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Barber LE, Maliniak ML, Moubadder L, Johnson DA, Miller-Kleinhenz JM, Switchenko JM, Ward KC, McCullough LE. Neighborhood Deprivation and Breast Cancer Mortality Among Black and White Women. JAMA Netw Open 2024; 7:e2416499. [PMID: 38865125 PMCID: PMC11170302 DOI: 10.1001/jamanetworkopen.2024.16499] [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: 02/08/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024] Open
Abstract
Importance Neighborhood deprivation has been associated with increased breast cancer mortality among White women, but findings are inconsistent among Black women, who experience different neighborhood contexts. Accounting for interactions among neighborhood deprivation, race, and other neighborhood characteristics may enhance understanding of the association. Objective To investigate whether neighborhood deprivation is associated with breast cancer mortality among Black and White women and whether interactions with rurality, residential mobility, and racial composition, which are markers of access, social cohesion, and segregation, respectively, modify the association. Design, Setting, and Participants This population-based cohort study used Georgia Cancer Registry (GCR) data on women with breast cancer diagnosed in 2010 to 2017 and followed-up until December 31, 2022. Data were analyzed between January 2023 and October 2023. The study included non-Hispanic Black and White women with invasive early-stage (I-IIIA) breast cancer diagnosed between 2010 and 2017 and identified through the GCR. Exposures The Neighborhood Deprivation Index (NDI), assessed in quintiles, was derived through principal component analysis of 2011 to 2015 block group-level American Community Survey (ACS) data. Rurality, neighborhood residential mobility, and racial composition were measured using Georgia Public Health Department or ACS data. Main Outcomes and Measures The primary outcome was breast cancer-specific mortality identified by the GCR through linkage to the Georgia vital statistics registry and National Death Index. Cox proportional hazards regression was used to estimate age-adjusted and multivariable-adjusted hazard ratios (HRs) and 95% CIs for the association between neighborhood deprivation and breast cancer mortality. Results Among the 36 795 patients with breast cancer (mean [SD] age at diagnosis, 60.3 [13.1] years), 11 044 (30.0%) were non-Hispanic Black, and 25 751 (70.0%) were non-Hispanic White. During follow-up, 2942 breast cancer deaths occurred (1214 [41.3%] non-Hispanic Black women; 1728 [58.7%] non-Hispanic White women). NDI was associated with an increase in breast cancer mortality (quintile 5 vs 1, HR, 1.36; 95% CI, 1.19-1.55) in Cox proportional hazards models. The association was present only among non-Hispanic White women (quintile 5 vs 1, HR, 1.47; 95% CI, 1.21-1.79). Similar race-specific patterns were observed in jointly stratified analyses, such that NDI was associated with increased breast cancer mortality among non-Hispanic White women, but not non-Hispanic Black women, irrespective of the additional neighborhood characteristics considered. Conclusions and Relevance In this cohort study, neighborhood deprivation was associated with increased breast cancer mortality among non-Hispanic White women. Neighborhood racial composition, residential mobility, and rurality did not explain the lack of association among non-Hispanic Black women, suggesting that factors beyond those explored here may contribute to breast cancer mortality in this racial group.
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Affiliation(s)
- Lauren E. Barber
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Maret L. Maliniak
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Leah Moubadder
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Dayna A. Johnson
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | | | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Kevin C. Ward
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Lauren E. McCullough
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
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Sarfraz Z, Sarfraz A, Mehak O, Akhund R, Bano S, Aftab H. Racial and socioeconomic disparities in triple-negative breast cancer treatment. Expert Rev Anticancer Ther 2024; 24:107-116. [PMID: 38436305 DOI: 10.1080/14737140.2024.2326575] [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: 08/09/2023] [Accepted: 02/29/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Triple-negative breast cancer (TNBC) continues to be a significant concern, especially among minority populations, where treatment disparities are notably pronounced. Addressing these disparities, especially among African American women and other minorities, is crucial for ensuring equitable healthcare. AREAS COVERED This review delves into the continuum of TNBC treatment, noting that the standard of care, previously restricted to chemotherapy, has now expanded due to emerging clinical trial results. With advances like PARP inhibitors, immunotherapy, and antibody-drug conjugates, a more personalized treatment approach is on the horizon. The review highlights innovative interventions tailored for minorities, such as utilizing technology like text messaging, smartphone apps, and targeted radio programming, coupled with church-based behavioral interventions. EXPERT OPINION Addressing TNBC treatment disparities demands a multifaceted approach, blending advanced medical treatments with culturally sensitive community outreach. The potential of technology, especially in the realm of promoting health awareness, is yet to be fully harnessed. As the field progresses, understanding and integrating the socio-economic, biological, and access-related challenges faced by minorities will be pivotal for achieving health equity in TNBC care.
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Affiliation(s)
- Zouina Sarfraz
- Department of Medicine, Fatima Jinnah Medical University, Lahore, Pakistan
| | - Azza Sarfraz
- Department of Pediatrics, Aga Khan University, Karachi, Pakistan
| | - Onaiza Mehak
- Department of Medicine, Aziz Fatimah Medical and Dental College, Faisalabad, Pakistan
| | - Ramsha Akhund
- Department of Surgery, University of Alabama at Birmingham, Tuscaloosa, AL, USA
| | - Shehar Bano
- Department of Medicine, Fatima Jinnah Medical University, Lahore, Pakistan
| | - Hinna Aftab
- Department of Medicine, CMH Lahore Medical College, Lahore, Pakistan
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Goel N, Lubarsky M, Hernandez AE, Benck K, Lee E, Kesmodel S, Knaul F, Kobetz E, Anderson BO. Unmet Social Needs and Breast Cancer Screening Utilization and Stage at Presentation. JAMA Netw Open 2024; 7:e2355301. [PMID: 38353954 PMCID: PMC10867685 DOI: 10.1001/jamanetworkopen.2023.55301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/12/2023] [Indexed: 02/16/2024] Open
Abstract
Importance Unmet social needs in local populations may hinder the development of targeted cancer control interventions aimed at improving screening utilization and early-stage breast cancer diagnosis to ultimately improve breast cancer survival disparities. Objective To evaluate if (1) city-funded screening mammography is associated with utilization of screening mammography, (2) unmet social needs are associated with utilization of screening mammography, and (3) unmet social needs are associated with later-stage disease at diagnosis. Design, Setting, and Participants This cohort study included patients with stages I-IV invasive ductal or lobular carcinoma treated at an academic medical center (including both an underserved safety-net hospital [SNH] and a National Cancer Institute-designated academic cancer center [ACC]) from 2020 to 2023. Eligible patients were aged 18 years or older and able to consent. Data were analyzed between July 2023 and September 2023. Exposure The Health Leads Social Needs Screening Toolkit, a screening tool that gathers information on the most common social need domains affecting patient health. Main Outcomes and Measures Univariable and multivariable logistic regression was utilized to evaluate the following primary outcomes: (1) routine screening mammography and (2) American Joint Committee on Cancer 8th edition clinical stage at presentation. Results Of the 322 women who completed the Health Leads Social Needs Screening Toolkit, 201 (62%) self-identified as Hispanic, 63 (19%) as non-Hispanic Black, and 63 (19%) as non-Hispanic White. Two hundred fifty-five (76%) patients with access to city-funded screening mammography completed a screening mammogram. Patients who presented to the SNH were more likely to present with late-stage disease compared with early-stage disease (15 of 48 [31%] vs 50 of 274 [18%]; P = .04). On multivariable logistic regression, not completing a screening mammography was associated with having an increasing number of unmet social needs (OR, 0.74; 95% CI, 0.55-0.99; P = .047) and an increasing age at diagnosis (OR, 0.92; 95% CI, 0.89-0.96; P < .001). Moreover, increasing unmet social needs was significantly associated with late-stage diagnosis above and beyond screening mammography (OR, 1.38; 95% CI, 1.01-1.89; P = .04). Conclusions and Relevance In this cohort study, access to screening mammography did not translate to utilization of screening mammography, increasing unmet social needs were significantly associated with lower rates of screening mammography, and those with increasing unmet social needs were more likely to present with late-stage disease. This association transcended recruitment site (SNH vs ACC), indicating that patients in either hospital setting may benefit from unmet social needs screening to overcome access to care barriers associated with late-stage disease at diagnosis.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Division of Surgical Oncology, University of Miami, Miami, Florida
- University of Miami Sylvester Comprehensive Cancer Center, Miami, Florida
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
- University of Miami Miller School of Medicine, Miami, Florida
- World Health Organization, Geneva, Switzerland
| | - Maya Lubarsky
- University of Miami Miller School of Medicine, Miami, Florida
| | - Alexandra E. Hernandez
- Department of Surgery, Division of Surgical Oncology, University of Miami, Miami, Florida
| | - Kelley Benck
- University of Miami Miller School of Medicine, Miami, Florida
| | - Emma Lee
- University of Miami Miller School of Medicine, Miami, Florida
| | - Susan Kesmodel
- Department of Surgery, Division of Surgical Oncology, University of Miami, Miami, Florida
- University of Miami Sylvester Comprehensive Cancer Center, Miami, Florida
- University of Miami Miller School of Medicine, Miami, Florida
| | - Felicia Knaul
- University of Miami Institute for Advanced Study of the Americas, Coral Gables, Florida
| | - Erin Kobetz
- University of Miami Sylvester Comprehensive Cancer Center, Miami, Florida
- University of Miami Miller School of Medicine, Miami, Florida
- Department of Public Health Sciences, University of Miami, Miami, Florida
- Department of Medicine, Division of Internal Medicine, University of Miami, Miami, Florida
| | - Benjamin O. Anderson
- Department of Surgery, University of Washington, Seattle
- World Health Organization, Geneva, Switzerland
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Elmohr MM, Javed Z, Dubey P, Jordan JE, Shah L, Nasir K, Rohren EM, Lincoln CM. Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities. Radiology 2024; 310:e223097. [PMID: 38376404 PMCID: PMC10902599 DOI: 10.1148/radiol.223097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 02/21/2024]
Abstract
Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.
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Affiliation(s)
- Mohab M. Elmohr
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Zulqarnain Javed
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Prachi Dubey
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - John E. Jordan
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Lubdha Shah
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Khurram Nasir
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Eric M. Rohren
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
| | - Christie M. Lincoln
- From the Department of Radiology, Baylor College of Medicine, Houston, 1 Baylor Plaza, BCM 360, Houston, TX 77030 (M.M.E., E.M.R.); Division of Health Equity and Disparities Research, Center for Outcomes Research, Houston Methodist Hospital, Houston, Tex (Z.J., K.N.); Houston Radiology Associates, Houston Methodist Hospital, Houston, Tex (P.D.); ACR Commission on Neuroradiology, American College of Radiology, Reston, Va (J.E.J.); Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford University School of Medicine, Stanford, Calif (J.E.J.); Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah (L.S.); Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Tex (K.N.); Center for Cardiovascular Computational Health & Precision Medicine (C3-PH), Houston Methodist Hospital, Houston, Tex (K.N.); and Department of Neuroradiology, Division of Diagnostic Imaging, MD Anderson Cancer Center, Houston, Tex (C.M.L.)
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Goel N, Hernandez A, Kwon D, Antoni MH, Cole S. Impact of Neighborhood Disadvantage on Tumor Biology and Breast Cancer Survival. Ann Surg 2024; 279:346-352. [PMID: 37638386 DOI: 10.1097/sla.0000000000006082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the association between neighborhood disadvantage and Oncotype DX score, a surrogate for tumor biology, among a national cohort. BACKGROUND Women living in disadvantaged neighborhoods have shorter breast cancer (BC) survival, even after accounting for individual-level, tumor, and treatment characteristics. This suggests unaccounted social and biological mechanisms by which neighborhood disadvantage may impact BC survival. METHODS This cross-sectional study included stage I and II, ER + /HER2 - BC patients with Oncotype DX score data from the National Cancer Database (NCDB) from 2004 to 2019. Multivariate regression models tested the association of neighborhood-level income on Oncotype DX score controlling for age, race/ethnicity, insurance, clinical stage, and education. Cox regression assessed overall survival. RESULTS Of the 294,283 total BC patients selected, the majority were non-Hispanic White (n=237,197, 80.6%) with 7.6% non-Hispanic Black (n=22,495) and 4.5% other (n=13,383). 27.1% (n=797,254) of the population lived in the disadvantaged neighborhoods with an annual neighborhood-level income of <$48,000, while 59.62% (n=175,305) lived in advantaged neighborhoods with a neighborhood-level income of >$48,000. On multivariable analysis controlling for age, race/ethnicity, insurance status, neighborhood-level education, and pathologic stage, patients in disadvantaged neighborhoods had greater odds of high-risk versus low-risk Oncotype DX scores compared with those in advantaged neighborhoods [odds ratio=1.04 (1.01-1.07), P =0.0067]. CONCLUSION AND RELEVANCE This study takes a translational epidemiologic approach to identify that women living in the most disadvantaged neighborhoods have more aggressive tumor biology, as determined by the Oncotype DX score.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
| | - Alexandra Hernandez
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
- Department of Internal Medicine, Division of Clinical and Translational Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston. Houston, TX
| | - Michael H Antoni
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
- Department of Psychology, University of Miami Miller School of Medicine, Miami, FL
| | - Steve Cole
- Department of Psychiatry/Biobehavioral Sciences and Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA
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Hernandez AE, Westrick AC, Stoler J, Kesmodel SB, Pinheiro PS, Figueroa M, Kobetz EN, Rebbeck T, Goel N. Associations Between Neighborhood-Level Income and Triple-Negative Breast Cancer in a Majority-Minority Population. Ann Surg Oncol 2024; 31:988-996. [PMID: 37978105 DOI: 10.1245/s10434-023-14517-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Previous studies on disparities in triple-negative breast cancer (TNBC) focus on race/ethnicity, with few exploring the impact of contextual factors such as neighborhood-level income. This study evaluates the effect of neighborhood-level income on disparities in TNBC among a racially and ethnically diverse cohort, after accounting for granular individual-level risk factors of TNBC. PATIENTS AND METHODS Patients with stage I-IV breast cancer from 2005 to 2017 were identified from our local tumor registry. The primary outcome was diagnosis of TNBC. Using 5-years estimates from the American Community Survey, we obtained median household income for each census tract which was categorized into quartiles. Mixed effects logistic regression was conducted and stratified by race and ethnicity, controlling for individual-level sociodemographic, comorbidities, and tumor characteristics. RESULTS Among 5377 breast cancer registry patients, 16.5% were diagnosed with TNBC. The majority were Hispanic (50.1%) followed by non-Hispanic Black (NHB) (28.0%). After controlling for individual-level covariables including race and ethnicity, comorbidities, and tumor characteristics, women from low-income neighborhoods had increased odds of TNBC compared with other breast cancer subtypes, compared with those in high-income neighborhoods [odds ratio (OR) 1.33; 95% confidence interval (CI) 1.04, 1.70, p < 0.001]. In stratified analyses, NHB patients from low-income neighborhoods had two times the odds of TNBC diagnosis compared with those from high-income neighborhoods (OR 2.11; 95% CI 1.02, 4.37). CONCLUSION We found that living in a low-income neighborhood is associated with an increased odds of TNBC independent of granular individual-level TNBC risk factors, particularly NHB race. More striking, NHB living in low-income neighborhoods had increased odds of TNBC compared with NHB living in high-income neighborhoods. Our results suggest potential unaccounted gene-environment and/or social (api)genomic interactions between neighborhood-level income and TNBC subtype development.
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Affiliation(s)
- Alexandra E Hernandez
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ashly C Westrick
- Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor, MI, USA
| | - Justin Stoler
- Department of Geography and Sustainable Development, University of Miami, Coral Gables, FL, USA
- Abess Center for Ecosystem Science and Policy, University of Miami, Coral Gables, FL, USA
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Susan B Kesmodel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Paulo S Pinheiro
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Maria Figueroa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Biochemistry and Molecular Biology Research, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin N Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
- Division of Computational Medicine and Population Health, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Timothy Rebbeck
- Harvard T.H. Chan School of Public Health and Dana-Farber Cancer Institute, Boston, MA, USA
| | - Neha Goel
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
- Harvard T.H. Chan School of Public Health and Dana-Farber Cancer Institute, Boston, MA, USA.
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Rolle LD, Chery MJ, Larson M, Lopez-Pentecost M, Calfa CJ, Schlumbrecht MP, Crane TE. The Effect of Disability and Social Determinants of Health on Breast and Cervical Cancer Screenings During the COVID-19 Pandemic. Prev Chronic Dis 2024; 21:E05. [PMID: 38271492 PMCID: PMC10833830 DOI: 10.5888/pcd21.230234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Introduction The objective of this study was to examine the effect of disability status and social determinants of health (SDOH) on adherence to breast and cervical cancer screening recommendations during the COVID-19 pandemic. Methods We conducted a secondary analysis of the 2018 and 2020 Behavioral Risk Factor Surveillance System (BRFSS) data sets. We defined adherence to screenings according to the US Preventive Services Task Force guidelines for breast and cervical cancer screening. The analysis included respondents assigned female at birth, aged 50 to 74 years (breast cancer screening) or aged 21 to 65 years (cervical cancer screening). We performed logistic regression to evaluate breast and cervical cancer screening adherence, by disability status and SDOH (health insurance coverage, marital status, and urban residency), independently and simultaneously. Results Our analysis included 27,526 BRFSS respondents in 2018 and 2020. In 2018, women with disabilities had lower adjusted odds than women without disabilities of being up to date with mammograms (adjusted odds ratio [AOR] = 0.76, 95% CI, 0.63-0.93) and Pap (Papanicolaou) tests (AOR = 0.73; 95% CI, 0.59-0.89). In 2020, among women with disabilities, the adjusted odds of mammogram and Pap test adherence decreased (AOR = 0.69; 95% CI, 0.54-0.89; AOR = 0.59; 95% CI, 0.47-0.75, respectively). In 2018, the adjusted odds of mammogram adherence among rural residents with and without disabilities were 0.83 (95% CI, 0.70-0.98), which decreased to 0.76 (95% CI, 0.62-0.93) in 2020. Conclusion The findings of this study highlight the effect of disability status and SDOH on breast and cervical cancer screening rates during the COVID-19 pandemic. Public health strategies that acknowledge and address these disparities are crucial in preparing for future public health crises.
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Affiliation(s)
- LaShae D Rolle
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
- University of Miami, 1120 NW 14th St, Miami, FL 33136
| | - Maurice J Chery
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Michaela Larson
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Melissa Lopez-Pentecost
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Carmen J Calfa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Matthew P Schlumbrecht
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Miller School of Medicine, Miami, Florida
| | - Tracy E Crane
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
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8
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Kasper G, Momen M, Sorice KA, Mayhand KN, Handorf EA, Gonzalez ET, Devlin A, Brownstein K, Esnaola N, Fisher SG, Lynch SM. Effect of neighborhood and individual-level socioeconomic factors on breast cancer screening adherence in a multi-ethnic study. BMC Public Health 2024; 24:63. [PMID: 38166942 PMCID: PMC10763410 DOI: 10.1186/s12889-023-17252-9] [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: 12/29/2022] [Accepted: 11/16/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Although mammography can significantly reduce breast cancer mortality, many women do not receive their annual breast cancer screening. Differences in screening adherence exist by race/ethnicity, socioeconomic status (SES), and insurance status. However, more detailed investigations into the impact of neighborhood disadvantage and access to resources on screening adherence are lacking. METHODS We comprehensively examined the effect of individual social, economic, and demographic factors (n = 34 variables), as well as neighborhood level SES (nSES) indicators (n = 10 variables) on breast cancer screening adherence across a multi-ethnic population (n = 472). In this cross-sectional study, participants were surveyed from 2017 to 2018. The data was analyzed using univariate regression and LASSO for variable reduction. Significant predictors were carried forward into final multivariable mixed-effect logistic regression models where odds ratios (OR), 95% confidence intervals and p-values were reported. RESULTS Nineteen percent of participants were non-adherent to breast screening guidelines. Race/ethnicity was not associated with adherence; however, increasing age (OR = 0.97, 95%CI = 0.95-0.99, p = 0.01), renting a home (OR = 0.53, 95%CI = 0.30-0.94, p = 0.04), food insecurity (OR 0.46, 95%CI = 0.22-0.94, p = 0.01), and overcrowding (OR = 0.58, 95% CI = 0.32-0.94, p = 0.01) were significantly associated with lower breast cancer screening adherence. CONCLUSION Socioeconomic indicators at the individual and neighborhood levels impact low breast cancer screening adherence and may help to inform future screening interventions.
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Affiliation(s)
- Gillian Kasper
- Temple University School of Medicine, Philadelphia, PA, USA.
| | - Mahsa Momen
- Temple University School of Medicine, Philadelphia, PA, USA
| | - Kristen A Sorice
- Fox Chase Cancer Center, 4th Floor Young Pavilion, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Kiara N Mayhand
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth A Handorf
- Fox Chase Cancer Center, 4th Floor Young Pavilion, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Evelyn T Gonzalez
- Fox Chase Cancer Center, 4th Floor Young Pavilion, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Amie Devlin
- Temple University School of Medicine, Philadelphia, PA, USA
| | | | | | - Susan G Fisher
- Temple University School of Medicine, Philadelphia, PA, USA
- Fox Chase Cancer Center, 4th Floor Young Pavilion, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Shannon M Lynch
- Fox Chase Cancer Center, 4th Floor Young Pavilion, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
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9
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Jayasekera J, El Kefi S, Fernandez JR, Wojcik KM, Woo JMP, Ezeani A, Ish JL, Bhattacharya M, Ogunsina K, Chang CJ, Cohen CM, Ponce S, Kamil D, Zhang J, Le R, Ramanathan AL, Butera G, Chapman C, Grant SJ, Lewis-Thames MW, Dash C, Bethea TN, Forde AT. Opportunities, challenges, and future directions for simulation modeling the effects of structural racism on cancer mortality in the United States: a scoping review. J Natl Cancer Inst Monogr 2023; 2023:231-245. [PMID: 37947336 PMCID: PMC10637025 DOI: 10.1093/jncimonographs/lgad020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/23/2023] [Accepted: 07/03/2023] [Indexed: 11/12/2023] Open
Abstract
PURPOSE Structural racism could contribute to racial and ethnic disparities in cancer mortality via its broad effects on housing, economic opportunities, and health care. However, there has been limited focus on incorporating structural racism into simulation models designed to identify practice and policy strategies to support health equity. We reviewed studies evaluating structural racism and cancer mortality disparities to highlight opportunities, challenges, and future directions to capture this broad concept in simulation modeling research. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Articles published between 2018 and 2023 were searched including terms related to race, ethnicity, cancer-specific and all-cause mortality, and structural racism. We included studies evaluating the effects of structural racism on racial and ethnic disparities in cancer mortality in the United States. RESULTS A total of 8345 articles were identified, and 183 articles were included. Studies used different measures, data sources, and methods. For example, in 20 studies, racial residential segregation, one component of structural racism, was measured by indices of dissimilarity, concentration at the extremes, redlining, or isolation. Data sources included cancer registries, claims, or institutional data linked to area-level metrics from the US census or historical mortgage data. Segregation was associated with worse survival. Nine studies were location specific, and the segregation measures were developed for Black, Hispanic, and White residents. CONCLUSIONS A range of measures and data sources are available to capture the effects of structural racism. We provide a set of recommendations for best practices for modelers to consider when incorporating the effects of structural racism into simulation models.
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Affiliation(s)
- Jinani Jayasekera
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Safa El Kefi
- NYU Langone Health, New York University, New York, NY, USA
| | - Jessica R Fernandez
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlyn M Wojcik
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Jennifer M P Woo
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Adaora Ezeani
- Health Behaviors Research Branch of the Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Jennifer L Ish
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Manami Bhattacharya
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, and the Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Kemi Ogunsina
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Che-Jung Chang
- Epidemiology Branch at the National Institute of Environmental Health Sciences at the National Institutes of Health, Bethesda, MD, USA
| | - Camryn M Cohen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD, USA
| | - Stephanie Ponce
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Dalya Kamil
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Julia Zhang
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
- Sophomore at Williams College, Williamstown, MA, USA
| | - Randy Le
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Amrita L Ramanathan
- Diabetes, Endocrinology, & Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Gisela Butera
- Office of Research Services, National Institutes of Health Library, Bethesda, MD, USA
| | - Christina Chapman
- Department of Radiation Oncology, Baylor College of Medicine, and the Center for Innovations in Quality, Effectiveness, and Safety in the Department of Medicine, Baylor College of Medicine and the Houston Veterans Affairs, Houston, TX, USA
| | - Shakira J Grant
- Department of Medicine, Division of Hematology, University of North Carolina, Chapel Hill, NC, USA
| | - Marquita W Lewis-Thames
- Department of Medical Social Science, Center for Community Health at Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chiranjeev Dash
- Office of Minority Health and Health Disparities Research at the Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Traci N Bethea
- Office of Minority Health and Health Disparities Research at the Georgetown-Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Allana T Forde
- Division of Intramural Research at the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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10
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Webster JL, Goldstein ND, Rowland JP, Tuite CM, Siegel SD. A catchment and location-allocation analysis of mammography access in Delaware, US: implications for disparities in geographic access to breast cancer screening. Breast Cancer Res 2023; 25:137. [PMID: 37941020 PMCID: PMC10631173 DOI: 10.1186/s13058-023-01738-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: 02/17/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. Access to breast cancer screening was evaluated in Delaware, a state that experiences an elevated burden from breast cancer but is otherwise representative of the US in terms of race and urban-rural characteristics. We first conducted a catchment analysis of mammography facilities. Finding evidence of disparities by race and rurality, we next conducted a location-allocation analysis to identify candidate locations for the establishment of new mammography facilities to optimize equitable access. METHODS A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines. RESULTS The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 68% (95% CI 38-85%) fewer mammography units and 89% (95% CI 60-98%) fewer BICOEs. The more rural counties in the state accounted for 41% of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas. CONCLUSIONS The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.
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Affiliation(s)
- Jessica L Webster
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Neal D Goldstein
- Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, PA, USA
| | - Jennifer P Rowland
- Department of Radiology, Breast Imaging Section, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA
| | - Catherine M Tuite
- Department of Radiology, Breast Imaging Section, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, DE, USA
| | - Scott D Siegel
- Cawley Center for Translational Cancer Research, Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, 4701 Ogletown-Stanton Road, Newark, DE, 19713, USA.
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11
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Lawson AB, Kim J, Johnson C, Ratnapradipa KL, Alberg AJ, Akonde M, Hastert T, Bandera EV, Terry P, Mandle H, Cote ML, Bondy M, Marks J, Peres LC, Schildkraut J, Peters ES. The Association between Mediated Deprivation and Ovarian Cancer Survival among African American Women. Cancers (Basel) 2023; 15:4848. [PMID: 37835542 PMCID: PMC10571563 DOI: 10.3390/cancers15194848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Deprivation indices are often used to adjust for socio-economic disparities in health studies. Their role has been partially evaluated for certain population-level cancer outcomes, but examination of their role in ovarian cancer is limited. In this study, we evaluated a range of well-recognized deprivation indices in relation to cancer survival in a cohort of self-identified Black women diagnosed with ovarian cancer. This study aimed to determine if clinical or diagnostic characteristics lie on a mediating pathway between socioeconomic status (SES) and deprivation and ovarian cancer survival in a minority population that experiences worse survival from ovarian cancer. METHODS We used mediation analysis to look at the direct and indirect causal effects of deprivation indices with main mediators of the SEER stage at diagnosis and residual disease. The analysis employed Bayesian structural equation models with variable selection. We applied a joint Bayesian structural model for the mediator, including a Weibull mixed model for the vital outcome with deprivation as exposure. We selected modifiers via a Monte Carlo model selection procedure. RESULTS The results suggest that high SES-related indices, such as Yost, Kolak urbanicity (URB), mobility (MOB) and SES dimensions, and concentrated disadvantage index (CDI), all have a significant impact on improved survival. In contrast, area deprivation index (ADI)/Singh, and area level poverty (POV) did not have a major impact. In some cases, the indirect effects have very wide credible intervals, so the total effect is not well estimated despite the estimation of the direct effect. CONCLUSIONS First, it is clear that commonly used indices such as Yost, or CDI both significantly impact the survival experience of Black women diagnosed with epithelial ovarian cancer. In addition, the Kolak dimension indices (URB, MOB, mixed immigrant: MICA and SES) also demonstrate a significant association, depending on the mediator. Mediation effects differ according to the mediator chosen.
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Affiliation(s)
- Andrew B. Lawson
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
- Usher Institute, School of Medicine, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Joanne Kim
- Department of Biomedical Informatics, College of Medicine, Ohio State University, Columbus, OH 43210, USA;
| | - Courtney Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (C.J.)
| | - Kendra L. Ratnapradipa
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA
| | - Maxwell Akonde
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA
| | - Theresa Hastert
- Department of Oncology, Wayne State University School of Medicine, Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI 48201, USA
| | - Elisa V. Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08625, USA
| | - Paul Terry
- Department of Medicine, University of Tennessee Medical Center-Knoxville, Knoxville, TN 37920, USA
| | - Hannah Mandle
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (C.J.)
| | - Michele L. Cote
- Bren Simon Comprehensive Cancer Center, Indiana University Melvin, Inidianapolis, IN 46202, USA;
| | - Melissa Bondy
- Department of Epidemiology and Population Health, College of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Jeffrey Marks
- Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA;
| | - Lauren C. Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA;
| | - Joellen Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA; (C.J.)
| | - Edward S. Peters
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
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12
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Lawson AB, Kim J, Johnson C, Hastert T, Bandera EV, Alberg AJ, Terry P, Akonde M, Mandle H, Cote ML, Bondy M, Marks J, Peres L, Ratnapradipa KL, Xin Y, Schildkraut J, Peters ES. Deprivation and segregation in ovarian cancer survival among African American women: a mediation analysis. Ann Epidemiol 2023; 86:57-64. [PMID: 37423270 PMCID: PMC10538403 DOI: 10.1016/j.annepidem.2023.07.001] [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: 04/05/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE Deprivation and segregation indices are often examined as possible explanations for observed health disparities in population-based studies. In this study, we assessed the role of recognized deprivation and segregation indices specifically as they affect survival in a cohort of self-identified Black women diagnosed with ovarian cancer who enrolled in the African American Cancer Epidemiology Study. METHODS Mediation analysis was used to examine the direct and indirect effects between deprivation or segregation and overall survival via a Bayesian structural equation model with Gibbs variable selection. RESULTS The results suggest that high socioeconomic status-related indices have an association with increased survival, ranging from 25% to 56%. In contrast, index of concentration at the extremes-race does not have a significant impact on overall survival. In many cases, the indirect effects have very wide credible intervals; consequently, the total effect is not well estimated despite the estimation of the direct effect. CONCLUSIONS Our results show that Black women living in higher socioeconomic status neighborhoods are associated with increased survival with ovarian cancer using area-level economic indices such as Yost or index of concentration at the extremes-income. In addition, the Kolak urbanization index has a similar impact and highlights the importance of area-level deprivation and segregation as potentially modifiable social factors in ovarian cancer survival.
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Affiliation(s)
- Andrew B Lawson
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston; Usher Institute, Centre for Population Health Sciences, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK.
| | - Joanne Kim
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus
| | - Courtney Johnson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Theresa Hastert
- Department of Oncology, Wayne State University School of Medicine, Population Studies and Disparities Research Program, Karmanos Cancer Institute, Detroit, MI
| | - Elisa V Bandera
- Cancer Epidemiology and Health Outcomes, Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Anthony J Alberg
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia
| | - Paul Terry
- Department of Medicine, University of Tennessee Medical Center-Knoxville, Knoxville
| | - Maxwell Akonde
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia
| | - Hannah Mandle
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michele L Cote
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
| | - Melissa Bondy
- Department of Epidemiology and Population Health, Stanford University, College of Medicine, Stanford, CA
| | - Jeffrey Marks
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Lauren Peres
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kendra L Ratnapradipa
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha
| | - Yao Xin
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston
| | - Joellen Schildkraut
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Edward S Peters
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha
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13
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Goel N, Hernandez A, Merchant N, Rebbeck T. Translational Epidemiology: Genetic Ancestry in Breast Cancer: What Is the Role of Genetic Ancestry and Socioeconomic Status in Triple-Negative Breast Cancer? Adv Surg 2023; 57:1-14. [PMID: 37536846 DOI: 10.1016/j.yasu.2023.03.001] [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] [Indexed: 08/05/2023]
Abstract
Racial/ethnic and socioeconomic disparities seen in triple-negative breast cancer (TNBC) have prompted questions regarding the role of genetic ancestry in breast cancer (BC) subtype development, tumor biology, and ultimately prognosis. The causes of disparities in TNBC are influenced greatly by both sociopolitical factors and genetic ancestry, and now, the potential genomic underpinnings of social factors. To comprehensively understand disparities in TNBC, it is critical to take a translational epidemiologic approach that takes into account genomic and non-genomic factors. Understanding the interplay between genetic ancestry and social genomics and their proportional influence on outcomes can guide our priorities for screening, diagnosis, and interventions for this aggressive BC subtype.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, 4th Floor, Miami, FL 31336, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, 4th Floor, Miami, FL 31336, USA.
| | - Alexandra Hernandez
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, 4th Floor, Miami, FL 31336, USA
| | - Nipun Merchant
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, 4th Floor, Miami, FL 31336, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, 4th Floor, Miami, FL 31336, USA
| | - Timothy Rebbeck
- Harvard T.H. Chan School of Public Health and Dana-Farber Cancer Institute, 1101 Dana. 450 Brookline Avenue, Boston, MA 02215, USA
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14
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Mani C, Acharya G, Saamarthy K, Ochola D, Mereddy S, Pruitt K, Manne U, Palle K. Racial differences in RAD51 expression are regulated by miRNA-214-5P and its inhibition synergizes with olaparib in triple-negative breast cancer. Breast Cancer Res 2023; 25:44. [PMID: 37081516 PMCID: PMC10120249 DOI: 10.1186/s13058-023-01615-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/03/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Triple-negative breast cancer (TNBC) affects young women and is the most aggressive subtype of breast cancer (BC). TNBCs disproportionally affect women of African-American (AA) descent compared to other ethnicities. We have identified DNA repair gene RAD51 as a poor prognosis marker in TNBC and its posttranscriptional regulation through microRNAs (miRNAs). This study aims to delineate the mechanisms leading to RAD51 upregulation and develop novel therapeutic combinations to effectively treat TNBCs and reduce disparity in clinical outcomes. METHODS Analysis of TCGA data for BC cohorts using the UALCAN portal and PrognoScan identified the overexpression of RAD51 in TNBCs. miRNA sequencing identified significant downregulation of RAD51-targeting miRNAs miR-214-5P and miR-142-3P. RT-PCR assays were used to validate the levels of miRNAs and RAD51, and immunohistochemical and immunoblotting techniques were used similarly for RAD51 protein levels in TNBC tissues and cell lines. Luciferase assays were performed under the control of RAD51 3'-UTR to confirm that miR-214-5P regulates RAD51 expression. To examine the effect of miR-214-5P-mediated downregulation of RAD51 on homologous recombination (HR) in TNBC cells, Dr-GFP reporter assays were performed. To assess the levels of olaparib-induced DNA damage responses in miR-214-5P, transfected cells, immunoblots, and immunofluorescence assays were used. Furthermore, COMET assays were used to measure DNA lesions and colony assays were performed to assess the sensitivity of BRCA-proficient TNBC cells to olaparib. RESULTS In-silico analysis identified upregulation of RAD51 as a poor prognostic marker in TNBCs. miRNA-seq data showed significant downregulation of miR-214-5P and miR-142-3P in TNBC cell lines derived from AA women compared to Caucasian-American (CA) women. miR-214-5P mimics downregulated RAD51 expression and induces HR deficiency as measured by Dr-GFP assays in these cell lines. Based on these results, we designed a combination treatment of miR-214-5P and olaparib in HR-proficient AA TNBC cell lines using clonogenic survival assays. The combination of miR-214-5P and olaparib showed synergistic lethality compared to individual treatments in these cell lines. CONCLUSIONS Our studies identified a novel epigenetic regulation of RAD51 in TNBCs by miR-214-5P suggesting a novel combination therapies involving miR-214-5P and olaparib to treat HR-proficient TNBCs and to reduce racial disparity in therapeutic outcomes.
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Affiliation(s)
- Chinnadurai Mani
- Department of Cell Biology and Biochemistry, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Ganesh Acharya
- Department of Cell Biology and Biochemistry, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Karunakar Saamarthy
- Department of Cell Biology and Biochemistry, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Damieanus Ochola
- Department of Cell Biology and Biochemistry, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Srinidhi Mereddy
- Department of Cellular and Molecular Biology, University of Washington, 1400 NE Campus Parkway, Seattle, WA, 98195, USA
| | - Kevin Pruitt
- Department of Immunology and Infectious Diseases, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA
| | - Upender Manne
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, 35294, USA
| | - Komaraiah Palle
- Department of Cell Biology and Biochemistry, Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, TX, 79430, USA.
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, 79430, USA.
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15
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Goel N, Hernandez A, Thompson C, Choi S, Westrick A, Stoler J, Antoni MH, Rojas K, Kesmodel S, Figueroa ME, Cole S, Merchant N, Kobetz E. Neighborhood Disadvantage and Breast Cancer-Specific Survival. JAMA Netw Open 2023; 6:e238908. [PMID: 37083666 PMCID: PMC10122178 DOI: 10.1001/jamanetworkopen.2023.8908] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/28/2023] [Indexed: 04/22/2023] Open
Abstract
Importance Neighborhood-level disadvantage is an important factor in the creation and persistence of underresourced neighborhoods with an undue burden of disparate breast cancer-specific survival outcomes. Although studies have evaluated neighborhood-level disadvantage and breast cancer-specific survival after accounting for individual-level socioeconomic status (SES) in large national cancer databases, these studies are limited by age, socioeconomic, and racial and ethnic diversity. Objective To investigate neighborhood SES (using a validated comprehensive composite measure) and breast cancer-specific survival in a majority-minority population. Design, Setting, and Participants This retrospective multi-institutional cohort study included patients with stage I to IV breast cancer treated at a National Cancer Institute-designated cancer center and sister safety-net hospital from January 10, 2007, to September 9, 2016. Mean (SD) follow-up time was 60.3 (41.4) months. Data analysis was performed from March 2022 to March 2023. Exposures Neighborhood SES was measured using the Area Deprivation Index (tertiles), a validated comprehensive composite measure of neighborhood SES. Main Outcomes and Measures The primary outcome was breast cancer-specific survival. Random effects frailty models for breast cancer-specific survival were performed controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The Area Deprivation Index was calculated for each patient at the census block group level and categorized into tertiles (T1-T3). Results A total of 5027 women with breast cancer were included: 55.8% were Hispanic, 17.5% were non-Hispanic Black, and 27.0% were non-Hispanic White. Mean (SD) age was 55.5 (11.7) years. Women living in the most disadvantaged neighborhoods (T3) had shorter breast cancer-specific survival compared with those living in the most advantaged neighborhoods (T1) after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics (T3 vs T1: hazard ratio, 1.29; 95% CI, 1.01-1.65; P < .04). Conclusions and Relevance In this cohort study, a shorter breast cancer-specific survival in women from disadvantaged neighborhoods compared with advantaged neighborhoods was identified, even after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The findings suggest potential unaccounted mechanisms, including unmeasured social determinants of health and access to care measures. This study also lays the foundation for future research to evaluate whether social adversity from living in a disadvantaged neighborhood is associated with more aggressive tumor biologic factors, and ultimately shorter breast cancer-specific survival, through social genomic and/or epigenomic alterations.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Alexandra Hernandez
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Cheyenne Thompson
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Seraphina Choi
- Medical student, University of Miami Miller School of Medicine, Miami, Florida
| | - Ashly Westrick
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Justin Stoler
- Department of Geography and Regional Studies, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael H. Antoni
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
- Department of Psychology, University of Miami Miller School of Medicine, Miami, Florida
| | - Kristin Rojas
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Susan Kesmodel
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Maria E. Figueroa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
- Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida
| | - Steve Cole
- Department of Psychiatry/Biobehavioral Sciences and Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles
| | - Nipun Merchant
- Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Erin Kobetz
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
- Division of Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Eom KY, Berg KA, Joseph NE, Runner K, Tarabichi Y, Khiyami A, Perzynski AT, Sossey-Alaoui K. Neighborhood and racial influences on triple negative breast cancer: evidence from Northeast Ohio. Breast Cancer Res Treat 2023; 198:369-381. [PMID: 36781520 PMCID: PMC10716786 DOI: 10.1007/s10549-023-06883-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) with higher recurrence rates and poorer prognoses and most prevalent among non-Hispanic Black women. Studies of multiple health conditions and care processes suggest that neighborhood socioeconomic position is a key driver of health disparities. We examined roles of patients' neighborhood-level characteristics and race on prevalence, stage at diagnosis, and mortality among patients diagnosed with BC at a large safety-net healthcare system in Northeast Ohio. METHODS We used tumor registry to identify BC cases from 2007 to 2020 and electronic health records and American Community Survey for individual- and area-level factors. We performed multivariable regression analyses to estimate associations between neighborhood-level characteristics, measured by the Area Deprivation Index (ADI), race and comparative TNBC prevalence, stage at diagnosis, and total mortality. RESULTS TNBC was more common among non-Hispanic Black (53.7%) vs. non-Hispanic white patients (46.4%). Race and ADI were individually significant predictors of TNBC prevalence, stage at diagnosis, and total mortality. Race remained significantly associated with TNBC subtype, adjusting for covariates. Accounting for TNBC status, a more disadvantaged neighborhood was significantly associated with a worse stage at diagnosis and higher death rates. CONCLUSION Our findings suggest that both neighborhood socioeconomic position and race are strongly associated with TNBC vs. other BC subtypes. The burden of TNBC appears to be highest among Black women in the most socioeconomically disadvantaged neighborhoods. Our study suggests a complex interplay of social conditions and biological disease characteristics contributing to racial disparities in BC outcomes.
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Affiliation(s)
- Kirsten Y Eom
- Center for Health Care Research and Policy, The MetroHealth System and Case Western Reserve University, 2500 MetroHealth Dr. Rammelkamp Building R225, Cleveland, OH, 44109, USA.
| | - Kristen A Berg
- Center for Health Care Research and Policy, The MetroHealth System and Case Western Reserve University, 2500 MetroHealth Dr. Rammelkamp Building R225, Cleveland, OH, 44109, USA
| | - Natalie E Joseph
- Division of Surgical Oncology, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Kristen Runner
- Division of Surgical Oncology, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | - Yasir Tarabichi
- Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center of Case Western Reserve University, Cleveland, OH, USA
| | - Amer Khiyami
- Department of Pathology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Adam T Perzynski
- Center for Health Care Research and Policy, The MetroHealth System and Case Western Reserve University, 2500 MetroHealth Dr. Rammelkamp Building R225, Cleveland, OH, 44109, USA
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Siegel SD, Brooks MM, Berman JD, Lynch SM, Sims-Mourtada J, Schug ZT, Curriero FC. Neighborhood factors and triple negative breast cancer: The role of cumulative exposure to area-level risk factors. Cancer Med 2023. [PMID: 36916687 DOI: 10.1002/cam4.5808] [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: 08/20/2022] [Revised: 01/08/2023] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Despite similar incidence rates among Black and White women, breast cancer mortality rates are 40% higher among Black women. More than half of the racial difference in breast cancer mortality can be attributed to triple negative breast cancer (TNBC), an aggressive subtype of invasive breast cancer that disproportionately affects Black women. Recent research has implicated neighborhood conditions in the etiology of TNBC. This study investigated the relationship between cumulative neighborhood-level exposures and TNBC risk. METHODS This single-institution retrospective study was conducted on a cohort of 3316 breast cancer cases from New Castle County, Delaware (from 2012 to 2020), an area of the country with elevated TNBC rates. Cases were stratified into TNBC and "Non-TNBC" diagnosis and geocoded by residential address. Neighborhood exposures included census tract-level measures of unhealthy alcohol use, metabolic dysfunction, breastfeeding, and environmental hazards. An overall cumulative risk score was calculated based on tract-level exposures. RESULTS Univariate analyses showed each tract-level exposure was associated with greater TNBC odds. In multivariate analyses that controlled for patient-level race and age, tract-level exposures were not associated with TNBC odds. However, in a second multivariate model that included patient-level variables and considered tract-level risk factors as a cumulative exposure risk score, each one unit increase in cumulative exposure was significantly associated with a 10% increase in TNBC odds. Higher cumulative exposure risk scores were found in census tracts with relatively high proportions of Black residents. CONCLUSIONS Cumulative exposure to neighborhood-level risk factors that disproportionately affect Black communities was associated with greater TNBC risk.
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Affiliation(s)
- Scott D Siegel
- Institute for Research on Equity & Community Health, Christiana Care Health System, Newark, Delaware, USA.,Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, Delaware, USA
| | - Madeline M Brooks
- Institute for Research on Equity & Community Health, Christiana Care Health System, Newark, Delaware, USA
| | - Jesse D Berman
- Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Shannon M Lynch
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jennifer Sims-Mourtada
- Helen F. Graham Cancer Center & Research Institute, Christiana Care Health System, Newark, Delaware, USA
| | - Zachary T Schug
- The Wistar Institute Cancer Center, Philadelphia, Pennsylvania, USA
| | - Frank C Curriero
- Department of Epidemiology, Johns Hopkins School of Public Health, John Hopkins Spatial Science for Public Health Center, Baltimore, Maryland, USA
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Lower breast cancer survival among Black women in Brazil: a population-based retrospective study. Public Health 2023; 217:190-195. [PMID: 36907028 DOI: 10.1016/j.puhe.2023.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVES To analyze the rates of breast cancer survival among Black and White women according to age and stage at diagnosis. STUDY DESIGN A retrospective cohort study. METHODS The study examined women registered in the population-based cancer registry of Campinas in 2010-2014. The primary variable was the declared race (White or Black). Other races were excluded. Data were linked with the Mortality Information System, and missing information was accessed by active search. Overall survival (OS) was calculated by the Kaplan-Meier method, comparisons were done by chi-squared tests, and hazard ratios were examined by Cox regression. RESULTS The total numbers of new cases of staged breast cancer among Black and White women were 218 and 1522 cases, respectively. The rates of stages III/IV were 35.5% among White women and 43.1% among Black women (P = 0.024). The frequencies among White and Black women under 40 years old were 8.0% and 12.4% (P = 0.031), 19.6% and 26.6% (P = 0.016) for ages of 40-49 years, and 23.8% and 17.4% (P = 0.037) for ages of 60-69 years, respectively. The mean OS was 7.5 years (7.0; 8.0) among Black women and 8.4 years (8.2; 8.5) among White women. The 5-year OS was 72.3% among Black women and 80.5% among White women (P = 0.001). Black women had an age-adjusted risk of death that was 1.7 times higher (1.33; 2.20). The risk was 6.4 times higher for diagnoses in stage 0 (1.65; 24.90) and 1.5 times for diagnoses in stage IV (1.04; 2.17). CONCLUSION The 5-year OS for women with breast cancer was significantly lower among Black women than White women. Black women were more frequently diagnosed in stages III/IV, and their age-adjusted risk of death was 1.7 times higher. Differences in access to care may explain these differences.
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Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum. Mol Psychiatry 2023; 28:1494-1501. [PMID: 36869227 DOI: 10.1038/s41380-023-02006-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/05/2023]
Abstract
The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.
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20
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Early breast cancer survival of black and white American women with equal diagnostic and therapeutic management. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:583-588. [PMID: 36464602 PMCID: PMC9974573 DOI: 10.1016/j.ejso.2022.11.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/20/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Breast cancer (BC) survival favors White versus Black Americans despite advances in screening and treatment. We hypothesized that these differences were dependent upon quality of care by analyzing long-term outcomes of 3139 early BC patients at our quaternary care center where uniform access and management of BC is provided to women irrespective of race. METHODS Prospectively collected data for clinical stage I-II BC patients from our quaternary care cancer center were analyzed, focusing on disease-specific survival (DSS). Subgroup analyses included the overall cohort, triple-negative BC (TNBC), non-TNBC and HER2/neu positive patients. Multivariable analyses to evaluate associations of variables with DSS were performed for each subgroup. RESULTS The overall cohort consisted of 3139 BC patients (1159 Black, 1980 White). Black and White patients did not differ by most baseline variables. Black patients had higher rates of TNBC (18% versus 10%, p < 0.0001). Kaplan-Meier analysis of all subgroups (overall, TNBC, non-TNBC, HER2/neu positive) did not reveal DSS differences between Black and White patients. Multivariable analysis of subgroups also did not find race to be associated with DSS. CONCLUSION In this large, carefully controlled, long term, single-institution prospective cohort study DSS in Black and White early BC patients with equal access to high quality care, did not differ. While BC patients with adverse molecular markers did slightly worse than those with more favorable markers, there is no observable difference between Black and White women with the same markers. These observations support the conclusion that equal access to, and quality, of BC care abolishes racial disparities in DSS.
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21
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Webster JL, Goldstein ND, Rowland JR, Tuite CM, Siegel SD. A Catchment and Location-Allocation Analysis of Mammography Access in Delaware, US: Implications for disparities in geographic access to breast cancer screening. RESEARCH SQUARE 2023:rs.3.rs-2600236. [PMID: 36909545 PMCID: PMC10002803 DOI: 10.21203/rs.3.rs-2600236/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Background Despite a 40% reduction in breast cancer mortality over the last 30 years, not all groups have benefited equally from these gains. A consistent link between later stage of diagnosis and disparities in breast cancer mortality has been observed by race, socioeconomic status, and rurality. Therefore, ensuring equitable geographic access to screening mammography represents an important priority for reducing breast cancer disparities. This study conducted a catchment and location-allocation analysis of mammography access in Delaware, a state that is representative of the US in terms of race and urban-rural characteristics and experiences an elevated burden from breast cancer. Methods A catchment analysis using the ArcGIS Pro Service Area analytic tool characterized the geographic distribution of mammography sites and Breast Imaging Centers of Excellence (BICOEs). Poisson regression analyses identified census tract-level correlates of access. Next, the ArcGIS Pro Location-Allocation analytic tool identified candidate locations for the placement of additional mammography sites in Delaware according to several sets of breast cancer screening guidelines. Results The catchment analysis showed that for each standard deviation increase in the number of Black women in a census tract, there were 64% (95% CI, 0.18-0.66) fewer mammography units and 85% (95% CI, 0.04-0.48) fewer BICOEs. The more rural counties in the state accounted for 41 % of the population but only 22% of the BICOEs. The results of the location-allocation analysis depended on which set of screening guidelines were adopted, which included increasing mammography sites in communities with a greater proportion of younger Black women and in rural areas. Conclusions The results of this study illustrate how catchment and location-allocation analytic tools can be leveraged to guide the equitable selection of new mammography facility locations as part of a larger strategy to close breast cancer disparities.
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22
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Dao K, Afran A, LeBedis C, Fishman MDC. The Impact of Social Determinants of Health on the Time Between Diagnostic Breast Imaging and Biopsy at a Safety Net Hospital. J Am Coll Radiol 2023; 20:393-401. [PMID: 36682645 DOI: 10.1016/j.jacr.2022.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 01/22/2023]
Abstract
PURPOSE Although social determinants of health (SDH) are thought to be associated with health outcomes, there is limited literature on the direct impact of SDH on delays in breast cancer diagnosis via breast imaging. Identifying SDH associated with longer lapses (defined in this study as a time interval between two events) between imaging and biopsy is essential to early-stage detection of breast cancer, which has a significant impact on survival. Previous work demonstrated associations between both housing and food insecurity with longer lapses between diagnostic imaging and biopsy. We aim to expand upon this retrospective analysis with a longer study period, more participants, and improved data cleaning techniques to better understand how SDH may affect the lapse between imaging and biopsy. METHODS This retrospective study was institutional review board approved and HIPAA compliant. Informed consent was waived. Patients who underwent screening mammography between January 1, 2015, and January 1, 2020, were assessed for timing of recommended biopsy due to a BI-RADS category 4 or 5. SDH were assessed with the unique Tool for Health & Resilience in Vulnerable Environments screening questionnaire developed at Boston Medical Center. Associations between imaging and biopsy timing and eight explanatory SDH variables (food insecurity, housing insecurity, ability to pay for medications, transportation access, ability to pay for utilities, caretaking needs, employment, and desire for more education) were assessed with multivariate Cox proportional hazard modeling, as well as demographic data. RESULTS There were 2,885 unique patients who underwent 3,142 unique diagnostic imaging studies and were included in the multivariate analysis. Of those 3,142 imaging studies, 196 (6.2%) had not yet been followed by the recommended biopsy by the end of the study period; 2,271 patients (78.7%) had SDH data in at least one domain; and the individual domains ranged from 962 patients (32.1%) with complete data for education to 2,175 patients (75.4%) with complete data for food insecurity. A positive screen for at least one SDH was associated with a longer lapse between diagnostic imaging and biopsy (P = .048). Furthermore, housing insecurity alone was nearly associated with longer lapses between diagnostic imaging and biopsy (P = .059). Those who desired more education were found to have shorter lapses between diagnostic imaging and biopsy (P = .037). CONCLUSIONS Only a positive screen of the aggregate of all SDH (using a novel tool developed at our safety net hospital) was associated with a statistically significant lengthening of this lapse. Of the eight SDH screened, housing insecurity was the closest to association with longer lapses between diagnostic imaging and biopsy, whereas patients who desired more education were found to have statistically significant shorter lapses; however, this survey domain had the lowest completion rate. CLINICAL RELEVANCE Identification of which SDH might affect the time from imaging to biopsy can potentially inform targeted programs to intervene. Government and health system interventions addressing SDH, notably housing insecurity, could allow for shorter time to breast cancer diagnosis and treatment.
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Affiliation(s)
- Kevin Dao
- Boston University School of Medicine, Boston, Massachusetts, and Ascension St Joseph Hospital, Chicago, Illinois.
| | - Aaron Afran
- Boston University School of Medicine, Boston, Massachusetts, and The Mount Sinai Hospital, New York, New York
| | - Christina LeBedis
- Vice Chair of Research, Assistant Professor of Radiology, and Radiologist, Body Imaging, Boston University School of Medicine, Boston, Massachusetts; and Boston Medical Center, Boston, Massachusetts
| | - Michael D C Fishman
- Assistant Professor of Radiology, Radiologist, Breast Imaging, Wellcoaches Certified Health and Wellness Coach, Boston University School of Medicine, Boston, Massachusetts; and Boston Medical Center, Boston, Massachusetts
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Bikomeye JC, Balza JS, Kwarteng JL, Beyer AM, Beyer KMM. The impact of greenspace or nature-based interventions on cardiovascular health or cancer-related outcomes: A systematic review of experimental studies. PLoS One 2022; 17:e0276517. [PMID: 36417344 PMCID: PMC9683573 DOI: 10.1371/journal.pone.0276517] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
SIGNIFICANCE Globally, cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality. While having different etiologies, CVD and cancer are linked by multiple shared risk factors, the presence of which exacerbate adverse outcomes for individuals with either disease. For both pathologies, factors such as poverty, lack of physical activity (PA), poor dietary intake, and climate change increase risk of adverse outcomes. Prior research has shown that greenspaces and other nature-based interventions (NBIs) contribute to improved health outcomes and climate change resilience. OBJECTIVE To summarize evidence on the impact of greenspaces or NBIs on cardiovascular health and/or cancer-related outcomes and identify knowledge gaps to inform future research. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and Peer Review of Electronic Search Strategies (PRESS) guidelines, we searched five databases: Web of Science, Scopus, Medline, PsycINFO and GreenFile. Two blinded reviewers used Rayyan AI and a predefined criteria for article inclusion and exclusion. The risk of bias was assessed using a modified version of the Newcastle-Ottawa Scale (NOS). This review is registered with PROSPERO, ID # CRD42021231619. RESULTS & DISCUSSION Of 2565 articles retrieved, 31 articles met the inclusion criteria, and overall had a low risk of bias. 26 articles studied cardiovascular related outcomes and 5 studied cancer-related outcomes. Interventions were coded into 4 categories: forest bathing, green exercise, gardening, and nature viewing. Outcomes included blood pressure (BP), cancer-related quality of life (QoL) and (more infrequently) biomarkers of CVD risk. Descriptions of findings are presented as well as visual presentations of trends across the findings using RAW graphs. Overall studies included have a low risk of bias; and alluvial chart trends indicated that NBIs may have beneficial effects on CVD and cancer-related outcomes. CONCLUSIONS & IMPLICATIONS (1) Clinical implication: Healthcare providers should consider the promotion of nature-based programs to improve health outcomes. (2) Policy implication: There is a need for investment in equitable greenspaces to improve health outcomes and build climate resilient neighborhoods. (3) Research or academic implication: Research partnerships with community-based organizations for a comprehensive study of benefits associated with NBIs should be encouraged to reduce health disparities and ensure intergenerational health equity. There is a need for investigation of the mechanisms by which NBIs impact CVD and exploration of the role of CVD biological markers of inflammation among cancer survivors.
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Affiliation(s)
- Jean C. Bikomeye
- Division of Epidemiology & Social Sciences, PhD Program in Public and Community Health, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Joanna S. Balza
- Division of Epidemiology & Social Sciences, PhD Program in Public and Community Health, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Jamila L. Kwarteng
- Division of Community Health, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, United States of America
- MCW Cancer Center, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Andreas M. Beyer
- MCW Cancer Center, Medical College of Wisconsin, Milwaukee, WI, United States of America
- Division of Cardiology, Department of Medicine, Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Kirsten M. M. Beyer
- Division of Epidemiology & Social Sciences, PhD Program in Public and Community Health, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, United States of America
- MCW Cancer Center, Medical College of Wisconsin, Milwaukee, WI, United States of America
- * E-mail:
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Makhani SS, Bouz A, Stavros S, Zucker I, Tercek A, Chung-Bridges K. Racial and Ethnic Inequality in Survival Outcomes of Women With Triple Negative Breast Cancer. Cureus 2022; 14:e27120. [PMID: 36000130 PMCID: PMC9391620 DOI: 10.7759/cureus.27120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 07/18/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose Triple-negative breast cancer (TNBC) is the most lethal group of breast cancers. Socioeconomic factors may contribute to differences in survival rates. This study aims to identify racial/ethnic disparities in five-year survival rates among women affected by TNBC in the United States. Methods This retrospective study analyzed data from the 2010-2016 Surveillance, Epidemiology, and End Results Program database. Patients with a primary malignancy of triple-negative breast cancer were included in this study. Cancer-specific survival was measured at five years post-diagnosis. Cox regression models were used to calculate hazard ratios (HR) and corresponding 95% confidence intervals (CI). Results From 2010-2016, there were 26,963 women with a primary diagnosis of TNBC. After adjustment for age, insurance, marital status, stage, and surgery type, Hispanic women had the highest hazard of death when compared to White women (adjusted (adj) HR, 1.14, p<0.001). Further, non-Hispanic Black women also had a lower survival probability when compared to White women (adj HR, 1.06, p=0.002). Conclusion This study reveals that Hispanic women had the highest hazard of death when compared to White women. As TNBC is the most fatal breast cancer, future studies should investigate socioeconomic factors that may worsen prognosis of this disease.
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Shen J, Fuemmeler BF, Sheppard VB, Bear HD, Song R, Chow WH, Zhao H. Neighborhood disadvantage and biological aging biomarkers among breast cancer patients. Sci Rep 2022; 12:11006. [PMID: 35773311 PMCID: PMC9246873 DOI: 10.1038/s41598-022-15260-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/21/2022] [Indexed: 11/09/2022] Open
Abstract
Living in a disadvantaged neighborhood is associated with adverse clinical outcomes among breast cancer patients, but the underlying pathway is still unclear. Limited evidence has suggested that accelerated biological aging may play an important role. In this study, using a sub-sample of 906 women with newly diagnosed breast cancer at M.D. Anderson, we examined whether levels of selected markers of biological aging (e.g., allostatic load, telomere length, and global DNA methylation) were affected by neighborhood disadvantage. The Area Deprivation Index was used to determine the neighborhood disadvantage. Based on the median ADI at the national level, the study population was divided into low and high ADI groups. Overall, breast cancer patients from the high ADI group were more likely to be younger and non-Hispanic Black than those from the low ADI group (P < 0.001, respectively). They were also more likely to have higher grade and poorly differentiated breast tumors (P = 0.029 and 0.019, respectively). For the relationship with markers, compared to the low ADI group, high ADI group had higher median levels of allostatic load (P = 0.046) and lower median levels of global DNA methylation (P < 0.001). Compared to their counterparts, those from the high ADI group were 20% more likely to have increased allostatic load and 51% less likely to have increased levels of global DNA methylation. In summary, we observed that levels of allostatic load and global DNA methylation are influenced by neighborhood disadvantage among breast cancer patients.
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Affiliation(s)
- Jie Shen
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Bernard F Fuemmeler
- Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Vanessa B Sheppard
- Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Harry D Bear
- Department of Surgery, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
| | - Renduo Song
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Wong-Ho Chow
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Hua Zhao
- Departments of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA.
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Tan R, Cassoli L, Yan Y, Shen V, Day BM, Mitchell EP. Assessing Real-World Racial Differences Among Patients With Metastatic Triple-Negative Breast Cancer in US Community Practices. Front Public Health 2022; 10:859113. [PMID: 35685754 PMCID: PMC9171051 DOI: 10.3389/fpubh.2022.859113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveReal-world data characterizing differences between African American (AA) and White women with metastatic triple-negative breast cancer (mTNBC) are limited. Using 9 years of data collected from community practices throughout the United States, we assessed racial differences in the proportion of patients with mTNBC, and their characteristics, treatment, and overall survival (OS).MethodsThis retrospective study analyzed de-identified data from 2,116 patients with mTNBC in the Flatiron Health database (January 2011 to March 2020). Characteristics and treatment patterns between AA and White patients with mTNBC were compared using descriptive statistics. OS was examined using Kaplan-Meier analysis and a multivariate Cox proportional hazards regression model.ResultsAmong patients with metastatic breast cancer, more AA patients (23%) had mTNBC than White patients (12%). This difference was particularly pronounced in patients who lived in the Northeast, were aged 45–65, had commercial insurance, and had initial diagnosis at stage II. AA patients were younger and more likely to have Medicaid. Clinical characteristics and first-line treatments were similar between AA and White patients. Unadjusted median OS (months) was shorter in AA (10.3; 95% confidence interval [CI]: 9.1, 11.7) vs. White patients (11.9; 95% CI: 10.9, 12.8) but not significantly different. After adjusting for potential confounders, the hazard ratio for OS was 1.09 (95% CI: 0.95, 1.25) for AA vs. White patients.ConclusionsThe proportion of patients with mTNBC was higher in AA than White mBC patients treated in community practices. Race did not show an association with OS. Both AA and White patients with mTNBC received similar treatments. OS was similarly poor in both groups, particularly in patients who had not received any documented anti-cancer treatment. Effective treatment remains a substantial unmet need for all patients with mTNBC.
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Affiliation(s)
- Ruoding Tan
- Genentech Inc., San Francisco, CA, United States
- *Correspondence: Ruoding Tan
| | | | - Ying Yan
- Genentech Inc., San Francisco, CA, United States
| | - Vincent Shen
- Genentech Inc., San Francisco, CA, United States
| | - Bann-mo Day
- Genentech Inc., San Francisco, CA, United States
| | - Edith P. Mitchell
- Gastroesophageal Center, Thomas Jefferson University Hospital, Philadelphia, PA, United States
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Sorice KA, Fang CY, Wiese D, Ortiz A, Chen Y, Henry KA, Lynch SM. Systematic review of neighborhood socioeconomic indices studied across the cancer control continuum. Cancer Med 2022; 11:2125-2144. [PMID: 35166051 PMCID: PMC9119356 DOI: 10.1002/cam4.4601] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/03/2021] [Accepted: 12/28/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND There is extensive interest in understanding how neighborhood socioeconomic status (nSES) may affect cancer incidence or survival. However, variability regarding items included and approaches used to form a composite nSES index presents challenges in summarizing overall associations with cancer. Given recent calls for standardized measures of neighborhood sociodemographic effects in cancer disparity research, the objective of this systematic review was to identify and compare existing nSES indices studied across the cancer continuum (incidence, screening, diagnosis, treatment, survival/mortality) and summarize associations by race/ethnicity and cancer site to inform future cancer disparity studies. METHODS Using PRISMA guidelines, peer-reviewed articles published between 2010 and 2019 containing keywords related to nSES and cancer were identified in PubMed. RESULTS Twenty-four nSES indices were identified from 75 studies. In general, findings indicated a significant association between nSES and cancer outcomes (n = 64/75 studies; 85.33%), with 42/64 (65.63%) adjusting for highly-correlated individual SES factors (e.g., education). However, the direction of association differed by cancer site, race/ethnicity, and nSES index. CONCLUSIONS This review highlights several methodologic and conceptual issues surrounding nSES measurement and potential associations with cancer disparities. Recommendations pertaining to the selection of nSES measures are provided, which may help inform disparity-related disease processes and improve the identification of vulnerable populations in need of intervention.
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Affiliation(s)
- Kristen A. Sorice
- Cancer Prevention and ControlFox Chase Cancer CenterPhiladelphiaPAUSA
| | - Carolyn Y. Fang
- Cancer Prevention and ControlFox Chase Cancer CenterPhiladelphiaPAUSA
| | - Daniel Wiese
- Geography and Urban StudiesTemple UniversityPhiladelphiaPAUSA
| | - Angel Ortiz
- Cancer Prevention and ControlFox Chase Cancer CenterPhiladelphiaPAUSA
| | - Yuku Chen
- Cancer Prevention and ControlFox Chase Cancer CenterPhiladelphiaPAUSA
| | - Kevin A. Henry
- Geography and Urban StudiesTemple UniversityPhiladelphiaPAUSA
| | - Shannon M. Lynch
- Cancer Prevention and ControlFox Chase Cancer CenterPhiladelphiaPAUSA
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Michaels EK, Canchola AJ, Beyer KMM, Zhou Y, Shariff-Marco S, Gomez SL. Home mortgage discrimination and incidence of triple-negative and Luminal A breast cancer among non-Hispanic Black and non-Hispanic White females in California, 2006-2015. Cancer Causes Control 2022; 33:727-735. [PMID: 35113296 PMCID: PMC9010391 DOI: 10.1007/s10552-022-01557-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 01/24/2022] [Indexed: 11/24/2022]
Abstract
Purpose In the United States, Black females are burdened by more aggressive subtypes and increased mortality from breast cancer compared to non-Hispanic (NH) White females. Institutional racism may contribute to these inequities. We aimed to characterize the association between home mortgage discrimination, a novel measure of institutional racism, and incidence of Luminal A and triple-negative breast cancer (TNBC) subtypes among NH Black and NH White females in California metropolitan areas. Methods We merged data from the California Cancer Registry on females aged 20 + diagnosed with primary invasive breast cancer between 2006 and 2015 with a census tract-level index of home mortgage lending bias measuring the odds of mortgage loan denial for Black versus White applicants, generated from the 2007–2013 Home Mortgage Disclosure Act database. Poisson regression estimated cross-sectional associations of census tract-level racial bias in mortgage lending with race/ethnicity- and Luminal A and TNBC-specific incidence rate ratios, adjusting for neighborhood confounders. Results We identified n = 102,853 cases of Luminal A and n = 15,528 cases of TNBC over the study period. Compared to NH Whites, NH Black females had higher rates of TNBC, lower rates of Luminal A breast cancer, and lived in census tracts with less racial bias in home mortgage lending. There was no evidence of association between neighborhood racial bias in mortgage lending at the time of diagnosis and either subtype among either racial/ethnic group. Conclusion Future research should incorporate residential history data with measures of institutional racism to improve estimation and inform policy interventions.
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Affiliation(s)
- Eli K Michaels
- Division of Epidemiology, Berkeley School of Public Health, University of California, 2121 Berkeley Way #5302, Berkeley, CA, 94720-7360, USA.
| | - Alison J Canchola
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.,Greater Bay Area Cancer Registry, San Francisco, CA, USA
| | - Kirsten M M Beyer
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yuhong Zhou
- Division of Epidemiology and Social Sciences, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Salma Shariff-Marco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.,Greater Bay Area Cancer Registry, San Francisco, CA, USA.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Scarlett L Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.,Greater Bay Area Cancer Registry, San Francisco, CA, USA.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
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van den Bruele AB, Sevilimedu V, Jochelson M, Formenti S, Norton L, Sacchini V. Mobile mammography in New York City: analysis of 32,350 women utilizing a screening mammogram program. NPJ Breast Cancer 2022; 8:14. [PMID: 35064104 PMCID: PMC8782895 DOI: 10.1038/s41523-022-00381-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/07/2021] [Indexed: 11/21/2022] Open
Abstract
Mobile mammography vans (mammovans) may help close the gap to access of breast cancer screening by providing resources to underserved communities. Minimal data exists on the populations served, the ability of mammovans to reach underserved populations, and the outcomes of participants. We sought to determine the demographic characteristics, number of breast cancers diagnosed, and number of women who used the American Italian Cancer Foundation (AICF) Mobile, No-Cost Breast Cancer Screening Program within the five boroughs of New York City. Data were collected by the AICF from 2014 to 2019 on a voluntary basis from participants at each screening location. Women aged 40 to 79 years who had not had a mammogram in the previous 12 months were invited to participate. Each participant underwent a clinical breast exam by a nurse practitioner followed by a screening mammogram. Images were read by a board-certified radiologist contracted by the AICF from Multi Diagnostic Services. There were 32,350 participants in this study. Sixty-three percent reported an annual household income ≤$25,000, and 30% did not have health insurance. More than half of participants identified as either African American (28%) or Hispanic (27%). Additional testing was performed for 5359 women found to have abnormal results on screening. In total, 68 cases of breast cancer were detected. Breast cancer disparities are multifactorial, with the greatest factor being limited access to care. Mobile, no-cost mammogram screening programs show great promise in helping to close the gap to screening access.
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Affiliation(s)
| | - Varadan Sevilimedu
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maxine Jochelson
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Silvia Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Larry Norton
- Breast Medicine, Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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30
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A tool to predict disparities in the timeliness of surgical treatment for breast cancer patients in the USA. Breast Cancer Res Treat 2022; 191:513-522. [PMID: 35013916 PMCID: PMC8747888 DOI: 10.1007/s10549-021-06460-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/15/2021] [Indexed: 11/26/2022]
Abstract
Purpose Breast cancer outcomes are impaired by both delays and disparities in treatment. This study was performed to assess their relationship and to provide a tool to predict patient socioeconomic factors associated with risk for delay. Methods The National Cancer Database was reviewed between 2004 and 2017 for patients with non-metastatic breast cancer managed with upfront surgery. Times to treatment were measured from the date of diagnosis. Patient, tumor, and treatment factors were assessed with attention paid to sociodemographic variables. Results 514,187 patients remained after exclusions, with 84.3% White, 10.8% Black, 3.7% Asian, and Hispanics comprising 5.6% of the cohort. Medicaid and uninsured patients had longer mean adjusted time to surgery (≥ 46 days) versus private (36.7 days), Medicare (35.9 days), or other governmental insurance (39.8 days). After adjustment, Black race and Hispanic ethnicity were most impactful, adding 6.0 and 6.4 preoperative days, 10.9 and 11.5 days to chemotherapy, 11.1 and 9.1 days to radiation, and 12.5 and 8.9 days to endocrine therapy, respectively. Income, education, and insurance, among other factors, also affected delay. A nomogram, including race and sociodemographic factors, was created to predict the risk of preoperative delay. Conclusion Significant disparities exist in timeliness of care for factors, including but not limited to, race and ethnicity. Although exact causes cannot be discerned, these data indicate population subsets whose intervals of care risk being longer than those specified by national quality standards. The nomogram created here may help direct resources to those at highest risk of incurring a treatment delay. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06460-9.
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31
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Rygiel K. Interface between obesity with dysfunctional metabolism and inflammation, and the triple-negative breast cancer in African American women. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2021; 2:602-616. [PMID: 36046117 PMCID: PMC9400742 DOI: 10.37349/etat.2021.00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/30/2021] [Indexed: 11/19/2022] Open
Abstract
Obesity has dramatically increased over the past fifty years. In the last decade, it has been noted that augmented body mass, metabolic abnormalities, and the relevant “obese” tumor microenvironment (TME) are connected with signaling molecular networks, which in turn, may contribute to aggressive tumor biology in some patients with breast malignancies. This article presents the associations between obesity, metabolic derangements, inflammatory processes in the adipose tissue or TME, and aggressive behavior of triple-negative breast cancer (TNBC) in African American (AA) women. It also describes some abnormal molecular signaling patterns in the “obese” TME with relevance to TNBC biology. Ethnic disparities in TNBC can be due to a variety of biological features (e.g., genetic mutations and tumor heterogeneity), comorbidities (e.g., cardio-metabolic diseases, including diabetes mellitus), and reproductive factors (e.g., multiparty or short breastfeeding period). Such a constellation of biological variables potentially leads to the association between obesity, metabolic derangements, inflammatory processes in the adipose tissue or TME, and aggressive behavior of TNBC in AA women. Since the TNBC and its TME can display very aggressive behavior, it is crucial that the afflicted AA women make efforts to maintain healthy body weight, “flexible” metabolism, and a well-functioning immune system. Further studies are merited to explore the multi-disciplinary factors that can affect TNBC prevention, management, and outcomes to optimize treatment strategies and survival among AA women.
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Affiliation(s)
- Katarzyna Rygiel
- Department of Family Practice, Medical University of Silesia, 41-800 Katowice-Zabrze, Poland
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32
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Area-Level Determinants in Colorectal Cancer Spatial Clustering Studies: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910486. [PMID: 34639786 PMCID: PMC8508304 DOI: 10.3390/ijerph181910486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 12/12/2022]
Abstract
The increasing pattern of colorectal cancer (CRC) in specific geographic region, compounded by interaction of multifactorial determinants, showed the tendency to cluster. The review aimed to identify and synthesize available evidence on clustering patterns of CRC incidence, specifically related to the associated determinants. Articles were systematically searched from four databases, Scopus, Web of Science, PubMed, and EBSCOHost. The approach for identification of the final articles follows PRISMA guidelines. Selected full-text articles were published between 2016 and 2021 of English language and spatial studies focusing on CRC cluster identification. Articles of systematic reviews, conference proceedings, book chapters, and reports were excluded. Of the final 12 articles, data on the spatial statistics used and associated factors were extracted. Identified factors linked with CRC cluster were further classified into ecology (health care accessibility, urbanicity, dirty streets, tree coverage), biology (age, sex, ethnicity, overweight and obesity, daily consumption of milk and fruit), and social determinants (median income level, smoking status, health cost, employment status, housing violations, and domestic violence). Future spatial studies that incorporate physical environment related to CRC cluster and the potential interaction between the ecology, biology and social determinants are warranted to provide more insights to the complex mechanism of CRC cluster pattern.
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Bikomeye JC, Namin S, Anyanwu C, Rublee CS, Ferschinger J, Leinbach K, Lindquist P, Hoppe A, Hoffman L, Hegarty J, Sperber D, Beyer KMM. Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8420. [PMID: 34444169 PMCID: PMC8392137 DOI: 10.3390/ijerph18168420] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/31/2021] [Accepted: 08/01/2021] [Indexed: 01/14/2023]
Abstract
The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.
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Affiliation(s)
- Jean C. Bikomeye
- Institute for Health & Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA; (J.C.B.); (S.N.); (C.A.)
| | - Sima Namin
- Institute for Health & Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA; (J.C.B.); (S.N.); (C.A.)
| | - Chima Anyanwu
- Institute for Health & Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA; (J.C.B.); (S.N.); (C.A.)
| | - Caitlin S. Rublee
- Department of Emergency Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA;
| | - Jamie Ferschinger
- Sixteenth Street Community Health Centers, Environmental Health & Community Wellness, 1337 S Cesar Chavez Drive, Milwaukee, WI 53204, USA;
| | - Ken Leinbach
- The Urban Ecology Center, 1500 E. Park Place, Milwaukee, WI 53211, USA;
| | - Patricia Lindquist
- Wisconsin Department of Natural Resources, Division of Forestry, 101 S. Webster Street, P.O. Box 7921, Madison, WI 53707, USA;
| | - August Hoppe
- The Urban Wood Lab, Hoppe Tree Service, 1813 S. 73rd Street, West Allis, WI 53214, USA;
| | - Lawrence Hoffman
- Department of GIS, Groundwork Milwaukee, 227 West Pleasant Street, Milwaukee, WI 53212, USA;
| | - Justin Hegarty
- Reflo—Sustainable Water Solutions, 1100 S 5th Street, Milwaukee, WI 53204, USA;
| | - Dwayne Sperber
- Wudeward Urban Forest Products, N11W31868 Phyllis Parkway, Delafield, WI 53018, USA;
| | - Kirsten M. M. Beyer
- Institute for Health & Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA; (J.C.B.); (S.N.); (C.A.)
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Sheth Bhutada J, Hwang A, Liu L, Deapen D, Freyer DR. Poor-Prognosis Metastatic Cancers in Adolescents and Young Adults: Incidence Patterns, Trends, and Disparities. JNCI Cancer Spectr 2021; 5:pkab039. [PMID: 34250441 PMCID: PMC8266435 DOI: 10.1093/jncics/pkab039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/28/2021] [Accepted: 04/21/2021] [Indexed: 01/07/2023] Open
Abstract
Background For adolescents and young adults (AYAs, aged 15-39 years) with cancer, metastatic disease at diagnosis is the strongest predictor of mortality, but its associations with age and sociodemographic factors are largely unexplored. Methods Using Surveillance, Epidemiology, and End Results Program data from 2000 to 2016, we collected incident cases of poor-prognosis metastatic cancer (5-year survival < 50%) and compared the proportion, incidence, time trends, and incidence rate ratios for race and ethnicity, sex, and socioeconomic status among AYAs, middle-aged adults (aged 40-64 years) and older adults (aged 65-79 years). Results From 2000 to 2016, a total of 17 210 incident cases of poor-prognosis metastatic cancer were diagnosed in AYAs, 121 274 in middle-aged adults, and 364 228 in older adults. Compared with older patients, the proportion of AYAs having metastatic disease was equivalent or substantially lower in nearly every site except stomach and breast cancers, which were statistically significantly higher for AYAs compared with middle-aged and older adults (stomach: 57.3% vs 46.4% and 39.5%; breast: 6.6% vs 4.4% and 5.6%, respectively; 2-sided P < .001 for all comparisons). Incidence rates rose significantly faster among AYAs for breast, stomach, and kidney cancers and among AYAs and middle-aged adults for colorectal cancer. Markedly higher incidence rate ratios were noted for AYA racial and ethnic minorities with breast, stomach, and especially kidney cancer, where only non-Hispanic Black AYAs were at considerably higher risk. For most sites, incidence rate ratios were higher among male patients and individuals of low socioeconomic status across age groups. Conclusions For most cancers, AYAs are not more likely to present with metastases than middle-aged and older adults. Further investigation is warranted for the disproportionate rise in incidence of metastatic breast, stomach, and kidney cancer among AYAs and their excess burden among AYA racial and ethnic minorities. The rising incidence of colorectal cancer among AYAs and middle-aged adults remains an additional concern.
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Affiliation(s)
- Jessica Sheth Bhutada
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Amie Hwang
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Los Angeles Cancer Surveillance Program, Los Angeles, CA, USA
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lihua Liu
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Los Angeles Cancer Surveillance Program, Los Angeles, CA, USA
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Dennis Deapen
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Los Angeles Cancer Surveillance Program, Los Angeles, CA, USA
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - David R Freyer
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- USC Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Tsui J, Yang A, Anuforo B, Chou J, Brogden R, Xu B, Cantor JC, Wang S. Health Related Social Needs Among Chinese American Primary Care Patients During the COVID-19 Pandemic: Implications for Cancer Screening and Primary Care. Front Public Health 2021; 9:674035. [PMID: 34123992 PMCID: PMC8192797 DOI: 10.3389/fpubh.2021.674035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/23/2021] [Indexed: 12/28/2022] Open
Abstract
Research Objective: Initiatives to address social determinants of health (SDOH) and measure health-related social needs (HRSN) within clinic settings are increasing. However, few have focused on the specific needs of Asian Americans (AA). We examine the prevalence of HRSN during a period spanning the COVID-19 pandemic to inform strategies to improve cancer screening and primary care among AA patients. Methods: We implemented a self-administered HRSN screening tool in English and Chinese, traditional (T) or simplified (S) text, within a hospital-affiliated, outpatient primary care practice predominantly serving AA in New Jersey. HRSN items included food insecurity, transportation barriers, utility needs, interpersonal violence, housing instability, immigration history, and neighborhood perceptions on cohesion and trust. We conducted medical chart reviews for a subset of participants to explore the relationship between HRSN and history of cancer screening. Results: Among 236 participants, most were Asian (74%), non-US born (79%), and privately insured (57%). One-third responded in Chinese (37%). Half reported having ≥1 HRSN. Interpersonal violence was high across all participants. Transportation needs were highest among Chinese-T participants, while food insecurity and housing instability were higher among Chinese-S participants. Lower-income patients had higher odds of having ≥2 HRSN (OR:2.53, 95% CI: 1.12, 5.98). Older age and public insurance/uninsured were significantly associated with low neighborhood perceptions. Conclusions: We observed higher than anticipated reports of HRSN among primary care patients in a suburban, hospital-affiliated practice serving AA. Low neighborhood perceptions, particularly among Chinese-S participants, highlight the importance of addressing broader SDOH among insured, suburban AA patients. These study findings inform the need to augment HRSN identification to adequately address social needs that impact health outcomes and life course experiences for Asian patients. As HRSN measuring efforts continue, and COVID-19's impact on the health of minority communities emerge, it will be critical to develop community-specific referral pathways to connect AA to resources for HRSN and continue to address more upstream social determinants of health for those who are disproportionately impacted.
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Affiliation(s)
- Jennifer Tsui
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Annie Yang
- Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Bianca Anuforo
- Section of Behavioral Sciences, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Jolene Chou
- Rutgers Center for State Health Policy, Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ, United States
| | - Ruth Brogden
- RWJBarnabas Health Medical Group, Center for Asian Health, Saint Barnabas Medical Center, Florham Park, NJ, United States
| | - Binghong Xu
- RWJBarnabas Health Medical Group, Center for Asian Health, Saint Barnabas Medical Center, Florham Park, NJ, United States
| | - Joel C. Cantor
- Rutgers Center for State Health Policy, Institute for Health, Health Care Policy, and Aging Research, New Brunswick, NJ, United States
- Rutgers Edward J. Bloustein School of Planning and Public Policy, New Brunswick, NJ, United States
| | - Su Wang
- RWJBarnabas Health Medical Group, Center for Asian Health, Saint Barnabas Medical Center, Florham Park, NJ, United States
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36
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Zhao H, Song R, Ye Y, Chow WH, Shen J. Allostatic score and its associations with demographics, healthy behaviors, tumor characteristics, and mitochondrial DNA among breast cancer patients. Breast Cancer Res Treat 2021; 187:587-596. [PMID: 33507481 DOI: 10.1007/s10549-021-06102-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/09/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Allostatic load (AL), a composite index, has been used to capture variation in life-course stresses. However, few studies have been carried out among breast cancer patients. METHODS In this study, we examined the cross-sectional association of AL with demographics, healthy behaviors, tumor characteristics, and mitochondrial DNA copy number in breast cancer patients. The study used a sub-sample of 934 women with newly diagnosed breast cancer at M.D. Anderson from 2013 to 2018. To construct the AL score, the study used a battery of seventeen factors that represents the activity of five physiological systems: metabolic, cardiovascular, immunological, renal, and liver. RESULTS AL was positively associated with the age of disease diagnosis (P = 0.002), and was higher in Black and Hispanic populations than White (P = 0.001 and 0.032, respectively). AL was also found more abundant in those who experienced marital dissolution (P = 0.006), lacked a college education (P = 0.045), currently smoked (P = 0.011), and had low levels of physical activity (P = 0.037) than their counterparts. The study then found that higher AL was associated with increased odds of having poorly differentiated tumors (Odds ratio (OR): 1.40, 95% confidence interval (CI): 1.28, 1.62). An additional significant association was observed between AL with estrogen receptor negative (ER-) (OR = 1.56, 95%CI: 1.02, 2.36) among Black patients. Finally, we observed a significant positive correlation between AL with leukocyte mitochondrial DNA copy number variation (P < 0.001). CONCLUSIONS We conclude AL is influenced by selected demographics and healthy behaviors, and further is correlated with tumor characteristics and mitochondrial DNA copy number in breast cancer patients.
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Affiliation(s)
- Hua Zhao
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA. .,Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA.
| | - Renduo Song
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yuanqing Ye
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Precision Health and Data Science, School of Public Health, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wong-Ho Chow
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jie Shen
- Departments of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth University, Richmond, VA, 23284, USA
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Prakash O, Hossain F, Danos D, Lassak A, Scribner R, Miele L. Racial Disparities in Triple Negative Breast Cancer: A Review of the Role of Biologic and Non-biologic Factors. Front Public Health 2020; 8:576964. [PMID: 33415093 PMCID: PMC7783321 DOI: 10.3389/fpubh.2020.576964] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022] Open
Abstract
Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer that lacks expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor (HER2). TNBC constitutes about 15–30 percent of all diagnosed invasive breast cancer cases in the United States. African-American (AA) women have high prevalence of TNBC with worse clinical outcomes than European-American (EA) women. The contributing factors underlying racial disparities have been divided into two major categories based on whether they are related to lifestyle (non-biologic) or unrelated to lifestyle (biologic). Our objective in the present review article was to understand the potential interactions by which these risk factors intersect to drive the initiation and development of the disparities resulting in the aggressive TNBC subtypes in AA women more likely than in EA women. To reach our goal, we conducted literature searches using MEDLINE/PubMed to identify relevant articles published from 2005 to 2019 addressing breast cancer disparities primarily among AA and EA women in the United States. We found that disparities in TNBC may be attributed to racial differences in biological factors, such as tumor heterogeneity, population genetics, somatic genomic mutations, and increased expression of genes in AA breast tumors which have direct link to breast cancer. In addition, a large number of non-biologic factors, including socioeconomic deprivation adversities associated with poverty, social stress, unsafe neighborhoods, lack of healthcare access and pattern of reproductive factors, can promote comorbid diseases such as obesity and diabetes which may adversely contribute to the aggression of TNBC biology in AA women. Further, the biological risk factors directly linked to TNBC in AA women may potentially interact with non-biologic factors to promote a higher prevalence of TNBC, more aggressive biology, and poor survival. The relative contributions of the biologic and non-biologic factors and their potential interactions is essential to our understanding of disproportionately high burden and poor survival rates of AA women with TNBC.
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Affiliation(s)
- Om Prakash
- Louisiana Health Sciences Center, School of Medicine, New Orleans, LA, United States
| | - Fokhrul Hossain
- Louisiana Health Sciences Center, School of Medicine, New Orleans, LA, United States
| | - Denise Danos
- Louisiana Health Sciences Center, School of Medicine, New Orleans, LA, United States
| | - Adam Lassak
- Louisiana Health Sciences Center, School of Medicine, New Orleans, LA, United States
| | - Richard Scribner
- Department of Public Health and Preventive Medicine, St. George's University, True Blue, Grenada
| | - Lucio Miele
- Louisiana Health Sciences Center, School of Medicine, New Orleans, LA, United States
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Hill HE, Schiemann WP, Varadan V. Understanding breast cancer disparities-a multi-scale challenge. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:906. [PMID: 32793750 DOI: 10.21037/atm.2020.04.37] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite convergence of overall breast cancer incidence rates between European American (EA) and African American (AA) women, disparities in mortality persist. The factors contributing to differences in mortality rates across population groups remain controversial and range from population genetics to sociodemographic influences. This review explores the complex multi-factorial nature of tumor-intrinsic and -extrinsic factors that impact the biology and clinical outcomes of breast cancer patients. In addition to summarizing the current state of breast cancer disparities research, we also motivate the development of integrative multi-scale approaches involving interdisciplinary teams to tackle this complex clinical challenge.
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Affiliation(s)
- Hannah E Hill
- Department of Pharmacology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - William P Schiemann
- Department of Pharmacology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of General Medical Sciences-Oncology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vinay Varadan
- Department of Pharmacology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of General Medical Sciences-Oncology, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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39
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Hasan SMS, Rivera D, Wu XC, Durbin EB, Christian JB, Tourassi G. Knowledge Graph-Enabled Cancer Data Analytics. IEEE J Biomed Health Inform 2020; 24:1952-1967. [PMID: 32386166 PMCID: PMC8324069 DOI: 10.1109/jbhi.2020.2990797] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cancer registries collect unstructured and structured cancer data for surveillance purposes which provide important insights regarding cancer characteristics, treatments, and outcomes. Cancer registry data typically (1) categorize each reportable cancer case or tumor at the time of diagnosis, (2) contain demographic information about the patient such as age, gender, and location at time of diagnosis, (3) include planned and completed primary treatment information, and (4) may contain survival outcomes. As structured data is being extracted from various unstructured sources, such as pathology reports, radiology reports, medical records, and stored for reporting and other needs, the associated information representing a reportable cancer is constantly expanding and evolving. While some popular analytic approaches including SEER*Stat and SAS exist, we provide a knowledge graph approach to organizing cancer registry data. Our approach offers unique advantages for timely data analysis and presentation and visualization of valuable information. This knowledge graph approach semantically enriches the data, and easily enables linking with third-party data which can help explain variation in cancer incidence patterns, disparities, and outcomes. We developed a prototype knowledge graph based on the Louisiana Tumor Registry dataset. We present the advantages of the knowledge graph approach by examining: i) scenario-specific queries, ii) links with openly available external datasets, iii) schema evolution for iterative analysis, and iv) data visualization. Our results demonstrate that this graph based solution can perform complex queries, improve query run-time performance by up to 76%, and more easily conduct iterative analyses to enhance researchers' understanding of cancer registry data.
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Davis M, Martini R, Newman L, Elemento O, White J, Verma A, Datta I, Adrianto I, Chen Y, Gardner K, Kim HG, Colomb WD, Eltoum IE, Frost AR, Grizzle WE, Sboner A, Manne U, Yates C. Identification of Distinct Heterogenic Subtypes and Molecular Signatures Associated with African Ancestry in Triple Negative Breast Cancer Using Quantified Genetic Ancestry Models in Admixed Race Populations. Cancers (Basel) 2020; 12:E1220. [PMID: 32414099 PMCID: PMC7281131 DOI: 10.3390/cancers12051220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
Triple negative breast cancers (TNBCs) are molecularly heterogeneous, and the link between their aggressiveness with African ancestry is not established. We investigated primary TNBCs for gene expression among self-reported race (SRR) groups of African American (AA, n = 42) and European American (EA, n = 33) women. RNA sequencing data were analyzed to measure changes in genome-wide expression, and we utilized logistic regressions to identify ancestry-associated gene expression signatures. Using SNVs identified from our RNA sequencing data, global ancestry was estimated. We identified 156 African ancestry-associated genes and found that, compared to SRR, quantitative genetic analysis was a more robust method to identify racial/ethnic-specific genes that were differentially expressed. A subset of African ancestry-specific genes that were upregulated in TNBCs of our AA patients were validated in TCGA data. In AA patients, there was a higher incidence of basal-like two tumors and altered TP53, NFB1, and AKT pathways. The distinct distribution of TNBC subtypes and altered oncologic pathways show that the ethnic variations in TNBCs are driven by shared genetic ancestry. Thus, to appreciate the molecular diversity of TNBCs, tumors from patients of various ancestral origins should be evaluated.
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Affiliation(s)
- Melissa Davis
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065, USA; (M.D.); (R.M.); (L.N.)
| | - Rachel Martini
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065, USA; (M.D.); (R.M.); (L.N.)
| | - Lisa Newman
- Department of Surgery, Weill Cornell Medicine, New York, NY 10065, USA; (M.D.); (R.M.); (L.N.)
| | - Olivier Elemento
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, NY 10065, USA;
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY 10065, USA;
- Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Jason White
- Department of Biology and Center for Cancer Research, Tuskegee University, Tuskegee, AL 36088, USA; (J.W.); (W.D.C.)
| | - Akanksha Verma
- Department of Computational Biology, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Indrani Datta
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (I.D.); (I.A.); (Y.C.)
| | - Indra Adrianto
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (I.D.); (I.A.); (Y.C.)
| | - Yalei Chen
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI 48202, USA; (I.D.); (I.A.); (Y.C.)
| | - Kevin Gardner
- Department of Pathology and Cell Biology, Columbia University, New York, NY 10027, USA;
| | - Hyung-Gyoon Kim
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (H.-G.K.); (I.-E.E.); (A.R.F.); (W.E.G.)
| | - Windy D. Colomb
- Department of Biology and Center for Cancer Research, Tuskegee University, Tuskegee, AL 36088, USA; (J.W.); (W.D.C.)
- Department of Hematology and Oncology, Our Lady of Lourdes JD Moncus Cancer Center, Lafayette, LA 70508, USA
| | - Isam-Eldin Eltoum
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (H.-G.K.); (I.-E.E.); (A.R.F.); (W.E.G.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Andra R. Frost
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (H.-G.K.); (I.-E.E.); (A.R.F.); (W.E.G.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - William E. Grizzle
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (H.-G.K.); (I.-E.E.); (A.R.F.); (W.E.G.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Andrea Sboner
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, New York, NY 10065, USA;
- Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY 10065, USA
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10062, USA
| | - Upender Manne
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35233, USA; (H.-G.K.); (I.-E.E.); (A.R.F.); (W.E.G.)
- O’Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Clayton Yates
- Department of Biology and Center for Cancer Research, Tuskegee University, Tuskegee, AL 36088, USA; (J.W.); (W.D.C.)
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Bauer D, Mazzio E, Hilliard A, Oriaku ET, Soliman KFA. Effect of apigenin on whole transcriptome profile of TNFα-activated MDA-MB-468 triple negative breast cancer cells. Oncol Lett 2020; 19:2123-2132. [PMID: 32194710 PMCID: PMC7038999 DOI: 10.3892/ol.2020.11327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/30/2019] [Indexed: 12/12/2022] Open
Abstract
The lack of hormone receptors in triple negative breast cancer (TNBC) is associated with the inefficacy of anti-estrogen chemotherapies, leaving fewer options for patient treatment and higher mortality rates. Additionally, as with numerous types of inflammatory breast cancer, infiltration of tumor associated macrophages and other leukocyte sub-populations within the tumor inevitably lead to aggressive, chemo-resistant, metastatic and invasive types of cancer which escape immune surveillance. These processes are orchestrated by the release of potent cytokines, including TNFα, IL-6 and CCL2 from the stroma, tumor and immune cells within the tumor microenvironment. The present study evaluated apigenin modulating effects on the pro-inflammatory activating action of TNFα in TNBC MDA-MB-468 cells, derived from an African American woman. Initially, cell viability was determined to establish an optimal sub-lethal dose of TNFα and apigenin in MDA-MB-468 cells. Subsequently, various treatments effects were evaluated using whole transcriptomic analysis of mRNA and long intergenic non-coding RNA with Affymetrix HuGene-2.1-st human microarrays. Gene level differential expression analysis was conducted on 48,226 genes where TNFα caused significant upregulation of 53 transcripts and downregulation of 11 transcripts. The largest upward differential shift was for CCL2 [+61.86 fold change (FC); false discovery rate (FDR), P<0.0001]; which was down regulated by apigenin (to +10.71 FC vs. Control; FDR P-value <0.001), equivalent to an 83% reduction. Several TNFα deferentially upregulated transcripts were reduced by apigenin, including CXCL10, C3, PGLYRP4, IL22RA2, KMO, IL7R, ROS1, CFB, IKBKe, SLITRK6 (a checkpoint target) and MMP13. Confirmation of CCL2 experimentally induced transcript alterations was corroborated at the protein level by ELISA assays. The high level of CCL2 transcript in the cell line was comparable to that in our previous studies in MDA-MB-231 cells. The differential effects of TNFα were corroborated by ELISA, where the data revealed a >10-fold higher releasing rate of CCL2 in MDA-MB-468 cells compared with in MDA-MB-231 cells, both of which were attenuated by apigenin. The data obtained in the present study demonstrated a high level of CCL2 in MDA-MB-468 cells and a possible therapeutic role for apigenin in downregulating TNFα-mediated processes in these TNBC cells.
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Affiliation(s)
- David Bauer
- Division of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA
| | - Elizabeth Mazzio
- Division of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA
| | - Aaron Hilliard
- Division of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA
| | - Ebenezer T Oriaku
- Division of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA
| | - Karam F A Soliman
- Division of Pharmaceutical Sciences, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL 32307, USA
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Coughlin SS. A review of social determinants of prostate cancer risk, stage, and survival. Prostate Int 2019; 8:49-54. [PMID: 32647640 PMCID: PMC7335972 DOI: 10.1016/j.prnil.2019.08.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/15/2019] [Indexed: 11/15/2022] Open
Abstract
Social determinants of health that have been examined in relation to prostate cancer incidence, stage at diagnosis, and survival include socioeconomic status (income, education), neighborhood disadvantage, immigration status, social support, and social network. Other social determinants of health include geographic factors such as neighborhood access to health services. Socioeconomic factors influence risk of prostate cancer. Prostate cancer incidence rates tend to be positively associated with socioeconomic status. On the other hand, low socioeconomic status is associated with increased risk of poorer survival. There are well-documented disparities in prostate cancer survival by socioeconomic status, race, education, and census tract-level poverty. The results of this review indicate that social determinants such as poverty, lack of education, immigration status, lack of social support, and social isolation play an important role in prostate cancer stage at diagnosis and survival. To address these social determinants and eliminate cancer disparities, effective interventions that account for the social and environmental contexts in which patients with cancer live and are treated are needed.
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Affiliation(s)
- Steven S Coughlin
- Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, GA, USA.,Institute of Public and Preventive Health, Augusta University, Augusta, GA, USA
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43
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Coughlin SS. Social determinants of breast cancer risk, stage, and survival. Breast Cancer Res Treat 2019; 177:537-548. [DOI: 10.1007/s10549-019-05340-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
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