Racial variation in breast cancer treatment among Department of Defense beneficiaries

BACKGROUND:

Although the overall age‐adjusted incidence rates for female breast cancer are higher among whites than blacks, mortality rates are higher among blacks. Many attribute this discrepancy to disparities in health care access and to blacks presenting with later stage disease. Within the Department of Defense (DoD) Military Health System, all beneficiaries have equal access to health care. The aim of this study was to determine whether female breast cancer treatment varied between white and black patients in the DoD system.

METHODS:

The study data were drawn from the DoD cancer registry and medical claims databases. Study subjects included 2308 white and 391 black women diagnosed with breast cancer between 1998 and 2000. Multivariate logistic regression analyses that controlled for demographic factors, tumor characteristics, and comorbidities were used to assess racial differences in the receipt of surgery, chemotherapy, and hormonal therapy.

RESULTS:

There was no significant difference in surgery type, particularly when mastectomy was compared with breast‐conserving surgery plus radiation (blacks vs whites: odds ratio [OR], 1.1; 95% confidence interval [CI], 0.8‐1.5). Among those with local stage tumors, blacks were as likely as whites to receive chemotherapy (OR, 1.2; 95% CI, 0.9‐1.7) and hormonal therapy (OR, 1.0; 95% CI, 0.6‐1.4). Among those with regional stage tumors, blacks were significantly less likely than whites to receive chemotherapy (OR, 0.4; 95% CI, 0.2‐0.7) and hormonal therapy (OR, 0.5; 95% CI, 0.3‐0.8).

CONCLUSIONS:

Even within an equal access health care system, stage‐related racial variations in breast cancer treatment are evident. Studies that identify driving factors behind these within‐stage racial disparities are warranted. Cancer 2012;. © 2011 American Cancer Society.     

Racial/ethnic differences in receipt of pelvic lymph node dissection among men with localized/regional prostate cancer

BACKGROUND:

Black and Hispanic men have a lower prostate cancer (PCa) survival rate than white men. This racial/ethnic survival gap has been explained in part by differences in tumor characteristics, stage at diagnosis, and disparities in receipt of definitive treatment. Another potential contributing factor is racial/ethnic differences in the timely and accurate detection of lymph node metastases. The current study was conducted to examine the association between race/ethnicity and the receipt of pelvic lymph node dissection (PLND) among men with localized/regional PCa.

METHODS:

Logistic regression was used to estimate the adjusted odds of undergoing PLND among men who were diagnosed during 2000 to 2002 with PCa, who underwent radical prostatectomy or PLND without radical prostatectomy, and who were diagnosed in regions covered by the Surveillance, Epidemiology, and End Results database (n = 40,848).

RESULTS:

Black men were less likely to undergo PLND than white men (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.84‐0.98). When the analysis was stratified by PCa grade, black men with well differentiated PCa (OR, 0.48; 95% CI, 0.27‐0.84) and poorly differentiated PCa (OR, 0.73; 95% CI, 0.60‐0.89) were less likely to undergo PLND than their white counterparts, but racial differences were not observed among men with moderately differentiated PCa (OR, 0.96; 95% CI, 0.88‐1.05).

CONCLUSIONS:

Among men with poorly differentiated PCa, failure to undergo PLND was associated with worse survival. Racial disparities in the receipt of PLND, especially among men with poorly differentiated PCa, may contribute to racial differences in prostate cancer survival. Cancer 2011;. © 2011 American Cancer Society.     

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.     

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.     

Racial disparities in the development of breast cancer metastases among older women

BACKGROUND:

Distant metastases are the most common and lethal type of breast cancer relapse. The authors examined whether older African American breast cancer survivors were more likely to develop metastases compared with older white women. They also examined the extent to which 6 pathways explained racial disparities in the development of metastases.

METHODS:

The authors used 1992‐1999 Surveillance, Epidemiology, and End Results (SEER) data with 1991‐1999 Medicare data. They used Medicare's International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify metastases of respiratory and digestive systems, brain, bone, or other unspecified sites. The 6 pathways consisted of patient characteristics, tumor characteristics, type of treatment received, access to medical care, surveillance mammography use, and area‐level characteristics (poverty rate and percentage African American) and were obtained from the SEER or Medicare data.

RESULTS:

Of the 35,937 women, 10.5% developed metastases. In univariate analysis, African American women were 1.61 times (95% confidence interval [CI], 1.54‐1.83) more likely to develop metastasis than white women. In multivariate analysis, tumor grade, stage at diagnosis, and census‐tract percentage African American explained why African American women were more likely to develop metastases than white women (hazard ratio, 0.84; 95% CI, 0.68‐1.03).

CONCLUSIONS:

Interventions to reduce late‐stage breast cancer among African Americans also may reduce racial disparities in subsequent increased risk of developing metastasis. African Americans diagnosed with high‐grade breast cancer could be targeted to reduce their risk of metastasis. Future studies should identify specific reasons why the racial distribution in census tracts was associated with racial disparities in the risk of breast cancer metastases. Cancer 2009. © 2009 American Cancer Society.     

Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women

Objective

This study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women.

Methods

The study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40?C86?years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (n?=?67), bilingual (n?=?173), and Spanish-dominant (n?=?148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression.

Results

In age-adjusted models, mammography use was non-significantly lower among English-dominant (OR?=?0.84; 95% CI: 0.45?C1.59) and bilingual (OR?=?0.86; 95% CI: 0.55?C1.35) MAs and significantly lower among Spanish-dominant MAs (OR?=?0.53; 95% CI: 0.34?C0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90?days (17%).

Conclusions

These findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional.     

Disparities in cancer screening in individuals with a family history of breast or colorectal cancer

BACKGROUND:

Understanding racial/ethnic disparities in cancer screening by family history risk could identify critical opportunities for patient and provider interventions tailored to specific racial/ethnic groups. The authors evaluated whether breast cancer (BC) and colorectal cancer (CRC) disparities varied by family history risk using a large, multiethnic population‐based survey.

METHODS:

By using the 2005 California Health Interview Survey, BC and CRC screening were evaluated separately with weighted multivariate regression analyses, and stratified by family history risk. Screening was defined for BC as mammogram within the past 2 years for women aged 40 to 64 years; for CRC, screening was defined as annual fecal occult blood test, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years for adults aged 50 to 64 years.

RESULTS:

The authors found no significant BC screening disparities by race/ethnicity or income in the family history risk groups. Racial/ethnic disparities were more evident in CRC screening, and the Latino‐white gap widened among individuals with family history risk. Among adults with a family history for CRC, the magnitude of the Latino‐white difference in CRC screening (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11‐0.60) was more substantial than that for individuals with no family history (OR, 0.74; 95% CI, 0.59‐0.92).

CONCLUSIONS:

Knowledge of their family history widened the Latino‐white gap in CRC screening among adults. More aggressive interventions that enhance the communication between Latinos and their physicians about family history and cancer risk could reduce the substantial Latino‐white screening disparity in Latinos most susceptible to CRC. Cancer 2011;. © 2011 American Cancer Society.     

Prevalence and predictors of interval colorectal cancers in medicare beneficiaries

BACKGROUND:

After a colonoscopy that is negative for cancer, a subset of patients may be diagnosed with colorectal cancer, also termed interval cancer. The frequency and predictors have not been well studied in a population‐based US cohort.

METHODS:

The authors used the linked Surveillance, Epidemiology, and End Results (SEER)‐Medicare database to identify 57,839 patients aged ≥69 years who were diagnosed with colorectal cancer between 1994 and 2005 and who underwent colonoscopy within 6 months of cancer diagnosis. Colonoscopy performed between 6 and 36 months before cancer diagnosis was a proxy for interval cancer.

RESULTS:

By using the case definition, 7.2% of patients developed interval cancers. Factors that were associated with interval cancers included proximal tumor location (distal colon: multivariable odds ratio [OR], 0.42; 95% confidence interval [CI], 0.390‐0.46; rectum: OR, 0.47; 95% CI, 0.42‐0.53), increased comorbidity (OR, 1.89; 95% CI, 1.68 2.14 for ≥3 comorbidities), a previous diagnosis of diverticulosis (OR, 6.00; 95% CI, 5.57‐6.46), and prior polypectomy (OR, 1.74; 95% CI, 1.62‐1.87). Risk factors at the endoscopist level included a lower polypectomy rate (OR, 0.70; 95% CI, 0.63‐0.78 for the highest quartile), higher colonoscopy volume (OR, 1.27; 95% CI, 1.13‐1.43), and specialty other than gastroenterology (colorectal surgery: OR, 1.45; 95% CI, 1.16‐1.83; general surgery: OR, 1.42; 95% CI, 1.24‐1.62; internal medicine: OR, 1.38; 95% CI, 1.17‐1.63; family practice: OR, 1.16; 95% CI, 1.00‐1.35).

CONCLUSIONS:

A significant proportion of patients developed interval colorectal cancer, particularly in the proximal colon. Contributing factors likely included both procedural and biologic factors, emphasizing the importance of meticulous examination of the mucosa. Cancer 2012;118: 3044–52. © 2011 American Cancer Society.     

Physician over-recommendation of mammography for terminally ill women

BACKGROUND:

There has been recent, sometimes intense, debate about when to begin screening and how often to screen women for breast cancer with mammography. However, there should be no controversy regarding screening women who are unlikely to benefit from the procedure, such as those with a serious, life‐limiting illness who would not live long enough to benefit from the potential detection and treatment of breast cancer. Identifying characteristics of physicians who recommend mammography for terminally ill women can help guide efforts to minimize patient risks and make better use of health care resources.

METHODS:

The authors used data from a nationally representative survey of primary care physicians (PCPs) (N = 1196; response rate, 67.5%) conducted in 2006 and 2007 to examine PCPs' breast cancer screening recommendations for hypothetical patients ages 50 years, 65 years, and 80 years who were healthy, had a moderate comorbidity, or had a terminal comorbidity.

RESULTS:

Many PCPs (47.7%) reported that they would recommend mammography to a woman aged 50 years, 65 years, or 80 years with terminal lung cancer, indicating over‐recommendation. Physician characteristics associated with over‐recommending mammography included obstetrician/gynecologist (odds ratio [OR], 1.69) or internal medicine (OR, 0.45) specialty, being a woman (OR, 1.40), being a racial/ethnic minority (OR, 1.72), and working in a smaller practice (OR, 1.41).

CONCLUSIONS:

The current results indicated that physician over‐recommendation of screening mammography among terminally ill women is common. Certain physician and practice characteristics, including specialty, were associated with over‐recommending mammography. The authors concluded that an informed and shared mammography decision‐making process for terminally ill women may eliminate unnecessary patient risks and health care expenditures. Cancer 2012;. © 2011 American Cancer Society.     

Black/white differences in treatment and survival among women with stage IIIB–IV breast cancer at diagnosis: a US population-based study

Introduction

Non-Hispanic black (NHB) women with breast cancer have poorer survival than non-Hispanic white (NHW) women. Although NHB women are more often diagnosed at later stages, it is less established whether racial disparities exist among women diagnosed with late-stage breast cancer, particularly when care is provided in the community setting.

Methods

Treatment and survival were examined by race/ethnicity among women diagnosed in 2012 with stage IIIB–IV breast cancer using the National Cancer Institute’s population-based Patterns of Care Study. Medical records were re-abstracted and treating physicians were contacted to verify therapy. Vital status was available through 2014.

Results

A total of 533 women with stage IIIB–C and 625 with stage IV tumors were included; NHW women comprised about 70% of each group. Among women with stage IIIB–C disease, racial/ethnicity variations in systemic treatment were not observed but there was a borderline association indicating worse all-cause mortality among NHB women (hazard ratio 1.52; 95% confidence interval (CI) 0.96–2.41). In contrast, among women with stage IV disease, borderline associations indicating NHB women were more likely to receive chemotherapy (OR 1.44, 95% CI 0.90–2.30) and, among those with hormone receptor-positive tumors, less likely to receive endocrine therapy (OR 0.60, 95% CI 0.35–1.04). All-cause mortality did not vary by race/ethnicity for stage IV disease (hazard ratio 0.92; 95% CI 0.68–1.25).

Conclusions

More research is needed to identify additional factors associated with the potential survival disparities among women with stage IIIB–C disease and potential treatment disparities among women with stage IV disease.

     

Racial disparities in the use of hospice services according to geographic residence and socioeconomic status in an elderly cohort with nonsmall cell lung cancer

BACKGROUND:

The authors investigated whether there were racial disparities in the receipt of hospice services within geographic residence and socioeconomic status (SES) levels.

METHODS:

In total, 117,894 patients aged ≥66 years with nonsmall cell lung cancer (NSCLC) were identified from the Surveillance, Epidemiology, and End Results‐Medicare linked database who had received hospice services in the last 6 months before death and who died between January 1, 1991 and December 31, 2005. Multivariate odds ratios (ORs) with 95% confidence intervals (CIs) using mixed‐effects logistic regression models were used to describe relations.

RESULTS:

In urban areas, there were significant disparity trends in age/sex‐adjusted rates for blacks and Asians/Pacific Islanders compared with whites (P = .003 and P = .036, respectively). Blacks (OR, 0.79; 95% CI, 0.75‐0.82), Asians/Pacific Islanders (OR, 0.42; 95% CI, 0.39‐0.46), and Hispanics (OR, 0.81; 95% CI, 0.73‐0.91) were less likely to receive hospice services. In rural areas, blacks were 21% less likely to receive hospice services (OR, 0.79; 95% CI, 0.63‐0.98). Patients in the poorest socioeconomic status (SES) quartile were 7% less likely to receive hospice services (OR, 0.93; 95% CI, 0.86‐1.00). Moreover, within stratified SES quartiles, blacks and Asians/Pacific Islanders had lower receipt of hospice services, and Asians/Pacific Islanders were the least likely to receive hospice services, particularly those in the poorest SES quartile. In general, older patients and women were more likely to receive hospice services.

CONCLUSIONS:

There were substantial disparities in the receipt of hospice services among ethnic minorities within urban and rural areas and within SES levels. The results indicated that efforts are needed to identify barriers, enhance support, and educate patients on the benefits of hospice services. Cancer 2010. © 2010 American Cancer Society.     

Racial and socioeconomic disparities in adjuvant chemotherapy for older women with lymph node‐positive,operable breast cancer

BACKGROUND:

Consistent with findings from clinical trials, a recent population‐based study indicated that adjuvant chemotherapy for lymph node‐positive, operable breast cancer is effective at improving survival in older women, specifically those ages 65 years to 69 years; however, to the authors' knowledge, no conclusion has been reached about the relative benefit of chemotherapy for women aged ≥70 years, probably because of small number of patients. However, little is known about racial and socioeconomic disparities in adjuvant chemotherapy for breast cancer among older women.

METHODS:

This study included 14,177 white women and 1277 black women aged ≥65 years who were diagnosed with operable breast cancer (stage II‐IIIA) and positive lymph nodes between 1991 and 2002. These women were identified from the Surveillance, Epidemiology, and End Results and Medicare‐linked database. Multivariate logistic regression was used to compute the odds ratios of receiving chemotherapy among black women compared with white women, and the causal step approach was used to test whether census tract‐level poverty mediated racial disparities.

RESULTS:

Interaction terms analyses indicated that regressions should be stratified by age group. In the group ages 65 years to 69 years, the adjusted odds ratio of receiving chemotherapy were lower for black women than for white women (odds ratio, 0.85; 95% confidence interval, 0.57‐0.97). Poverty mediated the association between chemotherapy and race in this age group. No racial or socioeconomic disparities were observed among women aged ≥70 years.

CONCLUSIONS:

This study documented racial disparities in adjuvant chemotherapy that were mediated by poverty in women ages 65 years to 69 years, an age group for which there is clear evidence for the efficacy of chemotherapy, but no disparities were observed among women aged ≥70 years. The authors concluded that it is important to work toward reducing treatment disparities among older women. Cancer 2009. © 2009 American Cancer Society.     

Knowledge,cultural, and attitudinal barriers to mammography screening among nonadherent immigrant Chinese women

BACKGROUND:

Chinese‐American women have much lower mammography screening rates than the general population. This study examined the collective impact of knowledge, cultural views, and health beliefs on intentions to obtain mammography among Chinese women who had not had a mammogram in the previous year.

METHODS:

Five hundred sixty‐six immigrant Chinese women from the Washington, District of Columbia and New York metropolitan areas completed baseline assessments for a longitudinal intervention study. Validated surveys were used to measure variables of interest. The outcomes were 1) past mammography use (ever vs never) and 2) future screening intention.

RESULTS:

Only 35% of the participants reported intentions to obtain mammograms, with approximately 19% of the never users reporting intentions (vs 44% ever users). Ever users had higher knowledge (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03‐1.25), less Eastern cultural views (OR, 0.78; 95% CI, 0.70‐0.87), and perceived fewer barriers (OR, 0.78; 95% CI, 0.70‐0.87) than never users, controlling for covariates. Never users were more likely to be recent immigrants, have low income, have limited English ability, and lack regular sources of care than ever users (all P < .001). Multivariate models showed that ever users who were employed received physician recommendations, had less Eastern views, perceived higher susceptibility, and were more likely to have intentions. Among never users, being 40‐49 years of age and perceiving fewer barriers led to increased intention.

CONCLUSIONS:

Understanding cultural patterns and health beliefs in Chinese women is critical to changing their screening behaviors. Interventions that address their common beliefs and specific group barriers are optimal for promoting mammography adherence. Cancer 2009. © 2009 American Cancer Society.     

Patterns of care and treatment outcomes for elderly women with cervical cancer

BACKGROUND:

Cervical cancer is common in the elderly. The authors examined the patterns of care, treatment, and outcomes of elderly women with cervical cancer.

METHODS:

Women with cervical cancer diagnosed between 1988 and 2005 and registered in the Surveillance, Epidemiology, and End Results database were analyzed. Patients were stratified by age: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 years. Multivariate logistic regression models were constructed to examine treatment; cancer‐specific survival was examined using Cox proportional hazards models.

RESULTS:

A total of 28,902 women were identified, including 2543 women 70 to 79 years old and 1364 ≥80 years. For women with early stage (IB1‐IIA) tumors, primary surgery was performed in 82.0% of women <50 years old compared with 54.5% of those 70 to 79 years old and 33.2% of those ≥80 years old (P < .0001). For women treated surgically, lymphadenectomy was performed in 66.8% of women <50 years old versus 9.1% of patients ≥80 years old (P < .0001). Compared with patients <50 years old, those >80 years old were less likely to undergo radical hysterectomy (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.07‐0.14) and lymphadenectomy (OR, 0.11; 95% CI, 0.08‐0.16) and to receive adjuvant radiation therapy (OR, 0.06; 95% CI, 0.01‐0.35). Among women with stage IIB‐IVA disease, use of brachytherapy declined with age (P < .0001). For women with stage IB1‐IIA tumors, the hazard ratio for death from cancer was 1.35 (95% CI, 1.16‐1.58) for women 70 to 79 years old and 2.08 (95% CI, 1.72‐2.48) for those ≥80 years old compared with younger women.

CONCLUSIONS:

Elderly women with cervical cancer are less likely to undergo surgery, receive adjuvant radiation, and receive brachytherapy. After adjusting for treatment disparities, cancer‐specific mortality is higher in older women. Cancer 2012;3618–3626. © 2011 American Cancer Society.     

Breast cancer screening beliefs, recommendations and practices: primary care physicians in the United States

BACKGROUND:

Primary care physicians (PCPs) play a key role in breast cancer screening, yet no current data exist regarding PCP practices.

METHODS:

The authors analyzed a nationally representative survey of PCPs that was fielded during September 2006 to May 2007 to investigate PCP breast cancer screening beliefs, recommendations, and practices.

RESULTS:

Most of the 1212 PCPs who participated in the survey (80%) reported that mammography for average‐risk women aged ≥ 50 years was very effective in reducing cancer mortality, and 54% reported that it was very effective for women ages 40 to 49 years. Fewer respondents reported that clinical breast examination (CBE) or breast self‐examination (BSE) was very effective, but the majority rated CBE and BSE as somewhat effective. The majority of PCPs routinely recommended mammography, CBE, and BSE to patients aged ≥ 40 years. In multivariate models, family/general practitioners (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.57‐3.17 for mammography; OR, 4.42; 95% CI, 2.60‐7.52 for CBE) and internal medicine specialists (OR, 3.21; 95% CI, 2.21‐4.66 for mammography; OR, 5.34; 95% CI, 3.21‐8.88 for CBE) were more likely to recommend an upper age limit for screening than obstetrician/gynecologists. Physicians who reported that US Preventive Services Task Force guidelines were very influential were more likely to recommend an age at which they no longer recommend mammography and CBE.

CONCLUSIONS:

To the authors' knowledge, the current study is the first national study in over 2 decades to report the breast cancer screening practices of PCPs and provides baseline data for monitoring the impact of changes in clinical practice guidelines. The current findings suggested that virtually all PCPs routinely recommend mammography, CBE, and BSE to their patients aged ≥ 40 years, although recommendations vary by primary care specialty. Cancer 2011. Published 2011 by the American Cancer Society.     

Black-white disparity in physical performance among older women with newly diagnosed non-metastatic breast cancer: Exploring the role of inflammation and physical activity

Objective

To examine racial differences in physical performance among older women with newly diagnosed non-metastatic breast cancer and identify clinical, behavioral and biological factors that might contribute to such disparities.

Persistent disparities in liver transplantation for patients with hepatocellular carcinoma in the United States, 1998 through 2007

BACKGROUND:

Prior studies have demonstrated that among patients with hepatocellular carcinoma (HCC), African Americans (AAs) and Asian/Pacific Islanders (APIs) are substantially less likely to undergo liver transplantation (LT) compared with whites. The authors examined whether disparities in the receipt of LT among LT‐eligible HCC patients changed over a 10‐year time period, and whether the disparities might be explained by sociodemographic or clinical factors.

METHODS:

The National Cancer Data Base, a national hospital‐based cancer registry, was used to study 7707 adults with small (≤ 5 cm), nonmetastatic HCC diagnosed between 1998 and 2007. Racial/ethnic patterns in the use of LT were compared during 2 periods of 5 years each: 1998 through 2002 (n = 2412 patients) and 2003 through 2007 (n = 5295 patients). Data regarding comorbid medical conditions were only available during the later time period.

RESULTS:

Large and persistent racial/ethnic differences in the probability of receiving LT were observed. Compared with whites, hazard ratios (HRs) and associated 95% confidence intervals (95% CIs) for receiving LT from 1998 through 2002 were 0.64 (95% CI, 0.46‐0.89) for AA patients, 1.01 (95% CI, 0.79‐1.29) for Hispanic patients, and 0.52 (95% CI, 0.39‐0.68) for API patients. Analogous results for 2003 through 2007 were 0.64 (95% CI, 0.54‐0.76) for AA patients, 0.86 (95% CI, 0.75‐0.99) for Hispanic patients, and 0.58 (95% CI, 0.49‐0.69) for API patients. AA patients were less likely than whites to undergo any form of surgery, and API patients were more likely than whites to undergo surgical resection. Adjustment for sociodemographic and clinical factors produced only small changes in these HRs.

CONCLUSIONS:

Between 1998 and 2007, there were large and persistent racial/ethnic disparities noted in the receipt of LT among patients with HCC. These disparities were not explained by sociodemographic or clinical factors. Cancer 2011;. © 2011 American Cancer Society.     

Racial/ethnic disparities in survival among men diagnosed with prostate cancer in Texas

BACKGROUND:

To the authors' knowledge, few studies to date have examined racial differences in prostate cancer survival while controlling for socioeconomic status (SES). No such studies have examined this association in Texas, a large state with significant ethnic and racial diversity. The objective of this analysis was to determine whether racial disparities in survival for men diagnosed with prostate cancer in Texas from 1995 through 2002 remained after adjusting for SES, rural residence, and stage of disease.

METHODS:

A cohort of 87,449 men who were diagnosed with prostate cancer was identified from the Texas Cancer Registry. The SES measure was based on census tract data reflecting median household income, median home value, and percentages of men living below poverty, with a college education, and with a management or professional occupation. The 5‐year survival rates were calculated using the Kaplan‐Meier method and Cox proportional hazard modeling was used to estimate hazard ratios (HRs) for race and all‐cause and disease‐specific mortality.

RESULTS:

After adjusting for SES, age, stage of disease, tumor grade, year of diagnosis, and rural residence, both black and Hispanic men were more likely (adjusted HR [aHR], 1.70 [95% confidence interval (95% CI), 1.58‐1.83] and aHR, 1.11 [95% CI, 1.02‐1.20], respectively) to die of prostate cancer compared with white men. The pattern of survival disadvantage for black men held for those diagnosed with localized disease and advanced disease, and for those with an unknown stage of disease at diagnosis.

CONCLUSIONS:

Substantial racial disparities in prostate cancer survival were found for men in Texas. Future studies should incorporate treatment data as well as comorbid conditions because this information may explain noted survival disparities. Cancer 2011. © 2010 American Cancer Society.     

Racial disparities in colorectal cancer survival

BACKGROUND:

Racial/ethnic differences in colorectal cancer (CRC) survival have been documented throughout the literature. However, the reasons for these disparities are difficult to decipher. The objective of this analysis was to determine the extent to which racial/ethnic disparities in survival are explained by differences in sociodemographics, tumor characteristics, diagnosis, treatment, and hospital characteristics.

METHODS:

A cohort of 37,769 Medicare beneficiaries who were diagnosed with American Joint Committee on Cancer stages I, II, and III CRC from 1992 to 2002 and resided in 16 Surveillance, Epidemiology, and End Results (SEER) regions of the United States was identified in the SEER‐Medicare linked database. Survival was estimated using the Kaplan‐Meier method. Cox proportional hazards modeling was used to estimate hazard ratios (HRs) of mortality and 95% confidence intervals (CIs).

RESULTS:

Black patients had worse CRC‐specific survival than white patients, but the difference was reduced after adjustment (adjusted HR [aHR], 1.24; 95% CI, 1.14‐1.35). Asian patients had better survival than white patients after adjusting for covariates (aHR, 0.80; 95% CI, 0.70‐0.92) for stages I, II, and III CRC. Relative to Asians, blacks and whites had worse survival after adjustment (blacks: aHR, 1.56; 95% CI, 1.33‐1.82; whites: aHR, 1.26; 95% CI, 1.10‐1.44). Comorbidities and socioeconomic Status were associated with a reduction in the mortality difference between blacks and whites and blacks and Asians.

CONCLUSIONS:

Comorbidities and SES appeared to be more important factors contributing to poorer survival among black patients relative to white and Asian patients. However, racial/ethnic differences in CRC survival were not fully explained by differences in several factors. Future research should further examine the role of quality of care and the benefits of treatment and post‐treatment surveillance in survival disparities. Cancer 2010. © 2010 American Cancer Society.     

Human papillomavirus vaccine uptake among 18‐ to 26‐year‐old women in the United States

BACKGROUND:

Human papillomavirus (HPV) vaccine uptake among young adult women has been reported to be very low. The authors conducted this study to provide an update on HPV vaccine uptake among 18‐ to 26‐year‐old women.

METHODS:

The authors used the National Health Interview Survey 2010 data to estimate HPV vaccine coverage and their correlates.

RESULTS:

Overall, 22.7% of women initiated (≥1 dose) and 12.7% completed the vaccine (≥3 doses). Thus, about 56% of women who initiated the vaccine completed it. Multivariate logistic regression analyses showed that younger age, unmarried status, Papanicolaou test, influenza vaccine, lifetime vaccines, and HPV vaccine awareness were positively associated with receiving ≥1 and ≥3 doses. In addition, uninsured women were less likely to receive ≥1 dose (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28‐0.84), and blacks (OR, 0.48; 95% CI, 0.23‐0.99) and women with a family income <100% of the federal poverty level (OR, 0.40; 95% CI, 0.21‐0.73) were less likely to receive ≥3 doses. Furthermore, based on vaccine initiators, blacks were less likely than whites to complete the vaccine (OR, 0.29; 95% CI, 0.16‐0.55). Two thirds of unvaccinated women were not interested in future vaccination. Among those who were interested, >76.4% preferred to receive it free or at a lower cost, whereas 20% would pay the full cost of the vaccine.

CONCLUSIONS:

One in 8 women completed the 3‐dose HPV vaccine. Educational and vaccine financing programs are needed to improve the uptake among low‐income minority women who are at increased risk for cervical cancer. Cancer 2013. © 2012 American Cancer Society.