Smith-Bindman R. Racial and ethnic differences in breast cancer survival: how much is explained by screening, tumor severity, biology, treatment, comorbidities, and demographics?

Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
Cancer (Impact Factor: 4.89). 01/2008; 112(1):171-80. DOI: 10.1002/cncr.23131
Source: PubMed


The reasons for race/ethnicity (R/E) differences in breast cancer survival have been difficult to disentangle.
Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify 41,020 women aged > or =68 years with incident breast cancer between 1994-1999 including African American (2479), Hispanic (1172), Asian/Pacific Island (1086), and white women (35,878). A Cox proportional hazards model assessed overall and stage-specific (0/I, II/III, and IV) R/E differences in breast cancer survival after adjusting for mammography screening, tumor characteristics at diagnosis, biologic markers, treatment, comorbidity, and demographics.
African American women had worse survival than white women, although controlling for predictor variables reduced this difference among all stage breast cancer (hazards ratio [HR], 1.08; 95% confidence interval [95% CI], 0.97-1.20). Adjustment for predictors reduced, but did not eliminate, disparities in the analysis limited to women diagnosed with stage II/III disease (HR, 1.30; 95% CI, 1.10-1.54). Screening mammography, tumor characteristics at diagnosis, biologic markers, and treatment each produced a similar reduction in HRs for women with stage II/III cancers. Asian and Pacific Island women had better survival than white women before and after accounting for all predictors (adjusted all stages HR, 0.61 [95% CI, 0.47-0.79]; adjusted stage II/III HR, 0.61 [95% CI, 0.47-0.79]). Hispanic women had better survival than white women in all and stage II/III analysis (all stage HR, 0.88; 95% CI, 0.75-1.04) and stage II/III analysis (HR, 0.88; 95% CI, 0.75-1.04), although these findings did not reach statistical significance. There was no significant difference in survival by R/E noted among women diagnosed with stage IV disease.
Predictor variables contribute to, but do not fully explain, R/E differences in breast cancer survival for elderly American women. Future analyses should further investigate the role of biology, demographics, and disparities in quality of care.

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Available from: Elana Curtis, Sep 11, 2014
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    • "This is a patient population that may be excluded from other centers' analyses due to referral patterns. African-American women are known to have lower incidence but higher mortality from breast cancer than Caucasians, even when accounting for possible differences in access to care and in screening practices (Curtis et al. 2008; Carey et al. 2006; Stark et al. 2010). The inclusion of this diverse patient population helps make our results translatable into real-world practices, whereas patient heterogeneity may make other studies' results less applicable. "
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    ABSTRACT: As the breast cancer survivor population increases, the topic of screening these women for recurrences is increasingly relevant. In our institution, we use both breast MRI and mammography in the surveillance of breast cancer survivors, although little data exists on the use of MRI in this setting. We present a retrospective analysis of our experience and compare the sensitivity and specificity of MRI vs. mammography in this setting. We identified women under 65 with a history of breast cancer and at least one follow-up MRI performed along with a mammogram done within 6 months of the MRI. We compared the outcomes of MRI and mammography in terms of biopsies performed as well as in detection of new cancers. Of 617 charts reviewed, 249 patients met inclusion criteria, with 571 paired MRI/mammogram results. There were 27 biopsies performed due to MRI findings alone, 10 done due to mammographic findings alone, and 15 done based on abnormalities seen on both imaging modalities. There were 8 malignancies identified based on an abnormal MRI, 3 detected on both MRI and mammography, and none identified via mammography alone. Overall, MRI had a sensitivity of 84.6% (the 95% CI 54.6-98.1) and a specificity of 95.3% (the 95% CI 93.3-96.9); mammography a sensitivity of 23.1% (the 95% CI 5.0-53.8), and a specificity of 96.4% (the 95% CI 94.5-97.8). Breast MRI is a useful surveillance modality in breast cancer survivors and may be more sensitive at detecting recurrences than mammography alone in this population.
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    • "Despite the unequivocal role of ethnic origin in the pathogenesis of cancer, the association between this characteristic and survival is more complex [29]. This complexity notwithstanding, limited treatment access explains much of the differences while the role of biological differences is less clear [29]. It is important to note that Israel has universal health insurance, and basic health coverage does not differ by ethnicity. "
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    ABSTRACT: Objectives: To assess the association between social networks on survival after cancer diagnosis in a population-based sample of elderly Israelis (>60 yo) living in the community in 1985 and followed for up to 20 years. Materials and methods: We conducted a historical prospective study, using baseline measurements from a 1985 survey of a representative sample of community-dwelling population. Five distinct social networks were defined using information regarding number and intensity of social contacts: traditional-family (reference category), friends and neighbors, narrow-family, diverse, and attenuated. Cancer was ascertained through the Israel Cancer Registry, and mortality through the Population Registry after 20 years of follow-up. Results: The final study population included 676 participants diagnosed with cancer after 1985. Persons in the diverse network showed a lower risk of death (HR=0.74, 95% CI: 0.56-0.98) after adjusting for age, sex, smoking and self-assessed health. On the other hand, poor self-rated health at baseline (HR=1.39, 95% CI: 1.10-1.74 poor vs. all other categories of self-assessed health) was associated with increased risk of death. After excluding cancers amenable to early detection (breast, prostate, and colon) a borderline significant decreased risk of death following a diagnosis of cancer (HR=0.72, 95% CI: 0.52-1.01) was found. Conclusion: There is evidence of a significant protective association between diverse social networks present before a cancer diagnosis and survival after the onset of disease. Social support from a variety of sources may be an important element in improving cancer survival in older individuals.
    No preview · Article · Oct 2014 · Journal of Geriatric Oncology
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    • "Incidence and mortality rates are well known to be significantly divergent among women of certain ethnic groups [1,4-6]. In the US, White women traditionally have a higher incidence of the disease overall, but in the pre-menopausal category, women of African descent have the highest incidence rate [1-3,6,7]. Aside from DNA changes, epigenetic modifications, which regulate the expression potential of a gene, have been increasingly implicated in breast tumorgenesis [8-13]. However, not much is known about the epigenetic regulators of molecular pathways leading to derivation of specific tumor subtypes. "
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    ABSTRACT: Background Co-Activator Arginine Methyltransferase 1(CARM1) is an Estrogen Receptor (ER) cofactor that remodels chromatin for gene regulation via methylation of Histone3. We investigated CARM1 levels and localization across breast cancer tumors in a cohort of patients of either European or African ancestry. Methods We analyzed CARM1 levels using tissue microarrays with over 800 histological samples from 549 female cancer patients from the US and Nigeria, Africa. We assessed associations between CARM1 expression localized to the nucleus and cytoplasm for 11 distinct variables, including; ER status, Progesterone Receptor status, molecular subtypes, ethnicity, HER2+ status, other clinical variables and survival. Results We found that levels of cytoplasmic CARM1 are distinct among tumor sub-types and increased levels are associated with ER-negative (ER-) status. Higher nuclear CARM1 levels are associated with HER2 receptor status. EGFR expression also correlates with localization of CARM1 into the cytoplasm. This suggests there are distinct functions of CARM1 among molecular tumor types. Our data reveals a basal-like subtype association with CARM1, possibly due to expression of Epidermal Growth Factor Receptor (EGFR). Lastly, increased cytoplasmic CARM1, relative to nuclear levels, appear to be associated with self-identified African ethnicity and this result is being further investigated using quantified genetic ancestry measures. Conclusions Although it is known to be an ER cofactor in breast cancer, CARM1 expression levels are independent of ER. CARM1 has distinct functions among molecular subtypes, as is indicative of its sub-cellular localization and it may function in subtype etiology. These sub-cellular localization patterns, indicate a novel role beyond its ER cofactor function in breast cancer. Differential localization among ethnic groups may be due to ancestry-specific polymorphisms which alter the gene product.
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