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.     

Disparities in receipt of adjuvant radiation therapy after breast-conserving surgery among the cancer-reporting regions of California

BACKGROUND:

Incidence and mortality of breast cancer vary according to demographic factors such as age, race/ethnicity, socioeconomic status (SES), and geographic region. This study assesses the variation of these factors in the use of adjuvant radiation therapy (RT) after breast‐conserving surgery (BCS) among 8 regions of California.

METHODS:

The authors identified 85,574 cases of first primary female invasive breast cancer with complete data diagnosed between January 1, 2000 and December 31, 2007. Logistic regression was used to determine the association between race/ethnicity, age, SES, and receipt of RT after BCS within each of the regions of California. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed.

RESULTS:

Age was a significant predictor of receipt of RT after BCS in all regions. In Los Angeles (LA), lower SES was associated with decreasing odds of RT. Racial disparities were evident only in LA, where black (OR, 0.85; 95% CI, 0.74‐0.97) and Hispanic (OR, 0.86; 95% CI, 0.78‐0.96) women were about 15% less likely to receive RT than white women.

CONCLUSIONS:

Racial disparities in the receipt of RT after BCS exist only in LA, where African American and Hispanic women are less likely to receive this form of adjuvant treatment. Lower SES was also associated with a reduced likelihood of receipt of RT in LA. Women age 70 years and older are less likely to receive RT after BCS in all regions of California. Cancer 2012. © 2011 American Cancer Society.     

Racial segregation and disparities in breast cancer care and mortality

BACKGROUND.

Questions have existed as to whether residential segregation is a mediator of racial/ethnic disparities in breast cancer care and breast cancer mortality, or has a differential effect by race/ethnicity.

METHODS.

Data from the Surveillance, Epidemiology, and End Results–Medicare database on white, black, and Hispanic women aged 66 to 85 years with breast cancer were examined for the receipt of adequate breast cancer care.

RESULTS.

Blacks were less likely than whites to receive adequate breast cancer care (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.71‐0.86). Individuals, both black and white, who lived in areas with greater black segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.64‐0.82). Black segregation was a mediator of the black/white disparity in breast cancer care, explaining 8.9% of the difference. After adjustment, adequate care for Hispanics did not significantly differ from whites, but individuals, both Hispanic and white, who lived in areas with greater Hispanic segregation were less likely to receive adequate breast cancer care (OR, 0.73; 95% CI, 0.61‐0.89). Although Blacks experienced greater breast cancer mortality than whites, black segregation did not substantially mediate the black‐white disparity in survival, and was not significantly associated with mortality (hazards ratio, 1.03; 95% CI, 0.87‐1.21). Breast cancer mortality did not differ between Hispanics and whites.

CONCLUSIONS.

Among seniors, segregation mediates some of the black‐white disparity in breast cancer care, but not mortality. Individuals who live in more segregated areas are less likely to receive adequate breast cancer care. Cancer 2008. © 2008 American Cancer Society.     

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

BACKGROUND:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

Racial 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 variation in receipt of quality radiation therapy for prostate cancer

Purpose

Racial disparities are apparent in the management and outcomes for prostate cancer; however, disparities in compliance to quality measures for radiation therapy for prostate cancer have not been previously studied. Therefore, the goal of the study was to characterize disparities in the compliance rates with quality measures.

Methods

The comparative effectiveness analysis of radiation therapy and surgery study is a population-based, prospective cohort study that enrolled 3708 men with clinically localized prostate cancer from 2011 to 2012. Compliance with 5 radiation-specific quality measures endorsed by national consortia as of 2011 was assessed, and compliance was compared by race using logistic regression.

Results

Overall, 604 men received definitive external beam radiation therapy (EBRT) of which 20% were self-reported black, 74% non-Hispanic white, and 6% Hispanic. Less than two-thirds of black and Hispanic men received EBRT that was compliant with all available quality measures (p?=?0.012). Compared to white men, black men were less likely to receive dose-escalated EBRT (95% vs. 87%, p?=?0.011) and less likely to avoid unnecessary pelvic radiation for low-risk disease (99% vs. 20%, p?<?0.001). Compared to white men, Hispanic men were less likely to undergo image guidance (87% vs. 71%, p?=?0.04). Black and Hispanic men were more likely to receive EBRT from low-quality providers than white men.

Conclusions

Addressing disparities in access to providers that meet quality guidelines, and improving adherence to evidence-based processes of care may decrease racial/ethnic disparities in prostate cancer outcomes.

     

Racial disparities in the use of radiotherapy after breast‐conserving surgery: A national Medicare study

BACKGROUND:

In prior studies, the use of standard breast cancer treatments has varied by race, but previous analyses were not nationally representative. Therefore, in a comprehensive, national cohort of Medicare patients, racial disparities in the use of radiotherapy (RT) after breast‐conserving surgery (BCS) for invasive breast cancer were quantified.

METHODS:

A national Medicare database was used to identify all beneficiaries (age >65 years) treated with BCS for incident invasive breast cancer in 2003. Claims codes identified RT use, and Medicare demographic data indicated race. Logistic regression modeled RT use in white, black, and other‐race patients, adjusted for demographic, clinical, and socioeconomic covariates.

RESULTS:

Of 34,080 women, 91% were white, 6% were black, and 3% were another race. The mean age of the patients was 76 ± 7 years. Approximately 74% of whites, 65% of blacks, and 66% of other‐race patients received RT (P < .001). After covariate adjustment, whites were found to be significantly more likely to receive RT than blacks (odds ratio, 1.48; 95% confidence interval, 1.34‐1.63 [P < .001]). Disparities between white and black patients varied by geographic region, with blacks in areas of the northeastern and southern United States demonstrating the lowest rates of RT use (57% in these regions). In patients age <70 years, racial disparities persisted. Specifically, 83% of whites, 73% of blacks, and 78% of other races in this younger group received RT (P < .001).

CONCLUSIONS:

In this comprehensive national sample of older breast cancer patients, substantial racial disparities were identified in RT use after BCS across much of the United States. Efforts to improve breast cancer care require overcoming these disparities, which exist on a national scale. Cancer 2010. © 2009 American Cancer Society.     

Use of adjuvant trastuzumab in women with human epidermal growth factor receptor 2 (HER2)‐positive breast cancer by race/ethnicity and education within the National Comprehensive Cancer Network

BACKGROUND.

Trastuzumab for human epidermal growth factor receptor 2 (HER2)‐positive breast cancer is highly efficacious yet costly and time‐intensive, and few data are available about its use. The authors of this report examined receipt and completion of adjuvant trastuzumab by race/ethnicity and education for women with HER2‐positive disease.

METHODS.

The National Comprehensive Cancer Network Breast Cancer Outcomes Database was used to identify 1109 women who were diagnosed with stage I through III, HER2‐positive breast cancer during September 2005 through December 2008 and were followed for ≥1 year. The authors used multivariable logistic regression to assess the association of race/ethnicity and education with the receipt of trastuzumab and, among those women who initiated trastuzumab, with the completion of > 270 days of therapy.

RESULTS.

The cohort was 75% white, 8% black, and 9% Hispanic; and 20% of women had attained a high school degree or less. Most women (83%) received trastuzumab, and no significant differences were observed according to race/ethnicity or socioeconomic status. Among the women who initiated trastuzumab, 73% of black women versus 87% of white women (P = .007) and 70% of women with less than a high school education versus 90% of women with a college degree completed > 270 days of therapy (P = .006). In adjusted analyses, black women (vs white women) and women without a high school degree (vs those with a college degree) had lower odds of completing therapy (black women: odds ratio, 0.45; 95% confidence interval, 0.27‐074; white women: odds ratio, 0.27, 95% confidence interval, 0.14‐0.51).

CONCLUSIONS.

Differences in completing trastuzumab therapy were observed according to race and educational attainment among women who received treatment at National Comprehensive Cancer Network centers. Efforts to assure the appropriate use of trastuzumab and to understand treatment barriers are needed and may lead to improved outcomes. The authors report differences in the rate at which patients complete treatment with trastuzumab according to race and education among women who receive treatment at National Comprehensive Cancer Network centers. Efforts to assure the appropriate use of trastuzumab and to understand treatment barriers are needed and may lead to improved outcomes. Cancer 2013. © 2012 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.     

Impact of race,ethnicity, and socioeconomic factors on receipt of radiation after breast conservation surgery: analysis of the national cancer database

Introduction

Many eligible women with invasive breast cancer do not receive recommended adjuvant radiation (RT), despite its role in local control and overall survival. We examined trends in RT use over 10 years, and the impact of sociodemographic factors on the receipt of standard-of-care RT, using the National Cancer Database (NCDB).

Materials/methods

Women under age 70 with invasive breast cancer who underwent BCS from 2004 to 2014 were analyzed. Receipt of RT was evaluated in the whole cohort and by time period to identify temporal trends. Multiple logistic regression models were used to assess associations between factors such as race, insurance status, ethnicity, and receipt of RT.

Results

A total of 501,733 patients met eligibility criteria. The percentage of patients undergoing adjuvant RT increased from 86.7% in 2004 to 92.4% in 2012, and then decreased in 2013 and 2014 to 88.9%. On univariate analysis, patients of white race were significantly more likely to receive RT compared with patients of black race (90.4% vs 86.9%, p?<?0.0001), as were non-Hispanic women compared to Hispanic patients (90.2% vs. 85.3%, p?<?0.0001). On multivariate analysis, race, ethnicity, insurance status, education level, and age remained significantly associated with receipt of RT. On temporal analysis, gaps remained stable, with no significant improvements over time.

Conclusions

This analysis suggests a recent decline in guideline-concordant receipt of RT in women under 70, and persistent disparities in the use of RT after BCS by race, ethnicity, and socioeconomic factors. These findings raise concern for a recent detrimental change in patterns of care delivery.

     

The impact of socioeconomic status and race on trial participation for older women with breast cancer

BACKGROUND: Older women, and older minorities in particular, are under represented in breast cancer trials. Although socioeconomic status (SES) is associated with both race and age, to the authors' knowledge little is known regarding the impact of SES on trial enrollment among older women with breast cancer. METHODS: The authors performed a case-control study comparing women who were participants in National Cancer Institute cooperative group breast cancer trials (cases) with a population-based sample of breast cancer patients (controls) obtained from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data base. The sample was restricted to women age >/= 65 years who were living in SEER areas. Proxies for SES included the proportion of the population below poverty level (by zip code) and unemployed (by county) as well those with Medicaid insurance coverage. A multivariable logistic regression model was used to test the association of SES with trial participation after accounting for other patient and county characteristics. RESULTS: In bivariate analysis, trial participants were significantly less likely than community cancer patients to reside in high-poverty zip codes (20.9% vs. 24.9%, respectively; P < 0.001) or to have Medicaid insurance (2.0% vs. 10.0%; P < 0.0001). After adjusting for race, age, and county, trial participation remained inversely related to residing in areas with high poverty (odds ratio [OR] vs. residents of remaining counties, 0.78; 95% confidence interval [95% CI], 0.62-0.98), high unemployment rates (OR vs. residents of residents of counties in the lowest quartile, 0.50; 95% CI, 0.35-0.71), and having Medicaid insurance (OR vs. women without Medicaid, 0.22; 95% CI, 0.13-0.37); black race was not found to be related to trial participation (OR for black vs. white, 1.0; 95% CI, 0.67-1.47). CONCLUSIONS: Low SES was associated inversely with trial enrollment for older women with breast cancer and appeared to account for the enrollment disparities between black patients and white patients. Future efforts to enhance enrollment of elderly women in cancer research should identify specific barriers related to SES that may be amenable to intervention.     

Breast cancer characteristics and outcomes among Hispanic Black and Hispanic White women

Evaluating breast cancer outcomes specific to Hispanics of different race (e.g. Hispanic Black, Hispanic White) may further explain variations in the burden of breast cancer among Hispanic women. Using data from the SEER 17 population-based registries, we evaluated the association between race/ethnicity and tumor stage, hormone receptor status, and breast cancer-specific mortality. The study cohort of 441,742 women, aged 20-79, who were diagnosed with primary invasive breast cancer between January 1, 1992 and December 31, 2008, included 44,246 Hispanic whites, 622 Hispanic Blacks, 44,797 non-Hispanic Blacks and 352,077 non-Hispanic whites. Hispanic black, Hispanic white and non-Hispanic black women had a 1.5-2.5 fold greater risk of presenting with stage IV breast cancer compared to non-Hispanic whites. All groups were significantly more likely than non-Hispanic whites to be diagnosed with ER+/PR- (1.1-1.5 fold increase) or ER-/PR- (1.4-2.2 fold increase) breast cancer. Hispanic black, Hispanic white and non-Hispanic black women had a 10-50?% greater risk of breast cancer-specific mortality compared to non-Hispanic whites. Our findings underscore the breast cancer disparities that continue to exist for Hispanic and black women, overall, as well as between Hispanic women of different race. These disparities highlight the factors that may lead to the poor outcomes observed among Hispanic and black women diagnosed with breast cancer, and for which targeted strategies aimed at reducing breast cancer disparities could be developed.     

Policy implications of early onset breast cancer among Mexican-origin women

BACKGROUND:

Overall, Latinas are more likely to be diagnosed with a more advanced stage of breast cancer and are 20% more likely to die of breast cancer than non‐Hispanic white women. It is estimated that from 2003 to 2006, $82.0 billion in direct medical care expenditures, in addition to 100,000 lives annually, could be saved by eliminating health disparities experienced by Latinos and increasing the use of up to 5 preventive services in the United States. An additional 3700 lives could be saved if 90% of women aged ≥40 years were recently screened for breast cancer.

METHODS:

The authors examined the risk for breast cancer in a case‐control, population‐based sample of Mexican‐origin women in Harris County, Texas (n = 714), where the rates of breast cancer mortality for Latina women have doubled since 1990.

RESULTS:

Half of breast cancer cases (n = 119) were diagnosed in women aged <50 years. In a multivariate model, women who had a family history of breast cancer (odds ratio [OR], 4.3), who were born in Mexico and had high levels of language acculturation (OR, 2.5), and who did not have health insurance (OR, 1.6) had the highest risk for breast cancer.

CONCLUSIONS:

Because the current results indicated that Mexican‐origin women are at high‐risk for early onset, premenopausal breast cancer, the authors recommended policies that target screening, education, and treatment to prevent increased disparities in mortality. The authors concluded that the inclusion of community members and policymakers as partners in these endeavors would further safeguard against an increase in cancer health disparities and aid in formulating a policy agenda congruent with scientifically based, community‐driven policy efforts that address breast cancer screening, education, and treatment in this vulnerable population. Cancer 2011. © 2010 American Cancer Society.     

Breast biopsy and race/ethnicity among women without breast cancer

BACKGROUNd: Breast biopsy is essential for definitive breast cancer diagnosis, but may also play a role in determining eligibility for breast cancer preventive measures or clinical trials. In addition, the prevalence of a history of negative breast biopsy can be viewed as an indicator of the adequacy or intensity of health care in a given population. We therefore analyzed the association of a history of breast biopsy with race/ethnicity and other factors in a cohort of women without a cancer diagnosis who completed a risk assessment form for participation in the Study of Tamoxifen and Raloxifene (STAR) and a sociodemographic questionnaire. METHODS: Subjects were recruited at our large, urban teaching hospital. We developed a logistic regression model with biopsy (ever/never) as the outcome and age, race/ethnicity, educational attainment, and insurance coverage as the independent variables. RESULTS: Among 805 unaffected predominantly minority subjects, white women were more than three times as likely as black and Hispanic women (OR=3.3, 95% CI 1.9-5.9), and insured women were twice as likely as uninsured women (OR=2.0, 95% CI 1.4-2.9) to have had a biopsy. Biopsy results were also associated with race/ethnicity. DISCUSSION: We view these observations as hypothesis-generating rather than definitive. If confirmed, the associations we observed between negative biopsies and insurance status may reflect disparities in the timeliness and effectiveness of follow-up of suspicious lesions found via mammography. Our findings may also be relevant to the well-known association of breast cancer stage at diagnosis with low income and minority race/ethnicity.     

Comparative analysis of clinicopathologic features, treatment, and survival of Asian women with a breast cancer diagnosis residing in the United States

BACKGROUND:

It has been established that disparities by ethnicity in the rates of breast cancer diagnoses and disease‐specific survival (DSS) exist in the United States. However, few studies have assessed differences specifically between Asians and other ethnic groups or among Asian subgroups.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results database to identify patients who were diagnosed with invasive breast cancer between 1988 and 2008. Clinicopathologic features, treatment, and DSS rates were compared among broad ethnic groups and among Asian subgroups.

RESULTS:

In total, there were 658,691 patients in the study, including 511,701 non‐Hispanic white (NHW) women (77.7%), 57,890 black women (8.8%), 45,461 Hispanic white (HW) women (6.9%), and 43,639 Asian women (6.6%). The Asian cohort was divided into the following subgroups: Filipino, Chinese, Japanese, Indian/Pakistani, Korean, Vietnamese, Hawaiian/Pacific Islander, and other. Patients in all the Asian subgroups, except Japanese, were younger at diagnosis than NHW patients. After adjustment for disease stage, Japanese patients diagnosed with stage I through III disease had better DSS rates than patients in the NHW group or in the other Asian subgroups. Hawaiian/Pacific Islander patients with stage III or IV disease had worse DSS rates than NHW patients and patients in the other Asian subgroups. All other Asian subgroups had DSS rates similar to the DSS rate in the NHW group.

CONCLUSIONS:

The current results indicated that disparities exist for Asian women with breast cancer who reside in the United States compared with NHW groups and among Asian subgroups. Differences in presenting clinicopathologic features may affect DSS rates, suggesting that further investigation of these disparities is warranted to increase early detection and treatment for specific subgroups. Cancer 2012. © 2012 American Cancer Society.     

Disparities in medical care among commercially insured patients with newly diagnosed breast cancer

BACKGROUND:

African‐American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity.

METHODS:

In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n = 476) and African‐American women (n = 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]‐positive status), treatment (breast‐conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and all‐cause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/treatment.

RESULTS:

White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African‐American women. More white women had positive ER/PR status (75% vs 56% African‐American; P = .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African‐American; P < .001). White women received slightly more breast‐conserving surgery and chemotherapy dose modification than African‐American women (P value nonsignificant). African‐American women had a higher mortality rate (8.1%) than white women (3.6%; P = .06). In adjusted analyses, African‐American women were diagnosed at later stages (odds ratio, 1.71; P = .02), and white women received more antiestrogen therapy (odds ratio, 2.1; P = .03).

CONCLUSIONS:

Disparities in medical care among patients with newly diagnosed breast cancer were evident between African‐American women and white women despite health plan insurance coverage. Interventions that address the gaps identified are needed. Cancer 2010. © 2010 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.     

Male breast cancer according to tumor subtype and race

BACKGROUND:

Breast cancer occurs rarely in men. To the authors' knowledge, no population‐based estimates of the incidence of human epidermal growth factor receptor 2 (HER2)‐positive breast cancer or of the distribution of breast cancer subtypes among male breast cancer patients have been published to date. Therefore, the objective of the current study was to explore breast tumor subtype distribution by race/ethnicity among men in the large, ethnically diverse population of California.

METHODS:

This study included men who were diagnosed with invasive breast cancer between 2005 and 2009 with known estrogen receptor (ER) and progesterone receptor (PR) (together, hormone receptor [HR]) status and HER2 status reported to the California Cancer Registry. Among the men with HR‐positive tumors, survival probabilities between groups were compared using log‐rank tests.

RESULTS:

Six hundred six patients were included. The median age at diagnosis was 68 years. Four hundred ninety‐four men (81.5%) had HR‐positive tumors (defined as ER‐positive and/or PR‐positive and HER2‐negative). Ninety men (14.9%) had HER2‐positive tumors, and 22 (3.6%) had triple receptor‐negative (TN) tumors. Among the patients with HR‐positive tumors, non‐Hispanic black men and Hispanic men were more likely to have PR‐negative tumors than non‐Hispanic white men. No statistically significant differences in survival were observed according to tumor subtype (P = .08). Differences in survival according to race/ethnicity were observed among all patients (P = .087) and among those with HR‐positive tumors (P = .0170), and non‐Hispanic black men had poorer outcomes.

CONCLUSIONS:

In this large, representative cohort of men with breast cancer, the distribution of tumor subtypes was different from that reported for women and varied by patient race/ethnicity. Non‐Hispanic black men were more likely to have TN tumors and ER‐positive/PR‐negative tumors than white men. Cancer 2013. © 2013 American Cancer Society.     

Occult breast cancer may originate from ectopic breast tissue present in axillary lymph nodes

Purpose

Evidence suggests substantial disparities in breast cancer survival by socioeconomic status (SES). We examine the extent to which receipt of newer, less invasive, or more effective treatments—a plausible source of disparities in survival—varies by SES among elderly women with early-stage breast cancer.

Methods

Multivariate regression analyses applied to 11,368 women (age 66–90 years) identified from SEER-Medicare as having invasive breast cancer diagnosed in 2006–2009. Socioeconomic status was defined based on Medicaid enrollment and level of poverty of the census tract of residence. All analyses controlled for demographic, clinical health status, spatial, and healthcare system characteristics.

Results

Poor and near-poor women were less likely than high SES women to receive sentinel lymph node biopsy and radiation after breast-conserving surgery (BCS). Poor women were also less likely than near-poor or high SES women to receive any axillary surgery and adjuvant chemotherapy. There were no significant differences in use of aromatase inhibitors (AI) between poor and high SES women. However, near-poor women who initiated hormonal therapy were more likely to rely exclusively on tamoxifen, and less likely to use the more expensive but more effective AI when compared to both poor and high SES women.

Conclusions

Our results indicate that SES disparities in the receipt of treatments for incident breast cancer are both pervasive and substantial. These disparities remained despite women’s geographic area of residence and extent of disease, suggesting important gaps in access to effective breast cancer care.

     

The influence of Hispanic ethnicity on nonsmall cell lung cancer histology and patient survival: An analysis of the Survival, Epidemiology, and End Results database

BACKGROUND:

Most studies exploring ethnic/racial disparities in nonsmall cell lung cancer (NSCLC) compare black patients with whites. Currently, the effect of Hispanic ethnicity on the overall survival of NSCLC is poorly understood. Therefore, the authors carried out a large‐scale, population‐based analysis using the Surveillance, Epidemiology, and End Results (SEER) data base to determine the impact of Hispanic ethnicity the survival of patients with NSCLC.

METHODS:

The authors identified 172,398 adult patients with pathologically confirmed NSCLC from the SEER data base who were diagnosed between 1988 and 2007. A multivariate Cox proportional hazards regression analysis was used to determine the impact of race/ethnicity on overall survival. Pair‐wise comparisons were used to determine whether Hispanic ethnicity influenced NSCLC histology or stage at diagnosis.

RESULTS:

Compared with non‐Hispanic white patients, Hispanic white patients had a statistically significant better overall survival (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.83‐0.87), and black patients had worse survival (HR, 1.091; 95% CI, 1.072‐1.109). Within the bronchioalveolar carcinoma (BAC) subtype, Hispanic‐white patients tend to be over represented (8.1% Hispanic whites vs 5.5% non‐Hispanic whites vs 3.7% blacks; P < .001).

CONCLUSIONS:

The current study demonstrated that Hispanic‐white patients with NSCLC had a decreased risk for overall mortality compared with non‐Hispanic whites and blacks. Moreover, Hispanic patients were over represented within the BAC histologic subtype. Thus, the overall survival advantage of Hispanic NSCLC patients may be because of their predilection toward developing certain histologic subtypes of NSCLC. Further studies are warranted to determine the etiologies of such predilections and may reveal certain genetic, environmental, and/or epigenetic factors associated with Hispanic ethnicity. Cancer 2012. © 2012 American Cancer Society.