Disparities in late stage diagnosis, treatment, and breast cancer-related death by race, age, and rural residence among women in Georgia

The objectives of this study were to examine the outcomes of late stage breast cancer diagnosis, receiving first course treatment, and breast cancer-related death by race, age, and rural/urban residence in Georgia. The authors used cross-sectional and follow-up data (1992-2007) for Atlanta and Rural Georgia cancer registries that are part of the National Cancer Institute's Surveillance, Epidemiology, and End Results Program (N = 23,500 incident breast cancer cases in non-Hispanic whites or non-Hispanic African Americans). Multilevel modeling and Cox proportional hazard models revealed that compared to whites, African American women had significantly increased odds of late stage diagnosis (odds ratio [OR] = 2.08, p = 0.0001) and unknown tumor stage (OR = 1.27, p = 0.0001), decreased odds of receiving radiation (OR = 0.93, p = 0.041) or surgery (OR = 0.50, p = 0.0001), and increased risk of death following breast cancer diagnosis (hazard rate ratio [HR] = 1.50, p = 0.0001). Increased age was significantly associated with the odds of late/unknown stage at diagnosis, worse treatment, and survival. Women residing in rural areas had significantly decreased odds of receiving radiation and surgery with radiation (OR = 0.59, p = 0.0001), and for receiving breast-conserving surgery compared to mastectomy (OR = 0.73, p = 0.005). Factors affecting each level of the breast cancer continuum are distinct and should be examined separately. Efforts are needed to alleviate disparities in breast cancer outcomes in hard-to-reach populations.     

Differences in Late‐Stage Diagnosis,Treatment, and Colorectal Cancer‐Related Death Between Rural and Urban African Americans and Whites in Georgia

Purpose: Disparities in health outcomes due to a diagnosis of colorectal cancer (CRC) have been reported for a number of demographic groups. This study was conducted to examine the outcomes of late‐stage diagnosis, treatment, and cancer‐related death according to race and geographic residency status (rural vs urban). Methods: This study utilized cross‐sectional and follow‐up data from the Surveillance, Epidemiology, and End Results (SEER) Program for all incident colon and rectal tumors diagnosed for the Atlanta and Rural Georgia Cancer Registries for the years 1992‐2007. Findings: Compared to whites, African Americans had a 40% increased odds (OR, 1.40; 95% CI, 1.30‐1.51) of late‐stage diagnosis, a 50% decreased odds (OR, 0.50; 95% CI, 0.37‐0.68) of having surgery for colon cancer, and a 67% decreased odds (OR, 0.33; 95% CI, 0.25‐0.44) of receiving surgery for rectal cancer. Rural residence was not associated with late stage at diagnosis or receipt of treatment. African Americans had a slightly increased risk of death from colon cancer (HR, 1.11; 95% CI, 1.00‐1.24) and a larger increased risk of death due to rectal cancer (HR, 1.24; 95% CI, 1.14‐1.35). Rural residents experienced a 15% increased risk of death (HR, 1.15; 95% CI, 1.01‐1.32) due to colon cancer. Conclusions: Further investigations should target African Americans and rural residents to gain insight into the etiologic mechanisms responsible for the poorer CRC outcomes experienced by these 2 segments of the population.     

Hospice Use by Hispanic and Non-Hispanic White Cancer Decedents

Objective. To investigate rates of hospice use between Hispanic and non-Hispanic white Medicare beneficiaries diagnosed with cancer using data from a large, population-based study.
Data Sources. Secondary data from the linked SEER-Medicare database including the SEER areas of Los Angeles, San Francisco, and San Jose–Monterey, California, and the state of New Mexico. All subjects were Hispanic or non-Hispanic whites, aged 67 and older, had a cancer diagnosis of breast, colorectal, lung, or prostate cancer from 1991–1996, and died of cancer from 1991–1998.
Study Design. This study employed a retrospective cohort design to compare rates of hospice use between Hispanics and non-Hispanic whites across patient characteristics and over time.
Principal Findings. Rates of hospice use were similar for Hispanics (39.2 percent) and non-Hispanic whites (41.5 percent). In a bivariate logistic regression model, Hispanics were significantly less likely to use hospice than non-Hispanic whites (OR 0.91; 95 percent CI 0.85–0.97). However, after adjusting for age, marital status, sex, educational attainment, income, urban versus rural residence, and type of insurance using multivariate logistic regression analysis, the estimated odds for being a hospice user among Hispanics is similar to the odds of being a hospice user among non-Hispanic whites (OR 1.05; 95 percent CI 0.98–1.13). Stratified analyses revealed significant differences between ethnic groups in the use of hospice by type of insurance and SEER area, indicating interactions between ethnicity and these variables.
Conclusions. Our findings indicate similar rates of hospice use for Hispanics and non-Hispanic whites diagnosed with one of the four leading cancers. Additional studies from other national registries may be necessary to confirm these findings.     

Breast cancer risk factors among black women and white women: similarities and differences.

To further explore whether breast cancer risk factors are the same for black women and white women, the authors investigated several biologic, cultural, and social factors in a 1980-1982 case-control study of non-Hispanic black subjects (490 cases, 485 controls) and non-Hispanic white subjects (3,934 cases, 3,901 controls) aged 20-54 years. Logistic regression analyses indicated that blacks and whites shared four risk factors at a comparable magnitude (age at first full-term birth, parity, surgical menopause, and history of benign breast disease). For two observed risk factors, the magnitude (breast feeding) and pattern (family history of breast cancer) of the relation were different in blacks and whites. The relative risks of breast cancer among black women who had first-degree relatives (odds ratio (OR) = 1.61) and second-degree relatives (OR = 1.71) with breast cancer were similar, whereas the relative risk among white women who had first-degree relatives (OR = 2.16) was distinctly larger than for those who had second-degree relatives (OR = 1.44) with breast cancer. The relation of early age at menarche appeared negligible for blacks although significant for whites aged 12 and under (OR = 1.26). The results also indicated that natural menopause, oral contraceptive use, and cigarette smoking may have different, and more complex, relations to breast cancer among blacks and whites.     

Differences in treatment and survival among African-American and Caucasian women with early stage operable breast cancer

Objective. To examine racial disparities associated with breast cancer treatment and survival in elderly patients with early stage operable breast cancer.

Methods. We studied 23,110 women with node-positive and 31,572 women with node-negative tumor who were aged ≥65 with stages I, II, or IIIA breast cancer in 1991–2002 using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked data. Logistic regression analyses were performed to assess the odds of receiving adjuvant chemotherapy and radiation after breast conserving surgery (BCS) for blacks compared to whites. Cox proportional hazard regression models were used to determine the risk of mortality in blacks compared to whites, stratified by types of treatment.

Results. Black women with node-positive and node-negative tumors were 25% (odds ratio = 0.75, 95% CI = 0.65–0.87) and 17% (0.83, 0.70–0.99) less likely to receive chemotherapy than white women, after adjusting for patient and tumor characteristics. This relation was not attenuated and remained statistically significant even after adjustment for socioeconomic status. In women with node-negative tumor who did not receive chemotherapy, black women were significantly more likely to die than white women (hazard ratio (HR) = 1.14, 95% CI = 1.04–1.24) after adjusting for patient and tumor characteristics, and comorbidity; and (1.11, 1.01–1.22) after additionally adjusting for socioeconomic status.

Conclusions. There were racial disparities between black and white women in receiving adjuvant chemotherapy and radiotherapy following BCS. Higher risk of mortality in black compared to white women was found only in those receiving no chemotherapy. Future studies should explore the root causes of racial disparities beyond treatment factors.     

Availability of Healthcare Resources and Colorectal Cancer Outcomes Among Non-Hispanic White and Non-Hispanic Black Adults

This study aims to examine if access to healthcare, measured through the availability of medical resources at the neighborhood level, influences colorectal cancer (CRC) stage, treatment and survival using the Surveillance Epidemiology and Ends Result (SEER) dataset (November 2012), linked with the 2004 Area Resource File. A cross-sectional study was conducted to determine the association between availability of healthcare resources and CRC outcomes among non-Hispanic Black (n = 9162) and non-Hispanic White patients (n = 97,264). CRC patients were identified using the SEER*Stat program, and individual socio-demographic, clinical, and county-level healthcare access variables were obtained for each patient. Among NH-W patients, residence in counties with lower number of oncology hospitals was associated with increased odds of late stage diagnosis (OR 1.09, 95 % CI 1.04–1.14), reduced odds of receiving surgery (OR 0.83, 95 % CI 0.74–0.92) and higher hazard rates (HR 1.09, 95 % CI 1.06–1.12). There were no significant associations among NH-B patients. Increased availability of healthcare resources improves CRC outcomes among NH-W patients. However, future studies are required to better understand healthcare utilization patterns in NH-B neighborhoods, and identify other important dimensions of healthcare access such as affordability, acceptability and accommodation.     

Economic, racial and ethnic disparities in breast cancer in the US: Towards a more comprehensive model

Using cancer registry data, we focus on racial and ethnic disparities in stage of breast cancer diagnosis in Cook County, IL. The county health system is the “last resort” health-care provider for low-income persons. Socioeconomic status is measured using empirical Bayes estimates of tract-level poverty, specific to non-Hispanic whites, non-Hispanic blacks or Hispanics in one of three age groups. We use ordinal logistic regression with non-proportional odds to model stage. Blacks and Hispanics are at greater risk for regional and distant stage diagnosis, but the disparity declines with age. Women in high-poverty areas are at substantially greater risk for late-stage diagnosis. The effects of poverty do not differ by age or across racial and ethnic groups.     

Race, rural residence, and control of diabetes and hypertension

PURPOSE: African Americans are at increased risk for diabetes mellitus and hypertension, and rural residents have historically had decreased access to care. It is unclear whether living in a rural area and being African American confers added risks for diagnosis and control of diabetes and hypertension. The purpose of this study was to examine the prevalence of diagnosed diabetes and hypertension, as well as control of both conditions, among rural and urban African Americans and whites. METHODS: We conducted an analysis of the Third National Health and Nutrition Examination Survey (1988-1994). Non-Hispanic African Americans and non-Hispanic white adults 20 years and older were classified according to rural or urban residence (n = 11,755). Investigated outcomes were previously diagnosed diabetes mellitus and hypertension and control of diabetes and hypertension. RESULTS: The prevalence of diagnosed diabetes was 4.5% for urban whites, 6.5% for rural whites, 6.0% for urban African Americans, and 9.5% for rural African Americans. Among patients with diagnosed diabetes, 33% of rural whites, 43% of urban whites, 45% of urban African American, and 61% of rural African Americans had glycosylated hemoglobin (HbA(1c)) levels of 8% or higher (P < .01). Among patients with diagnosed hypertension, 11% of rural whites, 13% of urban whites, 20% of urban African Americans, and 23% of rural African Americans had diastolic blood pressure greater than 90 mmHg (P < .01). In regression models controlling for relevant variables, including body mass index, health status, access to care, education, income, and insurance, compared with rural African Americans, rural and urban whites were significantly more likely to have better glycemic control and diastolic blood pressure control. Urban African Americans also had better diabetes control than rural African Americans. CONCLUSIONS: In this nationally representative sample, rural African Americans are at increased risk for a lack of control of diabetes and hypertension.     

Adult body size, hormone receptor status, and premenopausal breast cancer risk in a multiethnic population: the San Francisco Bay Area breast cancer study

Large body size has been associated with a reduced risk of premenopausal breast cancer in non-Hispanic white women. Data on other racial/ethnic populations are limited. The authors examined the association between premenopausal breast cancer risk and adult body size in 672 cases and 808 controls aged ≥35 years from a population-based case-control study conducted in 1995-2004 in the San Francisco Bay Area (Hispanics: 375 cases, 483 controls; African Americans: 154 cases, 160 controls; non-Hispanic whites: 143 cases, 165 controls). Multivariate adjusted odds ratios and 95% confidence intervals were calculated using unconditional logistic regression. Height was associated with increased breast cancer risk (highest vs. lowest quartile: odds ratio = 1.77, 95% confidence interval: 1.23, 2.53; P(trend) < 0.01); the association did not vary by hormone receptor status or race/ethnicity. Body mass index (measured as weight (kg) divided by height (m) squared) was inversely associated with risk in all 3 racial/ethnic groups, but only for estrogen receptor- and progesterone receptor-positive tumors (body mass index ≥30 vs. <25: odds ratio = 0.42; 95% confidence interval: 0.29, 0.61). Other body size measures (current weight, body build, adult weight gain, young adult weight and body mass index, waist circumference, and waist-to-height ratio) were similarly inversely associated with risk of estrogen receptor- and progesterone receptor-positive breast cancer but not estrogen receptor- and progesterone receptor-negative disease. Despite racial/ethnic differences in body size, inverse associations were similar across the 3 racial/ethnic groups when stratified by hormone receptor status.     

Concentrations of the sunscreen agent benzophenone-3 in residents of the United States: National Health and Nutrition Examination Survey 2003--2004

BACKGROUND: The capability of benzophenone-3 (BP-3) to absorb and dissipate ultraviolet radiation facilitates its use as a sunscreen agent. BP-3 has other uses in many consumer products (e.g., as fragrance and flavor enhancer, photoinitiator, ultraviolet curing agent, polymerization inhibitor). OBJECTIVES: Our goal was to assess exposure to BP-3 in a representative sample of the U.S. general population > or = 6 years of age. METHODS: Using automated solid-phase extraction coupled to high-performance liquid chromatography-tandem mass spectrometry, we analyzed 2,517 urine samples collected as part of the 2003--2004 National Health and Nutrition Examination Survey. RESULTS: We detected BP-3 in 96.8% of the samples. The geometric mean and 95th percentile concentrations were 22.9 microg/L (22.2 microg/g creatinine) and 1,040 microg/L (1,070 microg/g creatinine), respectively. Least-square geometric mean (LSGM) concentrations were significantly higher (p < or = 0.04) for females than for males, regardless of age. LSGM concentrations were significantly higher for non-Hispanic whites than for non-Hispanic blacks (p < or = 0.01), regardless of age. Females were more likely than males [adjusted odds ratio (OR) = 3.5; 95% confidence interval (95% CI), 1.9-6.5], and non-Hispanic whites were more likely than non-Hispanic blacks (adjusted OR = 6.8; 95% CI, 2.9-16.2) to have concentrations above the 95th percentile. CONCLUSIONS: Exposure to BP-3 was prevalent in the general U.S. population during 2003--2004. Differences by sex and race/ethnicity probably reflect differences in use of personal care products containing BP-3.     

Significance of Increasing Poverty Levels for Determining Late-Stage Breast Cancer Diagnosis in 1990 and 2000

We examine the association between late-stage breast cancer diagnosis and residential poverty in Detroit, Atlanta, and San Francisco in 1990 and 2000. We tested whether residence in census tracts with increasing levels of poverty were associated with increased odds of a late-stage diagnosis in 1990 and 2000 and found that it was. To test this, we linked breast cancer cases from the Surveillance, Epidemiology, and End Results cancer registries with poverty data from the census. Tracts were grouped into low, moderate, and high poverty based on the percentage of households reporting income below the poverty level. While late-stage breast cancer rates and the number of women living in high and moderate-poverty areas declined absolutely between 1990 and 2000, estimates from our combined three-city model showed that odds of a late-stage diagnosis remained stubbornly elevated in increasingly poor areas in both years. Non-Hispanic black women faced higher odds of a late-stage diagnosis relative to non-Hispanic white women in both years. In separate regressions for each city, the odds ratios affirm that combining data across cities may be misleading. In 1990 and 2000, only women living in moderately poor neighborhoods of San Francisco faced elevated odds, while in Detroit women in both moderate- and high-poverty areas faced increased likelihood of late-stage diagnosis. In Atlanta, none of the poverty measures were significant in 1990 or 2000. In our test of physician supply on stage, an increase in the number of neighborhood primary care doctor's offices was associated with decreased odds of a late-stage diagnosis only for Detroit residents and for non-Hispanic whites in the three-city model.     

Clinical and demographic predictors of late-stage cervical cancer

BACKGROUND: Despite increasingly widespread use of the Papanicolaou smear, almost half of all women with invasive cervical cancer are diagnosed at a late stage (regional or distant). Little is known about factors associated with late-stage diagnosis of cervical cancer. OBJECTIVE: To examine the relationship of age, race, education level, income level, smoking, marital status, health insurance type, comorbidity, and residence in an urban or rural setting to late stage at diagnosis of cervical cancer. METHODS: Incident cases of invasive cervical cancer occurring in 1994 in Florida were identified from the state tumor registry (N = 852). Cases were linked with state discharge abstracts and the 1990 US census. Multiple logistic regression was used to determine the relationship between predictor variables (age, race or ethnicity, marital status, smoking status, education level, income level, insurance type, comorbidity, and urban vs rural residence) and the odds of late-stage diagnosis. RESULTS: Age, marital status, and insurance type were associated with late-stage diagnosis. Each additional year of age was associated with a 3% increased odds of late-stage diagnosis (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.001). Being unmarried was associated with a 63% increased odds of late-stage diagnosis (OR, 1.63; 95% CI, 1.18-2.25; P=.003). Being uninsured was associated with a 60% increased odds of late-stage diagnosis (OR, 1.60; 95% CI, 1.07-2.38; P=.02). Having commercial health maintenance organization insurance was associated with a 46% decreased odds of late-stage disease (OR, 0.54; 95% CI, 0.30-0.96; P=.04). Race, education level, income level, smoking status, comorbidity, and urban residence were not associated with stage at diagnosis. CONCLUSIONS: Women with cervical cancer who are elderly, unmarried, and uninsured are more likely to be diagnosed at a late stage. These women should be targeted for cervical cancer education and screening programs.     

Breast and cervical cancer screening among low-income women in Nebraska: findings from the Every Woman Matters program, 1993-2004

OBJECTIVE: To examine the likelihood of enrollees in the Nebraska Every Woman Matters program being screened for breast and cervical cancer. METHODS: We explored the relationship between sociodemographic characteristics and receiving cancer screening services. RESULTS: Older and Native American women were more likely than younger and White women to have mammograms ordered [adjusted odds ratio (OR)=1.41, 95% confidence interval (CI) 1.08, 1.85]. African American [OR=0.54, 95% CI 0.46, 0.64] and Native American women [OR=0.47, 95% CI 0.39, 0.55] were less likely than White women to have clinical breast exams performed. Native American [OR=0.19, 95% CI 0.16, 0.23] and African American women [OR=0.56, 95% CI 0.46, 0.68] were less likely than White women to have a Pap test performed. CONCLUSION: Receiving cancer screening services was related to race; thus, understanding barriers for screening for minority women is warranted.     

Patient characteristics and treatments associated with a decline in upper-body function following breast cancer therapy

Breast cancer therapy is often followed by a decline in upper-body function. Women (303) diagnosed with stage I or II breast cancer were interviewed 5 and 21 months after surgery and their medical records were reviewed. Women with cardiopulmonary comorbidity had an odds ratio for decline at the 5-month interview of 2.8 (95% CI 1.3-5. 7), relative to women without. Women who received mastectomy (OR = 2. 5; 95% CI 0.9-6.7) or breast-conserving surgery with radiation therapy (OR = 2.9; 95% CI 1.0-8.9) were at higher risk for decline at the 5-month interview than women who received only breast-conserving surgery. Women who had axillary dissection were more likely to report numbness or pain in the axilla (OR = 6.4; 95% CI 1.2-33) at the 21-month interview than women who did not. Clinicians should consider the functional consequences of treatment when discussing treatment options and postoperative care with women who have early stage breast cancer.     

Differences in prognostic factors and survival among White men and Black men with prostate cancer, California, 1995-2004

The authors conducted a study to determine whether differences in prostate cancer survival between White men and Black men are reduced or eliminated after accounting for differences in prognostic factors. Using population-based statewide cancer registry data, the authors analyzed data from a cohort of 122,375 non-Hispanic White men and Black men from California who were newly diagnosed with prostate cancer between 1995 and 2004 and followed through 2004. Compared with White men, Black men were characterized by younger age at diagnosis, more distant stage, less treatment with surgery or radiation therapy, higher tumor grades, lower neighborhood socioeconomic status, and more recent year of diagnosis. Adjusted only for age, the hazard ratio for prostate cancer death (Blacks vs. Whites) was 1.61 (95% confidence interval (CI): 1.50, 1.72). Additional adjustment for potentially modifiable factors (stage and treatment) eliminated most of the racial difference in survival (adjusted hazard ratio = 1.10, 95% CI: 1.03, 1.18). The racial difference in survival was completely eliminated after further adjustment for other factors (grade, socioeconomic status, and year of diagnosis) (adjusted hazard ratio = 0.99, 95% CI: 0.92, 1.06). Thus, the large difference in prostate cancer survival between White men and Black men was completely explained by known prognostic factors, with potentially modifiable disparities playing the largest role.     

Rural-Urban Differences in Colon Cancer Risk in Blacks and Whites: The North Carolina Colon Cancer Study

CONTEXT: Geographic and racial variations in cancer incidence have been observed. Studies of colorectal carcinoma indicate a higher incidence and mortality rate for blacks than for whites in the United States. PURPOSE: We evaluated the effect of rural versus urban residence on colon cancer risk and stage of disease at diagnosis in blacks and whites. METHODS: Interviews were conducted with 558 colon cancer cases and 952 controls enrolled in the North Carolina Colon Cancer Study, a population-based case-control study of blacks and whites residing in 33 contiguous counties. FINDINGS: Residence in a rural area was associated with increased colon cancer risk (odds ratio, 1.4; 95% confidence interval, 1.1-1.8). This association was no longer significant after controlling for recent use of colorectal cancer screening tests (odds ratio, 1.2; 95% confidence interval, 0.9-1.6). Risk estimates were not modified by race nor were they markedly different for extent of disease at diagnosis. However, colorectal cancer screening rates were lower for blacks than for whites. CONCLUSION: Our findings suggest that rural blacks and whites are at increased risk of colon cancer regardless of stage of disease at diagnosis than their urban counterparts; this relationship may be mediated by screening behavior.     

Associations of weight,weight change,and body mass with breast cancer risk in Hispanic and non-Hispanic white women

PURPOSE: A wealth of studies have examined the effects of weight, weight gain, and obesity on breast cancer risk; however, few have examined this relationship in Hispanic white women, a population with the highest rate of obesity in the U.S. METHODS: A population-based case-control study was conducted in New Mexico of Hispanic (n = 694) and non-Hispanic (n = 813) white women with incident breast cancer during the period of January 1, 1992 through December 31, 1994. Conditional logistic regression models were fitted to estimate the relative risk of breast cancer for levels of weight, weight change, and body mass index (BMI) and to assess differences in the effects by ethnicity, menopausal status, early life BMI, and estrogen receptor/progesterone receptor (ER/PR) expression in tumors. RESULTS: Weight change from age 18 to usual adult weight was associated with increased risk of breast cancer among Hispanics [4th quartile vs. baseline, odds ratio (OR): 2.41; 95% confidence interval (CI): 1.45-4.03] with no substantial variation by menopausal status. In non-Hispanic white women, weight change was a risk factor for those in the post-menopausal group (4th quartile vs. baseline, OR: 2.27; 95% CI: 1.09-4.73). The effect of usual BMI (test for interaction p = 0.04) and weight change (test for interaction p = 0.03) differed by ethnicity. Increased risk from weight gain was largely restricted to women who were lean at age 18 and those with ER(+)/PR(+) tumors. Height, weight at age 18, and BMI at age 18 were not associated with risk in either ethnic group. CONCLUSIONS: Weight change and obesity are risk factors for breast cancer in both Hispanic and non-Hispanic white women. However, the risk for Hispanic women is evident independent of menopausal status, while the risk for non-Hispanics is apparent in post-menopausal women. Due to the increasing prevalence of adult obesity, particularly among Hispanic women, adult weight gain may be an important modifiable risk factor for the primary prevention of breast cancer among Hispanic populations.     

Correlates of late stage breast cancer and death in a Medicaid-insured population

The authors examine how patient and insurance characteristics influence breast cancer stage at diagnosis and survival in women insured by Medicaid (N = 1,159). Two risk factors were identified for women under 65: absence of Medicaid enrollment prior to diagnosis and residency in a nursing home. Women who were not Medicaid insured prior to diagnosis were nearly 2 times more likely to have late stage disease relative to women enrolled during the month of diagnosis, and women receiving nursing home benefits had 2.47 higher odds of late stage disease relative to women who did not receive this type of care. These two variables also influenced the likelihood of death. Additional investigation is needed to evaluate breast cancer care in nursing homes and to understand what, if any, care women receive prior to Medicaid enrollment.     

Race, anthropometric factors, and stage at diagnosis of breast cancer

A recent study suggested that the greater prevalence of severe obesity among African-American women explained almost one third of the observed differences between African-American and White women in stage at diagnosis of breast cancer. The objective of this investigation was to attempt to replicate these findings in a second, larger population and to expand the analyses by including a measure of body fat distribution, the waist:hip ratio. The authors used data from a population-based study in North Carolina comprising 791 breast cancer cases (302 in African-American women and 489 in White women) diagnosed between 1993 and 1996. African-American women were more likely to have later-stage (TNM stage >/=II) breast cancer (odds ratio (OR) = 2.2; 95% confidence interval (CI): 1.6, 2.9). They also were much more likely to be severely obese (body mass index >/=32.3) (OR = 9.7; 95% CI: 6.5, 14.5) and to be in the highest tertile of waist:hip ratio (OR = 5.7; 95% CI: 3.8, 8.6). In multivariate logistic regression models, adjustment for waist:hip ratio reduced the odds ratio for later-stage disease in African-American women by 20%; adjustment for both waist:hip ratio and severe obesity reduced the odds ratio by 27%. These observations suggest that obesity and body fat distribution, in addition to socioeconomic and medical care factors, contribute to racial differences in stage at breast cancer diagnosis.