The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care

BACKGROUND:

Few data are available on how race/ethnicity, insurance, and socioeconomic status (SES) interrelate to influence breast cancer treatment. The authors examined care for a national cohort of breast cancer patients to assess whether insurance and SES were associated with racial/ethnic differences in care.

METHODS:

The authors used multivariate logistic regression to assess the probability of definitive locoregional therapy, hormone receptor testing, and adjuvant systemic therapy among 662,117 white, black, and Hispanic women diagnosed with invasive breast cancer during 1998‐2005 at National Cancer Data Base hospitals. In additional models, the authors included insurance and area‐level SES to determine whether these variables were associated with observed racial/ethnic disparities.

RESULTS:

Most women were white (86%), 10% were black, and 4% were Hispanic. Most had private insurance (51%) or Medicare (41%). Among eligible patients, 80.0% (stage I/II) had definitive locoregional therapy, 98.5% (stage I‐IV) had hormone receptor testing, and 53.1% and 50.2% (stage I‐III) received adjuvant hormonal therapy and chemotherapy, respectively. After adjustment, black (vs white) women had less definitive locoregional therapy (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.88‐0.94), hormonal therapy (OR, 0.90; 95% CI, 0.87‐0.93), and chemotherapy (OR, 0.87; 95% CI, 0.84‐0.91). Hispanic (vs white) women were also less likely to receive hormonal therapy. Hormone receptor testing did not differ by race/ethnicity. Racial disparities persisted despite adjusting for insurance and SES.

CONCLUSIONS:

The modest association between black (vs white) race and guideline‐recommended breast cancer care was insensitive to adjustment for insurance and area‐level SES. Further study is required to better understand disparities and to ensure receipt of care. Cancer 2011. © 2010 American Cancer Society.     

Disparities in breast cancer characteristics and outcomes by race/ethnicity

Breast cancer (BC) survivors are at increased risk of second cancers. Obesity is commonly recognized as a risk factor of BC in postmenopausal period and a prognosis factor in BC regardless of menopausal status. Our aim was to study whether overweight BC survivors were at increased risk of contralateral BC (CBC). Our population was a large cohort of women followed since a first BC without distant spread and/or synchronous CBC. Body mass index (BMI) was assessed at diagnosis time. Binary codings of BMI were used to oppose overweight and obese patients to the others. Survival analyses were used including Cox models. Assumed hypothesis of proportional hazards was explored using graphical methods, Schoenfeld residuals and time-dependant covariates. In case of non-proportional hazards, survival models were computed over time periods. Over 15,000 patients were included in our study. Incidence of CBC was 8.8 (8.3–9.3)/1000 person-years and increased during follow-up. A significant time-dependent association between overweight and CBC was observed. After 10 years of follow-up, we found a significant increased hazard of CBC among patients with a BMI above 25 kg/m²: the adjusted hazard ratio was 1.50(1.21–1.86), P = 0.001. After 10 years of follow-up, our study found a poorer prognosis among overweight BC survivors regarding CBC events. While benefits from diet habits and weight control may be expected during the long-term follow-up, they have yet to be established using randomized clinical trials.     

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.     

HLA and prognostic factors in primary breast cancer

A group of 157 women with primary breast cancer (BC) were typed for HLA antigens, and gene frequencies were compared to those of 327 control healthy individuals. Diagnosis of BC was made for all patients on surgical mastectomy specimens; histologic grading, estrogen (ER) and progesterone (PgR) receptors were determined on all primary tumors. Typed antigens included the majority of the specificities controlled by the HLA-A, -B and -C loci, according to the 8th International Histocompatibility Testing Workshop recommendations. No significant discrepancy in their frequencies was found in the undivided sample as compared to controls. The analysis of HLA gene frequency was extended to subsets of patients identified by the following prognostic features: (a) age at tumor diagnosis (pre-menopause vs. post-menopause); (b) receptor status (presence vs. absence of ER and PgR); (c) mammary gland dysplasia (presence vs. absence); (d) histologic grade (grade 3 vs. grades 1 and 2 combined); (e) time to relapse before or after 24 months following mastectomy). A moderate deviation from normal of some genes was found in several subsets, often affecting only one of the antithetical subgroups (feature present vs. feature absent). In the instance of B5, the increase in frequency of the gene in one of the subset pair (ER + subjects) was balanced by a decrease of the same gene in the counterpart (ER-subjects). Increased frequencies were found for the B7 gene in the following prognostic groups: (a) lack of ER (0.08); (b) lack of PgR (0.09); (c) absence of mammary dysplasia (0.075); (d) histologic grade 3 (0.10); and (e) premenopause (0.12), the last two showing significant divergence from normal. When features (d) and (e) on the one hand and (a), (b), (d) and (e) on the other were combined, B7 reached frequencies of 0.18 (p less than 5 X 10(-4] and of 0.29 (p less than 5 X 10(-6], respectively.     

Utilizing prognostic and predictive factors in breast cancer

Opinion statement In order to make optimal treatment recommendations for patients with early-stage breast cancer, it is essential to accurately determine the patient’s underlying risk of disease recurrence and choose a therapy to which the individual is most likely to respond. Lymph node status, tumor size, histopathologic features including tumor type and grade, and hormone receptor status are well-accepted prognostic factors related to breast cancer. In addition, hormone receptor status is a very strong predictor of response to hormonal therapy. However, our currently accepted prognostic and predictive factors fall short and there is a critical need to more accurately identify those most likely to require or benefit from particular therapies. Attention has therefore focused on the determination of novel prognostic and predictive factors. The most promising new factor is the level of urokinase plasminogen activator and its inhibitor plasminogen activator inhibitor. Other putative factors include proliferative rate, the presence of lymphatic or vascular invasion, human epidermal growth factor receptor 2 (HER-2/neu or erbB-2) positivity, the presence of micrometastases in lymph nodes or bone marrow, and gene expression profile by microarray analysis, and by RNA-based methodology. Data regarding potential new prognostic factors are constantly emerging. These studies are frequently challenging to interpret as they are often retrospective, based on relatively small numbers of patients, include a mix of treated and untreated women, and often do not control for other known prognostic factors. Therefore, new data must be interpreted with caution.     

Dietary habits and prognostic factors in breast cancer

The relationship between dietary habits and prognostic factors for breast cancer was studied in 240 women aged 50-65 years who had surgery for breast cancer between 1983 and 1986. A dietary history interview was conducted within the 4 months following resection of the primary tumor. In the stepwise multivariate analysis, the multiple-odds ratio (OR) for having a tumor greater than or equal to 20 mm in diameter was 0.95 (95% confidence interval, 0.91-0.99) for each 1-g increase in fiber intake per 10 MJ of energy intake. Compared with patients having tumors poor in estrogen receptor (ER), those having ER-rich tumors (greater than or equal to 0.10 fmol/microgram of DNA) were older (P less than .01) and reported carbohydrate intake yielding higher E% (percentage of total energy intake) (P less than .01) and higher retinol intake per 10 MJ (P less than .05). The OR for having an ER-rich tumor was 1.58 (95% confidence interval, 1.08-2.31) for each 1-mg increase in retinol intake per 10 MJ; 1.09 (95% confidence interval, 1.02-1.16) for each additional year of age; and 1.08 (95% confidence interval, 1.02-1.13) for each 1% increment in E% from carbohydrates. These results suggest that the dietary patterns of the western world (e.g., high fat intake and low intake of carbohydrates and fiber) affect certain prognostic factors in breast cancer, such as tumor size and ER content of the tumor.     

Evaluation of prognostic factors in breast cancer

The survival of the patients with breast cancer depends on many factors. The TNM system, which is the most widely used prognostic system takes into account only the size, and the local extension of the tumor, and presence or not of axillary or supraclavicular lymph nodes. The axillary nodes involvement is the single precise prognostic variable. However, other valuable and important factors are to be considered. As a matter of fact, the growth rate of the tumors, their estrogen and progesterone receptor status, and their histopathological grade may reflect with a better accuracy the tumor biology, and should be integrated among the variables to study before the choice of an adjuvant treatment.     

The prognostic contribution of clinical breast cancer subtype, age, and race among patients with breast cancer brain metastases

BACKGROUND:

Brain metastases (BM) arising from triple‐negative breast cancer (TNBC) portend a poor prognosis. TNBC is more common in premenopausal and African‐American (AA) patients; both of these characteristics also confer a poor prognosis. In a single‐institution cohort study, the authors attempted to determine whether the inferior outcome noted with TNBC brain metastases is more reflective of a higher risk population or the subtype itself.

METHODS:

The University of North Carolina Breast Cancer Database identified patients with BC brain metastases who were diagnosed between 1988 and 2008. BC subtype was assigned by immunohistochemistry: hormone receptor (HR) positive (+);(HR, estrogen receptor [ER]+ and/or progesterone receptor [PR]+)/human epidermal growth factor receptor 2 (HER2) negative (‐), HR+/HER2+, HR‐/HER2+, and TN (ER‐/PR‐/HER2‐). Survival and disease recurrence patterns were evaluated by subtype, patient age (<40 years vs ≥40 years), and race (AA vs non‐AA) using the Kaplan‐Meier method and Cox regression analysis.

RESULTS:

Among 119 patients with BC brain metastases, 33% were AA and 31% were aged <40 years. BC subtype was confirmed in 98 patients (30% with HR+/HER2‐, 21% with HR+/HER2+, 18% with HR‐/HER2+, and 31% with TNBC). Survival after BM was found to be impacted by subtype (P = .002), and was shortest for patients with TNBC (0.24 years; 95% confidence interval, 0.17 years‐0.48 years). There were no age‐specific (P = .84) or race‐specific (P = .09) differences in survival noted after brain metastases; stratification of BC subtypes by age and race revealed no difference (all, P > .1). The receipt of systemic therapy after BC brain metastases was found to be an important predictor of survival after BC brain metastases (hazard ratio, 0.29; P = .002) when adjusted for race, age, number of central nervous system lesions, and BC subtype.

CONCLUSIONS:

TNBC confers a high risk of death after brain metastases regardless of patient race and age, supporting the need for novel agents capable of controlling both intracranial and extracranial TNBC across all races and ages. Cancer 2011. © 2010 American Cancer Society.     

Current status of prognostic profiling in breast cancer

Breast cancer is a clinically heterogeneous disease that can affect individuals with seemingly identical clinicopathologic parameters differently. This clinical heterogeneity is driven to a large extent by abnormal gene expression within tumors. Investigators now have the ability to identify the gene-expression fingerprint of an individual's tumor. This information may be used to rationally design therapeutic targets in the future, and also to predict the clinical course of an individual's disease, including response to a specific treatment. Genetic profiles of tumors are now being correlated with clinical outcome, and several prognostic and predictive indicators have emerged based on this research. There are at least four commercially available predictive or prognostic tests, and several more are looming on the horizon. The data gathered from these tests augment standard diagnostic and prognostic information obtained from traditional clinical pathological variables. The advent of gene-profiling technologies started to change the conduct of clinical trials. In the not too distant future, prospective tissue collection for molecular analysis may become routine in order to stratify patients for treatment arms and to optimize treatment strategies based on molecular features of the cancer. Coordinated efforts among oncologists, pathologists, surgeons, laboratory scientists, statisticians, and regulators will be essential in the quest to incorporate genetic profiling and molecular hypotheses into clinical trial planning and conduct.     

Prevalence and prognostic role of triple-negative breast cancer by race: a surveillance study

Introduction

Emerging research suggests a substantially greater prevalence of the adverse triple-negative (TN) subtype (human epidermal growth factor receptor [HER]2⁻, estrogen receptor [ER]⁻, and progesterone receptor [PR])⁻) among black patients with breast cancer. No reports however have been generated from a statewide cancer registry.

Patients and Methods

The study consisted of all black patients (N = 643) and a random sample of white patients (n = 719) diagnosed with primary invasive breast cancer (2000-2003) listed in the National Cancer Institute–Surveillance Epidemiology and End Results (NCI-SEER) Connecticut Tumor Registry (CTR). HER2 status was obtained from pathology reports submitted to the registry. Remaining data were obtained from the registry database.

Results

TN tumors were more prevalent in black compared with white patients (30.8% vs. 11.2%, respectively; P < .001.) There was a 2-fold greater frequency of ER⁻ and PR⁻ phenotypes among black patients, but HER2 status did not differ by race. Patients with lobular cancer were less likely to have TN breast cancer compared with patients with ductal tumors (odds ratio [OR] = 0.23; 95% confidence interval [CI], 0.10-0.58). Among patients with regional disease, black patients exhibited increased risk of death (relative risk [RR] = 2.71; 95% CI, 1.48-4.97) independent of TN status. No survival disparity was found among patients with local disease.

Discussion

These registry-based data corroborate reports that TN breast cancer varies substantially by race and histologic subtype. A survival disparity among patients with advanced disease, but not local disease, casts some doubt on TN status as an explanation for differences.

Conclusion

More research is warranted to understand why black patients with advanced breast cancer may be at increased risk for death whether or not their tumors express the TN phenotype.     

Relationship between epidermal growth factor receptor status and various prognostic factors in human breast cancer

Relationship between epidermal growth factor receptor (EGFR) status and various prognostic factors was investigated in 91 human breast cancer tissues. Epidermal growth factor receptor was measured by biochemical competitive binding assay using iodine 125 epidermal growth factor (125I)-EGF. The EGFR status was not correlated with axillary lymph node involvement, tumor size, stage, and histologic type, but significantly correlated with histologic grading (P less than 0.05) and lymphatic invasion (P less than 0.01). Between EGFR and estrogen receptor (ER) status, a clear inverse relationship was observed (P less than 0.01). The Ki-67-positive stained cell rate, which reveals the proportion of cycling cells, was significantly higher in EGFR-positive tumor tissues than in EGFR-negative cases. Furthermore, preliminary postoperative survey demonstrated a high tendency of recurrence rate of patients with EGFR-positive tumors as compared with those with EGFR-negative tumors. These data suggest that EGFR status may be important for the prediction of biologically high malignant potential.     

Trends in breast cancer by race and ethnicity

In this article, the American Cancer Society (ACS) describes trends in incidence, mortality, and survival rates of female breast cancer in the United States by race and ethnicity. It also provides estimates of new cases and deaths and shows trends in screening mammography. The incidence and survival data derive from the National Cancer Institute's Surveillance, Epidemiology, and End Results program; mortality data are from the National Center for Health Statistics. Approximately 211,300 new cases of invasive breast cancer, 55,700 in situ cases, and 39,800 deaths are expected to occur among women in the United States in 2003. Breast cancer incidence rates have increased among women of all races combined and white women since the early 1980s. The increasing rate in white women predominantly involves small (< or = 2 cm) and localized-stage tumors, although a small increase in the incidence of regional-stage tumors and those larger than five cm occurred since the early 1990s. The incidence rate among African American women stabilized during the 1990s for all breast cancers and for localized tumors. African American women are more likely than white women to be diagnosed with large tumors and distant-stage disease. Other racial and ethnic groups have lower incidence rates than do either white or African American women. However, the proportion of disease diagnosed at advanced stage and with larger tumor size in all minorities is greater than in white persons. Death rates decreased by 2.5% per year among white women since 1990 and by 1% per year among African American women since 1991. The disparity in mortality rates between white and African American women increased progressively between 1980 and 2000, so that by 2000 the age-standardized death rate was 32% higher in African Americans. Clinicians should be aware that 63% and 29% of breast cancers are diagnosed at local- and regional-stage disease, for which the five-year relative survival rates are 97% and 79%, respectively. This information, coupled with decreasing mortality rates and improvements in treatment, may motivate women to have regular mammographic and clinical breast examinations. Continued efforts are needed to increase the availability of high-quality mammography and treatment to all segments of the population.     

New prognostic factors for breast cancer recurrence

Decisions regarding the use of adjuvant therapy for breast cancer are strongly influenced by the risk of disease recurrence and death. These risks are now determined by examining the currently recognized breast cancer prognostic factors including clinical stage, axillary nodal status, tumor size and grade, hormone receptor status, and presence of lymphovascular involvement. Newer factors are being evaluated in an attempt to more precisely define disease-related prognosis. This article provides an overview of issues that need to be considered when analyzing studies of prognostic factors, as well as a review of the currently recognized and the newer candidate prognostic factors.     

Profiles of tamoxifen-related side effects by race and smoking status in women with breast cancer

Background: Tamoxifen (TAM) is a selective estrogen receptor modulator (SERM) that is widely used as adjuvant therapy in breast cancer patients; however, it is also associated with undesirable side effects. The goal of this study was to investigate TAM-related side effects, and determine profiles of side effects by race and by smoking status. Methods: A secondary data analysis was conducted using cross-sectional study data from 138 African American and Caucasian women with breast cancer taking TAM 20 mg daily for at least 30 days prior to enrollment. Participants completed questionnaires that obtained information about demographic characteristics, reproductive history, health and lifestyle characteristics, TAM use and its related side effects. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals. Results: Compared to never smokers, a significantly greater percentage of current smokers reported ever experiencing TAM-related nausea (28.0% versus 5.0%, P = 0.007), depression (40.0% versus 7.1%, P = 0.001) and migraines (19.2% versus 1.7%, P = 0.02). These differences remained statistically significant after controlling for race, age, obesity, tumor stage, and duration of TAM treatment. No significant differences by race were noted in women reporting TAM side effects. Conclusion: The findings from this study suggest that current smokers with breast cancer should be informed of the increased probability of reporting TAM-related side effects such as nausea, depression and migraines, and counseled about smoking cessation which may reduce the incidence of these side effects.     

Estrogen and progesterone receptors as prognostic factors in breast cancer

The relation between estrogen receptors (ER) and/or progesterone receptors (PgR) and some clinical factors such as tumor size, axillary node involvement, histological tumor grade, and disease-free interval (DFI) in 500 patients with operable (TNM stage I-III) breast cancer was studied. ER-positive (ER+) tumors were commoner in older patients, whereas PgR-positive (PgR+) tumors were similarly distributed within the age groups. The concentration of ER+ protein also increased with age in contrast to PgR+ protein concentration. However, receptor status was not associated with menopausal status independently of age. Axillary node involvement influenced neither ER nor PgR status, but there was a statistically significant relation between tumor size and positivity of ER or PgR. There was no association between histologic tumor grade and either steroid receptor phenotype. DFI was longer in patients with ER+ than those with ER- tumors, independently of axillary nodal status. The positivity of PgR in patients with ER+ tumors contributed to an even longer DFI, suggesting that the combination of ER/PgR is a better indicator of DFI than ER or PgR alone.     

c-erbB-2 and common prognostic factors in breast cancer patients

We report data on c-erbB-2, hormone receptors, and Ki-67 proliferation associated antigen in ninety-seven unselected breast carcinoma specimens. Immunohistochemical results and clinical data (age, axillary nodal involvement, menopausal status, tumor size) were compared. Positivity for c-erbB-2 staining was detected in the 46% of tumors. There was no correlation among c-erbB-2 status and age, menopausal status, tumor size, lymph nodes involvement or Ki-67 index. An inverse relationship of c-erbB-2 and estrogen and progesterone receptor status was detected, although not statistically significant. Increased levels of c-erbB-2 were observed in 40-50% of all the subsets of patients grouped on the basis of established prognostic factors. These higher levels could lead to the identification of further subsets of patients at higher risk of relapse. However, at present, the role of c-erbB-2 for clinical management of patients with breast cancer remains unclear.