Breast cancer incidence in young women by estrogen receptor status and race.

A population-based study was utilized to calculate breast cancer incidence rates in White and Black women, ages 30 to 54, according to tumor estrogen receptor status. Both racial groups had higher incidence curves for estrogen receptor negative breast cancer between ages 30 and 49. There was an excess of receptor negative cancer in young Black women, an observation that may help explain the racial disparity in breast cancer survival.     

Impact of Neighborhood Racial Composition and Metropolitan Residential Segregation on Disparities in Breast Cancer Stage at Diagnosis and Survival Between Black and White Women in California

We examined the impact of metropolitan racial residential segregation on stage at diagnosis and all-cause and breast cancer-specific survival between and within black and white women diagnosed with breast cancer in California between 1996 and 2004. We merged data from the California Cancer Registry with Census indices of five dimensions of racial residential segregation, quantifying segregation among Blacks relative to Whites; block group (“neighborhood”) measures of the percentage of Blacks and a composite measure of socioeconomic status. We also examined simultaneous segregation on at least two measures (“hypersegregation”). Using logistic regression we examined effects of these measures on stage at diagnosis and Cox proportional hazards regression for survival. For all-cause and breast-cancer specific mortality, living in neighborhoods with more Blacks was associated with lower mortality among black women, but higher mortality among Whites. However, neighborhood racial composition and metropolitan segregation did not explain differences in stage or survival between Black and White women. Future research should identify mechanisms by which these measures impact breast cancer diagnosis and outcomes among Black women.     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

Engaging diverse underserved communities to bridge the mammography divide

Background  

Breast cancer screening continues to be underutilized by the population in general, but is particularly underutilized by traditionally underserved minority populations. Two of the most at risk female minority groups are American Indians/Alaska Natives (AI/AN) and Latinas. American Indian women have the poorest recorded 5-year cancer survival rates of any ethnic group while breast cancer is the number one cause of cancer mortality among Latina women. Breast cancer screening rates for both minority groups are near or at the lowest among all racial/ethnic groups. As with other health screening behaviors, women may intend to get a mammogram but their intentions may not result in initiation or follow through of the examination process. An accumulating body of research, however, demonstrates the efficacy of developing 'implementation intentions' that define when, where, and how a specific behavior will be performed. The formulation of intended steps in addition to addressing potential barriers to test completion can increase a person's self-efficacy, operationalize and strengthen their intention to act, and close gaps between behavioral intention and completion. To date, an evaluation of the formulation of implementation intentions for breast cancer screening has not been conducted with minority populations.     

Black Women’s Awareness of Breast Cancer Disparity and Perceptions of the Causes of Disparity

Black women face the greatest breast cancer mortality burden of any racial or ethnic group in the United States. Breast cancer disparity is particularly pronounced in Chicago, where Black women were 62 percent more likely to die of breast cancer than their White counterparts in 2007. No work to date has examined views of disparity among a population living in the context of a large, well-documented, and grave health disparity. We examined (1) awareness of breast cancer disparities among Black women in Chicago; and (2) Black women’s perceptions of the causes of breast cancer disparity. Four focus groups with Black women were held in Chicago. Participants completed a brief survey about their views of breast cancer prior to the group discussion. In response to the survey question, “In your opinion, who is more likely to die from breast cancer?” 51 % of participants believed all women have the same chance of dying from breast cancer. In focus group discussions, participants placed responsibility for disparity on individual behaviors and community culture. Participants believed that disparity resulted from Black women’s lack of awareness of cancer screening and their failure to be screened or treated for breast cancer. The majority of participants were unaware of breast cancer mortality disparities. Moreover, while health researchers and professionals believe disparity in Chicago results from healthcare system inequalities, Black women largely viewed breast cancer disparity as a consequence of individual behaviors, knowledge and attitudes.     

Mammography screening and differences in stage of disease by race/ethnicity

OBJECTIVES: We examined the effect of routine screening on breast cancer staging by race/ethnicity. METHODS: We used a 1990 to 1998 mammography database (N = 5182) of metropolitan Denver, Colo, women to examine each racial/ethnic cohort's incident cancer cases (n = 1902) and tumor stage distribution given similar patterns of routine screening use. RESULTS: Regardless of race/ethnicity, women participating in routine screenings had earlier-stage disease by 5 to 13 percentage points. After control for possible confounding factors, White women were more likely to have early-stage disease compared with Black and Hispanic women. CONCLUSIONS: Lack of screening coverage in certain racial/ethnic populations has often been cited as a reason for tumor stage differences at detection. In this study, correcting for screening did not completely reduce stage differentials among Black and Hispanic women.     

Residential Racial Composition,Spatial Access to Care,and Breast Cancer Mortality among Women in Georgia

We explored the association between neighborhood residential racial composition and breast cancer mortality among Black and White breast cancer patients in Georgia and whether spatial access to cancer care mediates this association. Participants included 15,256 women living in 15 metropolitan statistical areas in Georgia who were diagnosed with breast cancer between 1999 and 2003. Residential racial composition was operationalized as the percent of Black residents in the census tract. We used gravity-based modeling methods to ascertain spatial access to oncology care. Multilevel Cox proportional hazards models and mediation analyses were used to test associations. Black women were 1.5 times more likely to die from breast cancer than White women. Residential racial composition had a small but significant association with breast cancer mortality (hazard ratios [HRs] = 1.04–1.08 per 10% increase in the percent of Black tract residents). Individual race did not moderate this relationship, and spatial access to care did not mediate it. Residential racial composition may be part of the socioenvironmental milieu that produces increased breast cancer mortality among Black women. However, there is a lack of evidence that spatial access to oncology care mediates these processes.     

Disparities in breast cancer treatment among American Indian, Hispanic and non-Hispanic White Women Enrolled in Medicare

Because racial/ethnic disparities in breast cancer survival have persisted, we investigated differences in breast cancer treatment among American Indian, Hispanic, and non-Hispanic White (NHW) women. Surveillance, Epidemiology and End Results data linked to Medicare claims in New Mexico and Arizona (1987-1997) among enrollees aged 65 and older were used to identify treatment, treatment interval, and mortality risk associated with delays in care. We identified 2,031 women (67 American Indian, 333 Hispanic and 1,631 NHW women with time to treatment information. Treatment intervals from diagnosis to surgery (all stages, 18 versus 4 days, p.     

Variation in mammographic breast density by race

PURPOSE: Because of the observed racial differences in risk of developing breast cancer, the authors conducted a study to determine the variation in breast density, a strong predictor of breast cancer risk, by race and age. METHODS: Study subjects were women enrolled in Group Health Cooperative of Puget Sound, Seattle, WA, aged 20-79 years, who had a screening mammogram between 6/1/96 and 8/1/97. Women with increased breast density (BI-RADS "heterogeneously dense" and "extremely dense") (n = 14,178) were compared to those with fatty breasts (BI-RADS "almost entirely fat" and "scattered fibroglandular tissue") (n = 14,323). Logistic regression was used with adjustment for age, parity, age at first birth, menopausal status, current use of hormone replacement therapy, and body mass index. RESULTS: The odds ratio (OR) for having dense breasts versus fatty breasts, comparing Asian to White women, increased from 1.2 [95% confidence interval (CI) 0.9-1.6] for women age <45 to 1.6 (95% CI 1.3-2.2) for women over 65. Conversely, the OR for Black compared to White women was highest for the women age 65 and younger (OR 1.7 (1.2-2.3), 1.3(1.0-1.7), and 1.7 (1.2-2.3) for women age <45, 46-55, and 56-65, respectively), whereas Black women over 65 had similar density as Whites. Hispanic women had similar density compared to Whites for all ages. CONCLUSIONS: These racial differences in breast density generally do not conform to differences in race and age-specific breast cancer incidence rates.     

Pap smear use in California: are we closing the racial/ethnic gap?

BACKGROUND: Minority women continue to be disproportionately affected by cervical cancer. Minority population groups at high risk for cervical cancer may be failing to fully comply with screening recommendations. The use of Pap smears among women in California was evaluated to identify ethnic groups at higher risk for noncompliance with cervical cancer screening. METHODS: Cross-sectional analysis of 2001 California Health Interview Survey data. Logistic regression was used to assess the independent contribution of race/ethnicity to the use of Pap smears. RESULTS: Hispanic (aPR = 1.03, 95% CI 1.02-1.05) and Black (aPR = 1.03, 95% CI 1.001-1.06) women are more likely to report a Pap smear in the past 3 years as compared to White women. Asians were the least likely to report cervical cancer screening despite a more favorable sociodemographic profile. Screening rates varied among Hispanic or Asian subgroups; Mexicans, Vietnamese, Chinese, and South Asians are particularly underserved. CONCLUSIONS: In contrast to the country as a whole, Hispanic women in California are more likely to report a recent Pap smear as compared to White women. However, racial/ethnic disparities in Pap smear use persist; Asian women are the least likely to report cervical cancer screening as compared to any other group.     

Recent trends in breast cancer mortality among white and black US women.

OBJECTIVES: Time trends in breast cancer mortality were analyzed from 1970 to 1992 among White and Black US women aged 25 and over. METHODS: Mortality data from the National Center for Health Statistics were summarized within three periods 1970 to 1979, 1980 to 1988, and 1989 to 1992. The annual change was calculated as the average yearly percentage of change based on the logistic model. RESULTS: For White women of all ages, breast cancer mortality decreased by 1.6% (95% confidence interval = -2.0%, -1.1%) per year on average during 1989 to 1992, in contrast to the flat mortality rates observed during the 1970s and a 0.5% average annual increase during 1980 to 1988. The decline was observed for White women under age 60, among whom breast cancer mortality had been decreasing, and for White women aged 60 to 79, among whom breast cancer mortality had been increasing, but it was not observed among Black women. CONCLUSIONS: The long-awaited decline in US breast cancer mortality has finally appeared, although only among White women. The possible contributions are changes in inherent risk of disease, changes in treatment effectiveness, and increased use of screening mammography.     

An assessment of American Indian women's mammography experiences

Background  

Mortality from breast cancer has increased among American Indian/Alaskan Native (AI/AN) women. Despite this alarming reality, AI/AN women have some of the lowest breast cancer screening rates. Only 37% of eligible AI/AN women report a mammogram within the last year and 52% report a mammogram within the last two years compared to 57% and 72% for White women. The experiences and satisfaction surrounding mammography for AI/AN women likely are different from that of women of other racial/ethnic groups, due to cultural differences and limited access to Indian Health Service sponsored mammography units. The overall goals of this study are to identify and understand the mammography experiences and experiential elements that relate to satisfaction or dissatisfaction with mammography services in an AI/AN population and to develop a culturally-tailored AI/AN mammography satisfaction survey.     

Multiple mediation analysis with survival outcomes: With an application to explore racial disparity in breast cancer survival

Mediation analysis allows the examination of effects of a third variable in the pathway between an exposure and an outcome. The general multiple mediation analysis method, proposed by Yu et al, improves traditional methods (eg, estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. In this paper, we extend the method for time-to-event outcomes and apply the method to explore the racial disparity in breast cancer survivals. Breast cancer is the most common cancer and the second leading cause of cancer death among women of all races. Despite improvement of survival rates of breast cancer in the US, a significant difference between white and black women remains. Previous studies have found that more advanced and aggressive tumors and less than optimal treatment may explain the lower survival rates for black women as compared to white women. Due to limitations of current analytic methods and the lack of comprehensive data sets, researchers have not been able to differentiate the relative effect each factor contributes to the overall racial disparity. We use the CDC-funded Patterns of Care study to examine the determinants of racial disparities in breast cancer survival using a novel multiple mediation analysis. Using the proposed method, we applied the Cox hazard model and multiple additive regression trees as predictive models and found that all racial disparity in survival among Louisiana breast cancer patients were explained by factors included in the study.     

Ethnicity and birthplace in relation to tumor size and stage in Asian American women with breast cancer.

OBJECTIVES: This study examined whether Asian American women with breast cancer have tumor characteristics associated with delayed detection of their disease. METHODS: Breast cancer size and stage were examined in relation to subjects' ethnic group and birthplace, on the basis of Surveillance, Epidemiology, and End Results program data. RESULTS: Asian-born Asian American women with breast cancer had a greater proportion of tumors larger than 1 cm at diagnosis (79%) than did US White women (70%) (P < .001). In contrast, the proportion of tumors larger than 1 cm among Asian American women born in the United States (67%) did not differ significantly from that among US White women. CONCLUSIONS: Lower utilization of breast cancer screening by Asian-born Asian American women is probably responsible for their greater proportion of tumors larger than 1 cm relative to US White women in the study population. Interventional measures should be taken to increase the use of mammographic screening by first-generation Asian American women.     

Psychosocial factors influencing breast cancer risk appraisal among older women

Although the incidence of breast cancer increases with age, many older women are uninformed about the increased risk and have lower mammography screening rates than younger women. Understanding older women's perceptions of risk might assist health care providers in offering appropriate resources that result in screening. In this study, we explored psychosocial components influencing older women's breast cancer risk appraisal. To identify key psychosocial components of breast cancer risk appraisal, we conducted focus group interviews. Data saturation occurred with four groups (N = 36) of older Black (58%) and White (42%) women with no prior history of breast cancer. On analysis of the data, we found three themes representing psychosocial factors influencing breast cancer risk appraisal with this cohort. Our findings revealed that worry/fear/anxiety, self-regulating empowerment, and realistic optimism were psychosocial mechanisms older Black and White women in this sample used in appraising breast cancer risk.     

Socioeconomic disadvantage, parenting responsibility, and women's smoking in the United States

OBJECTIVES: We carried out analyses of smoking in relation to poverty and child care responsibility among women aged 18-54 years residing in the United States. METHODS: With data from the Behavioral Risk Factor Surveillance System, we assessed the interaction effects of poverty and living with young children on maternal smoking behavior among 61,700 women aged 18-54 years in 4 different racial/ethnic groups. RESULTS: For non-White racial/ethnic groups, the prevalence of smoking among women with small children in the household was lower than that among women without small children. However, White women were more likely to smoke if they were poor and living with small children (odds ratio=1.14, 95% confidence interval=1.03, 1.26). CONCLUSIONS: These results suggest that child care responsibility confers an increased risk of smoking among low-income White women.     

Patient-physician racial and ethnic concordance and perceived medical errors

In this paper, I use nationally representative survey data to examine the relationship between patient-physician racial/ethnic concordance and perceived medical errors in the USA. After adjusting for potential confounding factors, we find that White patients treated by White physicians have 33% lower odds of reporting medical errors than White patients treated by non-White physicians. In contrast, patient-physician racial/ethnic concordance has no effect on perceived medical errors among non-White patients. The results suggest that the role of racial/ethnic concordance in perceptions of health care safety varies by patients' racial/ethnic background.     

Risk factors for fatal breast cancer in African-American women and White women in a large US prospective cohort

African-American women have a higher lifetime risk of fatal breast cancer than do White women. Recent studies suggest that breast cancer risk factors may vary by race. The authors examined risk factors for fatal breast cancer in postmenopausal African-American women and White women in a large US prospective cohort. In 1982, 21,143 African-American women and 409,093 White women in the Cancer Prevention Study II completed a questionnaire on reproductive, medical, anthropometric, and demographic factors. During a 20-year follow-up, 257 deaths from breast cancer occurred among African-American women and 4,265 among Whites. Cox proportional hazards modeling was used to calculate multivariate-adjusted rate ratios, stratified by race. Higher body mass index, taller height, and physical inactivity were associated with increased breast cancer mortality rates in both groups. A college education was associated with higher mortality from breast cancer only in Africa-American women (hazard ratio = 1.62, 95% confidence interval: 1.13, 2.30; p(trend) = 0.01, vs. less than a high school education). Most other risk factors were associated with breast cancer rates similarly in both groups. With few exceptions, established breast cancer risk factors were similarly associated with risk of death from breast cancer among African-American women and White women.     

Comparative analysis of breast cancer risk factors among African-American women and White women

The authors assessed risk factor profiles among 1,505 African-American and 1,809 White women in the 1993-2001 Carolina Breast Cancer Study. Multiple logistic regression models for case-control data were used to estimate odds ratios for several factors. Racial differences were observed in the prevalence of many breast cancer risk factors among both younger (aged 20-49 years) and older (aged 50-74 years) women. For older women, the magnitude and direction of associations were generally similar for African-American and White women, but important racial differences were observed among younger women. In particular, multiparity was associated with increased risk of breast cancer among younger African-American women (for three or four pregnancies: adjusted odds ratio (OR) = 1.5, 95% confidence interval (CI): 0.9, 2.6; for five or more pregnancies: OR = 1.4, 95% CI: 0.6, 3.1) but not among younger White women (for three or four pregnancies: OR = 0.7, 95% CI: 0.4, 1.2; for five or more pregnancies: OR = 0.8, 95% CI: 0.2, 3.0). The relations with age at first full-term pregnancy and nulliparity also varied by race. Case-only analyses before and after further adjustment for tumor stage and hormone receptor status revealed little effect on results. Hence, racial variations in both prevalences of and risks associated with particular factors may contribute to the higher incidence of breast cancer among younger African-American women.     

Racial trends in age-specific breast cancer mortality rates in US women

OBJECTIVES: This study examined recent trends in age- and race-specific patterns of breast cancer mortality. METHODS: We analyzed breast cancer mortality data for 1979 through 1996. RESULTS: From 1993 to 1996, White women of all age groups experienced average annual decreases in breast cancer mortality. Throughout the study, young Black women had higher rates of breast cancer mortality than young White women. Older Black women had lower mortality rates than older White women in the earlier years of the study but experienced higher rates in the later years (1993-1996). CONCLUSIONS: Trends in risk factors and early detection do not provide an adequate explanation for this recent substantial increase in breast cancer mortality among older Black women.