Breast cancer diagnoses, survival varies by race, ethnicity

Among nearly 375,000 U.S. women diagnosed with invasive breast cancer, the likelihood of diagnosis at an early stage, and survival after stage I diagnosis, varied by race and ethnicity, with much of the difference accounted for by biological differences, according to a study in JAMA.

In the United States, incidence rates of breast cancer among women vary substantially by racial/ethnic group. Race/ethnicity and sociodemographic factors may influence a woman’s adherence to recommendations for clinical breast examination, breast self-examination, or screening mammogram and the likelihood of her seeking appropriate care in the event that a breast mass is noticed. A growing body of evidence suggests that biological factors may also be important in determining stage at diagnosis (i.e., the growth rate and metastatic potential of small-sized breast cancer tumors may vary between women due to inherent differences in grade and other or unknown pathological features), according to background information in the article.

Javaid Iqbal, M.D., of Women’s College Hospital, Toronto, and colleagues examined the proportion of breast cancers that were identified at an early stage (stage I) in different racial/ethnic groups in the United States and whether ethnic differences may be better explained by early detection or by intrinsic biological differences in tumor aggressiveness. The study included women diagnosed with invasive breast cancer from 2004 to 2011 who were identified in the Surveillance, Epidemiology, and End Results (SEER) 18 registries database (n = 452,215). For each of 8 racial/ethnic groups, biological aggressiveness (triple-negative cancers [negative for estrogen receptor, progesterone receptor, and ERBB2 (formerly HER2 or HER2/neu)], lymph node metastases, and distant metastases) of small-sized tumors of 2.0 cm or less was estimated. In addition, the odds were determined for being diagnosed at stage I compared with a later stage, as was the risk of death from stage I breast cancer by racial/ethnic group.

Of 373,563 women with invasive breast cancer, 268 675 (71.9 percent) were non-Hispanic white; 34,928 (9.4 percent), Hispanic white; 38,751 (10.4 percent), black; 25,211(6.7 percent), Asian; and 5,998 (1.6 percent), other ethnicities. Average follow-up time was 40.6 months. The researchers found that Japanese women were significantly more likely to be diagnosed at stage I (56.1 percent) than non-Hispanic white women (50.8 percent), while black women were less likely to be diagnosed at stage I (37.0 percent), as were women of South Asian ethnicity (Asian Indian, Pakistani) (40.4 percent).

The 7-year actuarial risk for death from stage I breast cancer was highest for black women (6.2 percent) compared with white women (3.0 percent); it was 1.7 percent for South Asian women. The probability of a woman dying due to small-sized breast cancer tumors (2.0 cm or less) was significantly higher for black women (9.0 percent) compared with non-Hispanic white women (4.6 percent).

The authors write that much of the difference in diagnosis and survival could be statistically accounted for by intrinsic biological differences such as lymph node metastasis, distant metastasis, and triple-negative behavior of tumors.

Iqbal et al. Differences in breast cancer stage at diagnosis and cancer-specific survival by race and ethnicity in the United States. JAMA. 2015;313(2):165-173. doi:10.1001/jama.2014.17322 [Article]

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Race, hospital, insurance status all factors in how lung cancer is treated

African Americans, Hispanics, and those who receive care at a community hospital are all significantly less likely than other patients to receive treatment for early stage non-small cell lung cancer, according to a report in the Journal of Thoracic Oncology.

We found significant disparities for treatment of a curable cancer based on race, insurance status, and whether or not treatment was at an academic or community hospital,” said Dr. Matthew Koshy, a physician in the department of radiation oncology at the University of Illinois at Chicago College of Medicine, and lead author of the study. “Reducing these disparities could lead to significant improvements in survival for many people with inoperable early stage lung cancer.

The study is the largest to date looking at treatment received by patients with stage I non-small cell lung cancer, an early stage of lung cancer that has not spread to the lymph nodes and is characterized by a small nodules in the lung tissue. Treatment during this early stage offers the best chance for long-term survival.

Surgery to remove cancerous nodules in the lungs is the standard treatment for patients with stage I NSCLC. But many patients cannot undergo surgery, due to complicating medical conditions such as poor lung function or heart disease.

For those patients, radiation therapy has been the standard treatment, but outcomes are much poorer than for surgical treatment. Many patients deemed inoperable are only monitored, because the benefits of conventional radiation are regarded as minimal.

Over the last 10 years, a new radiation technology called stereotactic body radiotherapy, or SBRT, has replaced conventional radiation as the standard treatment for inoperable stage I NSCLC. It delivers much higher doses of radiation, requires fewer treatments, is better tolerated, and has survival outcomes comparable to surgery.

Koshy and his colleagues wanted to know if any factors predicted whether a patient was more likely to be observed, treated with conventional radiation, or treated with SBRT — and if there were any disparities in the use of those treatments.

They looked at data from nearly 40,000 patients with inoperable stage I NSCLC added to the National Cancer Database between 2003 and 2011. The hospital-based cancer registry collects information on patient demographics, insurance status, diagnosis, treatment and outcome.

The analysis showed that African Americans were 40 percent less likely, and Hispanics 60 percent less likely, to be treated with radiation — either conventional radiation or SBRT. Of patients who did receive radiation, African Americans and those with no insurance were less likely to receive SBRT.

Patients were two-and-a-half times more likely to receive SBRT in academic hospitals than in community hospitals, and seven times more likely to receive SBRT at a high-volume medical center than at a low-volume center.

The researchers found that in 2011, 46 percent of patients receiving care in community care centers were only observed, compared to 21 percent of patients at academic medical centers. Sixty-eight percent of patients at academic medical centers received SBRT compared to 25 percent of patients at community hospitals.

Koshy suggests that all patients with early stage inoperable lung cancer be evaluated by a radiation oncologist, and that more radiation oncologists trained in SBRT are needed. Better access to facilities that offer SBRT could help reduce the disparities the study uncovered, he said.

Koshy et al. Disparities in Treatment of Patients with Inoperable Stage I Non-Small Cell Lung Cancer: A Population-Based Analysis. J Thorac Oncol. 2014; EPub Ahead of Print. doi: 10.1097/JTO.0000000000000418 [Abstract]

Racial disparities in health care among older male cancer survivors

Older African-American and Hispanic men who have survived cancer are less likely than their white counterparts to see a specialist or receive basic preventive care, such as vaccinations, according to new research from Wake Forest Baptist Medical Center.

Researchers examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors. They found that disparities are evident among older, but not younger, cancer survivors, despite their access to Medicare.

Lead author Nynikka Palmer, Dr.P.H., a postdoctoral fellow at Wake Forest Baptist, said they identified 2,714 men 18 and older from the 2006-2010 National Health Interview Survey who reported a history of cancer. The researchers looked at health care receipt in four self-reported measures: primary care visit, specialist visit, flu vaccination and pneumonia vaccination.

“Overall, our results suggest that older minority male cancer survivors may need specific support to ensure they receive necessary post-treatment care,” Palmer said.

The study was recently published online ahead of print in the American Journal of Public Health.

Even when the researchers adjusted for factors that contribute to disparities, such as education and health insurance, they found that African American and Hispanic male cancer survivors 65 years and older may not be receiving appropriate follow-up care and preventive care. Palmer said this is a concern “because regular follow-up care is important to monitor for recurrence, new cancers, and late and long-term effects of cancer and its treatment, particularly for those with more co-morbidities.”

Overall, among older survivors, approximately 39 percent of African-Americans and 42 percent of Hispanics did not see a specialist, compared with 26 percent of older non-Hispanic whites. Likewise, about 40 percent of African-American and Hispanic cancer survivors did not receive the flu vaccination, compared with 22 percent of non-Hispanic white cancer survivors.

Similarly, 51 percent of African-Americans and 59 percent of Hispanic cancer survivors did not report receiving the pneumonia vaccine, compared with 29 percent of non-Hispanic whites.

“These findings are consistent with other reports of health care use among cancer survivors and suggest there may be differences in types of Medicare health plans, supplemental insurance and out-of-pocket costs among older survivors that could be contributing to this disparity,” Palmer said.

Palmer said further study is needed to identify other factors that may influence racial/ethnic disparities among male survivors, such as patients’ beliefs about care after cancer and patient-provider communication.

Palmer et al., (2013). Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors. Am. J. Public Health103: 1306-1313 [Abstract]