Amy B. Dailey

Associations of serum concentrations of organochlorine pesticides with breast cancer and prostate cancer in U.S. adults.

Background Organochlorine (OC) pesticides are a group of environmental endocrine disruptors that may be associated with an increased risk for hormone-related cancers including cancers of the breast and prostate. However, epidemiologic evidence is limited and inconsistent. Objectives and methods We used 1999–2004 National Health and Nutrition Examination Survey data to examine associations between serum concentrations of OC pesticides and prostate and breast cancers. Results After adjustment for other covariates, serum concentrations of β-hexachlorocyclohexane (HCH) (p for trend = 0.02), trans-nonachlor (p for trend = 0.002), and dieldrin (p for trend = 0.04) were significantly associated with the risk of prevalent prostate cancer. Adjusted odds ratios for the second and third tertiles of detectable values were 1.46 [95% confidence interval (CI), 0.52–4.13] and 3.36 (95% CI, 1.24–9.10) for β -HCH; 5.84 (95% CI, 1.06–32.2) and 14.1 (95% CI, 2.55–77.9) for trans-nonachlor; and 1.06 (95% CI, 0.30–3.73) and 2.74 (95% CI, 1.01–7.49) for dieldrin compared with concentrations in the lowest tertile or below the limit of detection. However, there was no positive association between serum concentrations of OC pesticides and breast cancer prevalence. Conclusion Although further study is necessary to confirm these findings, these results suggest that OC pesticide exposures may have a significant effect on cancer risk. Efforts to reduce worldwide OC use are warranted.

Neighborhood-level socioeconomic predictors of nonadherence to mammography screening guidelines.

As neighborhood context is increasingly recognized as an important predictor of health outcomes and health behaviors, this analysis sought to determine the relationship between neighborhood-level socioeconomic status (SES) and regular mammography screening behavior. One thousand four hundred fifty-one women ages 40 to 79 years who obtained an “index” screening mammogram at one of five urban hospitals in Connecticut between October 1996 and January 1998 were enrolled in this prospective study. The logistic regression analysis includes the 1,229 women [484 African-American (39%) and 745 White (61%)] who completed telephone interviews at baseline and follow-up (average 29.4 months later) and for whom the study outcome, nonadherence to age-specific mammography screening guidelines, was ascertained. Neighborhood-level SES was determined using 1990 census tract information. Neighborhood-level SES variables (quartiles) were associated with nonadherence for African-American women [neighborhood-level education and composite socioeconomic position index (SEP Index)] and White women (neighborhood-level crowding and neighborhood-level assets). Using race-specific categorizations reflective of individual-level SES distributions, the SEP Index and neighborhood-level education were associated with nonadherence to mammography screening guidelines for African-American women (marginally significant for White women), independent of individual-level SES and other known predictors of mammography screening use [African-American women: SEP Index odds ratio (OR), 3.55; 95% confidence interval (95% CI), 1.33-9.51; neighborhood-level education OR, 3.21; 95% CI, 1.25-8.26; White women: SEP Index OR, 2.13; 95% CI, 0.97-4.67; neighborhood-level education OR, 2.31; 95% CI, 0.93-5.76]. The results of this analysis underscore the importance of examining neighborhood social context as well as individual factors in the study of mammography screening behavior. (Cancer Epidemiol Biomarkers Prev 2007;16(11):2293–303)

The Potential of Survivorship Care Plans in Primary Care Follow-up of Minority Breast Cancer Patients

ABSTRACTBACKGROUNDWhen the clinical care of minority breast cancer survivors is transferred from oncology settings to primary care, quality of care may be compromised if their primary care providers do not have adequate cancer treatment records and follow-up care guidelines. Survivorship care plans (SCPs) given to survivors before they transition to primary care settings are designed to improve the transfer of this information. This study examined these issues in a sample of minority breast cancer survivors.DESIGNDuring four focus groups with minority breast cancer survivors, data were collected about the types of information survivors remember receiving from their oncologists about follow-up health care needs. Survivors were also asked their opinions on the value and content of a survivorship care plan.RESULTSMinority breast cancer survivors received variable amounts of information about their cancer treatments. They were dissatisfied with the amount of information they received on cancer-related side-effects, including race-specific information. The American Society of Clinical Oncology’s breast cancer survivorship care plan was viewed as important, but too highly technical and limited in information on side-effects and self-care approaches.CONCLUSIONSSurvivorship care plans may help increase information transfer from oncologists to patients and primary care providers, but the content of care plans needs to be adapted to minority patients’ concerns. Primary care physicians may be challenged by survivors to explain recommended surveillance guidelines and to respond to untreated physical and psychosocial problems.

Neighborhood- and individual-level socioeconomic variation in perceptions of racial discrimination

Objective. In approaching the study of racial discrimination and health, the neighborhood- and individual-level antecedents of perceived discrimination need further exploration. We investigated the relationship between neighborhood- and individual-level socioeconomic position (SEP), neighborhood racial composition, and perceived racial discrimination in a cohort of African-American and White women age 40–79 from Connecticut, USA. Design. The logistic regression analysis included 1249 women (39% African-American and 61% White). Neighborhood-level SEP and racial composition were determined using 1990 census tract information. Individual-level SEP indicators included income, education, and occupation. Perceived racial discrimination was measured as lifetime experience in seven situations. Results. For African-American women, living in the most disadvantaged neighborhoods was associated with fewer reports of racial discrimination (odds ratio (OR) 0.44; 95% confidence interval (CI) 0.26, 0.75), with results attenuated after adjustment for individual-level SEP (OR 0.54, CI: 0.29, 1.03), and additional adjustment for neighborhood racial composition (OR 0.70, CI: 0.30, 1.63). African-American women with 12 years of education or less were less likely to report racial discrimination, compared with women with more than 12 years of education (OR 0.57, CI: 0.33, 0.98 (12 years); OR 0.51, CI: 0.26, 0.99 (less than 12 years)) in the fully adjusted model. For White women, neither neighborhood-level SEP nor individual-level SEP was associated with perceived racial discrimination. Conclusion. Individual- and neighborhood-level SEP may be important in understanding how racial discrimination is perceived, reported, processed, and how it may influence health. In order to fully assess the role of racism in future studies, inclusion of additional dimensions of discrimination may be warranted.

Birth Weight as a Risk Factor for Breast Cancer: A Meta-Analysis of 18 Epidemiological Studies

BACKGROUND Birth weight has been identified as a birth-related factor associated with the risk of breast cancer. However, the evidence is inconsistent. METHODS To investigate the association between birth weight and breast cancer, we conducted a meta-analysis of published studies between 1996 and 2008. Eighteen studies encompassing 16,424 breast cancer cases were included in the meta-analysis. Data were combined using a fixed-effect or random-effect model depending on the heterogeneity across studies. RESULTS Women with their own birth weight >4000 g or 8.5 lb had a higher risk for developing breast cancer than those with birth weight <2500 g or 3000 g (OR = 1.20, 95% CI 1.08, 1.34). Findings were also consistent with a dose-response pattern effect. The summary effect estimate for breast cancer risk per 1 kg increase in birth weight was statistically significant (random effects OR = 1.07, 95% CI 1.02, 1.12). CONCLUSIONS Although these results provided no evidence indicating whether birth weight is more strongly related to early-onset than to later-onset breast cancer, our findings suggest an association between birth weight and breast cancer. The underlying biological mechanism relating to this phenomenon needs additional study.

Adequacy of Communicating Results From Screening Mammograms to African American and White Women

OBJECTIVE We examined whether African American women were as likely as White women to receive the results of a recent mammogram and to self-report results that matched the mammography radiology report (i.e., were adequately communicated). We also sought to determine whether the adequacy of communication was the same for normal and abnormal results. METHODS From a prospective cohort study of mammography screening, we compared self-reported mammogram results, which were collected by telephone interview, to results listed in the radiology record of 411 African American and 734 White women who underwent screening in 5 hospital-based facilities in Connecticut between October 1996 and January 1998. Using multivariate logistic regression, we identified independent predictors of inadequate communication of mammography results. RESULTS It was significantly more common for African American women to experience inadequate communication of screening mammography results compared with White women, after adjustment for sociodemographic, access-to-care, biomedical, and psychosocial factors. Abnormal mammogram results resulted in inadequate communication for African American women but not White women (P<.001). CONCLUSIONS African American women may not be receiving the full benefit of screening mammograms because of inadequate communication of results, particularly when mammography results are abnormal.

Screening Mammography: A Cross-Sectional Study to Compare Characteristics of Women Aged 40 and Older From the Deep South Who Are Current, Overdue, and Never Screeners

PURPOSE We sought to identify unique barriers and facilitators to breast cancer screening participation among women aged 40 and older from Mississippi who were categorized as current, overdue, and never screeners. METHODS Cross-sectional data from a 2003 population-based survey with 987 women aged 40 and older were analyzed. Chi-square analysis and multinomial logistic regression examined how factors organized under the guidance of the Model of Health Services Utilization were associated with mammography screening status. RESULTS Nearly one in four women was overdue or had never had a mammogram. Enabling factors, including poor access to care (no annual checkups, no health insurance) and to health information, lack of social support for screening, and competing needs, were significantly associated with being both overdue and never screeners. Pertaining to factors unique to each screening group, women were more likely to be overdue when they had no usual source of health care and believed that treatment was worse than the disease. In turn, women were more likely to be never screeners when they were African American, lacked a provider recommendation for screening, and held the fatalistic view that not much could be done to prevent breast cancer. CONCLUSION Similar and unique factors impact utilization of mammography screening services among women. Those factors could inform efforts to increase screening rates.

Area-Level Socioeconomic Position and Repeat Mammography Screening Use: Results from the 2005 National Health Interview Survey

Background: Despite a considerable number of studies describing the relationship between area-level socioeconomic conditions and mammography screening, definitive conclusions have yet to be drawn. The aim of this study was to examine the relationship between area-level socioeconomic position (SEP) and repeat mammography screening, using nationwide U.S. census SEP data linked to a nationally representative sample of women who participated in the 2005 National Health Interview Survey (NHIS). Methods: An area-level SEP index using 2000 U.S. census tract data was constructed and categorized into quartiles, including information on unemployment, poverty, housing values, annual family income, education, and occupation. Repeat mammography utilization (dichotomous variable) was defined as having three mammograms over the course of 6 years (24-month interval), which must have included a recent mammogram (in past 2 years). Results were obtained by ordinary multivariable logistic regression for survey data. Women ages 46 to 79 years (n = 7,352) were included in the analysis. Results: In a model adjusted for sociodemographics, health care factors, and known correlates of mammography screening, women living in more disadvantaged areas had lower odds of engaging in repeat mammography than women living in the most advantaged areas [OR comparing quartile 4 (most disadvantaged) to quartile 1 (most advantaged) = 0.63; 95% confidence interval, 0.50–0.80]. Conclusion: The results of this nationwide study support the hypothesis that area-level SEP is independently associated with mammography utilization. Impact: These findings underscore the importance of addressing area-level social inequalities, if uptake of mammography screening guidelines is to be realized across all social strata. Cancer Epidemiol Biomarkers Prev; 20(11); 2331–44. ©2011 AACR.

The effects of birthweight and breastfeeding on asthma among children aged 1–5 years

Aim:  Asthma is a major cause of morbidity and mortality among children and has steadily increased in prevalence. The combined effect of birthweight and breastfeeding on childhood asthma remains unclear.

Efforts to adjust for confounding by neighborhood using complex survey data.

In social epidemiology, one often considers neighborhood or contextual effects on health outcomes, in addition to effects of individual exposures. This paper is concerned with the estimation of an individual exposure effect in the presence of confounding by neighborhood effects, motivated by an analysis of National Health Interview Survey (NHIS) data. In the analysis, we operationalize neighborhood as the secondary sampling unit of the survey, which consists of small groups of neighboring census blocks. Thus the neighborhoods are sampled with unequal probabilities, as are individuals within neighborhoods. We develop and compare several approaches for the analysis of the effect of dichotomized individual-level education on the receipt of adequate mammography screening. In the analysis, neighborhood effects are likely to confound the individual effects, due to such factors as differential availability of health services and differential neighborhood culture. The approaches can be grouped into three broad classes: ordinary logistic regression for survey data, with either no effect or a fixed effect for each cluster; conditional logistic regression extended for survey data; and generalized linear mixed model (GLMM) regression for survey data. Standard use of GLMMs with small clusters fails to adjust for confounding by cluster (e.g. neighborhood); this motivated us to develop an adaptation. We use theory, simulation, and analyses of the NHIS data to compare and contrast all of these methods. One conclusion is that all of the methods perform poorly when the sampling bias is strong; more research and new methods are clearly needed.