Peer Reviewed: Differences in Knowledge of Breast Cancer Screening Among African American,Arab American,and Latina Women

Introduction

We examined differences in knowledge and socioeconomic factors associated with 3 types of breast cancer screening (breast self-examination, clinical breast examination, and mammogram) among African American, Arab, and Latina women.

Methods

Community health workers used a community-based intervention to recruit 341 women (112 Arab, 113 Latina, and 116 African American) in southeastern Michigan to participate in a breast cancer prevention intervention from August through October 2006. Before and after the intervention, women responded to a previously validated 5-item multiple-choice test on breast cancer screening (possible score range: 0 to 5) in their language of preference (English, Spanish, or Arabic). We used generalized estimating equations to analyze data and to account for family-level and individual correlations.

Results

Although African American women knew more about breast cancer screening at the baseline (pretest median scores were 4 for African American, 3 for Arab and 3 for Latina women), all groups significantly increased their knowledge after participating in the breast cancer prevention intervention (posttest median scores were 5 for African American and 4 for Arab and Latina women). Generalized estimating equations models show that Arab and Latina women made the most significant gains in posttest scores (P < .001).

Conclusion

Racial/ethnic differences in knowledge of breast cancer screening highlight the need for tailored information on breast cancer screening for African American, Arab, and Latina women to promote adherence to breast cancer screening guidelines.     

Surgery Wait Times and Specialty Services for Insured and Uninsured Breast Cancer Patients: Does Hospital Safety Net Status Matter?

Objective

To determine whether safety net and non-safety net hospitals influence inpatient breast cancer care in insured and uninsured women and in white and African American women.

Data Sources

Six years of Virginia Cancer Registry and Virginia Health Information discharge data were linked and supplemented with American Hospital Association data.

Study Design

Hierarchical generalized linear models and linear probability regression models were used to estimate the relationship between hospital safety net status, the explanatory variables, and the days from diagnosis to mastectomy and the likelihood of breast reconstruction.

Principal Findings

The time between diagnosis and surgery was longer in safety net hospitals for all patients, regardless of insurance source. Medicaid insured and uninsured women were approximately 20 percent less likely to receive reconstruction than privately insured women. African American women were less likely to receive reconstruction than white women.

Conclusions

Following the implementation of health reform, disparities may potentially worsen if safety net hospitals’ burden of care increases without commensurate increases in reimbursement and staffing levels. This study also suggests that Medicaid expansions may not improve outcomes in inpatient breast cancer care within the safety net system.     

Peer Reviewed: Feasibility of an Evidence-Based Weight Loss Intervention for a Faith-Based, Rural, African American Population

Background

African Americans and rural residents are disproportionately affected by obesity. Innovative approaches to address obesity that are sensitive to the issues of rural African Americans are needed. Faith-based and community-based participatory approaches show promise for engaging racial/ethnic minorities to change health outcomes, but few faith-based weight loss interventions have used a community-based participatory approach.

Community Context

A faith-based weight loss intervention in the Lower Mississippi Delta arose from a 5-year partnership between academic and community partners representing more than 30 churches and community organizations.

Methods

Community and academic partners translated the 16 core sessions of the Diabetes Prevention Program for rural, church-going African American adults. The feasibility of the lay health advisor–led delivery of the 16-week (January-May 2010), 16-session, adapted intervention was assessed in 26 participants from 3 churches by measuring recruitment, program retention, implementation ease, participant outcomes, and program satisfaction.

Outcome

Twenty-two of 26 participants (85%) provided 16-week follow-up data. Lay health advisors reported that all program components were easy to implement except the self-monitoring component. Participants lost an average of 2.34 kg from baseline to 16-week follow-up, for a mean weight change of −2.7%. Participants reported enjoying the spiritual and group-based aspects of the program and having difficulties with keeping track of foods consumed. The intervention engaged community partners in research, strengthened community-academic partnerships, and built community capacity.

Interpretation

This study demonstrates the feasibility of delivering this adapted intervention by lay leaders through rural churches.     

Statistical analyses in Swedish randomised trials on mammography screening and in other randomised trials on cancer screening: a systematic review

Objectives

We compared calculations of relative risks of cancer death in Swedish mammography trials and in other cancer screening trials.

Participants

Men and women from 30 to 74 years of age.

Setting

Randomised trials on cancer screening.

Design

For each trial, we identified the intervention period, when screening was offered to screening groups and not to control groups, and the post-intervention period, when screening (or absence of screening) was the same in screening and control groups. We then examined which cancer deaths had been used for the computation of relative risk of cancer death.

Main outcome measures

Relative risk of cancer death.

Results

In 17 non-breast screening trials, deaths due to cancers diagnosed during the intervention and post-intervention periods were used for relative risk calculations. In the five Swedish trials, relative risk calculations used deaths due to breast cancers found during intervention periods, but deaths due to breast cancer found at first screening of control groups were added to these groups. After reallocation of the added breast cancer deaths to post-intervention periods of control groups, relative risks of 0.86 (0.76; 0.97) were obtained for cancers found during intervention periods and 0.83 (0.71; 0.97) for cancers found during post-intervention periods, indicating constant reduction in the risk of breast cancer death during follow-up, irrespective of screening.

Conclusions

The use of unconventional statistical methods in Swedish trials has led to overestimation of risk reduction in breast cancer death attributable to mammography screening. The constant risk reduction observed in screening groups was probably due to the trial design that optimised awareness and medical management of women allocated to screening groups.     

Obesity/Weight Gain and Breast Cancer Risk: Findings From the Japan Collaborative Cohort Study for the Evaluation of Cancer Risk

Background

We analyzed data from the Japan Collaborative Cohort Study (36 164 women aged 40–79 years at baseline in 1988–1990 with no previous diagnosis of breast cancer and available information on weight and height) to examine the association between baseline body mass index (BMI)/weight gain from age 20 years and breast cancer risk in a non-Western population.

Methods

The participants were followed prospectively from enrollment until 1999–2003 (median follow-up: 12.3 years). During follow-up, breast cancer incidence was mainly confirmed through record linkage to population-based cancer registries. A Cox proportional hazards model was used to calculate hazard ratios (HRs) and 95% CIs for the association between breast cancer risk and body size.

Results

In 397 644.1 person-years of follow-up, we identified 234 breast cancer cases. Among postmenopausal women, the adjusted HR increased with BMI, with a significant linear trend (P < 0.0001). Risk was significantly increased among women with a BMI of 24 or higher (HR: 1.50, 95% CI: 1.09–2.08 for BMI of 24–28.9, and 2.13, 1.09–4.16 for BMI ≥ 29) as compared with women with a BMI of 20 to 23.9. Weight gain after age 20 years and consequent overweight/obesity were combined risk factors for postmenopausal breast cancer risk. This combined effect was stronger among women aged 60 years or older. However, the HRs were not significant in premenopausal women.

Conclusions

Our findings support the hypothesis that weight gain and consequent overweight/obesity are combined risk factors for breast cancer among postmenopausal women, particularly those aged 60 years or older.Key words: breast cancer, obesity, weight gain, cohort study     

Peer Reviewed: Anthropometric Measures,Presence of Metabolic Syndrome,and Adherence to Physical Activity Guidelines Among African American Church Members,Dallas, Texas, 2008

Introduction

The low prevalence of physical activity among African Americans and high risk of cardiovascular disease lends urgency to assessing the association between metabolic syndrome, abdominal obesity, and adherence to current physical activity guidelines. Few studies have examined this association among African American adults.

Methods

We examined the association between demographic characteristics, anthropometric measures, and metabolic syndrome and adherence to the 2008 Department of Health and Human Services guidelines for moderate and vigorous physical activity. Participants were 392 African American church members from congregations in Dallas, Texas. Physical activity levels were assessed via a validated questionnaire (7-Day Physical Activity Recall), and metabolic syndrome was determined on the basis of the American Heart Association/National Heart, Lung, and Blood Institute diagnostic criteria. We used bivariate and multinomial logistic regression to examine the associations.

Results

Meeting guidelines for vigorous physical activity was significantly and independently associated with the absence of metabolic syndrome among women (odds ratio, 4.71; 95% confidence interval, 1.63-13.14; P = .003), after adjusting for covariates. No association was found between meeting moderate or vigorous physical activity guidelines and metabolic syndrome among men. Meeting physical activity guidelines was not associated with body mass index or waist circumference among this sample of predominantly overweight and obese African American church members.

Conclusion

Results indicate that meeting the 2008 guidelines for vigorous physical activity is associated with the absence of metabolic syndrome among African American women. This finding might suggest the need to integrate vigorous physical activity into interventions for African American women as a preventive therapy for cardiovascular risk.      

Disparities in Use of Gynecologic Oncologists for Women with Ovarian Cancer in the United States

Objective

To examine disparities in utilization of gynecologic oncologists (GOs) across race and other sociodemographic factors for women with ovarian cancer.

Data Sources

Obtained SEER-Medicare linked dataset for 4,233 non-Hispanic White, non-Hispanic African American, Hispanic of any race, and Non-Hispanic Asian women aged ≥66 years old diagnosed with ovarian cancer during 2000–2002 from 17 SEER registries. Physician specialty was identified by linking data to the AMA master file using Unique Physician Identification Numbers.

Study Design

Retrospective claims data analysis for 1999–2006. Logistic regression models were used to analyze the association between GO utilization and race/ethnicity in the initial, continuing, and final phases of care.

Principal Findings

GO use decreased from the initial to final phase of care (51.4–28.8 percent). No racial/ethnic differences were found overall and by phase of cancer care. Women >70 years old and those with unstaged disease were less likely to receive GO care compared to their counterparts. GO use was lower in some SEER registries compared to the Atlanta registry.

Conclusions

GO use for the initial ovarian cancer treatment or for longer term care was low but not different across racial/ethnic groups. Future research should identify factors that affect GO utilization and understand why use of these specialists remains low.     

Hormonal Contraceptive Use and Breast Cancer in Thai Women

Background

Breast cancer is the most common cancer in women worldwide. We investigated the association of hormonal contraceptive use and breast cancer in Thai women.

Methods

A cohort study was conducted in Khon Kaen, Thailand. There were 70 cases of histologically confirmed breast cancer among 11 414 women aged 30 to 69 years who were recruited as participants in the cohort study during the period from 1990 through 2001. The study population was followed-up until December 31, 2011. To identify factors associated with incidence of breast cancer, hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using a Cox proportional hazards model.

Results

The 11 414 women provided a total observation time of 157 200 person-years. Breast cancer risk among women with a history of hormonal contraceptive use was 1.31 times that of women without such a history, but the difference was not statistically significant (95% CI, 0.65–2.65). No type of hormonal contraceptive was associated with a significant increase in breast cancer risk as compared with women who had never used hormonal contraceptives (oral contraception: HR = 1.35, 95% CI, 0.65–2.78; injection contraception: HR = 1.25, 95% CI, 0.56–2.80), and there was no relationship between duration of hormonal contraceptive use and breast cancer.

Conclusions

There was no association between hormonal contraceptive use and breast cancer; however, this finding should be viewed with caution due to the small number of cases.Key words: hormonal contraceptive, breast cancer, Thai women     

Predictors of Adherence and Treatment Delays among African American Women Recommended to Receive Breast Cancer Chemotherapy

Background

Recognition of potential explanations for nonadherence or treatment delays is crucial to improving survival, particularly among African American women, for whom there is limited research assessing patient factors that influence adherence to breast cancer chemotherapy.

Peer Reviewed: Health Behaviors and Quality of Life of Cancer Survivors in Massachusetts, 2006: Data Use for Comprehensive Cancer Control

Introduction

Nearly 12 million cancer survivors are living in the United States. Few state-based studies have examined the health status and health-related quality of life (HRQOL) of this growing population. The objective of this study was to use Massachusetts Behavioral Risk Factor Surveillance System (BRFSS) data to describe cancer survivors'' demographics, health behaviors, quality of life, use of preventive care services, and influenza vaccination rates.

Methods

The demographic characteristics of cancer survivors and respondents without cancer were estimated on the basis of responses to questions in the 2006 Massachusetts BRFSS. We used multivariate logistic regression to compare health behaviors, comorbidities, quality of life, and cancer screening and influenza vaccination rates for cancer survivors compared with respondents who did not have cancer.

Results

Cancer survivors and respondents who did not have cancer had similar rates of health behavioral risk factors including smoking, obesity, and physical activity. Rates of chronic disease (eg, heart disease, asthma) and disability were higher among cancer survivors. Cancer survivors reported higher rates of influenza vaccination and breast, colorectal, and cervical cancer screening than did respondents who did not have cancer. Survivors'' self-reported health status and HRQOL (physical and mental health) improved as length of survivorship increased.

Conclusion

This state-based survey allowed Massachusetts to assess health-related issues for resident cancer survivors. These findings will help state-based public health planners develop interventions to address the long-term physical and psychosocial consequences of cancer diagnosis and treatment.     

An Analysis of Mass Screening Strategies Using a Mathematical Model: Comparison of Breast Cancer Screening in Japan and the United States

Background

Although the United States Preventive Services Task Force (USPSTF) downgraded their recommendation for breast cancer screening for women aged 40–49 years in 2009, Japanese women in their 40s have been encouraged to attend breast cancer screenings since 2004. The aim of this study is to examine whether these different mass-screening strategies are justifiable by the different situations of these countries and to provide evidence for suitable judgment.

Methods

Performance of screening strategies (annual/biennial intervals; initiating/terminating ages) was evaluated using a mathematical model based on the natural history of breast cancer and the transition between its stages. Benefits (reduced number of deaths and extended average life expectancy) and harm (false-positives) associated with these strategies were calculated.

Results

Additional average life expectancy by including women in their 40s as participants were 13 days (26%) and 25 days (22%) in Japan and the United States, respectively, under the biennial screening condition; however, the respective increases in numbers of false-positive cases were 65% and 53% in Japan and the United States. Moreover, the number of screenings needed to detect one diagnosis or to avert one death was smaller when participants were limited to women of age 50 or over than when women in their 40s were included. The validity of including women in their 40s in Japan could not be determined without specifying the weight of harms compared to benefits.

Conclusions

Whether screening of women in their 40s in Japan is justifiable must be carefully determined based the quantitative balance of benefits and harms.Key words: breast cancer, mass screening, mathematical model, benefit, harm     

Active smoking, passive smoking, and breast cancer risk: findings from the Japan Collaborative Cohort Study for Evaluation of Cancer Risk

Background

Evidence is lacking regarding the relationship between cigarette smoking and breast cancer in Japanese women. We examined the association between breast cancer incidence and active and passive smoking in the Japan Collaborative Cohort Study for Evaluation of Cancer Risk.

Methods

Our study comprised 34,401 women aged 40-79 years who had not been diagnosed previously with breast cancer and who provided information on smoking status at baseline (1988-1990). The subjects were followed from enrollment until December 31, 2001. Cox proportional-hazards models were used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the association between breast cancer incidence and tobacco smoke.

Results

During 271,412 person-years of follow-up, we identified 208 incident cases of breast cancer. Active smoking did not increase the risk of breast cancer, with a HR for current smokers of 0.67 (95% CI: 0.32-1.38). Furthermore, an increased risk of breast cancer was not observed in current smokers who smoked a greater number of cigarettes each day. Overall, passive smoking at home or in public spaces was also not associated with an increased risk of breast cancer among nonsmokers. Women who reported passive smoking during childhood had a statistically insignificant increase in risk (HR: 1.24; 95% CI: 0.84-1.85), compared with those who had not been exposed during this time.

Conclusion

Smoking may not be associated with an increased risk of breast cancer in this cohort of Japanese women.Key words: Smoking, Breast Neoplasms, Risk, Cohort Studies     

Disparities in cervical and breast cancer mortality in Brazil

OBJECTIVE

To analyze cervical and breast cancer mortality in Brazil according to socioeconomic and welfare indicators.

METHODS

Data on breast and cervical cancer mortality covering a 30-year period (1980-2010) were analyzed. The data were obtained from the National Mortality Database, population data from the Brazilian Institute of Geography and Statistics database, and socioeconomic and welfare information from the Institute of Applied Economic Research. Moving averages were calculated, disaggregated by capital city and municipality. The annual percent change in mortality rates was estimated by segmented linear regression using the joinpoint method. Pearson’s correlation coefficients were conducted between average mortality rate at the end of the three-year period and selected indicators in the state capital and each Brazilian state.

RESULTS

There was a decline in cervical cancer mortality rates throughout the period studied, except in municipalities outside of the capitals in the North and Northeast. There was a decrease in breast cancer mortality in the capitals from the end of the 1990s onwards. Favorable socioeconomic indicators were inversely correlated with cervical cancer mortality. A strong direct correlation was found with favorable indicators and an inverse correlation with fertility rate and breast cancer mortality in inner cities.

CONCLUSIONS

There is an ongoing dynamic process of increased risk of cervical and breast cancer and attenuation of mortality because of increased, albeit unequal, access to and provision of screening, diagnosis and treatment.      

High-density lipoprotein cholesterol, obesity, and mammographic density in Korean women: the Healthy Twin study

Background

High-density lipoprotein cholesterol (HDL-C) is reported to be associated with breast cancer risk. To better understand this association, we examined the relationship between HDL-C and mammographic density, a putative intermediate risk factor for breast cancer.

Methods

The study subjects were 711 Korean women from the Healthy Twin study. Lipid parameters were assayed enzymatically in fresh sera, and percent dense area (PDA) and absolute dense area were measured from digital mammograms using a computer-assisted method.

Results

PDA was positively associated with HDL-C in both premenopausal and postmenopausal women in a multivariable-adjusted linear mixed model, but the association did not persist when the model was additionally adjusted for body mass index (BMI). BMI was inversely associated with PDA, and this association did not change after additional adjustment for any lipid parameter. Multivariable-adjusted analysis showed that there were significant additive genetic cross-trait correlations between PDA and both HDL-C (coefficient, 0.175) and triglyceride (coefficient, −0.262). However, those correlations disappeared after additional adjustment for BMI.

Conclusions

HDL-C alone is unlikely to increase the risk of breast cancer in Korean women, particularly through changes in breast parenchyma that are apparent in mammographic density. BMI should be included in studies using analytical models where mammographic density is used as an intermediate risk factor for breast cancer.Key words: breast cancer, high-density lipoprotein cholesterol, mammography, obesity     

Mammography in asymptomatic women aged 40-49 years

OBJECTIVE

To assess findings of mammography of and interventions resulting from breast cancer screening in women aged 40-49 years with no increased risk (typical risk) of breast cancer.

METHODS

This cross-sectional study evaluated women aged 40-49 years who underwent mammography screening in a mastology reference center in Recife, PE, Northeastern Brazil, between January 2010 and October 2011. Women with breast-related complaints, positive findings in the physical examination, or high risk of breast cancer were excluded.

RESULTS

The 1,000 mammograms performed were classified into the following Breast Imaging-Reporting and Data System (BI-RADS) categories BI-RADS 0, 232; BI-RADS 1, 294; BI-RADS 2, 294; BI-RADS 3, 16; BI-RADS 4A, 2; BI-RADS 5, 1. There was one case of grade II invasive ductal carcinoma and various interventions, including 469 ultrasound scans, 53 referrals to mastologists, 11 cytological examinations, and 8 biopsies.

CONCLUSIONS

Mammography screening in women aged 40-49 years with typical risk of breast cancer led to the performance of other interventions. However, it also resulted in increased costs without demonstrable efficacy in decreasing mortality.     

Cancer mortality among atomic bomb survivors exposed as children

Objectives

To compare cancer mortality among A-bomb survivors exposed as children with cancer mortality among an unexposed control group (the entire population of Japan, JPCG).

Methods

The subjects were the Hiroshima and Nagasaki A-bomb survivor groups (0–14 years of age in 1945) reported in life span study report 12 (follow-up years were from 1950 to 1990), and a control group consisting of the JPCG. We estimated the expected number of deaths due to all causes and cancers of various causes among the exposed survivors who died in the follow-up interval, if they had died with the same mortality as the JPCG (0–14 years of age in 1945). We calculated the standardized mortality ratio (SMR) of A-bomb survivors in comparison with the JPCG.

Results

SMRs were significantly higher in exposed boys overall for all deaths, all cancers, leukemia, and liver cancer, and for exposed girls overall for all cancers, solid cancers, liver cancer, and breast cancer. In boys, SMRs were significantly higher for all deaths and liver cancer even in those exposed to very low doses, and for all cancers, solid cancers, and liver cancer in those exposed to low doses. In girls, SMRs were significantly higher for liver cancer and uterine cancer in those exposed to low doses, and for leukemia, solid cancers, stomach cancer, and breast cancer in those exposed to high doses.

Conclusions

We calculated the SMRs for the A-bomb survivors versus JPCG in childhood and compared them with a true non-exposed group. A notable result was that SMRs in boys exposed to low doses were significantly higher for solid cancer.     

Hormone Replacement Therapy and Risk of Breast Cancer in Korean Women: A Quantitative Systematic Review

Objectives:

The epidemiological characteristics of breast cancer incidence by age group in Korean women are unique. This systematic review aimed to investigate the association between hormone replacement therapy (HRT) and breast cancer risk in Korean women.

Methods:

We searched electronic databases such as KoreaMed, KMbase, KISS, and RISS4U as well as PubMed for publications on Korean breast cancer patients. We also conducted manual searching based on references and citations in potential papers. All of the analytically epidemiologic studies that obtained individual data on HRT exposure and breast cancer occurrence in Korean women were selected. We restricted the inclusion of case-control studies to those that included age-matched controls. Estimates of summary odds ratio (SOR) with 95% confidence intervals (CIs) were calculated using random effect models.

Results:

One cohort and five case-control studies were finally selected. Based on the heterogeneity that existed among the six studies (I-squared=70.2%), a random effect model was applied. The summary effect size of HRT history from the six articles indicated no statistical significance in breast cancer risk (SOR, 0.983; 95% CI, 0.620 to 1.556).

Conclusions:

These facts support no significant effect of HRT history in the risk of breast cancer in Korean women. It is necessary to conduct a pooled analysis.     

Cultural attitudes toward weight, diet, and physical activity among overweight African American girls

Introduction

The growing epidemic of childhood obesity has led to an increasing focus on strategies for prevention. However, little is known about attitudes and perceptions toward weight, diet, and physical activity among American youth, and particularly among young African American females. This pilot study sought to qualitatively explore cultural attitudes and perceptions toward body image, food, and physical activity among a sample of overweight African American girls.

Methods

We recruited 12 overweight girls, aged 12 to 18 years, from a hospital-based pediatric diabetes screening and prevention program. Five semistructured group interviews were conducted to explore attitudes on weight, diet, and physical activity. Sessions averaged 1 hour and were conducted by trained interviewers. Data were transcribed and evaluated for content and relevant themes.

Results

The following themes emerged: weight and body size preferences were primarily determined by the individual and her immediate social circle and were less influenced by opinions of those outside of the social circle; food choices depended on texture, taste, appearance, and context more than on nutritional value; engagement in recreational physical activity was influenced by time constraints from school and extracurricular activities and by neighborhood safety; participation in structured exercise was limited because of the cost and time related to maintenance of personal aesthetics (hair and nails); and celebrities were not perceived as role models for diet and physical activity habits.

Conclusion

In this sample of girls, the findings imply that perceptions of weight and healthy lifestyle behaviors are largely determined by environmental and personal influences. These factors should be considered in the development of healthy-weight interventions for African American girls.