Race is a Fundamental Prognostic Indicator for 2325 Northeastern Ohio Women with Infiltrating Breast Cancer

Differences in Breast Cancer Presentation at Time of Diagnosis for Black and White Women in High Resource Settings

This paper provides a narrative review of the existing literature on differences in demographic and biological features of breast cancer at time of diagnosis between Black and White women in Canada, the United Kingdom and the United States. Electronic database searches for published peer-reviewed articles on this topic were conducted, and 78 articles were included in the final narrative review. Differences between Black and White women were compared for eight categories including age, tumour stage, size, grade, lymph node involvement, and hormone status. Black women were significantly more likely to present with less favourable tumour features at the time of diagnosis than White women. Significant differences were reported in age at diagnosis, tumour stage, size, grade and hormone status, particularly triple negative breast cancer. Limitations on the generalizability of the review findings are discussed, as well as the implications of these findings on future research, especially within the Canadian context.

Comprehensive molecular profiling of Taiwanese breast cancers revealed potential therapeutic targets: prevalence of actionable mutations among 380 targeted sequencing analyses

BACKGROUND

Breast cancer is one of the leading causes of cancer-related deaths in women, and there is a demand in developing an Asian-based genetic profiling database for breast cancer in improving the treatment response. This study aimed to determine molecular alternations and identify potential therapeutic targets by analyzing the genetic profiling from a cohort of Taiwanese breast cancers using a commercialized next-generation sequencing (NGS) targeted panel.

METHODS

The study population comprised a broad spectrum of breast cancer patients in Taiwan, including Group 1: planned to receive first-line surgery and followed by adjuvant therapy, or early relapse within three years, Group 2: planned to receive first-line neoadjuvant therapy and followed by surgery, and Group 3: de novo stage IV, or stage IV with recurrence beyond three years. Molecular profiles were determined using Thermo Fisher™ Oncomine™ Comprehensive Assay version 3 (TMO comprehensive assay) from Formalin-Fixed Paraffin-Embedded (FFPE) tissues. Level of actionability was evaluated with the ESMO Scale of clinical actionability of molecular targets (ESCAT).

RESULTS

A total of 380 TMO comprehensive assays were conducted on 372 patients, and we presented targeted sequencing analyses of Tier I: alteration-drug match associated with improved outcome in clinical trials including ERBB2 amplification, BRCA1/2 germline mutation, PIK3CA mutation, and NTRK translocation, and Tier II: antitumor activity associated with the matched alteration-drug but lack of prospective outcome data including PTEN loss, ESR1 mutation, AKT1 mutation, and ERBB2 mutation, and Tier III: matched drug-alteration that led to clinical benefit in another tumor type including MDM2 amplification, and ERBB3 mutation. Among them, 249 (66%) showed at least one actionable alternation based on the ESCAT criteria. The most frequent impacted genes (all variants combined within each sample) were PIK3CA (38%), followed by ERBB2 (23%), ESR1 (10%), AKT1 (6%), and BRCA2 (5%), and the remaining rare variants (less than 5% of assayed cohort) were BRCA1 (3%), MDM2 (2.2%), and ERBB3 (1.1%).

CONCLUSION

Targeted sequencing of actionable genes is believed to provide clinical applicability and substantial benefits for Taiwanese breast cancer patients. A valid scale of clinical actionability should be adopted for precision medicine practice under multidisciplinary molecular tumor board.

Literature review of data-based models for identification of factors associated with racial disparities in breast cancer mortality

In the United States, early detection methods have contributed to the reduction of overall breast cancer mortality but this pattern has not been observed uniformly across all racial groups. A vast body of research literature shows a set of health care, socio-economic, biological, physical, and behavioural factors influencing the mortality disparity. In this paper, we review the modelling frameworks, statistical tests, and databases used in understanding influential factors, and we discuss the factors documented in the modelling literature. Our findings suggest that disparities research relies on conventional modelling and statistical tools for quantitative analysis, and there exist opportunities to implement data-based modelling frameworks for (1) exploring mechanisms triggering disparities, (2) increasing the collection of behavioural data, and (3) monitoring factors associated with the mortality disparity across time.

Influence of clinical, societal, and treatment variables on racial differences in ER-/PR- breast cancer survival

BACKGROUND

African American (AA) women with breast cancer have persistently higher mortality compared to whites. We evaluated racial disparities in mortality among women with estrogen receptor (ER)/progesterone receptor (PR)-negative breast cancer.

METHODS

The study population included 542 women (45% AA) diagnosed with ER/PR-negative Stage I through III breast cancer treated at the Henry Ford Health System (HFHS) between 1996 and 2005. Linked datasets from HFHS, Metropolitan Detroit Cancer Surveillance System, and the U.S. Census Bureau were used to obtain demographic, socioeconomic, and clinical information. Economic deprivation was categorized using a previously validated deprivation index, which included 5 categories based on the quintile of census tract socioeconomic deprivation. Cox proportional hazards models were used to assess the relationship between race and mortality.

RESULTS

AA women were more likely to have larger tumors, have higher Charlson Comorbidity Indices (CCI), and to reside in economically deprived areas. In an unadjusted analysis, AA women demonstrated a significantly higher risk of death compared to whites [hazard ratio (HR) 1.47, 95% confidence interval (CI) 1.09-2.00]. Following adjustment for clinical factors (age, stage, CCI) and treatment (radiation and chemotherapy), AA race continued to have a significant impact on mortality (HR 1.51, CI 1.10-2.08 and HR 1.63, CI 1.20-2.21). Only after adjusting for deprivation was race no longer significant (HR 1.26, CI 0.84-1.87).

CONCLUSIONS

Social determinants of health play a large role in explaining racial disparities in breast cancer outcomes, especially among women with aggressive subtypes.

Racial differences in breast cancer survival in a large urban integrated health system

BACKGROUND

African American (AA) women are known to have poorer breast cancer survival than whites, and the differences may be related to underlying disparities in their clinical presentation or access to care. This study evaluated the relationship between demographic, treatment, and socioeconomic factors and breast cancer survival among women in southeast Michigan.

METHODS

The population included 2387 women (34% AA) with American Joint Committee on Cancer stage I to III breast cancer who were treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Linked data sets from the HFHS, the Metropolitan Detroit Cancer Surveillance System, and the US Census Bureau were used to obtain demographic and clinical information. Comorbidities were classified with the modified Charlson comorbidity index (CCI). Economic deprivation was categorized with a census tract-based deprivation index (DI), which was stratified into 5 quintiles of increasing socioeconomic disadvantage.

RESULTS

Compared with whites, AA women were significantly more likely to have larger, hormone receptor-negative tumors and more comorbidities and to reside in an economically deprived area. In an unadjusted analysis, AAs had a significantly higher risk of death (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.16-1.59); however, after adjustments for clinical (age, stage, hormone receptor, and CCI) and societal factors (DI), the effect of race was not significant (HR, 1.13 [95% CI, 0.96-1.34] , and HR, 0.97 [0.80-1.19] respectively).

CONCLUSIONS

Racial differences in breast cancer survival can be explained by clinical and socioeconomic factors. Nonetheless, AA women with breast cancer remain disproportionately affected by unfavorable tumor characteristics and economic deprivation, which likely contribute to their increased overall mortality.

Insertion/deletion polymorphisms are convenient and reliable markers to assess chromosomal instability in human tumors

Chromosomal instability (CIN) is frequently associated with a poor outcome in human carcinomas. The genomes of the main human malignancies are well defined as hundreds of tumors have been characterized by arrays. Targeting the appropriate chromosomes with set of markers appears as a realistic approach for CIN assessment. We decided to test the reliability of different insertion/deletion (InDel) polymorphisms to detect allelic loss in a subset of previously characterized hepatocellular carcinomas (HCC). To this aim 3 kinds of markers, L1 insertion (n=1), Alu insertions (n=4) and Marshfield InDel (MID, n=8) markers, were tested on a series of 68 paired HCC/non-tumor liver samples that were previously characterized for loss of heterozygosity (LOH). All markers were analyzed on agarose gels and some were tested with the high resolution melting (HRM) technique. Heterozygosity of the tested markers was high with a mean of 0.489 and a range of 0.265-0.525. Using 6 markers for chromosome 8p, the sensitivity of the method was high. LOH was detected in all samples known to be affected (n=34) whereas retention was found in 29/30 samples (specificity of 96.6%). Finally, the HRM analysis applied to 2 MID markers provided consistent profiles enabling closed-tube determination of chromosomes 17p and 18q status. Overall, our work suggests that different types of InDel markers are suitable for CIN detection in human tumors and may provide convenient and useful information for basic or translational research as well as for future applications in clinical practice.

Ethnic disparities in breast cancer

Breast cancer is the leading cause of cancer death for women worldwide. While breast cancer incidence is lower for many ethnic minority women than for white women, stage at diagnosis and survival are often worse. These disparities are most marked for African-American women, but are also present for Asians, Latinas, Native Americans and Hawaiians. The etiology of ethnic disparities in breast cancer is multifactorial, including differences in tumor characteristics, genetics, access to care and insurance, prevalence of risk factors, screening participation and processes of care, such as timeliness of diagnosis and quality of communication and treatment. This review will examine what is known regarding ethnic differences in all of these areas, what questions remain, and where researchers and policy makers should focus their future efforts.

Outcomes in black patients with early breast cancer treated with breast conservation therapy

BACKGROUND

The race-specific impact of prognostic variables for early breast cancer is unknown for black patients undergoing breast conservation.

METHODS AND MATERIALS

This was a retrospective study of 1,231 consecutive patients ≥40 years of age with Stage I-II invasive breast cancer treated with lumpectomy and radiation therapy at the University of Chicago Hospitals and affiliates between 1986 and 2004. Patients were classified as either black or nonblack. Cox proportional hazards regression was used to model the effects of known prognostic factors and interactions with race.

RESULTS

Median follow-up for surviving patients was 82 months. Thirty-four percent of patients were black, and 66% were nonblack (Caucasian, Hispanic, and Asian). Black patients had a poorer 10-year overall survival (64.6% vs. 80.8%; adjusted hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.23-2.06) and 10-year disease-free survival (58.1% vs. 75.4%; HR 1.49; 95% CI, 1.18-1.89) compared with nonblack patients. Tumor sizes were similar between nonblack and black patients with mammographically detected tumors (1.29 cm vs. 1.20 cm, p = 0.20, respectively). Tumor size was significantly associated with overall survival (HR 1.48; 95% CI, 1.12-1.96) in black patients with mammographically detected tumors but not in nonblack patients (HR 1.09; 95% CI, 0.78-1.53), suggesting that survival in black patients depends more strongly on tumor size in this subgroup. Tests for race-size method of detection interactions were statistically significant for overall survival (p = 0.049), locoregional control (p = 0.036), and distant control (p = 0.032) and borderline significant for disease-free survival (p = 0.067).

CONCLUSION

Despite detection at comparable sizes, the prognostic effect of tumor size in patients with mammographically detected tumors is greater for black than in nonblack patients.

A profile of prognostic and molecular factors in European and Māori breast cancer patients

Background

New Zealand Māori have a poorer outcome from breast cancer than non-Māori, yet prognostic data are sparse. The objective of this study was to quantify levels of prognostic factors in a cohort of self-declared Māori and European breast cancer patients from Christchurch, New Zealand.

Methods and Results

Clinicopathological and survival data from 337 consecutive breast cancer patients (27 Māori, 310 European) were evaluated. Fewer tumours were high grade in Māori women than European women (p = 0.027). No significant ethnic differences were detected for node status, tumour type, tumour size, human epidermal growth factor receptor, oestrogen and progesterone receptor (ER/PR) status, or survival.

In addition, tumour and serum samples from a sub-cohort of 14 Māori matched to 14 NZ European patients were analyzed by immunohistochemistry and enzyme linked immunosorbent assay for molecular prognostic factors. Significant correlations were detected between increased grade and increased levels of hypoxia inducible factor-1 (HIF-1α), glucose transporter-1 (GLUT-1), microvessel density (MVD) and cytokeratins CK5/6 (p < 0.05). High nodal status correlated with reduced carbonic anhydrase IX (CA-IX). Negative ER/PR status correlated with increased GLUT-1, CA-IX and MVD. Within the molecular factors, increased HIF-1α correlated with raised GLUT-1, MVD and CK5/6, and CK5/6 with GLUT-1 and MVD (p < 0.05). The small number of patients in this sub-cohort limited discrimination of ethnic differences.

Conclusions

In this Christchurch cohort of breast cancer patients, Māori women were no more likely than European women to have pathological or molecular factors predictive of poor prognosis. These data contrast with data from the North Island NZ, and suggest potential regional differences.

Do lifestyle or social factors explain ethnic/racial inequalities in breast cancer survival?

Despite numerous studies documenting ethnic inequalities in breast cancer survival between minority and majority ethnic groups worldwide, reasons for these inequalities remain unclear. The authors performed a systematic review of published literature to identify studies that investigated the explanatory power of smoking, alcohol consumption, body mass index (BMI), and socioeconomic position (SEP) on ethnic inequalities in breast cancer survival. Sixteen studies were included in the review. From 5 studies, the authors found that differences in breast cancer survival between ethnic groups may be in part explained by BMI, but there was little evidence to implicate smoking or alcohol consumption as explanatory factors of this inequality. From 12 studies, the authors found that SEP explains part of the ethnic inequality in all-cause survival but that it was not evident for breast-cancer-specific survival. SEP explains more of the disparities among African-American versus white women in the United States compared with other ethnic comparisons. Furthermore, given social patterning of BMI and other lifestyle habits, it is possible that results for SEP and BMI are measuring the same effect. In this review, the authors make suggestions regarding the role of epidemiology in facilitating further research to better inform the development of effective policies to address ethnic differences in survival.

Survival analysis of 1148 women diagnosed with breast cancer in Southern Iran

BACKGROUND

While there has been much research regarding risk factors and prognostic factors for breast cancer in general, research specific to Iran is sparse. Further, the association between breast cancer survival and socio-demographic and pathologic factors has been widely studied but the majority of these studies are from developed countries. Southern Iran has a population of approximately 4 million. To date, no research has been performed to determine breast cancer survival and to explore the association between the survival and socio-demographic and pathologic factors in Southern Iran, where this study was conducted.

METHODS

The data were obtained from the cancer registry in Fars province, Southern Iran and included 1148 women diagnosed with breast cancer between 2000 and 2005. The association between survival, and sociodemographic and pathological factors, distant metastasis at diagnosis, and treatment options was investigated using Cox regression.

RESULTS

The majority of patients were diagnosed with an advanced tumour size. Five-year overall survival was 58% (95%CI; 53%-62%). Cox regression showed that family income (good vs poor: hazard ratio 0.46, 95%CI; 0.23-0.90) smoking (HR = 1.40, 95%CI; 1.07-1.86), metastases to bone (HR = 2.25, 95%CI; 1.43-3.52) and lung (HR = 3.21, 95%CI;1.70-6.05), tumour size (< or = 2 cm vs > or = 5 cm: HR = 2.07, 95%CI;1.39-3.09) and grade (poorly vs well differentiated HR = 2.33, 95%CI; 1.52-3.37), lymph node ratio (0 vs 1: HR = 15.31, 95%CI; 8.89-26.33) and number of involved node (1 vs >15: HR = 14.98, 95%CI; 8.83-25.33) were significantly related to survival.

CONCLUSION

This is the first study to evaluate breast cancer survival in Southern Iran and has used a wide range of explanatory factors, 44. The results demonstrate that survival is relatively poor and is associated with diagnosis with late stage disease. We hypothesise that this is due to low level of awareness, lack of screening programs and subsequent late access to treatment.

Impact of treatment and socioeconomic status on racial disparities in survival among older women with breast cancer

OBJECTIVE

To examine racial/ethnic disparities in mortality and survival in a large nationwide and population-based cohort of women with breast cancer after simultaneously controlling for differences in comorbidity, treatment, and socioeconomic status.

METHODS

A cohort of 35,029 women with stage I-IIIA breast cancer at age > or = 65 from 1992 to 1999 was identified from the surveillance, epidemiology, and end results-medicare linked databases with up to 11 years of follow-up. Cox proportional hazard regression analysis was performed to determine the risk of all-cause and breast cancer-specific mortality.

RESULTS

African-American women with breast cancer were more likely to live in the poorest quartiles of socioeconomic status at the census tract level than whites (73.7% versus 20.7%, P < 0.001). Those living in communities with the lowest socioeconomic status were 11% more likely to die than those in the highest (hazard ratio, 1.10; 95% confidence interval, 1.04-1.16). The risk of dying changed slightly after controlling for race/ethnicity (1.11; 1.05-1.18). Compared with white women with breast cancer, crude hazard ratios of all-cause and breast cancer-specific mortality were 1.35 (1.27-1.45) and 1.83 (1.56-2.16) for African-Americans. After adjusting for treatment and socioeconomic status, hazard ratio of all-cause mortality was no longer significant in African-Americans (1.02; 0.84-1.10), whereas the risk of breast cancer-specific mortality was marginally higher in African-Americans (1.21; 1.01-1.46).

CONCLUSIONS

Racial disparities in overall survival between African-American and white women with breast cancer were not present after controlling for treatment and socioeconomic status. Efforts to eliminate these barriers have important public health implications for reducing disparities in health outcomes.

Increased racial differences on breast cancer care and survival in America: historical evidence consistent with a health insurance hypothesis, 1975-2001

PURPOSE

This study examined whether race/ethnicity had differential effects on breast cancer care and survival across age strata and cohorts within stages of disease.

METHODS

The Detroit Cancer Registry provided 25,997 breast cancer cases. African American and non-Hispanic white, older Medicare-eligible and younger non-eligible women were compared. Successive historical cohorts (1975-1980 and 1990-1995) were, respectively, followed until 1986 and 2001.

RESULTS

African American disadvantages on survival and treatments increased significantly, particularly among younger women who were much more likely to be uninsured. Within node positive disease all treatment disadvantages among younger African American women disappeared with socioeconomic adjustment.

CONCLUSIONS

Growth of this racial divide implicates social, rather than biological, forces. Its elimination will require high quality health care for all.

Differences in breast carcinoma characteristics in newly diagnosed African–American and Caucasian patients

BACKGROUND

Breast carcinomas in African-American patients appear to be more aggressive than in Caucasian patients due to multifactorial differences.

METHODS

The authors compiled pathology data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database regarding stage, histologic grade, and estrogen receptor (ER) expression in breast carcinomas diagnosed in 197,274 African-American and Caucasian patients between 1990 and 2000, and the same information, along with nuclear grade, Ki-67, c-erb-B2, and p53 expression, in 2230 African-American and Caucasian patients diagnosed at Thomas Jefferson University Hospital between 1995 and 2002. Immunohistochemical markers were assayed in paraffin-embedded, formalin-fixed tissue stained with hematoxylin and eosin using antibodies to these proteins, with differences in expression analyzed by the chisquare test.

RESULTS

In both databases, more African-American patients presented with advanced stage tumors and higher histologic (P < .001) and nuclear grade (P < .001) than Caucasian patients. African-American patients had less ER positivity (51.9% vs 63.1%; P < .001) but significantly higher Ki-67 (42.4% vs 28.7%; P < .001) and p53 expression (19.4% vs 13.1%; P < .05) than Caucasian patients with all stages of disease. In addition, the basal or "triple-negative" breast cancer phenotype was more common in African-American patients than in Caucasian patients (20.8% vs 10.4%; P < .0001), and was associated with higher histologic and nuclear grade (P < .0001).

CONCLUSIONS

African-American patients with breast carcinomas are more likely than Caucasian patients to present with tumors that are of a later stage and higher grade, with higher Ki-67 expression and more ER negativity, thereby highlighting a greater need for early screening among African-American women. Molecular studies that may explain these differences, and correlations with survival, have been proposed to identify therapeutic targets.

Meta-analysis of survival in African American and white American patients with breast cancer: ethnicity compared with socioeconomic status

PURPOSE

The extent to which socioeconomic disadvantages and inadequate health care access account for the disproportionately elevated mortality hazard observed in African American compared with white American patients with breast cancer is poorly defined.

METHODS

We identified 20 studies reported between January 1980 and June 2005 that provided survival analyses in patients with breast cancer after adjusting for ethnicity and some measurement of socioeconomic status. These studies also adjusted for age and stage of disease at time of diagnosis.

RESULTS

The pooled outcome data yielded estimates for the mortality hazard in 14,013 African American and 76,111 white American patients with breast cancer. Studies varied in their methods for assigning socioeconomic status, with most relying on area-wide measures such as census tract and census block data. The combined analysis (adjusted for age, stage, and socioeconomic status) revealed that African American ethnicity was associated with a statistically significant excess mortality risk in overall survival (mortality hazard, 1.27; 95% CI, 1.18 to 1.38) and in breast cancer-specific survival (mortality hazard, 1.19; 95% CI, 1.10 to 1.29).

CONCLUSION

Our pooled analysis demonstrated that African American ethnicity is a significant and independent predictor of poor outcome from breast cancer, even after accounting for socioeconomic status by conventional measures. These findings support the need for further investigation of the biologic, genetic, and sociocultural factors that may influence survival in African American patients with breast cancer.