and other unidentified cultural factors may be responsible for the disparity. This study investigated occurrences of p53 tumor suppressor gene mutations in South Florida white Hispanic and white non-Hispanic women with primary breast cancer. Tumor tissues were obtained from a consecutive series of women with breast cancer who underwent breast resection at the Jackson Memorial Hospital, Miami, Florida between 1984 and 1986. A total of 231 women with primary breast cancer, aged 31-85 years, were included in the study. Among them, 64 (27.7%) were white Hispanic and 167 (72.3%) were white non-Hispanic. The majority of the patients were white non-Hispanics (72.3%). Compared to white non-Hispanics, however, white Hispanics had significantly higher proportions of tumors larger than 2 cm (53.1% v.s. 28.7%, p = 0.00) as well as larger tumor size at diagnosis (mean: 4.2 v.s. 3.0 cm, p = 0.00). The p53 gene mutation rate was significantly lower in white Hispanics than in white non-Hispanics (51.6% v.s. 70.7%, p = 0.01). Furthermore, among node-negative breast cancer patients, after adjustment for tumor size at diagnosis, logistic regression results showed that white Hispanics were 71% less likely than white non-Hispanics to carry p53 mutations (OR = 0.29 and 95% CI = 0.09-0.91). We conclude that white Hispanic women with breast cancer might have lower p53 gene mutation prevalence than white non-Hispanic women.

Socioeconomic status and breast carcinoma survival in four racial/ethnic groups: a population-based study

BACKGROUND

Although overall survival for invasive breast carcinoma remains high, black women experience poorer survival than whites. Less is known about the survival of Hispanics and Asians, who may share clinical and socioeconomic risk factors similar to blacks. To better understand racial/ethnic survival patterns, we investigated the effect of socioeconomic status (SES) and disease stage on racial/ethnic differences in breast carcinoma survival in a large population-based cohort.

METHODS

Using data from the Surveillance, Epidemiology, and End Results program (SEER), we identified 10,414 white, 940 black, 1100 Hispanic, and 1180 Asian females diagnosed with breast carcinoma in the Greater San Francisco Bay Area between 1988 and 1992. We used the Kaplan-Meier method to generate survival rates and Cox proportional hazards regression to estimate the risk of death by race/ethnicity, after adjustment for clinical, demographic, and census-derived SES variables.

RESULTS

The 10-year unadjusted survival rates were 81% for whites, 69% for blacks, 75% for Hispanics, and 79% for Asians. Adjusting for stage decreased the relative risk of mortality for blacks from 1.81 to 1.29; the stage-adjusted relative risk for Hispanics (1.11) and Asians (1.02) did not differ significantly from whites. Additional adjustment for age, tumor characteristics, and treatment factors did little to alter the relative risk in blacks; adding blue-collar status to the model further decreased the relative risks for blacks to 1.22. Residing in a blue-collar neighborhood was independently associated with a 1.16 increase in risk of death.

CONCLUSIONS

After adjustment for multiple factors, blacks continue to have slight but significantly poorer survival after breast carcinoma compared with whites, whereas the survival of Hispanics and Asians did not differ from whites.

Hormone replacement therapy and breast carcinoma risk in Hispanic and non-Hispanic women

BACKGROUND

Hormone replacement therapy (HRT) alleviates menopausal symptoms and prevents osteoporosis, but there is concern that long-term use may have an adverse impact on breast carcinoma risk. Epidemiologic studies report inconsistent findings regarding the relationship between HRT and postmenopausal breast carcinoma risk and there is little information on the HRT-associated risk among minority women.

METHODS

To investigate the effects of HRT on breast carcinoma risk among Hispanic women, we examined data from the New Mexico Women's Health Study (NMWHS), a statewide case-control study comprising 366 postmenopausal women with breast carcinoma and 403 controls. Conditional logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

After adjustment for sociodemographic, medical, and reproductive factors, we found an increased risk associated with long-term users of estrogen replacement therapy (ERT; OR for ERT use longer than 140 months was 2.57, 95%CI, 1.25-5.28, compared with ERT use shorter than 17 months). In addition, there was a positive trend with the duration of ERT use (P < 0.01). Hispanic postmenopausal women appeared to be at a significantly greater risk than non-Hispanic white women (OR for ERT use longer than 140 months in Hispanics was 5.53, 95%CI, 1.47-20.87; OR in non-Hispanics was 2.65, 95%CI, 0.95-7.34, compared with ERT use shorter than 17 months). In contrast, no significant association was observed for combined estrogen-progesterone use in either Hispanic or non-Hispanic women.

CONCLUSIONS

The results of this study indicated that postmenopausal women had significantly increased breast carcinoma risk for long-term ERT use. The risks among Hispanic women were substantially higher than among non-Hispanic white women although they were not statistically significant.

Breast and cervical cancer screening among migrant and seasonal farmworkers: a review

Women constitute about one in five hired farmworkers in the US. Their health may be affected by exposure to unhealthy living and working conditions, by increased exposure to health hazards, by poverty, and by poor utilization of health care and preventive services. About 69% of migrant and seasonal farmworkers were born outside the US, mostly in Mexico and central America, and many speak little English. The health concerns of women who are migrant and seasonal farmworkers include breast and cervical cancer, which can be prevented or controlled through routine screening, but cancer incidence and mortality data for migrant workers are sparse. We reviewed published studies that examined breast and cervical cancer screening in this population. These studies include cross-sectional surveys, health needs assessments, and randomized and non-randomized intervention trials. A review of published studies of cancer screening among women who are migrant and seasonal farmworkers indicates that underutilization of mammograms and Papanicolau (Pap) tests among this population may stem from their limited awareness of the importance of cancer screening and cultural beliefs. Other barriers include cost, lack of health insurance, lack of transportation and child care difficulties. The extent to which results obtained in selected localities are generalizable to other settings is uncertain, but results to date provide important information about possible approaches for increasing cancer screening among women migrant farmworkers.

Breast and cervical cancer screening practices among Hispanic women in the United States and Puerto Rico, 1998-1999

BACKGROUND

Results from recent studies suggest that Hispanic women in the United States may underuse cancer screening tests and face important barriers to screening.

METHODS

We examined the breast and cervical cancer screening practices of Hispanic women in 50 states, the District of Columbia, and Puerto Rico from 1998 through 1999 by using data from the Behavioral Risk Factor Surveillance System.

RESULTS

About 68.2% (95% confidence interval [CI] = 66.3 to 70.1%) of 7,253 women in this sample aged 40 years or older had received a mammogram in the past 2 years. About 81.4% (95% CI = 80.3 to 82.5%) of 12,350 women aged 18 years or older who had not undergone a hysterectomy had received a Papanicolaou test in the past 3 years. Women with lower incomes and those with less education were less likely to be screened. Women who had seen a physician in the past year and those with health insurance coverage were much more likely to have been screened. For example, among those Hispanic women aged 40 years or older who had any health insurance coverage (n = 6,063), 72.7% (95% CI 70.7-74.6%) had had a mammogram in the past 2 years compared with only 54.8% (95% CI 48.7-61.0%) of women without health insurance coverage (n = 1,184).

CONCLUSIONS

These results underscore the need for continued efforts to ensure that Hispanic women who are medically underserved have access to cancer screening services.

Factors related to cancer screening in Hispanics: a comparison of the perceptions of Hispanic community members, health care providers, and representatives of organizations that serve Hispanics

Hispanics have lower rates of screening for cervical, breast, and colon cancer than non-Hispanics. Activities to increase cancer screening in this population may not be informed by Hispanics, which may have implications for success rates of interventions. In this study, the perceptions about cancer screening behaviors in Hispanics are compared among three groups: a random sample of respondents (75% Hispanic) to a population-based survey, health care providers (primarily non-Hispanic), and representatives of organizations that serve Hispanics (36% Hispanic). While there was agreement that socioeconomic factors were important for cancer screening, differing views were expressed regarding the importance of cultural factors for cancer screening among Hispanics. Interventions developed by those who serve the Hispanic population may be based on inaccurate perceptions about the beliefs and practices of the population served. For effective interventions, it will be necessary to understand the factors important to Hispanics for cancer screening.

Organochlorine exposures and breast cancer risk in New York City women

A hospital-based case-control study of breast cancer risk related to organochlorine (OC) exposure was conducted in a multiethnic setting in New York City. We enrolled 175 breast cancer patients and 355 control patients. The overall racial/ethnic distribution was 57% Caucasian, 21% Hispanic, 22% African-American; cases and controls were frequency-matched by age and race/ethnicity. Tumor markers (estrogen and progesterone receptors, p53, erbB-2) were assessed and organochlorines (DDE, DDT, trans-nonachlor, and higher (HPCB) and lower (LPCB) chlorinated biphenyls) were measured in blood serum. Tumors among minority women were of slightly higher stage than among Caucasians, but tumor markers were similar across the racial/ethnic groups. DDE levels were highest among African-American and Hispanic women; DDT was highest among Hispanics; HPCBs were highest among African-Americans; LPCBs were lowest among Hispanics; and trans-nonachlor was highest among African-Americans. However, OC levels were not associated with risk for breast cancer, nor did OCs differ with respect to tumor stage or tumor markers. Higher DDE levels were associated with increasing body mass index (BMI), but with decreasing level of education, frequency of nulliparity, and frequency of family history of breast cancer. HPCB levels decreased with BMI and were not correlated with breast cancer risk factors. These relationships can be attributed to historical patterns of exposure and to metabolic differences in OCs related to BMI.

Socioeconomic factors and breast carcinoma in multicultural women

Breast carcinoma is the most common cancer in women in the U.S. and the second leading cause of cancer death in women. Furthermore, there are racial differences in breast carcinoma incidence, mortality, and survival rates. Social and economic factors within racial/ethnic groups are being examined as risk factors not only for breast carcinoma mortality and survival but also as determinants of the rate of incidence. Social and economic factors have been associated in the literature predominantly with cancer mortality and survival. When socioeconomic status (SES) is considered, certain studies suggest that racial disparities in breast carcinoma are smaller than when social and economic factors are examined alone, but these disparities still persist. Sources of data for this discussion include the National Cancer Institute (NCI) (the Surveillance, Epidemiology, and End Results [SEER] program, a group of population-based cancer registries that cover up to 14% of the U.S. population. SEER reports cancer incidence, mortality, and survival rates), the U.S. Bureau of the Census, the National Center for Health Statistics (NCHS), and numerous articles from the scientific literature. Socioeconomic factors or SES can be considered "cross-cutting risk factors" (i.e., they can be related to the risk of developing breast carcinoma [rate of incidence] as well as to the risk of dying [mortality] from this disease). They also are the risk factors that "cut across" racial and ethnic populations. Socioeconomic factors are related to breast carcinoma mortality and survival rates in multicultural women. Racial disparities in breast carcinoma mortality and survival rates can be explained partially by stage distribution at the time of diagnosis, which may be related to SES. For example, African-American women present with more advanced stage distributions for breast carcinoma than white women. Similarly, women of lower SES present with higher stage disease than women of upper SES who present with more localized breast carcinoma. The lack of data regarding the SES of cancer patients limits our understanding of the contributions of SES to cancer incidence and mortality rates. SES appears to be related to breast carcinoma incidence, mortality, and survival rates. Breast carcinoma mortality is higher in women of lower SES. Additional research on SES, race, culture, and the relation of these factors to cancer incidence rate is needed.

Survival differences in breast cancer among racial/ethnic groups: a population-based study

In women, breast cancer is the most frequent solid tumor and the second leading cause of cancer death. Differences in survival of breast cancer have been noted among racial/ethnic groups, but the reasons are unclear. This report presents the characteristics and the survival experience of four racial/ethnic groups and evaluates the effects of stage, age, histology, and treatment on survival time. The distributions of prognostic factors and treatment among racial/ethnic groups are compared using female breast cancer patients from two population-based registries in Southern California. The main end points are observed survival time and survival by cause of death. The Cox model is used to estimate the relative risk of death in three minority groups compared with non-Hispanic whites, while controlling for several covariates. Breast cancer cases included in this study were 10,937 non-Hispanic whites, 185 blacks, 875 Hispanics, and 412 Asians. The median follow-up period was 76 months (range: 48-132). The median age at diagnosis was 64 years among non-Hispanic whites, 55 years among Hispanics (p = 0.001), 52 years among blacks (p = 0.001), and 50 years among Asians (p = 0. 001). There was more localized disease among non-Hispanic whites (61. 4%) than among blacks (50.8%) and Hispanics (52.2%), but not compared to Asians (59.7%). After controlling for stage, age, histology, treatment, and registry, overall survival significantly differed between non-Hispanic whites and blacks [relative risk (RR) = 2.27, 95% confidence interval (95% CI) 1.82-2.84) and between non-Hispanic whites and Hispanics (RR = 1.18, 95% CI 1.04-1.34). The same results were found for breast cancer death in blacks (RR = 2.32, 95% CI 1.76-3.07) and Hispanics (RR = 1.28, 95% CI 1.10-1.50). We found no difference between Asians and non-Hispanic whites in overall and cancer-related survival. These results show that stage of disease, age at diagnosis, histologic features and treatment for breast cancer differed among racial/ethnic groups. Moreover, black women, in particular, and Hispanic women with breast cancer had a higher risk of death compared to non-Hispanic white women, even after controlling for prognostic factors. These findings underline the necessity of improved screening and access to appropriate treatment among minority women for breast cancer.

Breast and cervical cancer screening practices among American Indian and Alaska Native women in the United States, 1992-1997

BACKGROUND

Recent studies suggest that American Indian and Alaska Native women have important barriers to cancer screening and underuse cancer screening tests.

METHODS

We examined the breast and cervical cancer screening practices of 4,961 American Indian and Alaska Native women in 47 states from 1992 through 1997 by using data from the Behavioral Risk Factor Surveillance System.

RESULTS

About 65.1% [95% confidence interval (CI) 60.2 to 69.9%] of women in this sample aged 50 years or older had received a mammogram in the past 2 years. About 82.6% (95% CI 80.1 to 85.2%) of women aged 18 years or older who had not undergone a hysterectomy had received a Papanicolaou test in the past 3 years. Older women and those with less education were less likely to be screened. Women who had seen a physician in the past year were much more likely to have been screened.

CONCLUSIONS

These results underscore the need for continued efforts to ensure that American Indian and Alaska Native women who are elderly or medically underserved have access to cancer screening services.

Trends in incidence and treatment for ductal carcinoma in situ in Hispanic, American Indian, and non-Hispanic white women in New Mexico, 1973-1994

BACKGROUND

Incidence rates of ductal carcinoma in situ (DCIS) breast carcinoma and the use of breast-conserving surgery (BCS) for its treatment show substantial geographic and ethnic variations nationwide. To the authors' knowledge, few studies have investigated incidence rates and treatment patterns in Hispanics and American Indians.

METHODS

The authors used data from the population-based New Mexico Tumor Registry to describe trends in DCIS incidence rates between 1973-1994 and investigate patient and physician characteristics related to BCS in a multiethnic population between 1985-1994. Multiple logistic regression was used to evaluate patient and physician factors related to receiving BCS.

RESULTS

Incidence rates for DCIS in Hispanics were approximately 50% lower compared with non-Hispanic whites. American Indians had the lowest incidence rate. Beginning in 1985, incidence rates for Hispanics and non-Hispanic whites showed a 21% annual increase. Between 1990-1994, incidence rates in American Indians increased more than twofold. BCS increased 5.8% per year between 1985-1994, with 50% of Hispanic and non-Hispanic white patients treated with BCS in 1994. The strongest factor associated with receiving BCS was geographic location of treatment (P < 0.001). The odds of receiving BCS were 5.8 times higher in the northern third of the state compared with the southern third. No significant variation in BCS was found by ethnicity, rural/urban residency, socioeconomic status, or physician characteristics.

CONCLUSIONS

Incidence rates for DCIS increased substantially in all three ethnic groups. The use of BCS was associated most strongly with the location of treatment, most likely reflecting differences in physician practices and treatment recommendations. Further research is needed to investigate the increasing incidence rates of DCIS and the determinants of BCS for the treatment of DCIS.

Essential fatty acids, insulin resistance, and breast cancer risk

This review compares the prevalence of hyperinsulinemic insulin resistance in Caucasian-American women with that in Japanese-American and Pima Indian minority groups in the United States. It also examines the differences in breast cancer risk between these ethnic groups and suggests that risk may be modulated by ethnic genetic susceptibility to the effect of the Western diet in precipitating insulin resistance. It is widely agreed that the Western diet with its high saturated fatty acid content and high n-6/n-3 ratio of polyunsaturated fatty acids (PUFAs) favors the manifestation of hyperinsulinemia in individuals who are genetically predisposed. A number of case-control studies have shown hyperinsulinemia to be a marker of increased breast cancer risk, particularly in obese postmenopausal women. Mechanisms that have been postulated include an increased sex steroid level associated with a decreased serum level of sex hormone-binding globulin and an increased bioactive level of insulin-like growth factor I, which may synergize with estrogen in promoting mammary carcinogenesis. Dietary supplements rich in n-3 PUFAs have been shown to inhibit the growth of human breast cancer implants in nude mice, and members of the n-3 PUFA series can inhibit the growth of human breast cancer cell lines in vitro. On the basis of this experimental evidence, some have proposed dietary supplements rich in n-3 PUFAs for breast cancer protection. However, increased consumption of PUFAs requires increased intake of antioxidants. Vitamin E may be the most suitable agent, especially because of its added advantage that in animal models it is reported to reduce the incidence of carcinogen-induced mammary tumors. Preliminary trials of the combination may best be planned as adjuvant treatment after primary surgery for breast cancer, and the insulin hypothesis could be tested in the trials by monitoring fasting insulin and sex steroid levels.

Differences in breast cancer stage at diagnosis between non-Hispanic white and Hispanic populations, San Diego County 1988-1993

The incidence of breast cancer in the U.S. is lower among Hispanic women than non-Hispanic white women. However, population-based studies show that Hispanic women are more likely to be diagnosed at a later stage than non-Hispanic whites. We aimed to determine whether: 1) a lower proportion of breast cancer was diagnosed at early vs. late stages in Hispanic compared to non-Hispanic white women from 1988-93 in San Diego County, and 2) lower income is related to later stage at diagnosis for both groups. All incident cases of breast cancer in San Diego County from the California Cancer Registry (10,161 cases) were stratified by 'early' (in situ or localized) or 'late' (regional or distant) stage, and by race/ethnicity. Annual average age-adjusted incidence rates/100,000 (AAIR) were calculated. Incidence rate ratios (IRR) (AAIR for early stages divided by AAIR for late stages) were used as a surrogate of early detection. AAIRs for early and late stage disease were significantly higher for non-Hispanic whites (89.3, 42.3) than Hispanic women (46.7, 27.2). The IRR was significantly higher for non-Hispanic whites than Hispanics, (2.11 vs 1.72, p = 0.01). This difference was greatest among women under 50 years old (IRR difference 0.63), and not apparent for women 65 or older (IRR difference 0.06). There was also an association between increasing census tract per capita income and higher rates of early stage disease among non-Hispanic whites but not Hispanics. Results suggest that Hispanic women and lower income women should be targeted for early detection.

Hormone receptor status of breast tumors in black, Hispanic, and non-Hispanic white women. An analysis of 13,239 cases

BACKGROUND

It has been postulated that different biologic characteristics of a tumor might account for at least a portion of the disparity in breast cancer survival for patients across racial and ethnic groups. The hormone receptor status of breast tumors is one characteristic with prognostic significance. Results of several studies indicate a higher proportion of estrogen receptor negative (ER-) breast tumors among black or Hispanic women compared with non-Hispanic whites. We investigated whether the association between race and ethnicity and the joint combination of ER and progesterone receptor (PR) status was independent of age and other tumor characteristics at diagnosis.

METHODS

Relevant data were obtained from 13,239 breast cancer cases identified as part of the 1990 Patient Care Evaluation Study of Breast Cancer.

RESULTS

In univariate analysis, the proportions of ER+PR+, ER+PR-, ER-PR+, and ER-PR- tumors among non-Hispanics whites were 59%, 15%, 6%, and 20%, respectively; among Hispanics the proportions were 58%, 12%, 8%, and 22%, respectively; and among blacks the proportions were 44%, 14%, 7%, and 35%, respectively. After controlling for age, tumor size, and histology, using polychotomous logistic regression, these was no difference in hormone-receptor status between Hispanic and non-Hispanic white women. However, ER-PR- tumors were more likely to occur in blacks than in non-Hispanic whites (odds ratio = 1.8, 95% confidence interval = 1.6, 2.1)

CONCLUSIONS

The results of this study corroborate differences in hormone-receptor status between non-Hispanic white and black women, but not between Hispanics. Future studies of breast cancer should examine differences in epidemiologic risk factors between blacks and whites stratified on ER/PR status.