Endometrial carcinoma recurrence according to race and ethnicity: An NRG Oncology/Gynecologic Oncology Group 210 Study

Non‐Hispanic black (NHB) women are more likely to experience an endometrial carcinoma (EC) recurrence compared to non‐Hispanic white (NHW) women. The extent to which tumor characteristics, socioeconomic status (SES) and treatment contribute to this observation is not well defined. In the NRG Oncology/Gynecology Oncology Group (GOG) 210 Study we evaluated associations between race/ethnicity and EC recurrence according to tumor characteristics with adjustment for potential confounders. Our analysis included 3,199 NHW, 532 NHB and 232 Hispanic women with EC. Recurrence was documented during follow‐up. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between race/ethnicity and EC recurrence in models stratified by histologic subtype (low‐grade endometrioid, high‐grade endometrioid, serous, mixed cell, carcinosarcoma, clear cell) or stage (I, II, III) and adjusted for age, SES, body mass index, smoking status and treatment. In histologic subtype‐stratified models, higher EC recurrence was noted in NHB women with low‐grade endometrioid (HR = 1.94, 95% CI = 1.21–3.10) or carcinosarcomas (HR = 1.66, 95% CI = 0.99–2.79) compared to NHWs. In stage‐stratified models, higher EC recurrence was noted among NHB women with stage I (HR = 1.48, 95% CI = 1.06–2.05) and Hispanic women with stage III disease (HR = 1.81, 95% CI = 1.11–2.95). Our observations of higher EC recurrence risk among NHB and Hispanic women, as compared to NHW women, were not explained by tumor characteristics, SES, treatment or other confounders. Other factors, such as racial differences in tumor biology or other patient factors, should be explored as contributors to racial disparities in EC recurrence.     

High cardiovascular disease mortality after endometrial cancer diagnosis: Results from the Surveillance,Epidemiology, and End Results (SEER) Database

Obesity is a strong risk factor for developing endometrial cancer and cardiovascular disease (CVD); consequently, understanding CVD mortality among endometrial cancer survivors is important. We analyzed Surveillance, Epidemiology and End Results Program data for 157,496 endometrial cancer cases diagnosed between 1988 and 2012. We calculated standardized mortality ratios (SMRs) for CVD and all‐cause mortality comparing endometrial cancer cases and general population women. We categorized women into one of three prognostic groups (excellent, intermediate and poor) based on tumor characteristics. Cumulative incidence function curves were plotted to visualize absolute mortality risk in the presence of competing risks. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression for cause‐specific mortality. Deaths were as follows: endometrial cancer 40.6%, CVD 20.5%, other cancers 18.7% and other causes 20.3%. Women with endometrial cancer were more likely to die from CVD (age‐adjusted SMR = 8.8, 95% CI = 8.7–9.0) and all causes (age‐adjusted SMR = 15.9, 95% CI = 15.8–16.0) compared to general population women. In case‐only analyses, higher CVD mortality was associated with older age, Black ethnicity and lack of surgical treatment. Poor prognosis cancers (non‐endometrioid histology and late stage) were related to higher mortality from each cause, with the highest HRs observed for endometrial cancer‐specific mortality. Among women diagnosed with excellent prognosis tumors (endometrioid, well‐differentiated and early stage), absolute risk of CVD mortality surpassed endometrial cancer‐specific mortality 5 years after diagnosis. Women diagnosed with common forms of endometrial cancer have a high CVD burden. After diagnosis, cardiovascular health should be emphasized for these women to reduce mortality.     

Type II diabetes mellitus is associated with a reduced risk of cholangiocarcinoma in patients with biliary tract diseases

It has not yet been reported whether Type II diabetes mellitus (DM) is associated with an increased cholangiocarcinoma (CC) risk in patients with biliary tract diseases. We identified 123,050 patients concomitantly diagnosed with biliary tract diseases and DM between 1998 and 2010. The control cohort consisted of 122,721 individuals with biliary tract diseases but not DM. Both cohorts were followed‐up until the end of 2010 to estimate the risk of CC. We also compared the risk of CC between DM and non‐DM cohorts without biliary tract diseases. Overall, the incidence of CC was 21% lower among the DM patients than among the control patients (1.11 vs. 1.41 per 1,000 person‐years). DM cohorts exhibited significantly reduced risks for both intrahepatic and extrahepatic CC. A multivariable Cox proportional hazards regression model was used, and the adjusted hazard ratio (HR) of CC was 0.74 (95% confidence interval [CI], 0.66–0.82) for the DM cohort in comparison with the control cohort. The age‐specific data indicated that compared with the control patients, the adjusted HRs for the DM patients were significantly lower among patients 50–64 (adjusted HR = 0.67; 95% CI = 0.55–0.82) and 65–74 years old (adjusted HR = 0.70; 95% CI, 0.59–0.84). Furthermore, DM was associated with a lower risk of CC among patients with biliary diseases, regardless of the presence of comorbidities and the status of cholecystectomy. In the patients without biliary tract diseases, DM is associated with significantly increased risk of CC (adjusted HR = 1.58; 95% CI, 1.37–1.82).     

Widening socioeconomic disparities in cervical cancer mortality among women in 26 states, 1993‐2007

BACKGROUND:

Despite substantial declines in cervical cancer mortality because of widespread screening, socioeconomic status (SES) disparities persist. The authors examined trends in cervical cancer mortality rates and the risk of late‐stage diagnoses by SES.

METHODS:

Using data from the National Vital Statistics System, trends in age‐standardized mortality rates among women ages 25 to 64 years (1993‐2007) by education level (≤12 years, 13‐15 years, and ≥16 years) and race/ethnicity for non‐Hispanic white (NHW) women and non‐Hispanic black (NHB) women in 26 states were assessed using log‐linear regression. Rate ratios (RRs) and 95% confidence intervals (CIs) were used to assess disparities between those with ≤12 years versus ≥16 years of education during 1993 to 1995 and 2005 to 2007. Avertable deaths were calculated by applying mortality rates from the most educated women to others in 48 states. Trends in the risk of late‐stage diagnosis by race/ethnicity and insurance status were evaluated in the National Cancer Data Base.

RESULTS:

Declines in mortality were steepest for those with the highest education levels (3.2% per year among NHW women and 6.8% per year among NHB women). Consequently, the education disparity widened between the periods 1993 to 1995 and 2005 to 2007 from 3.1 (95% CI, 2.4‐3.9) to 4.4 (95% CI, 3.5‐5.6) for NHW women and from 3.8 (95% CI, 2.0‐7.0) to 5.6 (95% CI, 3.1‐10.0) for NHB women. The risk of late‐stage diagnosis increased for uninsured versus privately insured women over time. During 2007, 74% of cervical cancer deaths in the United States may have been averted by eliminating SES disparities.

CONCLUSIONS:

SES disparities in cervical cancer mortality and the risk of late‐stage diagnosis increased over time. Most deaths in 2007 may have been averted by eliminating SES disparities. Cancer 2012. © 2012 American Cancer Society.     

Race and breast cancer survival by intrinsic subtype based on PAM50 gene expression

To evaluate whether differences in PAM50 breast cancer (BC) intrinsic (Luminal A, Luminal B, Basal-like, and HER2-enriched) subtypes help explain the Black–White BC survival disparity. Utilizing a stratified case-cohort design, this study included 1,635 women from the Pathways and Life After Cancer Epidemiology cohorts, selecting women with tumors based upon IHC classification, recurrences, and deaths.One millimeter punches were obtained from tumor tissue, and expression of the PAM50 genes for molecular subtype was determined by RT-qPCR of extracted RNA. Cox proportional hazards models were used to analyze associations between race and BC outcomes, adjusted for PAM50 BC subtype. All tests of statistical significance were two-sided. Black women had a higher prevalence of the Basal-like BC subtype. Adjusted for potential confounding variables and disease characteristics at diagnosis, Black women had higher risks of recurrence (HR 1.65, 95 % CI 1.06–2.57) and breast cancer-specific mortality (HR 1.71, 95 % CI 1.02–2.86) than White women, but adjusting further for subtype did not attenuate survival disparities. By contrast, Hispanic women had a lower risk of recurrence (HR 0.54, 95 % CI 0.30–0.96) than Whites. Among those with the Basal-like subtype, Black women had a similar recurrence risk as women in other race groups but a higher recurrence risk for all other subtypes. Hispanic women had a lower recurrence risk within each subtype, though associations were not significant, given limited power. Although Black women had a higher risk of the Basal-like subtype, which has poor prognosis, this did not explain the Black–White BC survival disparity.     

Stage and delay in breast cancer diagnosis by race, socioeconomic status, age and year.

Information on 23,567 Non-Hispanic White, 2,539 Black, and 2,380 Hispanic breast cancer cases diagnosed between 1977 and 1985 was used to evaluate the risk of late stage diagnosis and long duration of symptoms prior to diagnosis in relation to ethnicity, socioeconomic status, age and year of diagnosis. All data were collected by the University of Southern California Cancer Surveillance Program, the comprehensive population-based incidence registry of Los Angeles County. The results indicate that lower socioeconomic status, Black or Hispanic ethnicity, younger age, and earlier year of diagnosis are risk factors for late stage diagnosis and long duration of symptoms. The effect of ethnicity was not explained by lower SES levels among Black or Hispanic women. After controlling for duration of symptoms, race and SES remained significantly predictive of more advanced stage. More recent diagnosis across the 9 year time frame was not associated with improved stage for those of low SES. These results suggest that increased efforts are needed to reach low SES and Black and Hispanic women with campaigns to improve the stage at which breast cancer is detected.     

Contribution of clinical and socioeconomic factors to differences in breast cancer subtype and mortality between Hispanic and non-Hispanic white women

Purpose

To assess tumor subtype distribution and the relative contribution of clinical and sociodemographic factors on breast cancer survival between Hispanic and non-Hispanic whites (NHWs).

Methods

We analyzed data from the California Cancer Registry, which included 29,626 Hispanic and 99,862 NHW female invasive breast cancer cases diagnosed from 2004 to 2014. Logistic regression was used to assess ethnic differences in tumor subtype, and Cox proportional hazard modeling to assess differences in breast cancer survival.

Results

Hispanics compared to NHWs had higher odds of having triple-negative (OR = 1.29; 95% CI 1.23–1.35) and HER2-overexpressing tumors (OR = 1.19; 95% CI 1.14–1.25 [HR?] and OR = 1.39; 95% CI 1.31–1.48 [HR+]). In adjusted models, Hispanic women had a higher risk of breast cancer mortality than NHW women (mortality rate ratio [MRR] = 1.24; 95% CI 1.19–1.28). Clinical factors accounted for most of the mortality difference (MRR = 1.05; 95% CI 1.01–1.09); however, neighborhood socioeconomic status (SES) and health insurance together accounted for all of the mortality difference (MRR = 1.01; 95% CI 0.97–1.05).

Conclusions

Addressing SES disparities, including increasing access to health care, may be critical to overcoming poorer breast cancer outcomes in Hispanics.

     

Disparities in receipt of adjuvant radiation therapy after breast-conserving surgery among the cancer-reporting regions of California

BACKGROUND:

Incidence and mortality of breast cancer vary according to demographic factors such as age, race/ethnicity, socioeconomic status (SES), and geographic region. This study assesses the variation of these factors in the use of adjuvant radiation therapy (RT) after breast‐conserving surgery (BCS) among 8 regions of California.

METHODS:

The authors identified 85,574 cases of first primary female invasive breast cancer with complete data diagnosed between January 1, 2000 and December 31, 2007. Logistic regression was used to determine the association between race/ethnicity, age, SES, and receipt of RT after BCS within each of the regions of California. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed.

RESULTS:

Age was a significant predictor of receipt of RT after BCS in all regions. In Los Angeles (LA), lower SES was associated with decreasing odds of RT. Racial disparities were evident only in LA, where black (OR, 0.85; 95% CI, 0.74‐0.97) and Hispanic (OR, 0.86; 95% CI, 0.78‐0.96) women were about 15% less likely to receive RT than white women.

CONCLUSIONS:

Racial disparities in the receipt of RT after BCS exist only in LA, where African American and Hispanic women are less likely to receive this form of adjuvant treatment. Lower SES was also associated with a reduced likelihood of receipt of RT in LA. Women age 70 years and older are less likely to receive RT after BCS in all regions of California. Cancer 2012. © 2011 American Cancer Society.     

Racial/ethnic differences in breast cancer survival by inflammatory status and hormonal receptor status: an analysis of the Surveillance,Epidemiology, and End Results data

Background

Compared to non-inflammatory breast cancer (non-IBC), inflammatory breast cancer (IBC) has less favorable survival and is more likely to be estrogen receptor (ER) and progesterone receptor (PR) negative. ER?/PR? tumors, regardless of histology, have less favorable survival. While black women are more likely to have IBC and ER?/PR? tumors than white women, it is unclear whether the racial disparity in survival is explained by these factors. The objective of this study was to assess racial/ethnic differences in breast cancer survival by inflammatory status and hormone receptor status.

Methods

This study examined breast cancer mortality among non-Hispanic white (NHW), Hispanic white, black, and Asian/Pacific Islander (API) women diagnosed between 1990 and 2004 using the National Cancer Institute’s Surveillance, Epidemiology, and End Results data. Kaplan–Meier survival curves and Cox proportional hazard ratios (HRs) assessed the relationship between race/ethnicity and survival.

Results

Black women had significantly poorer survival than NHW women regardless of inflammatory status and hormone receptor status. Compared to NHWs, the HRs for black women were 1.32 (95 % confidence interval (CI) 1.21–1.44), 1.43 (95 % CI 1.20–1.69), and 1.30 (95 % CI 1.16–1.47) for IBC, IBC with ER+/PR+, and with ER?/PR?, respectively. Similar HRs were found for non-IBC, non-IBC with ER+/PR?, and non-IBC with ER?/PR?. API women had significantly better survival than NHW women regardless of inflammatory status and hormone receptor status.

Conclusion

Compared to NHW women, black women had poorer survival regardless of inflammatory status and hormone receptor status and API women had better survival. These results suggest that factors other than inflammatory status and hormone receptor status may play a role in racial/ethnic disparities in breast cancer survival.     

Low socioeconomic status is a poor prognostic factor for survival in stage I nonsmall cell lung cancer and is independent of surgical treatment, race, and marital status

BACKGROUND: Racial minorities exhibit poor survival with nonsmall cell lung cancer (NSCLC) that generally is attributed to low socioeconomic status (SES). In this study, the authors investigated the role of SES in this survival disparity among patients with stage I NSCLC. METHODS: A case-only analysis was performed on California Cancer Registry (CCR) data (1989-2003). Univariate survival analyses were performed using the Kaplan-Meier method. Multivariate survival analyses were performed using Cox proportional hazards ratios. RESULTS: In total, 19,702 incident cases of stage I NSCLC were analyzed. Low SES was identified more commonly in African-American and Hispanic patients and was associated significantly with men, unmarried status, stage IB disease, squamous cell histology, poorly differentiated tumors, fewer surgical resections performed, and less overall treatment received. Reasons for no surgery were associated strongly with low SES and unmarried status but not with race. In multivariate analysis, each incremental improvement in SES quintile was associated with statistically significant decreases in the hazard ratios (HRs) for death (second SES quintile [SES2] vs SES1: HR, 0.91; 95% confidence interval [95% CI], 0.85-0.98; SES3 vs SES1: HR, 0.90; 95% CI, 0.84-0.97; SES4 vs SES1: HR, 0.83; 95% CI, 0.77-0.89; SES5 vs SES1: HR, 0.78; 95% CI, 0.72-0.84; P(trend) < .0001). African-American or Hispanic race was not an independent poor prognostic factor for survival after adjustment for surgery, SES, and marital status. CONCLUSIONS: Low SES was an independent poor prognostic factor for survival in patients with stage I NSCLC and was independent of surgery, race, and marital status.     

Minority adult survivors of childhood cancer: a comparison of long-term outcomes, health care utilization, and health-related behaviors from the childhood cancer survivor study.

PURPOSE: To determine the influence of race/ethnicity on outcomes in the Childhood Cancer Survivor Study (CCSS). PATIENTS AND METHODS: Of CCSS adult survivors in the United States, 443 (4.9%) were black, 503 (5.6%) were Hispanic and 7,821 (86.6%) were white. Mean age at interview, 26.9 years (range, 18 to 48 years); mean follow-up, 17.2 years (range, 8.7 to 28.4 years). Late mortality, second malignancy (SMN) rates, health care utilization, and health status and behaviors were assessed for blacks and Hispanics and compared with white survivors. RESULTS: Late mortality rate (6.5%) and 15-year cumulative incidence of SMN (3.5%) were similar across racial/ethnic groups. Minority survivors were more likely to have lower socioeconomic status (SES); final models were adjusted for income, education, and health insurance. Although overall health status was similar, black survivors were less likely to report adverse mental health (females: odds ratio [OR], 0.6; 95% CI, 0.4 to 0.9; males: OR, 0.5; 95% CI, 0.3 to 0.8). Differences in health care utilization and behaviors noted: Hispanic survivors were more likely to report a cancer center visit (females: OR, 1.5; 95% CI, 1.1 to 2.0; males: OR, 1.7; 95% CI, 1.2 to 2.3); black females were more likely (OR, 1.6; 95% CI, 1.1 to 2.4), and Hispanic females less likely to have a recent Pap smear (OR, 0.7; 95% CI, 0.5 to 1.0); black and Hispanic survivors were less likely to report smoking; black survivors were less likely to report problem drinking. CONCLUSION: Adjusted for SES, adverse outcomes in CCSS were not associated with minority status. Importantly, black survivors reported less risky behaviors and better preventive practices. Hispanic survivors had equitable access to cancer related care.     

The expanding melanoma burden in California hispanics

BACKGROUND:

The incidence patterns and socioeconomic distribution of cutaneous melanoma among Hispanics are poorly understood.

METHODS:

The authors obtained population‐based incidence data for all Hispanic and non‐Hispanic white (NHW) patients who were diagnosed with invasive cutaneous melanoma from 1988 to 2007 in California. By using a neighborhood‐level measure of socioeconomic status (SES), the variables investigated included incidence, thickness at diagnosis, histologic subtype, anatomic site, and the relative risk (RR) for thicker (>2 mm) versus thinner (≤2 mm) tumors at diagnosis for groups categorized by SES.

RESULTS:

Age‐adjusted melanoma incidence rates per million were higher in NHWs (P < .0001), and tumor thickness at diagnosis was greater in Hispanics (P < .0001). Sixty‐one percent of melanomas in NHWs occurred in the High SES group. Among Hispanics, only 35% occurred in the High SES group; and 22% occurred in the Low SES group. Lower SES was associated with thicker tumors (P < .0001); this association was stronger in Hispanics. The RR of thicker tumors versus thinner tumors (≤2 mm) in the Low SES group versus the High SES group was 1.48 (95% confidence interval [CI], 1.37‐1.61) for NHW men and 2.18 (95% CI, 1.73‐2.74) for Hispanic men. Patients with lower SES had less of the superficial spreading melanoma subtype (especially among Hispanic men) and more of the nodular melanoma subtype. Leg/hip melanomas were associated with higher SES in NHW men but with lower SES in Hispanic men.

CONCLUSIONS:

The socioeconomic distribution of melanoma incidence and tumor thickness differed substantially between Hispanic and NHW Californians, particularly among men. Melanoma prevention efforts targeted to lower SES Hispanics and increased physician awareness of melanoma patterns among Hispanics are needed. Cancer 2011. © 2010 American Cancer Society.     

Breast cancer characteristics and outcomes among Hispanic Black and Hispanic White women

Evaluating breast cancer outcomes specific to Hispanics of different race (e.g. Hispanic Black, Hispanic White) may further explain variations in the burden of breast cancer among Hispanic women. Using data from the SEER 17 population-based registries, we evaluated the association between race/ethnicity and tumor stage, hormone receptor status, and breast cancer-specific mortality. The study cohort of 441,742 women, aged 20-79, who were diagnosed with primary invasive breast cancer between January 1, 1992 and December 31, 2008, included 44,246 Hispanic whites, 622 Hispanic Blacks, 44,797 non-Hispanic Blacks and 352,077 non-Hispanic whites. Hispanic black, Hispanic white and non-Hispanic black women had a 1.5-2.5 fold greater risk of presenting with stage IV breast cancer compared to non-Hispanic whites. All groups were significantly more likely than non-Hispanic whites to be diagnosed with ER+/PR- (1.1-1.5 fold increase) or ER-/PR- (1.4-2.2 fold increase) breast cancer. Hispanic black, Hispanic white and non-Hispanic black women had a 10-50?% greater risk of breast cancer-specific mortality compared to non-Hispanic whites. Our findings underscore the breast cancer disparities that continue to exist for Hispanic and black women, overall, as well as between Hispanic women of different race. These disparities highlight the factors that may lead to the poor outcomes observed among Hispanic and black women diagnosed with breast cancer, and for which targeted strategies aimed at reducing breast cancer disparities could be developed.     

Hair dye and chemical straightener use and breast cancer risk in a large US population of black and white women

Many hair products contain endocrine-disrupting compounds and carcinogens potentially relevant to breast cancer. Products used predominately by black women may contain more hormonally-active compounds. In a national prospective cohort study, we examined the association between hair dye and chemical relaxer/straightener use and breast cancer risk by ethnicity. Sister Study participants (n = 46,709), women ages 35–74, were enrolled between 2003 and 2009, and had a sister with breast cancer but were breast cancer-free themselves. Enrollment questionnaires included past 12-month hair product use. Cox proportional hazards models estimated adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between hair products and breast cancer; effect measure modification by ethnicity was evaluated. During follow-up (mean = 8.3 years), 2,794 breast cancers were identified. Fifty-five percent of participants reported using permanent dye at enrollment. Permanent dye use was associated with 45% higher breast cancer risk in black women (HR = 1.45, 95% CI: 1.10–1.90), and 7% higher risk in white women (HR = 1.07, 95% CI: 0.99–1.16; heterogeneity p = 0.04). Among all participants, personal straightener use was associated with breast cancer risk (HR = 1.18, 95% CI 0.99–1.41); with higher risk associated with increased frequency (p for trend = 0.02). Nonprofessional application of semipermanent dye (HR = 1.28, 95% CI 1.05–1.56) and straighteners (HR = 1.27, 95% CI 0.99–1.62) to others was associated with breast cancer risk. We observed a higher breast cancer risk associated with any straightener use and personal use of permanent dye, especially among black women. These results suggest that chemicals in hair products may play a role in breast carcinogenesis.     

Assessing the time dependence of prognostic values of cytology and human papillomavirus testing in cervical cancer screening

Accurate assessment of risks for developing cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) after a given set of screening test results is instrumental to reaching valid conclusions and informing cervical cancer screening recommendations. Using data from the Canadian Cervical Cancer Screening Trial (CCCaST), we assessed prognostic values of enrollment screening test results to predict CIN2+ among women attending routine cervical screening using multivariable Cox proportional hazards (PH) regression and its flexible extension during each of two follow-up periods (protocol-defined and extended). Nonproportional (time-dependent (TD)) and/or nonlinear effects were modeled, as appropriate. Women with abnormal cytology had hazard ratios (HRs) for CIN2+ detection of 17.61 (95% CI: 11.25–27.57) and 10.46 (95% CI: 5.41–20.24) relative to women with normal cytology during the protocol-defined and extended follow-up periods, respectively. High-risk human papillomavirus (HR-HPV) positivity was an even stronger predictor of CIN2+ risk, with significant TD effects during both follow-up periods (p <0.001 for both TD effects). Risks among women co-testing HR-HPV+ with and without abnormal cytology (relative to women co-testing negative) were highest immediately after baseline, and decreased significantly thereafter (p <0.001 for both TD effects). HRs for HPV16+ and HPV18+ women (relative to those testing HR-HPV-) did not vary significantly over time (HR = 182.96; 95% CI: 95.16–351.77 and HR = 111.81; 95% CI: 44.60–280.31, respectively). Due to TD effects, conventional Cox model estimates considerably underestimated adjusted HRs associated with positive HR-HPV testing results early on in the follow-up periods.     

Pubertal growth and adult height in relation to breast cancer risk in African American women

Adult height has been positively associated with breast cancer risk. The timing of pubertal growth—as measured by age at menarche and age at attained height—may also influence risk. We evaluated associations of adult height, age at attained height, and age at menarche with incidence of invasive breast cancer in 55,687 African American women in the prospective Black Women's Health Study. Over 20 years, 1,826 invasive breast cancers [1,015 estrogen receptor (ER) positive; 542 ER negative] accrued. We used multivariable Cox proportional hazards regression to estimate hazards ratios (HRs) and 95% confidence intervals (CIs) for associations with breast cancer overall and by ER status, mutually adjusted for the three factors of interest. Adult height was associated with increased risk of ER+ breast cancer (HR for ≥70 inches vs ≤63 inches: 1.44; 95% CI: 1.09, 1.89) but not ER? (corresponding HR: 1.16; 95% CI: 0.78, 1.71) (p heterogeneity = 0.34). HRs for attained height before age 13 versus age >17 were 1.30 (95% CI: 0.96, 1.76) for ER+ and 1.25 (95% CI: 0.80, 1.96) for ER? breast cancer. Results for age at menarche (≤11 vs ≥14 years) were similar for ER+ and ER? breast cancer (HR for breast cancer overall: 1.30; 95% CI: 1.12, 1.50). We confirmed height as a strong risk factor for ER+ breast cancer in African American women and identified early age at attained height as a risk factor for both ER+ and ER? breast cancer, albeit without statistical significance of the latter associations. While adult height and timing of pubertal growth are inter‐related, our findings suggest that they may be independent risk factors for breast cancer.     

Survival differences by race/ethnicity among children and adolescents diagnosed with germ cell tumors

Survival differences by racial and ethnic group have been reported in children and adolescents with germ cell tumors (GCTs), but whether these differences depend on stage of disease is unclear. Using the SEER 18 registries (2000–2015), we examined GCT survival differences by race/ethnicity (non-Hispanic white [NHW], Black, Asian/Pacific Islander [API], Hispanic) separately for males and females aged 0–19 years at diagnosis. We used Kaplan–Meier survival curves (Log-Rank p values) to characterize survival differences. Cox proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between race/ethnicity and death. Using an inverse odds weighting mediation analysis, we estimated the association between race/ethnicity and death treating stage of disease as the mediator. There were no significant racial/ethnic survival differences among females. Male survival differed by race/ethnicity (p < 0.0001) with NHW males having the best survival. Compared to NHW, API and Hispanic males had significantly higher risks of death (API HR: 2.18; 95% CI: 1.32–3.56; Hispanic HR: 1.98; 95% CI: 1.42–2.78) (model adjusted for age and year at diagnosis, tumor histology and location, stage). This association was mediated by stage of disease only among Hispanic males with gonadal tumors (indirect HR: 1.18; 95% CI: 1.03–1.35). The increased risk of death after a testicular GCT diagnosis observed among Hispanic males was mediated by stage of disease. For API males and Hispanic males with extragonadal tumors, other unidentified factors including differences in exposures, tumor biology or treatment received may impact the observed racial/ethnic survival disparities.     

Progesterone receptor status modifies the association between body mass index and prognosis in women diagnosed with estrogen receptor positive breast cancer

The role of progesterone receptor (PR) status on the association between obesity and prognosis of estrogen receptor positive (ER+) breast cancer (BC) remains poorly understood. We aim to examine whether this association varies according to the tumor PR status. Data for 3,747 women diagnosed with nonmetastatic ER+ invasive BC between 1995 and 2010 were analyzed. Women were classified according to their body mass index (BMI) (<18.5, 18.5–24.9, 25.0–29.9 or ≥30.0 kg/m²). Tumor PR status (PR−, PR+) was evaluated by immunohistochemistry. Hazard ratios (HR) for survival outcomes were estimated using multivariable Cox regression models. Effect modification was assessed on both additive and multiplicative scales using relative excess risk due to interaction and ratio of HRs, respectively. After a median follow-up of 5.9 years (range: 3.4–9.2), women with PR− tumors and underweight (HR = 2.76, 95% CI: 1.40–4.91), overweight (HR = 2.02, 95% CI: 1.43–2.81) or obese (HR = 2.51, 95% CI: 1.67–3.65) had increased risk of all-cause mortality, when compared to normal weight women with PR+ tumors. A similar pattern of associations was observed for BC-specific mortality. In contrast, women with PR+ tumors had similar risks for both mortality outcomes, regardless of BMI. On the additive scale, all-cause mortality was modified by PR status for overweight and obese women, whereas for BC-specific mortality, it was only modified for underweight women. The same observations were found on the multiplicative scale. These results suggest that poorer survival associated with low and high BMI among women diagnosed with ER+ BC may depend on the tumor PR status.     

Racial Differences in Clinical Progression Among Medicare Recipients After Treatment for Localized Prostate Cancer (United States)

OBJECTIVE: Prostate cancer recurrence impacts patient quality of life and risk of prostate-cancer specific death following definitive treatment. We investigate differences in disease-free survival among white, black, Hispanic, and Asian patients in a large, population-based database. METHODS: Merged Surveillance, Epidemiology, and End Results Program (SEER) and Medicare files provided data on 23,353 white patients, 2,814 black patients, 480 Hispanic patients, and 566 Asian patients diagnosed at age 65-84 years with clinically localized prostate cancer between 1986 and 1996 in five SEER sites. Patients were followed through 1998. Racial differences in disease-free survival were assessed using Kaplan-Meier survival curves and Cox regression models. RESULTS: The 75th percentile disease-free survival time for black patients was 13 months less than that for white patients (95% confidence interval [CI]: 6.2-19.8 months), 29.7 months less than that for Hispanic patients (95% CI: 4.4-55.0 months), and 39.1 months less than that for Asian patients (95% CI: 12.1-66.1 months). In multivariate analysis, black race predicted shorter disease-free survival among surgery patients, but not among radiation patients. CONCLUSIONS: Black patients experienced shorter disease-free survival compared to white, Hispanic, and Asian patients, and the disease-free survival of white, Hispanic, and Asian patients were not statistically different. Earlier recurrence of prostate cancer may help explain black patients' increased risk of mortality from prostate cancer.     

The impact of socioeconomic status on survival after cancer in the United States : findings from the National Program of Cancer Registries Patterns of Care Study

BACKGROUND: Understanding the ways in which socioeconomic status (SES) affects mortality is important for defining strategies to eliminate the unequal burden of cancer by race and ethnicity in the United States. METHODS: Disease stage, treatment, and 5-year mortality rates were ascertained by reviewing medical records, and SES was determined by analyzing income and education at the census tract level for 4844 women with breast cancer, 4332 men with prostate cancer, and 4422 men and women with colorectal cancer who were diagnosed in 7 U.S. states in 1997. RESULTS: Low SES was associated with more advanced disease stage and with less aggressive treatment for all 3 cancers. The hazard ratio (HR) for 5-year all-cause mortality associated with low SES was elevated after a diagnosis of breast cancer when the analysis was adjusted for age (HR, 1.59; 95% confidence interval [CI], 1.35-1.87). Adjustment for mediating factors of race/ethnicity, comorbid conditions, cancer stage, and treatment reduced the association. The age-adjusted mortality risk associated with low SES was elevated after a diagnosis of prostate cancer (HR, 1.33; 95% CI, 1.13-1.57), and multivariate adjustments for mediating factors also reduced that association. There was less association between SES and mortality after a diagnosis of colorectal cancer. For all 3 cancer sites, low SES was a much stronger predictor of mortality among individuals aged <65 years and among individuals from racial/ethnic minority groups. CONCLUSIONS: The current results indicated that low SES is a risk factor for all-cause mortality after a diagnosis of cancer, largely because of a later stage at diagnosis and less aggressive treatment. These findings support the need to focus on SES as an underlying factor in cancer disparities by race and ethnicity.