Survival of epithelial ovarian cancer in Black women: a society to cell approach in the African American cancer epidemiology study (AACES)

PURPOSE

The causes for the survival disparity among Black women with epithelial ovarian cancer (EOC) are likely multi-factorial. Here we describe the African American Cancer Epidemiology Study (AACES), the largest cohort of Black women with EOC.

METHODS

AACES phase 2 (enrolled 2020 onward) is a multi-site, population-based study focused on overall survival (OS) of EOC. Rapid case ascertainment is used in ongoing patient recruitment in eight U.S. states, both northern and southern. Data collection is composed of a survey, biospecimens, and medical record abstraction. Results characterizing the survival experience of the phase 1 study population (enrolled 2010-2015) are presented.

RESULTS

Thus far, ~ 650 patients with EOC have been enrolled in the AACES. The five-year OS of AACES participants approximates those of Black women in the Surveillance Epidemiology and End Results (SEER) registry who survive at least 10-month past diagnosis and is worse compared to white women in SEER, 49 vs. 60%, respectively. A high proportion of women in AACES have low levels of household income (45% < $25,000 annually), education (51% ≤ high school education), and insurance coverage (32% uninsured or Medicaid). Those followed annually differ from those without follow-up with higher levels of localized disease (28 vs 24%) and higher levels of optimal debulking status (73 vs 67%).

CONCLUSION

AACES is well positioned to evaluate the contribution of social determinants of health to the poor survival of Black women with EOC and advance understanding of the multi-factorial causes of the ovarian cancer survival disparity in Black women.

Abstract PR16: Investigating the determinants of racial disparities in ovarian cancer incidence: The OCWAA consortium

Background: The Ovarian Cancer in Women of African Ancestry consortium (OCWAA) was established to address racial disparities in epithelial ovarian cancer (EOC) risk and survival. Specifically, we aim to estimate the degrees to which racial differences in incidence and survival of EOC between African-American (AA) and white women are attributable to differences in the prevalence and timing of risk factors and in the magnitude of risk associations.

Methods: OCWAA includes four case-control studies (the African-American Cancer Epidemiology Study, the North Carolina Ovarian Cancer Study, the Los Angeles County Ovarian Cancer Study, and the Cook County Case-Control Study) and two nested case-control studies within cohort studies (the Black Women's Health Study and the Multiethnic Cohort Study). A centralized core database consisting of demographic and epidemiologic risk factors for borderline and invasive EOC, tumor characteristics and prognostic factors has been created, and the majority of data has been harmonized across studies. A histotype classification scheme was uniformly applied using a combination of morphology and grade information to best represent the most recent diagnostic guidelines for ovarian cancer as detailed in the 2014 WHO Classification of Tumors of the Female Reproductive System.

Results: A total of 1,169/2,324 AA cases and controls and 2,963/3,934 white cases and controls have been included in the OCWAA database to date. Approximately 83% of cases are invasive EOC, 15% are borderline tumors, and 2% are missing tumor behavior information. Among the invasive EOC cases, 61% are high-grade serous carcinomas. The average age at diagnosis of EOC cases is the same in AA and white women (57.2 years), and the year of diagnosis ranges from 1991 to 2016. The following risk factors showed marked prevalence differences in AA and white controls: obesity (46.3% vs 19.2%), breastfeeding (42.7% vs 54.3%), tubal ligation (31.1% vs 17.9%), postmenopausal hormone use (23.8% vs 40.8%), nulliparity (14.9% vs 19.2%), at least a college degree (35.5% vs 56.4%), and menarche age &lt;13 (51.6% vs 47.4%; p&lt;.01); p&lt;.0001 for all except where noted. In preliminary EOC risk analyses, we observed positive associations with body mass index and nulliparity and inverse associations with tubal ligation, oral contraceptive use and breastfeeding in both AA and white women. The harmonization of other factors including duration, frequency and timing of key risk factors, physical activity, comorbidities, medication use, and treatment information is ongoing.

Conclusions: OCWAA represents the largest study investigating disparities in ovarian cancer risk and survival between AA and white women. This consortium is uniquely positioned to study the epidemiology of ovarian cancer in AA, focusing on the role of lifestyle and behavioral characteristics, reproductive risk factors, treatment and other prognostic factors in explaining racial differences in ovarian cancer incidence and survival.

This abstract is also being presented as Poster C083.

Citation Format: Veronica Wendy Setiawan, Lauren Peres, Lynn Rosenberg, Traci Bethea, Patricia Moorman, Evan Myers, Anna Wu, Charlotte Joslin, Elisa Bandera, Deanna Chyn, Fabian Camacho, Joellen Schildkraut. Investigating the determinants of racial disparities in ovarian cancer incidence: The OCWAA consortium [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR16.

Abstract C42: Correlates of health-related quality of life among African-American survivors of ovarian cancer: Results from the AACES Study

Background: The incidence of epithelial ovarian cancer (EOC) is lower among African-American (AA) women compared to European American (EA) women (9.8 vs. 13.0 cases/100,000), but AA women have markedly worse outcomes. The purpose of this study is to describe the health-related quality of life (HRQL) in AA women with EOC and its correlates using data from a multisite population-based case-control study of invasive EOC in AA women, the African American Cancer Epidemiology Study (AACES).

Methods: 215 cases completed a first annual follow-up questionnaire, including the HRQL and psychosocial surveys &lt;18 months post diagnosis. The primary HRQL outcome was assessed with SF-8 component scores for physical (PCS) and mental (MCS) health. Correlates examined were patient, disease and treatment characteristics, modified Charlson index, perceived social support, perceived discrimination, leisure-time physical activity, the Life Orientation Test (LOTR), and phobic anxiety (Crown-Crisp Inventory, CCI-PA). Ordinary least squares regression was used to estimate linear trend effects for all predictors adjusting for age at diagnosis, comorbidity, BMI, stage and income.

Results: Higher household family income, lower phobic anxiety, higher social support, and higher leisure physical activity levels were associated with higher MCS and PCS (p &lt; 0.01). Higher perceived discrimination was associated with both lower MCS and PCS, while higher optimism (LOTR) was associated with higher MCS. In multivariable analyses including all predictors, CCI-PA and LOTR remained significant predictors of MCS (p &lt; 0.01), and BMI, phobic anxiety, and social support predicted PCS (p &lt; 0.001).

Conclusion: Prediagnosis characteristics and exposures of AA women with EOC are important predictors of HRQL after cancer diagnosis, and in AACES were more important than tumor characteristics. Cancer survivorship programs that enhance patients' social support and physical activity could have important benefits by reducing emotional distress and increasing perceived vitality.

Citation Format: Roger T. Anderson, Fabian Camacho, Elisa Bandera, Ellen Funkhouser, Patricia Moorman, Lisa Paddock, Lauren C. Peres, Edward Peters, Sarah E. Abbott, Anthony J. Alberg, Jill Barnholtz-Sloan, Melissa Bondy, Michele L. Cote, Ann Schwartz, Paul Terry, Joellen Schildkraut. Correlates of health-related quality of life among African-American survivors of ovarian cancer: Results from the AACES Study [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C42.

Abstract 1289: Evaluation of vitamin D receptor regulated genes reveals EGFR polymorphism is associated with high-grade serous ovarian cancer in African American women

Few studies have evaluated genetic risk factors for ovarian cancer in African American women. In a previous study with small sample sizes, Vitamin D Receptor (VDR) variants were shown to increase risk of epithelial ovarian cancer (EOC) in that population. This study sought to replicate those findings and assess gene variants from the VDR regulatory pathway. We assessed SNPs (genotyped+imputed) from 5 gene regions which included VDR and genes regulated by VDR, including UGT1A, UGT2B, CYP3A4/5 and EGFR in 755 EOC cases and 1,235 controls among women of African ancestry from the Ovarian Cancer Association Consortium (OCAC). We also performed analyses restricted to 537 patients with HGSOC represented in the overall analysis of EOC. SNPs were genotyped using the custom-designed 533,631 SNP Illumina OncoArray with imputation to the 1,000 Genomes Phase 3 v5 reference set for genotyped and imputed SNPs evaluated at the 5 gene regions (918 SNPs in UGT1A, 6302 SNPs in UGT2B, 410 SNPs in CYP3A4/5, and 824 SNPs in EGFR). Logistic regression was performed using an additive 1 degree of freedom model for genetic inheritance with adjustment for two principal components of ancestry to estimate odds ratios (OR) and 95 % confidence intervals (CI). For each gene region, we applied a gene-specific Bonferroni-threshold for statistical significance defined as 0.05 / number of SNPs examined for that gene. Based on this significance threshold, a statistically significant association with HGSOC was identified in the EGFR region for the imputed SNP, rs114972508 (per allele OR = 2.32, 95% CI = 1.58, 3.40 p=1.6e-05, imputation R-squared=0.89). We further identified suggestive associations (P &lt; 1.0e-06) with EOC for 10 imputed SNPs located within the UGT2B4 gene. We did not replicate previous associations in the 282 SNPs examined in the VDR gene for EOC overall or among HGSOC. In summary, we identified statistically significant association for variants from the EGFR region, and suggestive evidence of association for variants within the UGT2B region in genetic association analyses of ovarian cancer in women of African Ancestry. Data from in vitro experiments suggest that EGFR transcription and proliferative function is suppressed via VDR binding. Thus EGFR association with HGSOC may be a marker of VDR activity. UGT2B4 variants have not been previously explored in ovarian cancer but shown to be nominally associated with breast cancer in women of African ancestry. UGT2B4 enzymes, part of the phase II liver detoxification pathway, are important in the clearance of steroid hormones, bile acid and drug metabolism. Alterations in EGFR and UGT2B4 could perturb enzyme efficacy and proliferation in ovaries and impact susceptibility to ovarian cancer. Future studies will be needed to validate the associations of the imputed SNPs and to determine the impact of EGFR and UGT variants on cancer development.

Citation Format: Delores J. Grant, Ani Manichaikul, Lauren C. Peres, Xin-Qun Wang, Ann G. Schwartz, Anna Wu, Edward Peters, Patricia Moorman, Michele L. Cote, Melissa Bondy, Linda E. Kelemen, Jill Barnholtz-Sloan, Temitope O. Keku, Cathrine Hoyo, Andrew Berchuck, Paul Pharoah, Joellen M. Schildkraut, African American Cancer Epidemiology Study (AACES) and the Ovarian Cancer Assoc Consortium (OCAC). Evaluation of vitamin D receptor regulated genes reveals EGFR polymorphism is associated with high-grade serous ovarian cancer in African American women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1289. doi:10.1158/1538-7445.AM2017-1289

Abstract B58: Single-nucleotide polymorphisms of race-related alternatively spliced genes associate with prostate cancer risk, aggressiveness and/or survival

Background: African American (AA) men exhibit nearly 2-fold higher incidence and 3-fold higher mortality rates from prostate cancer (PC) compared with white men. This disparity likely results from a complex interplay between behavioral, social, neighborhood and biological factors, which all work collectively to generate increased tumor aggressiveness in AAs. Recent data from our laboratory, evaluating human PC biopsy tissue led to the identification of alternative splicing events between AA and white PC that track with increased growth and more aggressive invasion characteristics of PC in AA men. In the present study, we explored associations between genetic variants of 30 such alternatively spliced genes and PC risk, aggressiveness and survival in white and AA groups by analyzing published genome-wide association studies (GWAS) of PC.

Methods: We used GWAS datasets from the Multiethnic Cohort Study of Diet and Cancer (MEC), including AA PC cases and controls, and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), including white PC cases and controls, to evaluate associations of 11,073 and 10,385 single-nucleotide polymorphisms (SNPs), respectively, in 30 genes identified to be alternatively spliced between white and AA PC with PC risk, aggressiveness and survival. For risk, we evaluated 1150 cases and 1101 controls in PLCO and 670 cases and 658 controls in MEC, for aggressiveness, we evaluated 237 aggressive and 843 non-aggressive in PLCO and 234 aggressive and 436 non-aggressive in MEC, and for survival, we evaluated 1150 overall, 237 aggressive and 843 non-aggressive in PLCO. We then performed in silico bioinformatics to investigate potential functions of the SNPs.

Results: Significant associations between SNPs in FN1, COL6A3 and ACACA and SNPs in SEMA3C and FASN and PC risk in white and AA populations, respectively, were identified. In addition, SNPs in ACACA and SNPs in SEMA3C, RELN, MYBPC1, NCOR2 and WDR4 were found to be significantly associated with PC aggressiveness in white and AA populations, respectively. Furthermore, significant associations between SNPs in RHOU, FN1, COL6A3, SEMA3C, RELN, CD44, LMO7 and WDR4 and PC survival in a white population were identified. All of the aforementioned SNPs were predicted to play a role in splicing regulation.

Conclusions: SNPs of race-related alternatively spliced genes that are predicted to play a role in splicing regulation are significantly associated with PC risk, aggressiveness and/or survival in white and/or AA populations. Such variants have the potential to serve as novel molecular targets for development of biomarkers of increased risk of aggressive PC or therapeutics against aggressive PC. Ultimately, such biomarkers and therapeutic agents could serve as novel precision medicine interventions, reducing the mortality burden from PC among AA men.

Citation Format: Jennifer Freedman, Yanru Wang, Hongliang Liu, Patricia Moorman, Terry Hyslop, Daniel George, Norman Lee, Qingyi Wei, Steven Patierno. Single-nucleotide polymorphisms of race-related alternatively spliced genes associate with prostate cancer risk, aggressiveness and/or survival. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B58.

Physical and psychological health in rare cancer survivors

PURPOSE

Registries provide a unique tool for tracking quality of life in rare cancer survivors, whose survivorship experience is less known than for common cancers. This paper reports on these outcomes in 321 patients enrolled in the Rare Cancer Genetics Registry diagnosed with rare gastrointestinal, genitourinary, gynecologic, sarcoma, head/neck, or hematologic cancers.

METHODS

Four outcomes were assessed, reflecting registrants' self-reported physical and mental health, psychological distress, and loneliness. Combining all patients into a single analysis, regression was used to evaluate the association between outcomes and socio-demographic and clinical factors.

RESULTS

Median time since diagnosis was 3 years (range 0-9); 69 % were no longer in treatment. Poorer physical health was reported in registrants who were older at diagnosis, unmarried, and still in treatment. Poorer mental status was associated with younger diagnosis age and unmarried status. Psychological distress varied by cancer type and was higher among currently treated and unmarried registrants. Greater loneliness was reported in registrants with gynecological cancers, and those who were less educated or unmarried. The physical and mental health profile of rare cancer survivors is similar to what is reported for common cancers.

CONCLUSIONS

Unmarried participants reported poorer outcomes on all measures of quality of life. Furthermore, physical and mental health were not significantly different by cancer type after adjustment for diagnosis age, whether currently in treatment and marital status. Thus, the combined analysis performed here is a useful way to analyze outcomes in less common diseases. Our findings could be valuable in guiding evaluation and intervention for issues impacting quality of life.

IMPLICATIONS FOR CANCER SURVIVORS

Rare cancer survivors, particularly those without spousal support, should be monitored for challenges to the physical as well as psychological aspects of quality of life.

Benefits and Harms of Breast Cancer Screening: A Systematic Review

IMPORTANCE

Patients need to consider both benefits and harms of breast cancer screening.

OBJECTIVE

To systematically synthesize available evidence on the association of mammographic screening and clinical breast examination (CBE) at different ages and intervals with breast cancer mortality, overdiagnosis, false-positive biopsy findings, life expectancy, and quality-adjusted life expectancy.

EVIDENCE REVIEW

We searched PubMed (to March 6, 2014), CINAHL (to September 10, 2013), and PsycINFO (to September 10, 2013) for systematic reviews, randomized clinical trials (RCTs) (with no limit to publication date), and observational and modeling studies published after January 1, 2000, as well as systematic reviews of all study designs. Included studies (7 reviews, 10 RCTs, 72 observational, 1 modeling) provided evidence on the association between screening with mammography, CBE, or both and prespecified critical outcomes among women at average risk of breast cancer (no known genetic susceptibility, family history, previous breast neoplasia, or chest irradiation). We used summary estimates from existing reviews, supplemented by qualitative synthesis of studies not included in those reviews.

FINDINGS

Across all ages of women at average risk, pooled estimates of association between mammography screening and mortality reduction after 13 years of follow-up were similar for 3 meta-analyses of clinical trials (UK Independent Panel: relative risk [RR], 0.80 [95% CI, 0.73-0.89]; Canadian Task Force: RR, 0.82 [95% CI, 0.74-0.94]; Cochrane: RR, 0.81 [95% CI, 0.74-0.87]); were greater in a meta-analysis of cohort studies (RR, 0.75 [95% CI, 0.69 to 0.81]); and were comparable in a modeling study (CISNET; median RR equivalent among 7 models, 0.85 [range, 0.77-0.93]). Uncertainty remains about the magnitude of associated mortality reduction in the entire US population, among women 40 to 49 years, and with annual screening compared with biennial screening. There is uncertainty about the magnitude of overdiagnosis associated with different screening strategies, attributable in part to lack of consensus on methods of estimation and the importance of ductal carcinoma in situ in overdiagnosis. For women with a first mammography screening at age 40 years, estimated 10-year cumulative risk of a false-positive biopsy result was higher (7.0% [95% CI, 6.1%-7.8%]) for annual compared with biennial (4.8% [95% CI, 4.4%-5.2%]) screening. Although 10-year probabilities of false-positive biopsy results were similar for women beginning screening at age 50 years, indirect estimates of lifetime probability of false-positive results were lower. Evidence for the relationship between screening and life expectancy and quality-adjusted life expectancy was low in quality. There was no direct evidence for any additional mortality benefit associated with the addition of CBE to mammography, but observational evidence from the United States and Canada suggested an increase in false-positive findings compared with mammography alone, with both studies finding an estimated 55 additional false-positive findings per extra breast cancer detected with the addition of CBE.

CONCLUSIONS AND RELEVANCE

For women of all ages at average risk, screening was associated with a reduction in breast cancer mortality of approximately 20%, although there was uncertainty about quantitative estimates of outcomes for different breast cancer screening strategies in the United States. These findings and the related uncertainty should be considered when making recommendations based on judgments about the balance of benefits and harms of breast cancer screening.

Abstract A43: Barriers, strategies, and recommendations to engaging African American women in clinical research: The recruiter's perspective

The Purpose: The purpose of this study was to systematically gather information on the barriers interviewers encounter when recruiting African American women (AAW) study participants, identify approaches that increase the likelihood that an individual will agree to participate, and describe the resources and support that interviewers believe is important for them to be successful.

Background: The challenge of recruiting African Americans for clinical and epidemiologic research have been presented in numerous papers, with some focusing on patient/community perceptions (Herring, 2004; Corbie-Smith, 1999; Scharff, 2010) and others focusing on the perspective of the investigator. One viewpoint that has received relatively little attention is the role of the recruiter or interviewer. These individuals are often the first point of contact between the research study and the potential participant, and they may be a prime determinant of overall participation rates. Although some papers have examined the association between participation rates and interviewer characteristics such as race, age and years of experience, (Hansen, 2006; Davis 2010; Moorman, 1999) these papers have not solicited the input and opinions of the interviewers. There is little in the scientific literature about barriers to participation and strategies for improving response rates from the perspective of the interviewer.

Methods: To address this gap in knowledge, we conducted a series of focus groups with interviewers experienced in recruiting African American women for observational epidemiologic studies, including case-control and prospective cohort studies. Focus groups were conducted reaching 18 recruiters from three research intensive academic/medical institutions along the east coast and the Midwest. Sessions were conducted via 90 minute recorded conference calls and a $10 incentive was provided to each participant. Study approval was obtained through the University's IRB.

The following questions guided the focus groups: (1) What barriers do you hear and face when recruiting AAW into research? (2) What strategies have you used to overcome challenges associated with recruiting AAW in research studies? (3) What resources, tools, and skills would you find helpful so as to more effectively recruit AAW in research? Recordings were transcribed and a thematic analysis of the data was implemented using a systematic, multistep, rigorous process outlined by Braun and Clarke (2006).

Summary of Data: Commonly cited barriers to research participation among AAW include “the gatekeeper,” maintaining confidentiality, lack of community engagement among researchers, requesting bio specimens, and lack of buy-in among clinic staff. As with other studies, research participation among AAW included fear of being a guinea pig, historical medical atrocities, fear and distrust of the medical system, and competing priorities. Key strategies often used to address barriers and increase enrollment include being open about the historical relationship between research and minorities, emphasize the voluntary role, treat potential and current enrollees as a “whole” person, address competing needs with resources, be flexible with protocol, specimen requests, and schedules. Unique recommendations include highlighting the importance of system and research team engagement by understanding clinic culture and increasing researcher's engagement within local minority communities. Consistent with the literature, other cited recommendations to improve enrollment include training around building rapport, understanding bias, cultural competence, and role play with significant feedback on the nuances to consider when engaging minorities in clinical research.

Conclusion: The strategies and recommendations gleaned from front line recruiting personnel have significant policy and practice implications. These findings will inform training and interventions designed to more effectively support research teams as they aim to reach, enroll, and retain African American women and other minorities in clinical research.

Citation Format: Nadine J. Barrett, Patricia Moorman, Tracey Vann Hawkins, Chamali Wickramasekara. Barriers, strategies, and recommendations to engaging African American women in clinical research: The recruiter's perspective. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A43.

Obesity and risk of ovarian cancer subtypes: evidence from the Ovarian Cancer Association Consortium

Whilst previous studies have reported that higher BMI increases a woman's risk of developing ovarian cancer, associations for the different histological subtypes have not been well defined. As the prevalence of obesity has increased dramatically, and classification of ovarian histology has improved in the last decade, we sought to examine the association in a pooled analysis of recent studies participating in the Ovarian Cancer Association Consortium. We evaluated the association between BMI (recent, maximum and in young adulthood) and ovarian cancer risk using original data from 15 case-control studies (13 548 cases and 17 913 controls). We combined study-specific adjusted odds ratios (ORs) using a random-effects model. We further examined the associations by histological subtype, menopausal status and post-menopausal hormone use. High BMI (all time-points) was associated with increased risk. This was most pronounced for borderline serous (recent BMI: pooled OR=1.24 per 5 kg/m(2); 95% CI 1.18-1.30), invasive endometrioid (1.17; 1.11-1.23) and invasive mucinous (1.19; 1.06-1.32) tumours. There was no association with serous invasive cancer overall (0.98; 0.94-1.02), but increased risks for low-grade serous invasive tumours (1.13, 1.03-1.25) and in pre-menopausal women (1.11; 1.04-1.18). Among post-menopausal women, the associations did not differ between hormone replacement therapy users and non-users. Whilst obesity appears to increase risk of the less common histological subtypes of ovarian cancer, it does not increase risk of high-grade invasive serous cancers, and reducing BMI is therefore unlikely to prevent the majority of ovarian cancer deaths. Other modifiable factors must be identified to control this disease.

Southeast Raleigh Minority Faith-based Health Promotion Initiative

Faith-based organizations are a powerful resource for addressing health issues within the African American community. In this paper, we describe two projects led by volunteer faith-based leaders and community residents who collaborated with public agencies to design programs to combat obesity. The first project, the Southeast Raleigh Community Garden Project, involved the construction of a community garden and the delivery of educational programs on healthy eating among youth. The second one, Project FACT (Faith-based groups Addressing health issues through Community outreach Together in the community), implemented church-based nutrition education programs and community walking programs led by church volunteers. The purpose of the two faith-based health promotion projects was to increase opportunities for physical activity and to encourage consumption of more fruits and vegetables. These projects resulted in the construction of a walking trail with the community garden as its destination, implementation of education programs to increase nutritional awareness, the initiation of multiple walking programs, and policy changes within the church to encourage a healthier lifestyle. The projects demonstrated the feasibility of collaboration among faith-based organizations, community residents and government agencies to promote physical activity and healthful eating among families by creating physical changes in the environment and implementing educational and walking programs in low income communities.

Risk factors for breast cancer characterized by the estrogen receptor alpha A908G (K303R) mutation

Introduction

Estrogen is important in the development of breast cancer, and its biological effects are mediated primarily through the two estrogen receptors alpha and beta. A point mutation in the estrogen receptor alpha gene, ESR1, referred to as A908G or K303R, was originally identified in breast hyperplasias and was reported to be hypersensitive to estrogen. We recently detected this mutation at a low frequency of 6% in invasive breast tumors of the Carolina Breast Cancer Study (CBCS).

Methods

In this report, we evaluated risk factors for invasive breast cancer classified according to the presence or absence of the ESR1 A908G mutation in the CBCS, a population-based case-control study of breast cancer among younger and older white and African-American women in North Carolina. Of the 653 breast tumors evaluated, 37 were ESR1 A908G mutation-positive and 616 were mutation-negative.

Results

ESR1 A908G mutation-positive breast cancer was significantly associated with a first-degree family history of breast cancer (odds ratio [OR] = 2.69, 95% confidence interval [CI] = 1.15 to 6.28), whereas mutation-negative breast cancer was not. Comparison of the two case subgroups supported this finding (OR = 2.65, 95% CI = 1.15 to 6.09). There was also the suggestion that longer duration of oral contraceptive (OC) use (OR = 3.73, 95% CI = 1.16 to 12.03; P_trend = 0.02 for use of more than 10 years) and recent use of OCs (OR = 3.63, 95% CI = 0.80 to 16.45; P_trend = 0.10 for use within 10 years) were associated with ESR1 A908G mutation-positive breast cancer; however, ORs for comparison of the two case subgroups were not statistically significant. Hormone replacement therapy use was inversely correlated with mutation-negative breast cancer, but the effect on mutation-positive cancer was unclear due to the small number of postmenopausal cases whose tumors carried the mutation. Mutation-negative breast cancer was associated with several reproductive factors, including younger age at menarche (OR = 1.46, 95% CI = 1.09 to 1.94) and greater total estimated years of ovarian function (OR = 1.82, 95% CI = 1.21 to 2.74).

Conclusion

These preliminary results suggest that OCs may interact with the ESR1 A908G mutant receptor to drive the development of some breast tumors.

EGOOZ: Specifying the Components of Electronic Patient Record-related Education

Objective: To determine whether educators consider electronic patient record (EPR)-related education necessary and if so, what subjects have to be taught more extensively in the future.

Methods: A list of possibly relevant subjects was determined from the literature. A questionnaire was designed which contained those subjects and the respondents were asked to indicate, for each subject, its competency level and required competency level in current teaching. Since the response rate was low a second questionnaire was developed to have the results of the analysis of the first questionnaire validated by a larger group of educators.

Results: In total 45 learning goals were identified from the literature. The questionnaire was sent to representatives of several disciplines: basic medical education, medical specializations, pharmacy, dentistry and nursing. The analysis of the first questionnaire resulted in nine subjects that needed more attention in the future. Because of the low response the needs could not be specified for the individual disciplines. This insight was obtained from a second questionnaire. The response to this questionnaire was high. From the analysis of the second questionnaire differences between views of educators involved in the training of GPs and educators involved in the training of other specializations were observed.

Conclusion: Educators find EPR-related education important. There are different opinions about the phase in which EPR-related education should be given.

EGOOZ: specifying the components of electronic patient record-related education

OBJECTIVE

To determine whether educators consider electronic patient record (EPR)-related education necessary and if so, what subjects have to be taught more extensively in the future.

METHODS

A list of possibly relevant subjects was determined from the literature. A questionnaire was designed which contained those subjects and the respondents were asked to indicate, for each subject, its competency level and required competency level in current teaching. Since the response rate was low a second questionnaire was developed to have the results of the analysis of the first questionnaire validated by a larger group of educators.

RESULTS

In total 45 learning goals were identified from the literature. The questionnaire was sent to representatives of several disciplines: basic medical education, medical specializations, pharmacy, dentistry and nursing. The analysis of the first questionnaire resulted in nine subjects that needed more attention in the future. Because of the low response the needs could not be specified for the individual disciplines. This insight was obtained from a second questionnaire. The response to this questionnaire was high. From the analysis of the second questionnaire differences between views of educators involved in the training of GPs and educators involved in the training of other specializations were observed.

CONCLUSION

Educators find EPR-related education important. There are different opinions about the phase in which EPR-related education should be given.

Anthropometric Measurements and Epithelial Ovarian Cancer Risk in African–American and White women

Previous studies of anthropometric factors and ovarian cancer risk have been inconsistent and none have evaluated the association among African-American women. Data from a population-based, case-control study of 593 cases and 628 controls were used to evaluate ovarian cancer risk in relation to weight, height, body mass index (BMI) and waist-to-hip ratio (WHR). Odds ratios (ORs) and 95% confidence intervals (CIs) were computed and established risk factors were adjusted for using logistic regression models, stratified by race. Among all races, weight at age 18, WHR, weight and BMI one year prior to interview were associated with elevated ovarian cancer risk. When stratified by race, the association between WHR and ovarian was similar among Whites and among African Americans. However, African-American women in the fourth quartile of height had an elevated risk of ovarian cancer (OR = 3.2; 95% CI = 1.3-7.8), but this risk was not apparent in Whites (OR = 1.0; 95% CI = 0.7-1.4). These findings support the hypothesis that obesity is an important risk factor of ovarian cancer among African-Americans and Whites and also suggest that height may be a risk factor specific to African-Americans.

Transforming growth factor beta receptor I polyalanine repeat polymorphism does not increase ovarian cancer risk

OBJECTIVES

It has been suggested that the 6A allele of the type I TGFbeta receptor (TGFbetaR1) polyalanine repeat tract polymorphism may increase susceptibility to various types of cancer including ovarian cancer.

METHODS

The TGFbetaR1 polyalanine polymorphism was genotyped in 588 ovarian cancer cases and 614 controls from a population-based case-control study in North Carolina.

RESULTS

Significant racial differences in the frequency of the 6A allele were observed between Caucasian (10.7%) and African-American (2.4%) controls (P < 0.001). One or two copies of the 6A allele of the TGFbetaR1 polyalanine polymorphism was carried by 18% of all controls and 19% of cases, and there was no association with ovarian cancer risk (OR = 1.07, 95% CI 0.80-1.44). The odds ratio for 6A homozygotes was 1.81 (95% CI 0.655.06), but these comprised only 0.98% of controls and 1.70% of cases.

CONCLUSIONS

The 6A allele of the TGFbetaR1 polyalanine polymorphism does not appear to increase ovarian cancer risk. Larger studies would be needed to exclude the possibility that the small fraction of individuals who are 6A homozygotes have an increased risk of ovarian or other cancers.

Manganese superoxide dismutase Ala-9Val polymorphism and risk of breast cancer in a population-based case-control study of African Americans and whites

Introduction

A polymorphism in the manganese superoxide dismutase (MnSOD) gene, Ala-9Val, has been examined in association with breast cancer risk in several epidemiologic studies. Results suggest that the Ala allele increases the risk of breast cancer and modifies the effects of environmental exposures that produce oxidative damage to DNA.

Methods

We examined the role of the MnSOD Ala-9Val polymorphism in a population-based case–control study of invasive and in situ breast cancer in North Carolina. Genotypes were evaluated for 2025 cases (760 African Americans and 1265 whites) and for 1812 controls (677 African Americans and 1135 whites).

Results

The odds ratio for MnSOD Ala/Ala versus any MnSOD Val genotypes was not elevated in African Americans (odds ratio = 0.9, 95% confidence interval = 0.7–1.2) or in whites (odds ratio = 1.0, 95% confidence interval = 0.8–1.2). Greater than additive joint effects were observed for the Ala/Ala genotype and smoking, radiation to the chest, and occupational exposure to ionizing radiation. Antagonism was observed between the Ala/Ala genotype and the use of nonsteroidal anti-inflammatory drugs.

Conclusions

The MnSOD genotype may contribute to an increased risk of breast cancer in the presence of specific environmental exposures. These results provide further evidence for the importance of reactive oxygen species and of oxidative DNA damage in the etiology of breast cancer.

Making epidemiologic studies responsive to the needs of participants and communities: the Carolina Breast Cancer Study experience

In this report, we present the results of surveys administered to participants and nonparticipants in the Carolina Breast Cancer Study (CBCS). Surveys and structured interviews were administered to determine women's concerns regarding participation in research studies, access to health care, and beliefs regarding causes of breast cancer. Survey results showed the highest concern for the growing number of women diagnosed with breast cancer in North Carolina and potential environmental agents that may cause breast cancer. Negative responses were noted for time constraints related to participation and lack of familiarity with epidemiologic research; another concern noted was the lack of centralized information regarding breast cancer treatment. These issues were addressed by (1) developing a web site that provided background information about the CBCS, summaries of published study results, and information about the etiology of breast cancer; and (2) creating a statewide, comprehensive breast cancer resource directory for women who need information about breast cancer diagnosis, treatment, and support. These two projects were carried out in collaboration with breast cancer advocates, and demonstrate the important role that advocates can play in making epidemiologic research more responsive to the needs of communities.

Lactation and breast cancer risk

BACKGROUND

Data from the Carolina Breast Cancer Study, a population-based, case-control study of breast cancer in African-American and white women residents of North Carolina, were evaluated to determine whether specific aspects of lactation are associated with a reduction in the risk of breast cancer.

METHODS

Analyses included 751 parous cases and 742 parous controls frequency-matched on age and race. Information on lactation, reproductive history, lifestyle characteristics and family history were obtained through a personal interview.

RESULTS

When women who breastfed were compared to those who never breastfed, odds ratios and 95% confidence intervals of 0.8 (0.5-1.1) and 0.7 (0.5-0.9) were found for women 20-49 years and 50-74 years, respectively. Similar inverse associations were observed for each of three categories of lifetime duration (1-3, 4-12, 13+ months). The inverse associations persisted and did not vary when number of children breastfed, ages at first and last lactation and lactational amenorrhoea were examined.

CONCLUSIONS

Our findings suggest that any lactation, regardless of duration or timing, is associated with a slight reduction in the risk of breast cancer among younger and older parous women.

Comparison of 3,4-dimethoxyphenylethylamine treated plasma from chronic schizophrenics and controls

Plasma samples were collected from chronic schizophrenic patients not on drug therapy and from non-psychotic hospital volunteet controls and incubated with 3,4-dimethoxywhenylethylamine (DMPEA) when injected into monoamine oxidase inhibitor (MAOI) pretreated mice who were then aggregated (groups of 5 ea.) for four hours, the two kinds of plasma produced results so similar that no differences between them could be observed. Doubling the amount of plasma and DMPEA likewise failed to differentiate plasma origin. In our hands no differentiation between plasma samples from control subjects and schizophrenic patients could be determined under the conditions employed.