African-American and low-socioeconomic status patients have a worse prognosis for invasive ductal and lobular breast carcinoma: do screening criteria need to change?

Area Deprivation Index in Patients with Invasive Lobular Carcinoma of the Breast: Associations with Tumor Characteristics and Outcomes

BACKGROUND

Although investigators have shown associations between socioeconomic status (SES) and outcomes in breast cancer, there is a paucity of such data for invasive lobular carcinoma (ILC), the second most common type of breast cancer. Herein we evaluated the relationship between SES with tumor features and outcomes in stage I to III patients with ILC.

METHODS

We analyzed a prospectively maintained institutional ILC database and utilized the area deprivation index (ADI) to determine neighborhood adversity, an indicator of SES. We used Cox proportional hazards models in Stata 17.0 to evaluate relationships between ADI quintile (Q), race, body mass index (BMI), clinicopathologic features, treatment type, and event-free survival (EFS).

RESULTS

Of 804 patients with ILC, 21.4% lived in neighborhoods classified as ADI Q1 (least resource-deprived) and 19.7% in Q5 (most resource-deprived). Higher deprivation was significantly associated with larger tumor size (3.6 cm in Q5 vs. 3.1 cm in Q1), increased presence of lymphovascular invasion (8.9% in Q5 vs. 6.7% in Q1), and decreased use of adjuvant endocrine therapy (67.1% in Q5 vs. 73.6% in Q1). On multivariable analysis, tumor size, receptor subtypes, and omission of adjuvant endocrine therapy were associated with reduced EFS.

CONCLUSIONS

These data show that patients with ILC and higher ADI experience more aggressive tumors and differences in treatment. More data evaluating the complex relationships between these factors is needed to optimize outcomes for patients with ILC, regardless of SES.

IMPACT

ADI is associated with differences in patients with ILC.

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

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

Identifying the barriers to gastric cancer care at safety-net hospitals: A novel comparison of a safety-net hospital to a neighboring quaternary referral academic center in the same healthcare system

BACKGROUND

The three-delays model describes delays in seeking, reaching, and receiving care for vulnerable populations needing treatment. The dominant delay for patients with gastric adenocarcinoma (GAC) is unknown. We aimed to define patients with GAC who reached and received care at our regional safety-net hospital (Grady Memorial Hospital [GMH]) and our neighboring quaternary referral hospital (Emory University Hospital [EUH]).

METHODS

Clinicopathologic data from National Cancer Database (NCDB) participating academic centers were compared with GMH from 2004 to 2014. Outcomes of patients undergoing surgery at GMH were compared to those at EUH.

RESULTS

At presentation, compared to NCDB centers (n = 69 662), GMH patients (n = 154) were more often black (85.1 vs 17.2%; P < 0.001), uninsured (30.5 vs 4.7%; P < 0.001), have stage IV disease (43.5 vs 30.1%; P = 0.017), and received no treatment (40.3 vs 18.4%; P < 0.001). When only comparing patients who underwent curative-intent resection at GMH (n = 23) to EUH (n = 137), median overall survival was similar between both groups (GMH: median not reached; EUH: 59.8 mos; P = 0.785).

CONCLUSION

Although vulnerable patients with GAC within a safety-net hospital present with later stages of the disease, those who received surgery have acceptable outcomes. Thus, efforts should be made to overcome barriers in seeking care.

Disparidade racial na sobrevivência em 10 anos para o câncer de mama: uma análise de mediação usando abordagem de respostas potenciais

Os objetivos foram investigar a associação entre raça/cor e a sobrevivência em 10 anos de mulheres com câncer de mama e o papel do estadiamento como mediador. Coorte hospitalar com 481 mulheres com câncer invasivo de mama, diagnosticadas entre 2003 e 2005. Foram feitas comparações entre mulheres brancas e negras quanto às características sociodemográficas e ao estadiamento, usando o teste qui-quadrado, e à sobrevivência em 10 anos, usando os métodos de Kaplan-Meier e regressão de Cox. Foram estimados para a variável raça/cor efeitos diretos e indiretos, mediados pelo estadiamento, com ajuste para a condição social da área de residência e idade, utilizando o modelo de respostas potenciais (contrafactual) e regressão múltipla de Cox. As mulheres negras residiam em setores censitários de menor renda, eram usuárias do setor público em maior proporção e foram diagnosticadas com estadiamentos mais avançados. A sobrevivência específica em 10 anos foi de 64,3% (IC95%: 60,0; 68,9), com diferença significativa entre brancas (69,5%; IC95%: 64,8; 74,6) e negras (44%; IC95%: 35,2; 55,1). Nos modelos múltiplos, ajustados para renda e idade, as negras tiveram pior prognóstico (HR = 2,09; IC95%: 1,76; 2,51), e a proporção mediada pelo estadiamento foi de 40% (IC95%: 37; 42). Há disparidade racial na sobrevivência do câncer de mama em 10 anos, mediada principalmente pelo estadiamento mais avançado da doença nas mulheres negras. Isso aponta para a necessidade de ampliar a cobertura e a qualidade do programa de rastreamento dessa doença e facilitar o acesso ao diagnóstico e tratamento precoces, com vistas à redução da iniquidade racial.

Recruitment of a Population-Based Sample of Young Black Women with Breast Cancer through a State Cancer Registry

Given that Black women remain underrepresented in clinical research studies, we sought to recruit a population-based sample of young Black women with breast cancer through a state cancer registry. Demographic and clinical information on all Black women diagnosed with invasive breast cancer at or below age 50 between 2009 and 2012 in Florida was obtained through the state cancer registry. Survivors were invited to participate in the study through state-mandated recruitment methods. Participant demographic and clinical characteristics were compared using Chi-squared tests for categorical variables and the two sample t-test for continuous variables to identify differences between: (i) consented participants versus all other eligible; and (ii) living versus deceased. Of the 1,647 young Black women with breast cancer, mean age at diagnosis was 42.5, with the majority having localized or regional disease, unmarried, privately insured, and employed. There were no significant differences in demographic and clinical variables between the 456 consented study participants versus the remaining 1,191 presumed eligible individuals. Compared to potential participants, women determined to be deceased prior to recruitment (n = 182) were significantly more likely to have distant disease and a triple-negative phenotype. They were also significantly more likely to be unemployed, and uninsured or have public insurance (i.e., Medicaid or Medicare). Our results demonstrate that recruitment of a population-based sample of breast cancer survivors through a state cancer registry is a feasible strategy in this underserved and underrepresented population. However, survival bias, which was observed due to the lag time between diagnosis and recruitment, is important to adjust for when generalizing findings to all young Black breast cancer patients.

Screening Mammography in a Public Hospital Serving Predominantly African-American Women: A Stage-Survival-Cost Model

BACKGROUND

Ethnic and socioeconomic disparities pervade breast cancer patterns and outcomes. Mammography guidelines reflect the difficulty in optimizing mortality reduction and cost-effectiveness, with controversy still surrounding the 2009 U.S. Preventive Services Task Force (USPSTF) recommendations. This study simulates USPSTF and American Cancer Society (ACS) guidelines' effects on stage, survival, and cost of treatment in an urban public hospital.

METHODS

Charts of 274 women diagnosed with stage I, II, or III breast cancer (2008-2010) were reviewed. Published tumor doubling times were used to predict size at diagnosis under simulated screening guidelines. Stage distributions under ACS and USPSTF guidelines were compared with those observed. Cohort survival for observed and hypothetical scenarios was estimated using national statistics. Treatment costs by stage, calculated from Georgia Medicaid claims data, were similarly applied.

RESULTS

Mean age at diagnosis was 56 years. African Americans predominated (82.5%), with 96% publically insured or uninsured. Simulated stages at diagnosis significantly favored ACS guidelines (43.1% stage 1/38.3% stage 2/9.9% stage 3 vs. USPSTF 23.0%/53.3 %/15.0%), as did 5-year survival and cost of treatment relative to both observed and USPSTF-predicted schema (p<.0001). Following USPSTF guidelines predicted lower survival and additional costs.

CONCLUSIONS

Following ACS guidelines seems to lead to earlier diagnosis for low-income African-American women and increase 5-year survival with lower overall and breast-specific costs. The data suggest that adjusting screening practices for lower socioeconomic status, ethnic minority women may prove essential in addressing cancer disparities.

Needs of low-income african american cancer survivors: multifaceted and practical

This study aimed to identify the needs of low-income, African American cancer survivors in an urban setting. Data were collected from semi-structured interviews conducted with cancer survivors (n = 12), caregivers (n = 10), professionals (n = 10), and surveys from town hall meetings (n = 80). The major needs identified, across all groups, included a diverse array of practical needs including transportation, financial and job assistance, childcare, self-care assistance, more education and lifestyle information when diagnosed as well as after diagnosis, better post treatment plan, and more need for social support. They identified the ideal resource center as being located within the survivor's neighborhood and would provide a range of medically specific support as well as recreational services. Being of limited economic means has a host of implications for those diagnosed with cancer and for their family members. Participants suggested that needs for cancer survivors have to take into account a complexity of factors including culture, family, and especially economic implications.

"Cutting" on cancer: attitudes about cancer spread and surgery among primary care patients in the U.S.A

Many underserved groups in the United States experience disparities in cancer survival. Part of the disparity may be due to differences in treatment or treatment uptake. Previous studies uncovered patient beliefs that surgery could cause cancer to spread and have suggested that this belief may affect uptake of cancer treatment. We explored patients' explanations about surgical treatment of cancer and cancer spread, as well as the perceived impact on decision-making among primary care patients from an underserved area. Focus groups and interviews were conducted with patients (n = 42) at a primary care federally qualified health center in 2006 and 2007. Focus groups/interviews were semi-structured and were audio-taped and transcribed. An inductive text analysis with multiple coders was used to analyze the data and extract themes. We found that nearly all respondents had heard that surgery ("cutting") and exposing cancer to the air would hasten cancer spread and result in worse outcomes. Most participants expressed agreement with this belief. Many participants said this concern would influence their decision about whether to have surgery and/or reported that a family member had refused surgery for this reason. A smaller group of respondents disagreed with this belief and offered experiential evidence to the contrary or hypotheses about its origination. The idea that "cutting" and "air" during surgery can cause cancer to spread may be more prevalent among patients than suspected, based on this sample of predominantly African American patients. While we were unable to disentangle the ideas about "cutting" from those about "exposure to air", this set of beliefs, when held strongly, can negatively influence patients' or family members' decisions to seek surgical care and, if it is more prevalent in underserved groups, may contribute to cancer disparities.

The enduring and evolving relationship between social class and breast cancer burden: a review of the literature

INTRODUCTION

Breast cancer in women has historically been seen as a "cancer of affluence" and there is a well-documented higher incidence among women of higher social class, as well as in societies with higher resources. However, the relationship between social class and breast cancer disease characteristics, especially those associated with poorer prognosis, is less well documented, and the overall relationship between breast cancer mortality and social class has been shown to vary. Furthermore, rapid changes in women's health and health-related behaviors in societies around the world may have an impact on both incidence and mortality patterns for breast cancer in the future.

METHODS

A PUBMED search on breast cancer and social class (incorporating the MeSH-nested concept of SES) yielded 403 possible studies published between 1978 and 2009, of which 90 met criteria for review. Our review discusses conceptualization and measurement of women's social class in each study, as well as findings related to breast cancer incidence, tumor biology or mortality, associated with social class.

FINDINGS

We found mostly consistent evidence that breast cancer incidence continues to be higher in higher social class groups, with some modification of risk with adjustment for known risk factors, including physical activity and reproductive history. However, biologic characteristics associated with poorer prognosis were negatively associated with social class (i.e., greater occurrence among disadvantaged women), and mortality from breast cancer showed inconsistent relationship to social class.

CONCLUSIONS

We discuss these studies in relation to the growing burden of breast cancer among low resource groups and countries, and the need for cancer control strategies reflecting the emerging demographics of breast cancer risk.

Screening criteria for breast cancer

Breast cancer screening constitutes an integral part of surgical practice for many surgeons and is an important tool in the war against breast cancer. Among many modalities, mammography plays a central role, with MRI now being increasingly used for women with high risk for breast cancer. Current guidelines for screening are in the process of evolution as more scientific knowledge is gained. The challenge lies in developing cost-effective methods to reach the maximum number of the population at risk.

Do all patients with carcinoma of the esophagus benefit from treatment at teaching facilities?

BACKGROUND

We sought to determine whether patients with esophageal carcinoma benefit from regionalization of care.

METHODS

The Florida Cancer Data System (FCDS) and the Agency for Health Care Administration data sets (1998-2002) were merged and queried.

RESULTS

A total of 5,041 patients (87.6% Caucasian vs. 11.1% African American (AA)) demonstrated a median survival time of 9.8 months overall and 23.4 months following surgical resection (P < 0.001). Adenocarcinoma arose predominantly in Caucasian patients (98.1%). Patients with adenocarcinoma (n = 2,248) derived a treatment benefit at a TF (HR = 1.35, P = 0.003), including an improved 90-day mortality following surgery (2.1% vs. 4.0%, P < 0.001). Squamous cell carcinoma (SCC) arose predominantly in AA patients (91.6%). No overall survival benefit at TF was observed (HR = 1.01, P = 0.915), however a trend for reduced 90-day surgical mortality was observed at TF (1.9% vs. 5.2%, P = 0.062). Multivariate analysis for adenocarcinoma demonstrates that poverty, lack of chemotherapy or surgery, and failure to provide treatment at a TF are independent predictors of worse survival. For SCC patients, AA race was a significant predictor of poorer survival while TF and poverty level were not.

CONCLUSIONS

These data suggest no benefit from potential regionalized care for patients with squamous histology, which disproportionately affects AA.

Race/ethnicity-based concerns over understanding cancer diagnosis and treatment plan

BACKGROUND

Race/ethnicity and culture influence illness perceptions, health beliefs and behaviors, and communication with health care providers. However, information about the impact of race/ethnicity on the understanding of cancer diagnosis and treatment plan is limited.

METHODS

Nine hundred seventy-three cancer patients completed an information needs-assessment questionnaire prior to starting treatment at 20 geographically distinct clinical cancer sites within the University of Rochester Community Clinical Oncology Program network. Chi2 Test was used to examine the association between race/ethnicity and education, occupation, and perception and use of available information. T test and analysis of covariance were used to examine race/ethnicity-based differences in concerns over understanding cancer diagnosis/treatment plan and the effect of race/ethnicity controlling for demographics.

RESULTS

There were 904 non-Hispanic white and 69 nonwhite (blacks, Latinos, and others) patients in the sample. Whites and nonwhites were comparable in educational attainment and occupation. However, there was a statistically significant race/ethnicity-based difference in concerns over understanding the diagnosis and treatment plan for cancer, even after controlling for sex (male, female), age, education, and occupation (p < .001). More nonwhite patients indicated that additional information would have been helpful in dealing with these concerns (p <.001).

CONCLUSIONS

Nonwhite cancer patients reported more concerns about understanding their diagnosis and treatment plan and were more likely to indicate that additional information would have been helpful. The findings emphasize the need for oncology professionals to confirm patients' understanding and ensure patients' information needs have been met, particularly when working with racial/ethnic minorities.