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Collin LJ, Jones J, Nash R, Switchenko JM, Ward KC, McCullough LE. Racial disparities in initiation of chemotherapy among breast cancer patients with discretionary treatment indication in the state of Georgia. Breast Cancer Res Treat 2024; 205:609-618. [PMID: 38517602 PMCID: PMC11101533 DOI: 10.1007/s10549-024-07279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/07/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE The majority of breast cancer patients are diagnosed with early-stage estrogen receptor (ER) positive disease. Despite effective treatments for these cancers, Black women have higher mortality than White women. We investigated demographic and clinical factors associated with receipt of chemotherapy among those with a discretionary indication who are at risk for overtreatment. METHODS Using Georgia Cancer Registry data, we identified females diagnosed with ER positive breast cancer who had a discretionary indication for chemotherapy (2010-2017). We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) associating patient demographic and clinical characteristics with chemotherapy initiation overall, and comparing non-Hispanic Black (NHB) with non-Hispanic White (NHW) women within strata of patient factors. RESULTS We identified 11,993 ER positive breast cancer patients with a discretionary indication for chemotherapy. NHB patients were more likely to initiate chemotherapy compared with NHW women (OR = 1.41, 95% CI: 1.28, 1.56). Race differences in chemotherapy initiation were pronounced among those who did not receive Oncotype DX testing (OR = 1.47, 95% CI: 1.31, 1.65) and among those residing in high socioeconomic status neighborhoods (OR = 2.48, 95% CI: 1.70, 3.61). However, we observed equitable chemotherapy receipt among patients who received Oncotype DX testing (OR = 0.90, 95% CI: 0.71, 1.14), were diagnosed with grade 1 disease (OR = 1.00, 95% CI: 0.74, 1.37), and those resided in rural areas (OR = 1.01, 95% CI: 0.76, 1.36). CONCLUSION We observed racial disparities in the initiation of chemotherapy overall and by sociodemographic and clinical factors, and more equitable outcomes when clinical guidelines were followed.
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Affiliation(s)
- Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope Dr, Salt Lake City, UT, 84112, USA.
| | - Jade Jones
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Sacca L, Lobaina D, Burgoa S, Lotharius K, Moothedan E, Gilmore N, Xie J, Mohler R, Scharf G, Knecht M, Kitsantas P. Promoting Artificial Intelligence for Global Breast Cancer Risk Prediction and Screening in Adult Women: A Scoping Review. J Clin Med 2024; 13:2525. [PMID: 38731054 PMCID: PMC11084581 DOI: 10.3390/jcm13092525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/01/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Artificial intelligence (AI) algorithms can be applied in breast cancer risk prediction and prevention by using patient history, scans, imaging information, and analysis of specific genes for cancer classification to reduce overdiagnosis and overtreatment. This scoping review aimed to identify the barriers encountered in applying innovative AI techniques and models in developing breast cancer risk prediction scores and promoting screening behaviors among adult females. Findings may inform and guide future global recommendations for AI application in breast cancer prevention and care for female populations. Methods: The PRISMA-SCR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) was used as a reference checklist throughout this study. The Arksey and O'Malley methodology was used as a framework to guide this review. The framework methodology consisted of five steps: (1) Identify research questions; (2) Search for relevant studies; (3) Selection of studies relevant to the research questions; (4) Chart the data; (5) Collate, summarize, and report the results. Results: In the field of breast cancer risk detection and prevention, the following AI techniques and models have been applied: Machine and Deep Learning Model (ML-DL model) (n = 1), Academic Algorithms (n = 2), Breast Cancer Surveillance Consortium (BCSC), Clinical 5-Year Risk Prediction Model (n = 2), deep-learning computer vision AI algorithms (n = 2), AI-based thermal imaging solution (Thermalytix) (n = 1), RealRisks (n = 2), Breast Cancer Risk NAVIgation (n = 1), MammoRisk (ML-Based Tool) (n = 1), Various MLModels (n = 1), and various machine/deep learning, decision aids, and commercial algorithms (n = 7). In the 11 included studies, a total of 39 barriers to AI applications in breast cancer risk prediction and screening efforts were identified. The most common barriers in the application of innovative AI tools for breast cancer prediction and improved screening rates included lack of external validity and limited generalizability (n = 6), as AI was used in studies with either a small sample size or datasets with missing data. Many studies (n = 5) also encountered selection bias due to exclusion of certain populations based on characteristics such as race/ethnicity, family history, or past medical history. Several recommendations for future research should be considered. AI models need to include a broader spectrum and more complete predictive variables for risk assessment. Investigating long-term outcomes with improved follow-up periods is critical to assess the impacts of AI on clinical decisions beyond just the immediate outcomes. Utilizing AI to improve communication strategies at both a local and organizational level can assist in informed decision-making and compliance, especially in populations with limited literacy levels. Conclusions: The use of AI in patient education and as an adjunctive tool for providers is still early in its incorporation, and future research should explore the implementation of AI-driven resources to enhance understanding and decision-making regarding breast cancer screening, especially in vulnerable populations with limited literacy.
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Affiliation(s)
- Lea Sacca
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA; (D.L.); (S.B.); (K.L.); (E.M.); (N.G.); (J.X.); (R.M.); (G.S.); (M.K.); (P.K.)
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Miller-Kleinhenz JM, Barber LE, Maliniak ML, Moubadder L, Bliss M, Streiff MJ, Switchenko JM, Ward KC, McCullough LE. Historical Redlining, Persistent Mortgage Discrimination, and Race in Breast Cancer Outcomes. JAMA Netw Open 2024; 7:e2356879. [PMID: 38376843 PMCID: PMC10879950 DOI: 10.1001/jamanetworkopen.2023.56879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/28/2023] [Indexed: 02/21/2024] Open
Abstract
Importance Inequities created by historical and contemporary mortgage discriminatory policies have implications for health disparities. The role of persistent mortgage discrimination (PMD) in breast cancer (BC) outcomes has not been studied. Objective To estimate the race-specific association of historical redlining (HRL) with the development of BC subtypes and late-stage disease and a novel measure of PMD in BC mortality. Design, Setting, and Participants This population-based cohort study used Georgia Cancer Registry data. A total of 1764 non-Hispanic Black and White women with a BC diagnosis and residing in an area graded by the Home Owners' Loan Corporation (HOLC) in Georgia were included. Patients were excluded if they did not have a known subtype or a derived American Joint Committee on Cancer stage or if diagnosed solely by death certificate or autopsy. Participants were diagnosed with a first primary BC between January 1, 2010, to December 31, 2017, and were followed through December 31, 2019. Data were analyzed between May 1, 2022, and August 31, 2023. Exposures Scores for HRL were examined dichotomously as less than 2.5 (ie, nonredlined) vs 2.5 or greater (ie, redlined). Contemporary mortgage discrimination (CMD) scores were calculated, and PMD index was created using the combination of HRL and CMD scores. Main Outcomes and Measures Estrogen receptor (ER) status, late stage at diagnosis, and BC-specific death. Results This study included 1764 women diagnosed with BC within census tracts that were HOLC graded in Georgia. Of these, 856 women (48.5%) were non-Hispanic Black and 908 (51.5%) were non-Hispanic White; 1148 (65.1%) were diagnosed at 55 years or older; 538 (30.5%) resided in tracts with HRL scores less than 2.5; and 1226 (69.5%) resided in tracts with HRL scores 2.5 or greater. Living in HRL areas with HRL scores 2.5 or greater was associated with a 62% increased odds of ER-negative BC among non-Hispanic Black women (odds ratio [OR], 1.62 [95% CI, 1.01-2.60]), a 97% increased odds of late-stage diagnosis among non-Hispanic White women (OR, 1.97 [95% CI, 1.15-3.36]), and a 60% increase in BC mortality overall (hazard ratio, 1.60 [95% CI, 1.17-2.18]). Similarly, PMD was associated with BC mortality among non-Hispanic White women but not among non-Hispanic Black women. Conclusions and Relevance The findings of this cohort study suggest that historical racist policies and persistent discrimination have modern-day implications for BC outcomes that differ by race. These findings emphasize the need for a more nuanced investigation of the social and structural drivers of disparate BC outcomes.
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Affiliation(s)
| | - Lauren E. Barber
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maret L. Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maya Bliss
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Micah J. Streiff
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jeffrey M. Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kevin C. Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lauren E. McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Ubbaonu CD, Chang J, Ziogas A, Mehta RS, Kansal KJ, Zell JA. Disparities in Receipt of National Comprehensive Cancer Network Guideline-Adherent Care and Outcomes among Women with Triple-Negative Breast Cancer by Race/Ethnicity, Socioeconomic Status, and Insurance Type. Cancers (Basel) 2023; 15:5586. [PMID: 38067290 PMCID: PMC10705726 DOI: 10.3390/cancers15235586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The National Comprehensive Cancer Network guidelines were designed to improve patient outcomes. Here, we examine factors that may contribute to outcomes and guideline adherence in patients with triple-negative breast cancer. METHODS This was a retrospective cohort study of women with triple-negative breast cancer using the California Cancer Registry. Adherent treatment was defined as the receipt of a combination of surgery, lymph node assessment, adjuvant radiation, and/or chemotherapy. A multivariable logistic regression was used to determine the effects of independent variables on adherence to the NCCN guidelines. Disease-specific survival was calculated using Cox regression analysis. RESULTS A total of 16,858 women were analyzed. Black and Hispanic patients were less likely to receive guideline-adherent care (OR 0.82, 95%CI 0.73-0.92 and OR 0.87, 95%CI 0.79-0.95, respectively) compared to White patients. Hazard ratios adjusted for adherent care showed that Black patients had increased disease-specific mortality (HR 1.28, 95%CI 1.16-1.42, p < 0.0001) compared to White patients. CONCLUSIONS A significant majority of breast cancer patients in California continue to receive non-guideline-adherent care. Non-Hispanic Black patients and patients from lower SES quintile groups were less likely to receive guideline-adherent care. Patients with non-adherent care had worse disease-specific survival compared to recipients of NCCN guideline-adherent care.
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Affiliation(s)
- Chimezie D. Ubbaonu
- Division of Hematology/Oncology, Department of Medicine, School of Medicine, University of California Irvine, Orange, CA 92868, USA; (R.S.M.); (J.A.Z.)
| | - Jenny Chang
- Department of Internal Medicine, University of California, Irvine, CA 92868, USA; (J.C.); (A.Z.)
| | - Argyrios Ziogas
- Department of Internal Medicine, University of California, Irvine, CA 92868, USA; (J.C.); (A.Z.)
| | - Rita S. Mehta
- Division of Hematology/Oncology, Department of Medicine, School of Medicine, University of California Irvine, Orange, CA 92868, USA; (R.S.M.); (J.A.Z.)
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA 92868, USA;
| | - Kari J. Kansal
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA 92868, USA;
- Division of Surgical Oncology, Department of Surgery, University of California Irvine Medical Center, Orange, CA 92868, USA
| | - Jason A. Zell
- Division of Hematology/Oncology, Department of Medicine, School of Medicine, University of California Irvine, Orange, CA 92868, USA; (R.S.M.); (J.A.Z.)
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA 92868, USA;
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Lovejoy LA, Shriver CD, Haricharan S, Ellsworth RE. Survival Disparities in US Black Compared to White Women with Hormone Receptor Positive-HER2 Negative Breast Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2903. [PMID: 36833598 PMCID: PMC9956998 DOI: 10.3390/ijerph20042903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
Black women in the US have significantly higher breast cancer mortality than White women. Within biomarker-defined tumor subtypes, disparate outcomes seem to be limited to women with hormone receptor positive and HER2 negative (HR+/HER2-) breast cancer, a subtype usually associated with favorable prognosis. In this review, we present data from an array of studies that demonstrate significantly higher mortality in Black compared to White women with HR+/HER2-breast cancer and contrast these data to studies from integrated healthcare systems that failed to find survival differences. Then, we describe factors, both biological and non-biological, that may contribute to disparate survival in Black women.
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Affiliation(s)
- Leann A. Lovejoy
- Chan Soon-Shiong Institute of Molecular Medicine at Windber, Windber, PA 15963, USA
| | - Craig D. Shriver
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Svasti Haricharan
- Cancer Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Rachel E. Ellsworth
- Murtha Cancer Center/Research Program, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817, USA
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6
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Barriers to breast cancer screening in Atlanta, GA: results from the Pink Panel survey at faith-based institutions. Cancer Causes Control 2022; 33:1465-1472. [PMID: 36155862 PMCID: PMC9512953 DOI: 10.1007/s10552-022-01631-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022]
Abstract
Purpose Our research sought to describe barriers to mammography screening among a sample of predominantly Black women in metropolitan Atlanta, Georgia. Methods The Pink Panel project convened community leaders from faith-based institutions to administer an offline survey to women via convenience sampling at fourteen churches in Atlanta in late 2019 and early 2020. With the COVID-19 pandemic, the research team switched to an online survey. The survey included seven questions about breast cancer awareness, barriers to breast cancer screening, and screening status. We used residence information to attain the 9-digit zip code to link to the Area Deprivation Index at the Census Block Group neighborhood level. We report results as descriptive statistics of the barriers to mammography screening. Results The 643 women represented 21 counties in Georgia, predominantly from metropolitan Atlanta, and 86% identified as Black. Among women aged 40 and older, 90% have ever had a mammogram. Among all women, 79% have ever had a mammogram, and 86% indicated that they would get a mammogram if offered in their neighborhood. The top barriers to mammography screening were lack of health insurance and high cost. Barriers to mammography screening did not differ substantially by Area Deprivation Index. Conclusion Among metropolitan Atlanta women aged 40+ , nearly all reported ever having a mammogram. However, addressing the barriers, including lack of health insurance and high cost, that women reported may further improve mammography screening rates.
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Moubadder L, Collin LJ, Nash R, Switchenko JM, Miller-Kleinhenz JM, Gogineni K, Ward KC, McCullough LE. Drivers of racial, regional, and socioeconomic disparities in late-stage breast cancer mortality. Cancer 2022; 128:3370-3382. [PMID: 35867419 DOI: 10.1002/cncr.34391] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/08/2022] [Accepted: 06/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The authors identified tumor, treatment, and patient characteristics that may contribute to differences in breast cancer (BC) mortality by race, rurality, and area-level socioeconomic status (SES) among women diagnosed with stage IIIB-IV BC in Georgia. METHODS Using the Georgia Cancer Registry, 3084 patients with stage IIIB-IV primary BC (2013-2017) were identified. Cox proportional hazards regression was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) comparing mortality among non-Hispanic Black (NHB) versus non-Hispanic White (NHW), residents of rural versus urban neighborhoods, and residents of low- versus high-SES neighborhoods by tumor, treatment, and patient characteristics. The mediating effects of specific characteristics on the association between race and BC mortality were estimated. RESULTS Among the study population, 41% were NHB, 21% resided in rural counties, and 72% resided in low SES neighborhoods. The authors observed mortality disparities by race (HR, 1.27; 95% CI, 1.13, 1.41) and rurality (HR, 1.14; 95% CI, 1.00, 1.30), but not by SES (HR, 1.04; 95% CI, 0.91, 1.19). In the stratified analyses, racial disparities were the most pronounced among women with HER2 overexpressing tumors (HR, 2.30; 95% CI, 1.53, 3.45). Residing in a rural county was associated with increased mortality among uninsured women (HR, 2.25; 95% CI, 1.31, 3.86), and the most pronounced SES disparities were among younger women (<40 years: HR, 1.46; 95% CI, 0.88, 2.42). CONCLUSIONS There is considerable variation in racial, regional, and socioeconomic disparities in late-stage BC mortality by tumor, treatment, and patient characteristics.
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Affiliation(s)
- Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Keerthi Gogineni
- Department of Hematology and Medical Oncology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Devericks EN, Carson MS, McCullough LE, Coleman MF, Hursting SD. The obesity-breast cancer link: a multidisciplinary perspective. Cancer Metastasis Rev 2022; 41:607-625. [PMID: 35752704 PMCID: PMC9470704 DOI: 10.1007/s10555-022-10043-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/31/2022] [Indexed: 12/12/2022]
Abstract
Obesity, exceptionally prevalent in the USA, promotes the incidence and progression of numerous cancer types including breast cancer. Complex, interacting metabolic and immune dysregulation marks the development of both breast cancer and obesity. Obesity promotes chronic low-grade inflammation, particularly in white adipose tissue, which drives immune dysfunction marked by increased pro-inflammatory cytokine production, alternative macrophage activation, and reduced T cell function. Breast tissue is predominantly composed of white adipose, and developing breast cancer readily and directly interacts with cells and signals from adipose remodeled by obesity. This review discusses the biological mechanisms through which obesity promotes breast cancer, the role of obesity in breast cancer health disparities, and dietary interventions to mitigate the adverse effects of obesity on breast cancer. We detail the intersection of obesity and breast cancer, with an emphasis on the shared and unique patterns of immune dysregulation in these disease processes. We have highlighted key areas of breast cancer biology exacerbated by obesity, including incidence, progression, and therapeutic response. We posit that interception of obesity-driven breast cancer will require interventions that limit protumor signaling from obese adipose tissue and that consider genetic, structural, and social determinants of the obesity–breast cancer link. Finally, we detail the evidence for various dietary interventions to offset obesity effects in clinical and preclinical studies of breast cancer. In light of the strong associations between obesity and breast cancer and the rising rates of obesity in many parts of the world, the development of effective, safe, well-tolerated, and equitable interventions to limit the burden of obesity on breast cancer are urgently needed.
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Affiliation(s)
- Emily N Devericks
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Meredith S Carson
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Michael F Coleman
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen D Hursting
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Nutrition Research Institute, University of North Carolina at Chapel Hill, Kannapolis, NC, USA. .,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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9
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Multiple mediation analysis of racial disparity in breast cancer survival. Cancer Epidemiol 2022; 79:102206. [PMID: 35759875 DOI: 10.1016/j.canep.2022.102206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Racial (Black vs. White) disparities in breast cancer survival have proven difficult to mitigate. Targeted strategies aimed at the primary factors driving the disparity offer the greatest potential for success. The purpose of this study was to use multiple mediation analysis to identify the most important mediators of the racial disparity in breast cancer survival. METHODS This was a retrospective cohort study of non-Hispanic Black and non-Hispanic White women diagnosed with invasive breast cancer in Florida between 2004 and 2015. Cox regression was used to obtain unadjusted and adjusted hazard ratios (HR) with 95% confidence intervals (CI) for the association of race with 5- and 10-year breast cancer death. Multiple mediation analysis of tumor (advanced disease stage, tumor grade, hormone receptor status) and treatment-related factors (receipt of surgery, chemotherapy, radiotherapy, and hormone therapy) was used to determine the most important mediators of the survival disparity. RESULTS The study population consisted of 101,872 women of whom 87.0% (n = 88,617) were White and 13.0% were Black (n = 13,255). Black women experienced 2.3 times (HR, 2.27; 95% CI, 2.16-2.38) the rate of 5-year breast cancer death over the follow-up period, which decreased to a 38% increased rate (HR, 1.38; 95% CI, 1.31-1.45) after adjustment for age and the mediators of interest. Combined, all examined mediators explained 73% of the racial disparity in 5-year breast cancer survival. The most important mediators were: (1) advanced disease stage (44.8%), (2) nonreceipt of surgery (34.2%), and (3) tumor grade (18.2%) and hormone receptor status (17.6%). Similar results were obtained for 10-year breast cancer death. CONCLUSION These results suggest that additional efforts to increase uptake of screening mammography in hard-to-reach women, and, following diagnosis, access to and receipt of surgery may offer the greatest potential to reduce racial disparities in breast cancer survival for women in Florida.
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Collin LJ, Ross-Driscoll K, Nash R, Miller-Kleinhenz JM, Moubadder L, Osborn C, Subhedar PD, Gabram-Mendola SGA, Switchenko JM, Ward KC, McCullough LE. Time to Surgical Treatment and Facility Characteristics as Potential Drivers of Racial Disparities in Breast Cancer Mortality. Ann Surg Oncol 2022; 29:4728-4738. [PMID: 35435562 PMCID: PMC9703360 DOI: 10.1245/s10434-022-11720-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/21/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Black women are more likely to die of breast cancer than White women. This study evaluated the contribution of time to primary surgical management and surgical facility characteristics to racial disparities in breast cancer mortality among both Black and White women. METHODS The study identified 2224 Black and 3787 White women with a diagnosis with stages I to III breast cancer (2010-2014). Outcomes included time to surgical treatment (> 30 days from diagnosis) and breast cancer mortality. Odds ratios (ORs) and 95% confidence intervals (CIs) associating surgical facility characteristics with surgical delay were computed, and Cox proportional hazards regression was used to compute hazard ratios (HRs) and 95% CIs associating delay and facility characteristics with breast cancer mortality. RESULTS Black women were two times more likely to have a surgical delay (OR, 2.15; 95% CI, 1.92-2.41) than White women. Racial disparity in surgical delay was least pronounced among women treated at a non-profit facility (OR, 1.95; 95% CI, 1.70-2.25). The estimated mortality rate for Black women was two times that for White women (HR, 2.00; 95% CI, 1.83-2.46). Racial disparities in breast cancer mortality were least pronounced among women who experienced no surgical delay (HR, 1.81; 95% CI, 1.28-2.56), received surgery at a government facility (HR, 1.31; 95% CI, 0.76-2.27), or underwent treatment at a Commission on Cancer-accredited facility (HR, 1.82; 95% CI, 1.38-2.40). CONCLUSIONS Black women were more likely to experience a surgical delay and breast cancer death. Persistent racial disparities in breast cancer mortality were observed across facility characteristics except for government facilities.
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Affiliation(s)
- Lindsay J Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
| | - Katie Ross-Driscoll
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Leah Moubadder
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Catherine Osborn
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Preeti D Subhedar
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sheryl G A Gabram-Mendola
- Emory University, Atlanta, GA, USA.,Georgia Center for Oncology Research and Education, Atlanta, GA, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Collin LJ, Yan M, Jiang R, Gogineni K, Subhedar P, Ward KC, Switchenko JM, Lipscomb J, Miller-Kleinhenz J, Torres M, Lin J, McCullough LE. Receipt of Guideline-Concordant Care Does Not Explain Breast Cancer Mortality Disparities by Race in Metropolitan Atlanta. J Natl Compr Canc Netw 2021; 19:1242-1251. [PMID: 34399407 PMCID: PMC8847540 DOI: 10.6004/jnccn.2020.7694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 12/02/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Racial disparities in breast cancer mortality in the United States are well documented. Non-Hispanic Black (NHB) women are more likely to die of their disease than their non-Hispanic White (NHW) counterparts. The disparity is most pronounced among women diagnosed with prognostically favorable tumors, which may result in part from variations in their receipt of guideline care. In this study, we sought to estimate the effect of guideline-concordant care (GCC) on prognosis, and to evaluate whether receipt of GCC modified racial disparities in breast cancer mortality. PATIENTS AND METHODS Using the Georgia Cancer Registry, we identified 2,784 NHB and 4,262 NHW women diagnosed with a stage I-III first primary breast cancer in the metropolitan Atlanta area, Georgia, between 2010 and 2014. Women were included if they received surgery and information on their breast tumor characteristics was available; all others were excluded. Receipt of recommended therapies (chemotherapy, radiotherapy, endocrine therapy, and anti-HER2 therapy) as indicated was considered GCC. We used Cox proportional hazards models to estimate the impact of receiving GCC on breast cancer mortality overall and by race, with multivariable adjusted hazard ratios (HRs). RESULTS We found that NHB and NHW women were almost equally likely to receive GCC (65% vs 63%, respectively). Failure to receive GCC was associated with an increase in the hazard of breast cancer mortality (HR, 1.74; 95% CI, 1.37-2.20). However, racial disparities in breast cancer mortality persisted despite whether GCC was received (HRGCC: 2.17 [95% CI, 1.61-2.92]; HRnon-GCC: 1.81 [95% CI, 1.28-2.91] ). CONCLUSIONS Although receipt of GCC is important for breast cancer outcomes, racial disparities in breast cancer mortality did not diminish with receipt of GCC; differences in mortality between Black and White patients persisted across the strata of GCC.
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Affiliation(s)
- Lindsay J. Collin
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112
| | - Ming Yan
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Renjian Jiang
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Winship Cancer Institute of Emory University
| | - Keerthi Gogineni
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Preeti Subhedar
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Kevin C. Ward
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Winship Cancer Institute of Emory University
| | - Jeffrey M. Switchenko
- Winship Cancer Institute of Emory University,Department of Biostatistics and Bioinformatics; Rollins School of Public Health; Emory University; Atlanta, GA, 30322, USA
| | - Joseph Lipscomb
- Winship Cancer Institute of Emory University,Department of Health Policy and Management; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Jasmine Miller-Kleinhenz
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA
| | - Mylin Torres
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Jolinta Lin
- Winship Cancer Institute of Emory University,Emory University School of Medicine; Atlanta, GA, 30322, USA
| | - Lauren E. McCullough
- Department of Epidemiology; Rollins School of Public Health, Emory University; Atlanta, GA, 30322, USA,Winship Cancer Institute of Emory University
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12
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Cho B, Han Y, Lian M, Colditz GA, Weber JD, Ma C, Liu Y. Evaluation of Racial/Ethnic Differences in Treatment and Mortality Among Women With Triple-Negative Breast Cancer. JAMA Oncol 2021; 7:1016-1023. [PMID: 33983438 DOI: 10.1001/jamaoncol.2021.1254] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance To our knowledge, there is no consensus regarding differences in treatment and mortality between non-Hispanic African American and non-Hispanic White women with triple-negative breast cancer (TNBC). Little is known about whether racial disparities vary by sociodemographic, clinical, and neighborhood factors. Objective To examine the differences in clinical treatment and outcomes between African American and White women in a nationally representative cohort of patients with TNBC and further examine the contributions of sociodemographic, clinical, and neighborhood factors to TNBC outcome disparities. Design, Setting, and Participants This population-based, retrospective cohort study included 23 123 women who received a diagnosis of nonmetastatic TNBC between January 1, 2010, and December 31, 2015, followed up through December 31, 2016, and identified from the Surveillance, Epidemiology, and End Results data set. The study was conducted from July 2019 to November 2020. The analyses were performed from July 2019 to June 2020. Exposures Race and ethnicity, including non-Hispanic African American and non-Hispanic White race. Main Outcomes and Measures Using logistic regression analysis and competing risk regression analysis, we estimated odds ratios (ORs) of receipt of treatment and hazard ratios (HRs) of breast cancer mortality in African American patients compared with White patients. Results Of 23 213 participants, 5881 (25.3%) were African American women and 17 332 (74.7%) were White women. Compared with White patients, African American patients had lower odds of receiving surgery (OR, 0.69; 95% CI, 0.60-0.79) and chemotherapy (OR, 0.89; 95% CI, 0.81-0.99) after adjustment for sociodemographic, clinicopathologic, and county-level factors. During a 43-month follow-up, 3276 patients (14.2%) died of breast cancer. The HR of breast cancer mortality was 1.28 (95% CI, 1.18-1.38) for African American individuals after adjustment for sociodemographic and county-level factors. Further adjustment for clinicopathological and treatment factors reduced the HR to 1.16 (95% CI, 1.06-1.25). This association was observed in patients living in socioeconomically less deprived counties (HR, 1.26; 95% CI, 1.14-1.39), urban patients (HR, 1.21; 95% CI, 1.11-1.32), patients having stage II (HR, 1.19; 95% CI, 1.02-1.39) or III (HR, 1.15; 95% CI, 1.01-1.31) tumors that were treated with chemotherapy, and patients younger than 65 years (HR, 1.24; 95% CI, 1.12-1.37). Conclusions and Relevance In this retrospective cohort study, African American women with nonmetastatic TNBC had a significantly higher risk of breast cancer mortality compared with their White counterparts, which was partially explained by their disparities in receipt of surgery and chemotherapy.
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Affiliation(s)
- Beomyoung Cho
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Yunan Han
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Min Lian
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Graham A Colditz
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri.,Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Jason D Weber
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Cynthia Ma
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Ying Liu
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri.,Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
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13
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Collin LJ, Gaglioti AH, Beyer KM, Zhou Y, Moore MA, Nash R, Switchenko JM, Miller-Kleinhenz JM, Ward KC, McCullough LE. Neighborhood-Level Redlining and Lending Bias Are Associated with Breast Cancer Mortality in a Large and Diverse Metropolitan Area. Cancer Epidemiol Biomarkers Prev 2021; 30:53-60. [PMID: 33008873 PMCID: PMC7855192 DOI: 10.1158/1055-9965.epi-20-1038] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/29/2020] [Accepted: 09/28/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Structural inequities have important implications for the health of marginalized groups. Neighborhood-level redlining and lending bias represent state-sponsored systems of segregation, potential drivers of adverse health outcomes. We sought to estimate the effect of redlining and lending bias on breast cancer mortality and explore differences by race. METHODS Using Georgia Cancer Registry data, we included 4,943 non-Hispanic White (NHW) and 3,580 non-Hispanic Black (NHB) women with a first primary invasive breast cancer diagnosis in metro-Atlanta (2010-2014). Redlining and lending bias were derived for census tracts using the Home Mortgage Disclosure Act database. We calculated hazard ratios and 95% confidence intervals (CI) for the associations of redlining, lending bias on breast cancer mortality and estimated race-stratified associations. RESULTS Overall, 20% of NHW and 80% of NHB women lived in redlined census tracts, and 60% of NHW and 26% of NHB women lived in census tracts with pronounced lending bias. Living in redlined census tracts was associated with a nearly 1.60-fold increase in breast cancer mortality (hazard ratio = 1.58; 95% CI, 1.37-1.82) while residing in areas with substantial lending bias reduced the hazard of breast cancer mortality (hazard ratio = 0.86; 95% CI, 0.75-0.99). Among NHB women living in redlined census tracts, we observed a slight increase in breast cancer mortality (hazard ratio = 1.13; 95% CI, 0.90-1.42); among NHW women the association was more pronounced (hazard ratio = 1.39; 95% CI, 1.09-1.78). CONCLUSIONS These findings underscore the role of ecologic measures of structural racism on cancer outcomes. IMPACT Place-based measures are important contributors to health outcomes, an important unexplored area that offers potential interventions to address disparities.
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Affiliation(s)
- Lindsay J Collin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anne H Gaglioti
- National Center for Primary Care, Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Kristen M Beyer
- Division of Epidemiology, Institute for Health & Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yuhong Zhou
- Division of Epidemiology, Institute for Health & Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Miranda A Moore
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia
| | - Rebecca Nash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Lauren E McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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14
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John EM, McGuire V, Kurian AW, Koo J, Shariff-Marco S, Gomez SL, Cheng I, Keegan THM, Kwan ML, Bernstein L, Vigen C, Wu AH. Racial/Ethnic Disparities in Survival after Breast Cancer Diagnosis by Estrogen and Progesterone Receptor Status: A Pooled Analysis. Cancer Epidemiol Biomarkers Prev 2020; 30:351-363. [PMID: 33355191 DOI: 10.1158/1055-9965.epi-20-1291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/28/2020] [Accepted: 11/19/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Limited studies have investigated racial/ethnic survival disparities for breast cancer defined by estrogen receptor (ER) and progesterone receptor (PR) status in a multiethnic population. METHODS Using multivariable Cox proportional hazards models, we assessed associations of race/ethnicity with ER/PR-specific breast cancer mortality in 10,366 California women diagnosed with breast cancer from 1993 to 2009. We evaluated joint associations of race/ethnicity, health care, sociodemographic, and lifestyle factors with mortality. RESULTS Among women with ER/PR+ breast cancer, breast cancer-specific mortality was similar among Hispanic and Asian American women, but higher among African American women [HR, 1.31; 95% confidence interval (CI), 1.05-1.63] compared with non-Hispanic White (NHW) women. Breast cancer-specific mortality was modified by surgery type, hospital type, education, neighborhood socioeconomic status (SES), smoking history, and alcohol consumption. Among African American women, breast cancer-specific mortality was higher among those treated at nonaccredited hospitals (HR, 1.57; 95% CI, 1.21-2.04) and those from lower SES neighborhoods (HR, 1.48; 95% CI, 1.16-1.88) compared with NHW women without these characteristics. Breast cancer-specific mortality was higher among African American women with at least some college education (HR, 1.42; 95% CI, 1.11-1.82) compared with NHW women with similar education. For ER-/PR- disease, breast cancer-specific mortality did not differ by race/ethnicity and associations of race/ethnicity with breast cancer-specific mortality varied only by neighborhood SES among African American women. CONCLUSIONS Racial/ethnic survival disparities are more striking for ER/PR+ than ER-/PR- breast cancer. Social determinants and lifestyle factors may explain some of the survival disparities for ER/PR+ breast cancer. IMPACT Addressing these factors may help reduce the higher mortality of African American women with ER/PR+ breast cancer.
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Affiliation(s)
- Esther M John
- Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, California. .,Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, California.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Valerie McGuire
- Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, California
| | - Allison W Kurian
- Department of Epidemiology & Population Health, Stanford University School of Medicine, Stanford, California.,Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, California.,Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Jocelyn Koo
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Salma Shariff-Marco
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Scarlett Lin Gomez
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Iona Cheng
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Theresa H M Keegan
- Division of Hematology and Oncology, UC Davis Comprehensive Cancer Center, University of California, Davis, California
| | - Marilyn L Kwan
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Leslie Bernstein
- Department of Population Sciences, Beckman Research Institute of City of Hope, Duarte, California
| | - Cheryl Vigen
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Anna H Wu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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15
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Mavingire N, Campbell P, Wooten J, Aja J, Davis MB, Loaiza-Perez A, Brantley E. Cancer stem cells: Culprits in endocrine resistance and racial disparities in breast cancer outcomes. Cancer Lett 2020; 500:64-74. [PMID: 33309858 DOI: 10.1016/j.canlet.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/24/2020] [Accepted: 12/05/2020] [Indexed: 12/18/2022]
Abstract
Breast cancer stem cells (BCSCs) promote endocrine therapy (ET) resistance, also known as endocrine resistance in hormone receptor (HR) positive breast cancer. Endocrine resistance occurs via mechanisms that are not yet fully understood. In vitro, in vivo and clinical data suggest that signaling cascades such as Notch, hypoxia inducible factor (HIF), and integrin/Akt promote BCSC-mediated endocrine resistance. Once HR positive breast cancer patients relapse on ET, targeted therapy agents such as cyclin dependent kinase inhibitors are frequently implemented, though secondary resistance remains a threat. Here, we discuss Notch, HIF, and integrin/Akt pathway regulation of BCSC activity and potential strategies to target these pathways to counteract endocrine resistance. We also discuss a plausible link between elevated BCSC-regulatory gene levels and reduced survival observed among African American women with basal-like breast cancer which lacks HR expression. Should future studies reveal a similar link for patients with luminal breast cancer, then the use of agents that impede BCSC activity could prove highly effective in improving clinical outcomes among African American breast cancer patients.
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Affiliation(s)
- Nicole Mavingire
- Department of Basic Sciences, Loma Linda University Health School of Medicine, Loma Linda, CA, USA.
| | - Petreena Campbell
- Department of Basic Sciences, Loma Linda University Health School of Medicine, Loma Linda, CA, USA.
| | - Jonathan Wooten
- Department of Basic Sciences, Loma Linda University Health School of Medicine, Loma Linda, CA, USA; Center for Health Disparities and Molecular Medicine, Loma Linda University Health School of Medicine, Loma Linda, CA, USA.
| | - Joyce Aja
- National Institute of Molecular Biology and Biotechnology, University of the Philippines Diliman, Quezon City, Philippines.
| | - Melissa B Davis
- Department of Surgery, Weill Cornell Medicine-New York Presbyterian Hospital Network, New York, NY, USA.
| | - Andrea Loaiza-Perez
- Facultad de Medicina, Instituto de Oncología Ángel H. Roffo (IOAHR), Universidad de Buenos Aires, Área Investigación, Av. San Martin, 5481, C1417 DTB Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina.
| | - Eileen Brantley
- Department of Basic Sciences, Loma Linda University Health School of Medicine, Loma Linda, CA, USA; Center for Health Disparities and Molecular Medicine, Loma Linda University Health School of Medicine, Loma Linda, CA, USA; Department of Pharmaceutical and Administrative Sciences, Loma Linda University Health School of Pharmacy, Loma Linda, CA, USA.
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