Rural-urban differences in stage at diagnosis. Possible relationship to cancer screening

Stage at diagnosis was examined for various malignancies identifiable through screening to determine whether rural-urban differences exist in Georgia. Data were obtained from a population-based cancer registry which registers all incident cancers among residents of metropolitan Atlanta and ten neighboring rural counties. Black and white patients with a first primary invasive malignancy newly diagnosed between 1978 and 1985 were included in this study. Residents of the rural area were twice as likely to have unstaged cancers (18.3%) as were urban residents (9.6%). Among patients with known stage at diagnosis, rural patients tended to have more advanced disease than urban patients. The relative excess of nonlocalized malignancies in rural Georgia was 21% for whites and 37% for blacks. The rural excess of nonlocalized prostate cancer among blacks was especially pronounced. Differences in access to or utilization of early detection methods may contribute to the rural-urban differential in the extent of disease at diagnosis.     

Breast cancer stage at diagnosis: Caucasians versus Hispanics

In the Department of Defense health care system,all women have the same ability to accesshealth care. Thus, there should be no racialdifferences in stage at diagnosis solely based onability to seek health care. A retrospective reviewof breast cancer cases from 1980–1992 was conductedto determine if there were any differences instage at diagnosis between Caucasian and Hispanic females.Data was available for 6134 Caucasian and 182Hispanic females. Although not statistically significant, Hispanic femaleshad fewer Stage I (41% versus 53%) andmore Stage IIA (37% versus 28%) breast cancersthan Caucasian females. Hispanic females had statistically fewertumors 1 cm (p < 0.001). Caucasianfemales were older (median age 58 years) atpresentation than Hispanic females (median age 51 years).Significantly (p = 0.002) more Hispanic females (44%)were < 50 years old compared to Caucasianfemales (28%). When access to care is notan issue, Hispanic females tended to present ata more advanced stage although this did notreach statistical significance. Hispanic females with breast cancerwere significantly younger than Caucasian females.     

Breast cancer stage at diagnosis: Caucasians versus Afro-Americans

Summary In the Department of Defense health care system, all women have the same ability to access health care. Thus, there should be no racial differences in stage at diagnosis solely based on ability to seek health care. A retrospective review of breast cancer cases from 1976–1992 was conducted to determine if there were any differences in stage at diagnosis between Caucasian and Afro-American females. Data was available for 6414 Caucasian and 746 Afro-American females. Stage at diagnosis was similar for both groups. However, Afro-Americans had fewer tumors 1.0 cm than Caucasians. Afro-American females were younger (median age 50 years versus 58 years in Caucasians). Twenty-four per cent of Afro-Americans were < 40 years old compared to only 9% Caucasians. When access to care is not an issue, there are no racial differences in stage of breast cancer at diagnosis.     

Breast cancer in black and white women in New York State. Case distribution and incidence rates by clinical stage at diagnosis

Case distributions and incidence rates by clinical stage at diagnosis were examined for 47,198 white and 4443 black female breast cancer cases diagnosed among residents of New York State from 1976-1981 and reported to the population-based New York State Cancer Registry. Proportions of cases diagnosed at "regional" and (especially) "metastatic" clinical stages were significantly higher in blacks versus whites, and incidence rates for "metastatic" cancers were slightly higher in blacks in some age groups (less than 60 years). The proportion of metastatic cancers differed significantly by race for single, married, and widowed cases, with younger (less than 60 years) black single women showing the highest proportions. The ranking of counties by black-white differences in per capita income was significantly associated with rankings by black-white differences in proportion of metastatic cancers. Possible explanations for this association, in terms of patient delay, and implications for cancer screening and medical care, were discussed.     

Variation in tumor natural history contributes to racial disparities in breast cancer stage at diagnosis

Black women tend to be diagnosed with breast cancer at a more advanced stage than whites and subsequently experience elevated breast cancer mortality. We sought to determine whether there are racial differences in tumor natural history that contribute to these disparities. We used the University of Wisconsin Breast Cancer Simulation Model, a validated member of the National Cancer Institute’s Cancer Intervention and Surveillance Modeling Network, to evaluate the contribution of racial differences in tumor natural history to observed disparities in breast cancer incidence. We fit eight natural history parameters in race-specific models by calibrating to the observed race- and stage-specific 1975–2000 U.S. incidence rates, while accounting for known racial variation in population structure, underlying risk of breast cancer, screening mammography utilization, and mortality from other causes. The best fit models indicated that a number of natural history parameters must vary between blacks and whites to reproduce the observed stage-specific incidence patterns. The mean of the tumor growth rate parameter was 63.6 % higher for blacks than whites (0.18, SE 0.04 vs. 0.11, SE 0.02). The fraction of tumors considered highly aggressive based on their tendency to metastasize at a small size was 2.2 times greater among blacks than whites (0.41, SE 0.009 vs. 0.019, SE 0.008). Based on our simulation model, breast tumors in blacks grow faster and are more likely to metastasize earlier than tumors in whites. These differences suggest that targeted prevention and detection strategies that go beyond equalizing access to mammography may be needed to eliminate breast cancer disparities.     

Bone mass and breast cancer risk in older women: differences by stage at diagnosis.

BACKGROUND: Older women with low bone mineral density (BMD) have a decreased incidence of breast cancer. It is not known whether this association is confined to early-stage, slow-growing tumors. METHODS: We prospectively studied 8905 women who were 65 years of age or older during the period from 1986 through 1988 and had no history of breast cancer. At study entry, we used single-photon absorptiometry to measure each woman's BMD at three skeletal sites: the wrist, forearm, and heel. The women were followed for a mean of 6.5 years for the occurrence of breast cancer. All statistical tests were two-sided. RESULTS: During 57 516 person-years of follow-up, 315 women developed primary invasive or in situ breast cancer. Multivariate analyses that adjusted for age, obesity, and other covariates revealed that the risk of breast cancer for women in the highest quartile of BMD for all three skeletal sites was 2.7 (95% confidence interval [CI] = 1.4 to 5.3) times greater than that for women in the lowest quartile at all three skeletal sites. The magnitude of increased risk associated with high BMD differed by the stage of disease at diagnosis and was greater for more advanced tumors (relative risk [RR] for TNM [i.e., tumor-lymph node-metastasis] stage II or higher tumors = 5.6; 95% CI = 1.2 to 27.4) than for early-stage disease (RR for in situ/TNM stage I tumors = 2.2; 95% CI = 1.0 to 4.8). CONCLUSIONS: Elderly women with high BMD have an increased risk of breast cancer, especially advanced cancer, compared with women with low BMD. These findings suggest an association between osteoporosis and invasive breast cancer, two of the most prevalent conditions affecting an older woman's health.     

Influence of stage at diagnosis on survival differences for rectal cancer in three European populations.

Important differences have recently been highlighted between European countries in the survival of colorectal cancer patients. As data on stage at diagnosis were available for rectal cancers in three European population-based registries (Geneva Switzerland; Côte d''Or, France; Mallorca, Spain), we compared relative survival while assessing the effect of stage in a multiple regression model. We analysed 1005 rectal cancer cases diagnosed between 1982 and 1987 and followed up for at least 5 years. In the Mallorca registry, 16% of the patients were diagnosed in the TNM stage I (versus 21% in the Côte d''Or registry and 29% in the Geneva registry, P < 10⁻⁴) and the 5-year relative survival rate was lower (35%) than in the other two registries (Côte d’Or 47%, Geneva 48%, P = 0.01). In the multivariate analysis, stage was the only independent prognostic factor, whereas the excess death risk did not vary significantly among registries (compared to Geneva, Côte d''Or relative risk was 1.0, Mallorca relative risk 1.11, 95% confidence interval 0.76–1.32 and 0.85–1.44 respectively). Survival differences between the registries were mainly due to stage at diagnosis. Thus, diagnostic conditions appear to be the main determinant of the survival inequalities found in those three European populations. © 1999 Cancer Research Campaign     

Comorbidities and mammography use interact to explain racial/ethnic disparities in breast cancer stage at diagnosis

BACKGROUND:

Interactions with comorbidity burden and comorbidity‐related care have not been examined as potential explanations for racial/ethnic disparities in advanced‐stage breast cancer at diagnosis.

METHODS:

The authors used linked Surveillance, Epidemiology, and End Results‐Medicare data to determine whether comorbidity burden and comorbidity‐related care are associated with stage at diagnosis, whether these associations are mediated by mammography use, and whether they explain racial/ethnic disparities. Stage at diagnosis and mammography use were analyzed in multivariate regression models, adjusting for comorbidity burden and comorbidity‐race interactions among 118,742 women diagnosed with breast cancer during 1993 to 2005.

RESULTS:

Mammography utilization was higher among women with ≥3 stable comorbidities than among those without comorbidities. Advanced stage at diagnosis was associated with black race (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.6‐1.8), Hispanic ethnicity (OR, 1.3; 95% CI, 1.2‐1.5), unstable comorbidity, and age ≥80 years. Mammography was protective in all racial/ethnic groups, but neither mammography use (OR, 0.3; 95% CI, 0.3‐0.3 and OR, 0.2; 95% CI, 0.2‐0.2 for women with 1 and ≥2 prior mammograms, respectively) nor overall physician service use (OR, 0.7; 95% CI, 0.7‐0.8 for women with ≥16 visits) explained the association between race/ethnicity and stage at diagnosis. The black/white OR fell to 1.2 (95% CI, 0.9‐1.5) among women with multiple stable comorbidities who received ≥2 screening mammograms, and 1.0 (95% CI, 0.8‐1.3) among mammography users with unstable comorbidities.

CONCLUSIONS:

Comorbidity burden was associated with regular mammography and earlier stage at diagnosis. Racial/ethnic disparities in late stage disease were reduced among women who received both regular mammograms and comorbidity‐related care. Cancer 2011. © 2011 American Cancer Society.     

Racial differences in PSA screening interval and stage at diagnosis

Objectives  

This study examined PSA screening interval of black and white men aged 65 or older and its association with prostate cancer stage at diagnosis.     

Impact of smoking on cancer stage at diagnosis.

BACKGROUND: Studies evaluating the relationship between smoking and cancer spread are limited. METHODS: We studied the relationship between cancer stage at diagnosis (local, regional, or metastatic) and smoking history (current, previous, or nonsmoker). For lung cancer, patterns of spread were also studied. RESULTS: In a tumor registry for eastern North Dakota, northwestern Minnesota, and northern South Dakota, 11,716 cases were identified from 1986 to 2001. Current smokers (relative risk [RR], 2.11; 95% confidence interval, 1.93 to 2.32; P <.001) and previous smokers (RR, 1.56; 95% confidence interval, 1.42 to 1.72; P <.001) had an increased risk of metastatic disease at diagnosis. Current smokers (RR, 1.39; 95% confidence interval, 1.29 to 1.51; P <.001), but not previous smokers, also had an increased risk of regional disease. An increase in metastatic disease was most evident for prostate cancer (RR, 1.53; P =.003). An increase in regional disease was most evident for head and neck (RR, 3.53; P <.001), prostate (RR, 1.83; P =.030), and breast cancer (RR, 1.22; P =.005). Compared with previous smokers, current smokers with metastatic lung cancer were more likely to have involvement of the brain (33.6% v 23.0%; P =.004), bone marrow, adrenal gland, and pericardium (24.7% v 15.9%; P =.004). CONCLUSION: Previous or current smoking is a risk factor for increased cancer stage in a wide range of malignancies. Further study is required to determine whether this association is causal.     

Deprivation,stage at diagnosis and cancer survival

The association between an area-based measure of deprivation and survival from the 10 most common cancers was studied in 155,682 patients diagnosed between 1980 and 1989 in the area covered by the South Thames Regional Health Authority. Furthermore, the impact of stage of disease at diagnosis on this association was studied. The measure of deprivation was the Car-stairs Index of the census enumeration district of each patient's residence at diagnosis (5 categories) and the cancers studied were: lung, breast, colorectum, bladder, prostate, stomach, pancreas, ovary, uterus and cervix. In the univariate analyses the measure of outcome was the relative survival rate and in the multivariate analyses it was the hazard ratio. Both univariate and multivariate analyses showed that patients from affluent areas had better survival than patients from deprived areas for cancers of the lung, breast, colorectum, bladder, prostate, uterus and cervix. Stage of disease at diagnosis did not explain the survival differences by deprivation category. For cancers of the stomach, pancreas and ovary, no variation in survival by deprivation category was found. For most cancer sites, a clear gradient in survival by deprivation category was observed, which implies a large potential reduction of cancer mortality among the lower socioeconomic groups. Future studies need to incorporate other possible explanatory factors, besides stage, of the association between deprivation and survival.     

Rural and urban differences in stage at diagnosis of colorectal and lung cancers

There is evidence that patients living in outlying areas have poorer survival from cancer. This study set out to investigate whether they have more advanced disease at diagnosis. Case notes of 1323 patients in north and northeast Scotland who were diagnosed with lung or colorectal cancer in 1995 or 1996 were reviewed. Of patients with lung cancer, 42% (69/164) living 58 km or more from a cancer centre had disseminated disease at diagnosis compared to 33% (71/215) living within 5 km. For colorectal cancer the respective figures were 24% (38/161) and 16% (31/193). For both cancers combined, the adjusted odds ratio for disseminated disease at diagnosis in furthest group compared to the closest group was 1.59 (P = 0.037). Of 198 patients with non-small-cell lung cancer in the closest group, 56 (28%) had limited disease (stage I or II) at diagnosis compared to 23 of 165 (14%) of the furthest group (P = 0.002). The respective figures for Dukes A and B colorectal cancer were 101 of 196 (52%) and 67 of 172 (39%) (P = 0.025). These findings suggest that patients who live remote from cities and the associated cancer centres have poorer chances of survival from lung or colorectal cancer because of more advanced disease at diagnosis. This needs to be taken into account when planning investigation and treatment services.     

Surgical treatment of clinical stage A nonseminomatous testis cancer.

Until clinical staging improves, patients presenting with clinical stage A nonseminomatous testis cancer should be offered the option of initial nerve-sparing RPLND versus surveillance. Either method of management may be successful in the individual patient. We feel each patient with clinical stage A disease must be informed of alternative methods of management and be allowed to choose the method of management that he feels best suits his needs in terms of risk benefit.     

Body mass and stage of breast cancer at diagnosis

Obesity is a well-known risk factor for postmenopausal breast cancer. In contrast, the relationship between obesity and stage of breast cancer at diagnosis is less clear. We hypothesized that increased breast size in obese women may delay discovery of breast tumors. Thus, the purpose of our study was to examine whether there is an association between body mass and stage of breast cancer at diagnosis using hospital medical records. Newly diagnosed breast cancer cases (n = 966) in the Baltimore metropolitan area from 1991 to 1997 were included in our study. Patient information including age, ethnicity, weight, height and pathology data were obtained from hospital medical records. High body mass was significantly associated with late stage of breast cancer at diagnosis. Women who were obese (body mass index [BMI] > or = 27.3) were more likely to be at an advanced stage at diagnosis compared with women with a BMI of < 27.3 (multivariate-adjusted odds ratio [OR] 1.57, 95% confidence interval [CI] 1.15-2.14). The association between body mass and stage at diagnosis was stronger among women younger than 50 years (OR 2.34, 95% CI 1.34-4.08) compared with women 50 years or older (OR 1.30, 95% CI 0.89-1.91). Our study suggests that higher body mass is associated with advanced stage of breast cancer at diagnosis. This finding may be of considerable concern, given the increasing prevalence of obesity in women in the United States and the poor prognosis associated with late-stage tumors.     

Breast self examination and breast cancer stage at diagnosis

The relationship between breast self examination (BSE) and breast cancer stage at diagnosis was examined in 616 women aged 15-59 years. Differences in tumour characteristics between those not practising BSE and those practising but not taught were small and inconstant. However, women who had both practised and had been taught BSE had more favourable tumours than the non-practising group. The difference was most marked in terms of tumour size and the involvement of axillary nodes. The proportions of women in the non-BSE and taught-BSE groups with each characteristic were respectively: size less than or equal to 2 cm 33% and 45%, T1 clinical stage 27% and 42%, and N0 pathological stage 37% and 50%. This advantage to taught-BSE women persisted after adjustment for the identified confounding factors of age, social class and oral contraceptive use. The likely impact on breast cancer mortality is difficult to assess, although the potential benefit of the lead time gained must not be ignored when assessing the costs and benefits of BSE.     

Effects of obesity on breast cancer stage at diagnosis in Korean women.

This study was carried out to test the hypothesis that palpation for lumps may be more difficult in large breasts than in small breasts, resulting in a delay in the detection and diagnosis of breast cancer, and to determine whether this hypothesis is confirmed in Asian women. Of 833 new breast cancer patients registered in the Daegu Cancer Registry in 1997-1999, 579 were used in the final data analysis, after excluding patient records containing many missing data on study variables related with cancer staging. There was no difference in means of body mass index (BMI) according to tumour, either in all cases or in those under 49 years of age. In the 50+ age group, the means+/-standard deviations of BMI of T1, T2 and T3 were 23.7+/-2.8, 24.2+/-3.0, and 26.2+/-4.3, respectively (P=0.01). In univariate logistic regression of tumour characteristics with BMI, no statistically significant odds ratios were found either by continuous or quartiles of BMI. In conclusion, these results suggest that the hypothesis is partially confirmed in Korean breast cancer patients and further studies are needed to clarify the relationship between BMI and tumour stage at diagnosis.     

Combination therapy in stage C and D prostatic cancer: rationale and five-year clinical experience

In 1941, Huggins and his colleagues discovered that testicular androgens exert a stimulatory effect on prostate cancer growth. Our group has made the key observations that the human adrenals, in addition to the tests, also secrete important amounts of androgens and cancer cells exhibit a marked heterogeneity of androgen sensitivity. In fact, human adrenals secrete large amounts of precursor steroids that are converted into active androgens in peripheral tissues (including the prostate), thus providing 40% to 50% of total androgens in adult men. The action of these androgens remaining after castration can be inhibited in prostatic cancer tissue by administering a pure antiandrogen that also decreases the local concentration of dihydrotestosterone (DHT). The castration levels of serum testosterone left in men after castration have an important stimulatory activity on the growth of androgen-sensitive normal as well as cancer tissues. Cancer cells have markedly different requirements for androgens. Some cell clones can grow in the presence of minimal amounts of androgens, requiring more complete androgen blockade and more potent antiandrogens for inhibiting growth. Among the compounds recommended as antiandrogens, the most unexpected finding is that many of them are devoid of any antiandrogenic activity. In fact, medroxyprogesterone acetate, chlormadinone acetate, and megestrol acetate have androgenic activity, but do not inhibit the peripheral action of DHT in prostatic tissue. These compounds should not be classified as antiandrogens. Cyproterone acetate, on the other hand, is a mixed agonist-antagonist. The only compounds showing pure antiandrogenic activity are Flutamide and its analogues.There is thus a need for a more complete blockade of androgens of both testicular and adrenal origins in order to exert a maximal inhibitory effect on cancer growth. We have therefore performed clinical studies in previously untreated stage D₂ and C prostate cancer patients with the combination therapy using the LHRH agonist [D-Trp⁶, des Gly NH₂ ¹⁰] LHRH ethylamide and the antiandrogen Flutamide. There was a significant increase in patients with a complete response, as compared with studies limited to the removal or blockade of testicular androgens. There was also a significant decrease in the number of non-responders, an increased duration of positive response, and a decrease in the death rate. This was achieved with minimal or no side effects, thus preserving a good quality of life.     

Socioeconomic disparities in breast cancer survival: relation to stage at diagnosis, treatment and race

Background  

Previous studies have documented lower breast cancer survival among women with lower socioeconomic status (SES) in the United States. In this study, I examined the extent to which socioeconomic disparity in breast cancer survival was explained by stage at diagnosis, treatment, race and rural/urban residence using the Surveillance, Epidemiology, and End Results (SEER) data.