Measures of racial/ethnic health disparities in cancer mortality rates and the influence of socioeconomic status

OBJECTIVES: In the 1990s, U.S. cancer mortality rates declined due to reductions in tobacco use among men and beneficial cancer interventions, such as mammography and Pap smears. We examined the cancer rates by racial/ethnic group, socioeconomic status and time period to identify disparities underlying the overall mortality trend. METHODS: We examined racial/ethnic disparities by measuring excess cancer burden [rate ratio (RR) and ratio differences (RD)] and trends in their cancer rates for nine cancer sites. The trend (T) is calculated as a ratio of the average annual cancer mortality rate for 1995-2000 relative to the rate for 1990-1994 for three levels of poverty (counties with <10% living below the poverty level, 10% - <20% and > or =20%) for the major racial/ethnic populations. We also compared the trend for each racial/ethnic SES group to the trend for lowest SES white group (TD). RESULTS: Blacks have RR disparities relative to whites for each cancer site examined, except for female lung cancer, while the other minorities had RR disparities for cervical cancer (RR>1). There are increases in RR disparities from 1990-1994 to 1995-2000 (RD>0) for colorectal cancer, prostate cancer and breast cancer for each racial/ethnic minority. Whites and blacks had declining trends for every SES group (T<1) and positive high SES gradients (the highest SES group had the best trend and the lowest SES group had the worst trend) at each cancer site, except female lung cancer (T>1). In contrast, American Indians/Alaska natives, Hispanics and Asians/ Pacific Islanders had increasing trends for some of their cancer sites, and their trends did not have the SES gradients. CONCLUSIONS: Increases in racial/ethnic disparities (RD>0) for colorectal, breast and prostate cancer were largest in the lowest SES groups. At some cancer sites, the highest SES group for minorities had worse trend results than the trends for the lowest SES white group (TD>0).     

Caution in generalizing known genetic risk markers for breast cancer across all ethnic/racial populations

Genome-wide association studies (GWAS) have identified common variants associated with breast cancer risk among women of European and Asian ancestries. To assess the generalizability across ethnic/racial populations of a risk score derived from genotyping 12 highly replicated breast cancer GWAS hits, we performed a case-control study (2224 cases and 2827 controls) nested in the Multiethnic Cohort (MEC) study, which was initiated in 1993-1996 and consists of subjects mainly from European-American, African-American, Native Hawaiian, Japanese and Latino populations. When viewed as a summary risk score, the total number of risk alleles carried by women was significantly associated with breast cancer risk overall (OR per allele, 1.09; 95% CI, 1.06-1.12; P=2.0 × 10(-10)) and in all populations except African-Americans, in which no significant association was observed (OR, 1.03; 95% CI, 0.98-1.08). In aggregate, the number of risk alleles is strongly associated with breast cancer risk in all populations studied except African-Americans. These results emphasize the need for large-scale association studies of multiple racial/ethnic groups for discovery and characterization of risk alleles relevant to all populations in the United States.     

Decision-making support among racial and ethnic minorities diagnosed with breast or prostate cancer: A systematic review of the literature

ObjectiveTo describe the types of decision-making support interventions offered to racial and ethnic minority adults diagnosed with breast or prostate cancer and to draw any associations between these interventions and patient-reported quality of life (QoL) outcomes.MethodsWe conducted literature searches in five bibliographic databases. Studies were screened through independent review and assessed for quality. Results were analyzed using inductive qualitative methods to determine thematic commonalities and synthesized in narrative form.ResultsSearches across five databases yielded 2496 records, which were screened by title/abstract and full-text to identify 10 studies meeting inclusion criteria. The use of decision aids (DAs), trained personnel, delivery models and frameworks, and educational materials were notable decision-making support interventions. Analysis revealed six thematic areas: 1) Personalized reports; 2) Effective communication; 3) Involvement in decision-making; 4) Health literacy; 5) Social support; and 6) Feasibility in clinical setting.ConclusionEvidence suggests decision-making support interventions are associated with positive outcomes of racial and ethnic minorities with patient-reported factors like improved patient engagement, less decisional regret, higher satisfaction, improved communication, awareness of health literacy and cultural competence.Practice implicationsFuture decision-making interventions for racial and ethnic minority cancer patients should focus on social determinants of health, social support systems, and clinical outcomes like QoL and survival.     

Attitudes toward menopause and aging across ethnic/racial groups

OBJECTIVE: Attitudes have a potential role to play in the experience of menopause. The objective of this study was to examine the degree to which attitudes toward menopause and aging vary across ethnic groups and menopausal status (ie, premenopausal through postmenopausal). METHODS: More than 16,000 women were interviewed by telephone as part of the Study of Women's Health Across the Nation. They represented five ethnic/racial groups (African American, white, Chinese American, Japanese American, and Hispanic) from seven geographical sites (Boston, MA; Pittsburgh, PA; Chicago, IL; Michigan; New Jersey; and northern and southern California). RESULTS: African American women were significantly more positive in attitude. The least positive groups were the less acculturated Chinese American and Japanese American women. Menopausal status was not a consistent predictor of attitude across ethnic groups. CONCLUSIONS: In general, women's attitudes toward menopause range from neutral to positive. Ethnic groups within the United States vary slightly, but reliably, in their attitudes toward menopause and aging. Factors other than those directly associated with menopausal status seem to play a role in attitude.     

Examining differential treatment effects for depression in racial and ethnic minority women: a qualitative systematic review

OBJECTIVE: To examine effectiveness of depression treatment in racial and ethnic minority women. REVIEW METHODS: Inclusion criteria: 1) the study examined treatment of depression among racial and ethnic minority women age > 17, 2) data analysis was separated by race and ethnicity, and 3) the study was conducted in the United States. Interventions considered were: psychotropic medications, psychotherapy (including cognitive-behavioral, interpersonal therapy and any type of psychotherapy adapted for minority populations) and any type of psychotherapy combined with case management or a religious focus. Individual and group psychotherapy were eligible. Each study was critically reviewed to identify treatment effectiveness specific to racial and ethnic minority women. RESULTS: Ten published studies met the inclusion criteria (racial and ethnic minority participants n = 2,136). Seven of these were randomized clinical trials, one was a retrospective cohort study, one was a case series, and the remaining one had an indeterminate study design. Participants' age ranged from 18-74 years, with a higher proportion > 40 years. Most were low income. Differences in treatment responses between African-American, Latino and white women were found. Adapted models of care, including quality improvement and collaborative care, were found to be more effective than usual care and community referral in treating depression. Although medication and psychotherapy were both effective in treating depression, low-income women generally needed case management to address other social issues. CONCLUSION: Adapted models that allow patients to select the treatment of their choice (medication or psychotherapy or a combination) while providing outreach and other supportive services (case management, childcare and transportation) appear to result in optimal clinical benefits.     

Conditional risk for PTSD among Latinos: A systematic review of racial/ethnic differences and sociocultural explanations

Conditional risk for Posttraumatic Stress Disorder (PTSD)—defined as prevalence, onset, persistence, or severity of PTSD after traumatic exposure—appears to be higher among Latinos relative to non-Latinos after accounting for sociodemographic factors. This systematic review focuses on differences in conditional risk for PTSD between Latinos and non-Latinos (White, Black, or combined) and across Latino subgroups in studies that adjust for trauma exposure. We discuss methodological characteristics of existing articles and sociocultural explanatory factors. Electronic bibliographic searches were conducted for English-language articles published in peer-reviewed journals between 1991 and 2012. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-eight articles met inclusion criteria. Consistent support was found for elevated rates of PTSD onset and PTSD severity among Latinos relative to non-Latino Whites. The evidence on racial/ethnic differences in conditional risk for PTSD prevalence and PTSD persistence is mixed. Twenty-four articles evaluated sociocultural explanations, with the strongest support found for racial/ethnic variation in peri-traumatic responses and structure of PTSD. There were also consistent main effects for social disadvantage in studies that simultaneously adjusted for effects of race/ethnicity. Future research should use theoretically-driven models to formally test for interactions between sociocultural factors, race/ethnicity, and PTSD probability.     

Postmenopausal hormone therapy and breast cancer: a systematic review and meta-analysis

OBJECTIVE: There is a rapidly evolving debate on the indications and appropriate duration of therapy for postmenopausal hormone therapy. The objective of this meta-analysis was to examine the specific relationships of postmenopausal estrogen therapy (ET), postmenopausal combined (estrogen-progestogen) hormone therapy (CHT), and the incidence of breast cancer. DESIGN: We performed computerized searches of MEDLINE and CancerLit through September 2003 and reviewed reference lists of retrieved studies and meta-analyses. We included English-language studies that identified noncontraceptive postmenopausal hormone use; reported on the risks of "current use" of ET and/or CHT and breast cancer incidence; were case-control, cohort, or experimental; and reported either an odds ratio (OR), relative risk (RR), or HR with CIs. Two investigators were involved during all stages of study selection and independently extracted all data selected for inclusion in meta-analyses. RESULTS: Meta-analysis of 13 studies of ET and breast cancer (700,000 women) resulted in an OR of 1.16 (95% confidence limits [CL] 1.06, 1.28), with estimates for less than 5 years use 1.16 (1.02, 1.32) and more than 5 years use 1.20 (1.06, 1.37). Meta-analysis of eight studies of CHT and breast cancer (650,000 women) resulted in an OR of 1.39 (95% CL 1.12, 1.72), with estimates for less than 5 years use 1.35 (1.16, 1.57) and more than 5 years use 1.63 (1.22, 2.18). CONCLUSIONS: Data from observational studies support the association of increased but considerably different risks for breast cancer incidence among current users of ET and CHT. These represent the first pooled estimates for ET. CHT estimates correspond to those from randomized trials.     

Disparities in BRCA counseling across providers in a diverse population of young breast cancer survivors

PurposeAll women diagnosed with breast cancer (BC) ≤age 50 should be referred for genetic counseling (GC) and testing. We sought to compare differences in provider practices and access across a racially and ethnically diverse population of young BC survivors.MethodsA registry-based sample of women diagnosed with invasive BC ≤age 50 from 2009 to 2012 was recruited through the Florida Cancer Registry, and completed a questionnaire and medical record release. Differences were compared across those tested with or without the involvement of a board-certified or credentialed genetics health professional (GHP) in (1) clinical and demographic variables and (2) pretest GC elements.ResultsOf 1622 participants, there were 440 Blacks, 285 Hispanics, and 897 Non-Hispanic Whites. Of 831 participants with medical record verification of testing provider, 170 (20%) had documentation of GHP involvement. Among the 613 who recalled a pretest discussion and had GC elements collected, those with GHP involvement were significantly more likely to recall the seven recognized GC elements.ConclusionGHP involvement was associated with adherence to nationally recommended best practices. With the expanding importance of identifying inherited cancers, it is critical to ensure equitable access to best practices across all populations.     

Safety of hormone therapy after breast cancer: a qualitative systematic review

BACKGROUND: This qualitative review systematically analyses the safety of hormone therapy (HT) in breast cancer (BC) patients. METHODS: We systematically searched studies reporting the use of HT in BC patients. We selected 20 studies in which we evaluated the methodology, characteristics of the studied populations and outcomes in terms of mortality and recurrence rates (RRs). RESULTS: Many studies evaluating HT were uncontrolled and retrospective. Ten prospective and two randomized studies were found. These were characterized by heterogeneity in populations, tumour characteristics, prognostic factors and treatments. Two studies reported a reduced RR, and two reported lowered BC mortality rates in HT users. One randomized study reported an increased rate of new BC events in HT users. CONCLUSIONS: There are currently no reassuring data indicating the absence of a harmful effect of HT. Further studies should analyse whether some regimens are safer than others. There is a need for randomized trials assessing the safety of these regimens. In the meantime, patients should be informed about the absence of safety data.     

Utility of 18FDG-PET/CT in breast cancer diagnostics--a systematic review

18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG-PET/CT) is a non-invasive method for visualization of focally increased metabolism in the presence of discrete morphological changes. Based on a systematic review of current literature, PET/CT cannot be recommended as a primary diagnostic procedure in breast cancer; but it has the potential to be useful for the detection of distant metastases and for monitoring response to chemotherapy in breast cancer patients. PET/CT should still be regarded as a supplement to conventional diagnostic procedures such as CT and MRI.     

Physical activity and biomarkers in breast cancer survivors: A systematic review

Breast cancer is the most common cancer among women. The number of breast cancer survivors has increased due to screening and improved treatment methods, which makes it important to increase knowledge on their health and well-being. Physical activity has been reported to improve quality of life, decrease fatigue and reduce all-cause and breast cancer-specific mortality in breast cancer survivors. The beneficial effects of physical activity may manifest themselves in circulating levels of insulin, insulin-growth factors (IGFs) I and II and their binding proteins (IGFBPs), or inflammatory biomarkers. The aim of this report was to review available randomized controlled trials (RCTs) on the effects of physical activity on biomarkers in breast cancer survivors. We identified 12 publications based on nine RCTs that fulfilled our inclusion criteria published until 19th June 2012. The RCTs were small (16–101 breast cancer survivors); mean BMI was ≥25 and the mean age in 8 out of 9 RCTs was approximately 50 years. Five RCTs reported statistically significant effects of physical activity on insulin, IGF-I, IGF-II and IGFBP-3 in breast cancer survivors, but the results were not consistent. None of four RCTs found any evidence for a role of investigated interleukines. One trial reported some evidence that exercise may decrease C-reactive protein levels. In conclusion, available RCTs have produced some evidence that physical activity may result in beneficial changes in levels of insulin, IGFs, IGFBPs, and inflammatory biomarkers in breast cancer survivors. However, further larger RCTs on physical activity and biomarkers in breast cancer survivors are warranted.     

Addictive behaviors across the menstrual cycle: a systematic review

Archives of Women's Mental Health - Research examining relations between menstrual cycle phase and female addictive behaviors is accumulating. Theories suggest addictive behaviors may increase...     

Serum microRNA-21 as a potential diagnostic biomarker for breast cancer: a systematic review and meta-analysis

Serum microRNA-21 (miR-21) expression has been shown to be significantly up-regulated in breast cancer, which implies that it could be a biomarker to discriminate breast cancer patients from healthy controls. We therefore performed this meta-analysis to assess the diagnostic value of miR-21 for breast cancer. Relevant articles were collected from PubMed, Scopus, Embase, the Cochrane Library, BioMed Central, ISI Web of Knowledge, China National Knowledge Infrastructure, Wan Fang Data and Technology of Chongqing databases, from inception to June 10, 2014 by two independent researchers. Diagnostic capacity of miR-21 for breast cancer was assessed using pooled sensitivity and specificity, diagnostic odds ratio (DOR), area under the summary receiver operating characteristic (AUC) and Fagan’s nomogram. Meta-Disc software and Stata SE 12.0 were used to investigate the source of heterogeneity and to perform the meta-analysis. We used six studies with a total of 438 patients and 228 healthy controls in this meta-analysis. The pooled sensitivity, specificity and DOR were 0.79 [95 % confidence interval (CI) 0.66–0.87], 0.85 (95 % CI 0.75–0.91) and 19.46 (95 % CI 8.74–43.30), respectively; positive and negative likelihood ratios were 5 and 0.25, and AUC was 0.89 (95 % CI 0.86–0.91). In addition, heterogeneity was clearly apparent but was not caused by the threshold effect. This meta-analysis suggests that miR-21 is a potential biomarker for early diagnosis of breast cancer with high sensitivity and specificity, and its clinical application warrants further investigation.     

Recent trends in breast cancer incidence in US white women by county-level urban/rural and poverty status

Background  

Unprecedented declines in invasive breast cancer rates occurred in the United States between 2001 and 2004, particularly for estrogen receptor-positive tumors among non-Hispanic white women over 50 years. To understand the broader public health import of these reductions among previously unstudied populations, we utilized the largest available US cancer registry resource to describe age-adjusted invasive and in situ breast cancer incidence trends for non-Hispanic white women aged 50 to 74 years overall and by county-level rural/urban and poverty status.     

Higher incidence of aggressive breast cancers in African-American women: a review

Despite a lower incidence of breast cancers in African Americans than in Caucasians, mortality rates from breast cancer are higher in African Americans. This review summarizes disparate characteristics of breast cancer diagnosed in African Americans as compared with Caucasians, such as more advanced stage at diagnosis and less estrogen-receptor positivity of disease, in an effort to explain differences in their survival outcomes. Multifactorial explanations are offered, including differences in access to care, disparate utilization of mammography screening and often differences in treatment course-as well as biologic factors, such as higher incidence of aggressive breast cancer phenotypes, higher grade of tumor and higher growth index of tumors in African Americans as compared with Caucasians. Multiple population-based studies have been reviewed and screening and treatment interventions proposed in order to heighten awareness of these differences and to improve disease outcomes among this high-risk population.     

Expressive writing interventions in cancer patients: a systematic review

Decades of research have suggested that expressive writing produces physical and psychological benefits in controlled laboratory experiments among healthy college students. This work has been extended to clinical and medical populations, including cancer patients. Although expressive writing could be a promising and inexpensive intervention for this population, the effects have not been systematically examined in oncology samples. A systematic review using PRISMA guidelines was conducted for experimental trials of cancer patients who participated in an expressive writing intervention. PsycINFO and PubMed/Medline were searched for peer-reviewed studies. Thirteen articles met the inclusion/exclusion criteria. Although the majority of the intervention effects were null, there were several main effects for expressive writing on sleep, pain, and general physical and psychological symptoms. Several moderators were identified, suggesting that expressive writing may be more or less beneficial based on individual characteristics such as social constraints. The reviewed studies were limited due to representativeness of the samples, performance, detection and patient-reported outcomes biases, and heterogeneity of the intervention protocol and writing prompts. Future studies with rigorous designs are needed to determine whether expressive writing is therapeutically effective in cancer patients.     

Methods of assessment of magnesium status in humans: a systematic review

To understand humans' requirements for magnesium and the effect of magnesium on health, it is important to identify sensitive and population-specific biomarkers of magnesium status. Thus, we assessed the effectiveness of different magnesium status biomarkers through a systematic review of published magnesium supplementation and depletion trials in healthy humans. The methods used in this study included a structured search on Ovid MEDLINE, EMBASE (Ovid) and Cochrane databases up to September 2008, followed by the use of formal inclusion/exclusion criteria, data extraction, validity assessment, and meta-analysis. A total of 20?potential biomarkers of magnesium status were assessed from 21 included publications. The majority of studies included were magnesium supplementation studies. Fewer magnesium depletion studies were identified. Available data analysis suggests that serum/plasma magnesium concentration, red blood cell (RBC) concentration and urinary magnesium excretion responded to dietary manipulation. For other biomarkers with available data, it was not possible to draw any conclusions about their usefulness as magnesium status biomarkers. The lack of data prevented detailed subgroup analysis. In conclusion, although limited data were available, serum/plasma magnesium concentration, RBC magnesium concentration and urinary magnesium excretion appear to be useful biomarkers of magnesium status in the general population. Further high-quality studies are needed to assess the effectiveness of existing and newly developed biomarkers, especially in populations that are vulnerable to magnesium deficiency.