Ian K. Komenaka

Race and Ethnicity and Breast Cancer Outcomes in an Underinsured Population

BACKGROUNDnThe disparity in breast cancer mortality between African American women and non-Hispanic white women has been the subject of increased scrutiny. Few studies have addressed these differences in the setting of equal access to health care. We compared the breast cancer outcomes of underinsured African American and non-Hispanic white patients who were treated at a single institution.nnnMETHODSnWe conducted a retrospective review of medical records for breast cancer patients who were treated at Wishard Memorial Hospital from January 1, 1997, to February 28, 2006. A total of 574 patients (259 non-Hispanic whites and 315 African Americans) were evaluated. A Cox proportional hazards regression analysis for competing risks was performed. All statistical tests were two-sided.nnnRESULTSnSociodemographic characteristics were similar in the two groups, and both racial groups were equally unlikely to have undergone screening mammography during the 2 years before diagnosis. Most (84%) of the patients were underinsured. The median time from diagnosis to operation, receipt of adequate surgery, and use of all types of adjuvant therapy were similar in the two groups. Median follow-up was 80.3 months for non-Hispanic whites and 77.9 months for African Americans. After accounting for the effect of comorbidities, African American race was statistically significantly associated with breast cancer-specific mortality (African Americans vs non-Hispanic whites: 26.0% vs 17.5%, P = .028; hazard ratio [HR] of death = 1.64, 95% confidence interval [CI] = 1.06 to 2.55). Adjustment for age at diagnosis, clinical stage, and hormone receptor status attenuated the effect, and the effect of race on breast cancer-specific survival was no longer statistically significant (HR of death from breast cancer = 1.43, 95% CI = 0.89 to 2.30). After adjustment for sociodemographic factors, the hazard ratio for race was further attenuated (HR = 1.26; 95% CI = 0.79 to 2.00).nnnCONCLUSIONSnIn this underinsured population, African American patients had poorer breast cancer-specific survival than non-Hispanic white patients. After adjustment for clinical and sociodemographic factors, the effect of race on survival was no longer statistically significant.

The effect of dedicated breast surgeons on the short-term outcomes in breast cancer.

Objective:The impact of breast surgeons on short-term outcomes in breast cancer care was compared at a single institution. Summary Background Data:Many studies have demonstrated a correlation between high procedural volume and lower mortality in technically challenging procedures. Breast cancer treatment has significant impact on patient behavior, psychology, and appearance. Therefore, evaluation of outcomes cannot be limited to only operative mortality and morbidity. We sought to determine the effect of dedicated breast cancer surgeons on short-term outcomes at a single institution. Methods:Wishard Memorial Hospital is the county hospital affiliated with the Indiana University School of Medicine. A retrospective review was performed of all patients from January 1, 1997, to February 28, 2006. On July 1, 2003, coverage for the Breast Clinic was changed from general surgeons (G) to breast surgeons (B). There were 596 patients included in the study period. Results:There were no significant differences in patient demographics or disease characteristics between the 2 time periods. For early stage (stage I and II) breast cancer, a higher percentage of patients underwent breast conservation in the breast surgeon period than in the general surgeon period (P = 0.04). Lumpectomy margins in breast conserving operations during the G period were more often positive (P = 0.025) or close (<1 mm) (P = 0.01). Similarly, the rates of re-excision lumpectomy were also significantly lower during the B period (21% vs. 39%, respectively, P = 0.01). Breast surgeons were more likely to perform the sentinel node procedure (P = 0.001). There were no differences in the use of adjuvant chemotherapy and radiation therapy. The use of hormonal manipulation, however, was significantly higher in the B group than in the G group (P < 0.0002). Conclusions:Surgeons specialized in diseases of the breast demonstrate significant improvement in short-term outcomes associated with breast cancer treatment at a single institution. The differences identified cannot be attributed to differences in institutional function, patient population, surgeon case volume, or on the influence of nonsurgeon physicians.

Reproductive Factors, Heterogeneity, and Breast Tumor Subtypes in Women of Mexican Descent

Background: Published data support the presence of etiologic heterogeneity by breast tumor subtype, but few studies have assessed this in Hispanic populations. Methods: We assessed tumor subtype prevalence and associations between reproductive factors and tumor subtypes in 1,041 women of Mexican descent enrolled in a case-only, binational breast cancer study. Multinomial logistic regression comparing HER2+ tumors and triple-negative breast cancer (TNBC) to luminal A tumors was conducted. Results: Compared with women with luminal A tumors, those with a later age at first pregnancy were less likely to have TNBC [OR, 0.61; 95% confidence interval (CI), 0.39–0.95], whereas those with three or more full-term pregnancies were more likely to have TNBC (OR, 1.68; 95% CI, 1.10–2.55). A lower odds of TNBC was shown for longer menstruation duration, whether before first pregnancy (OR, 0.78; 95% CI, 0.65–0.93 per 10 years) or menopause (OR, 0.79; 95% CI, 0.69–0.91 per 10 years). Patients who reported breastfeeding for more than 12 months were over twice as likely to have TNBC than luminal A tumors (OR, 2.14; 95% CI, 1.24–3.68). Associations comparing HER2+ with luminal A tumors were weak or nonexistent except for the interval between last full-term pregnancy and breast cancer diagnosis. Conclusions: Findings show etiologic heterogeneity by tumor subtype in a population of Hispanic women with unique reproductive profiles. Impact: Identification of etiologically distinct breast tumor subtypes can further improve our understanding of the disease and help provide personalized prevention and treatment regimens. Cancer Epidemiol Biomarkers Prev; 22(10); 1853–61. ©2013 AACR.

Association of health literacy with adherence to screening mammography guidelines.

OBJECTIVE: To investigate the relationship of health literacy and screening mammography. METHODS: All patients seen at a breast clinic underwent prospective assessment of health literacy from January 2010 to April 2013. All women at least 40 years of age were included. Men and women diagnosed with breast cancer before age 40 years were excluded. Routine health literacy assessment was performed using the Newest Vital Sign. Demographic data were also collected. Medical records were reviewed to determine if patients had undergone screening mammography: women aged 40–49 years were considered to have undergone screening if they had another mammogram within 2 years. Women 50 years or older were considered to have undergone screening mammography if they had another mammogram within 1 year. RESULTS: A total of 1,664 consecutive patients aged 40 years or older were seen. No patient declined the health literacy assessment. Only 516 (31%) patients had undergone screening mammography. Logistic regression analysis that included ethnicity, language, education, smoking status, insurance status, employment, income, and family history found that only three factors were associated with not obtaining a mammogram: low health literacy (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.19–0.37; P<.001), smoking (OR 0.64, 95% CI 0.47–0.85; P=.002), and being uninsured (OR 0.66, 95% CI 0.51–0.85; P=.001). CONCLUSION: Of all the sociodemographic variables examined, health literacy had the strongest relationship with use of screening mammography. LEVEL OF EVIDENCE: III

Health literacy assessment and patient satisfaction in surgical practice

BACKGROUNDnIndividuals with limited health literacy have barriers to patient-physician communication. Problems in communication are known to contribute to malpractice litigation. Concern exists, however, about the feasibility and patient acceptance of a health literacy assessment. This study was performed to determine the feasibility of health literacy assessment in surgical practice and its effect on patient satisfaction.nnnSTUDY DESIGNnEvery patient seen in a Breast Surgery Clinic during a 2-year period was asked to undergo a health literacy assessment with the Newest Vital Sign (NVS) as part of the routine history and physical examination. During the year before routine NVS assessments and during the 2-year study period, all patients were asked to rate their overall satisfaction with clinic visit on a 5-point scale.nnnRESULTSnA total of 2,026 of 2,097 patients (96.6%) seen during the study were eligible for the health literacy assessment. Of those, no patients refused assessment, and only one patient was missed. Therefore, 2,025 of 2,026 eligible patients (99.9%) underwent the assessment. The average time for NVS assessment was 2:02 minutes. Only 19% of patients had adequate health literacy. Patient satisfaction ratings were slightly greater during the first year of the health literacy assessment (3.8 vs 3.7, P = .049) compared with the year prior to health literacy assessment and greater during the second year of health literacy assessment (4.1 vs 3.7, P < .0001).nnnCONCLUSIONnRoutine health literacy assessment is feasible in surgical practice and results in no decrease in patient satisfaction. In fact, satisfaction was greater during the years when health literacy assessments were performed.

Intraoperative touch imprint and frozen section analysis of sentinel lymph nodes after neoadjuvant chemotherapy for breast cancer

Objective:To evaluate the accuracy of touch imprint and frozen section analysis of sentinel nodes after neoadjuvant chemotherapy. Summary Background Data:Intraoperative evaluation of the sentinel node can determine the need for axillary dissection at the time of initial operation and therefore spare the patient a second operation. Little data, however, exists on the accuracy of intraoperative evaluation of sentinel nodes after neoadjuvant chemotherapy. Methods:A retrospective chart review was performed of all sentinel node procedures for breast cancer from 2004 to 2008 at a single institution. The sentinel node procedure was done before (no-NACT) chemotherapy in 107 patients and 37 had the procedure after neoadjuvant (NACT) chemotherapy. Intraoperative analysis of sentinel nodes was performed using touch imprint and frozen section techniques. Results:In the no-NACT group, intraoperative assessment by touch imprint analysis had 61% sensitivity, 100% specificity, and 87% accuracy. Frozen section analysis was similar with 74% sensitivity, 100% specificity, and 90% accuracy. In the NACT group, touch imprint analysis had 79% sensitivity, 100% specificity, and 90% accuracy. Frozen section analysis was again similar with 74% sensitivity, 100% specificity, and 83% accuracy. When the no-NACT group and the NACT group were compared, both frozen section and touch imprint analysis had similar sensitivity, specificity, and accuracy. Conclusions:Intraoperative evaluation of sentinel nodes with touch imprint and frozen section analysis in patients treated with neoadjuvant chemotherapy showed acceptable sensitivity, specificity, and accuracy. Nearly all of the misses in intraoperative evaluation were in patients with micrometastases.

Factors that influence mammography use and breast cancer detection among Mexican-American and African-American women

ObjectiveThis study examined factors that influence mammography use and breast cancer detection, including education, health insurance, and acculturation, among Mexican-American (MA) and African-American (AA) women.MethodsThe study included 670 breast cancer cases (388 MAs and 282 AAs), aged 40–86xa0years at diagnosis. Data on mammography use, detection, and delay in seeking care were collected via questionnaires and medical records. Using a language-based bidimensional acculturation measure, MAs were classified as English-dominant (nxa0=xa067), bilingual (nxa0=xa0173), and Spanish-dominant (nxa0=xa0148). Mammography prior to diagnosis was assessed by racial/ethnic acculturation subgroup using logistic regression.ResultsIn age-adjusted models, mammography use was non-significantly lower among English-dominant (ORxa0=xa00.84; 95% CI: 0.45–1.59) and bilingual (ORxa0=xa00.86; 95% CI: 0.55–1.35) MAs and significantly lower among Spanish-dominant MAs (ORxa0=xa00.53; 95% CI: 0.34–0.83) than among AA women. After adjustment for education or insurance, there was no difference in mammography use by race/ethnicity and acculturation subgroup. Despite high self-reported mammography use (75%), a large proportion of cases reported self-detection (59%) and delay in seeking care >90xa0days (17%).ConclusionsThese findings favor promoting culturally appropriate messaging about the benefits and limitations of mammography, education about breast awareness, and prompt reporting of findings to a health professional.

Participation of low-income women in genetic cancer risk assessment and BRCA 1/2 testing: the experience of a safety-net institution

Some communities and populations lack access to genetic cancer risk assessment (GCRA) and testing. This is particularly evident in safety-net institutions, which serve a large segment of low-income, uninsured individuals. We describe the experience of a safety-net clinic with limited resources in providing GCRA and BRCA1/2 testing. We compared the proportion and characteristics of high-risk women who were offered and underwent GCRA and genetic testing. We also provide a description of the mutation profile for affected women. All 125 patients who were offered GCRA accepted to undergo GCRA. Of these, 72xa0% had a breast cancer diagnosis, 70xa0% were Hispanic, 52.8xa0% were non-English speakers, and 66xa0% did not have health insurance. Eighty four (67xa0%) were offered genetic testing and 81 (96xa0%) agreed. Hispanic women, those with no medical insurance, and those with a family history of breast cancer were significantly more likely to undergo testing (pu2009>u20090.01). Twelve of 81 (15xa0%) patients were found to have deleterious mutations, seven BRCA1, and five BRCA2. Our experience shows that it is possible to offer GCRA and genetic testing even in the setting of limited resources for these services. This is important given that a large majority of the low-income women in our study agreed to undergo counseling and testing. Our experience could serve as a model for similar low-resource safety-net health settings.

Association Between Parity and Obesity in Mexican and Mexican–American Women: Findings from the Ella Binational Breast Cancer Study

Obesity at diagnosis of breast cancer is associated with higher all-cause mortality and treatment-associated toxicities. We evaluated the association between parity and obesity in the Ella study, a population of Mexican and Mexican–American breast cancer patients with high parity. Obesity outcomes included body mass index (BMI)xa0≥30xa0kg/m2, waist circumference (WC)xa0≥35 in (88xa0cm), and waist-to-hip-ratio (WHR)xa0≥0.85. Prevalence of obesity ([BMI]xa0≥xa030xa0kg/m2) was 38.9xa0%. For WC, the multivariate odds ratio (OR) (95xa0% confidence interval [CI]) for having WCxa0≥xa035 inches in women withxa0≥4 pregnancies relative to those with 1–2 pregnancies was 1.59 (1.01–2.47). Higher parity (≥4 pregnancies) was non-significantly associated with high BMI (ORxa0=xa01.10; 95xa0% CI 0.73–1.67). No positive association was observed for WHR. Our results suggest WC is independently associated with high parity in Hispanic women and may be an optimal target for post-partum weight loss interventions.

Hypothesized role of pregnancy hormones on HER2+ breast tumor development

Breast cancer incidence rates have declined among older but not younger women; the latter are more likely to be diagnosed with breast cancers carrying a poor prognosis. Epidemiological evidence supports an increase in breast cancer incidence following pregnancy with risk elevated as much as 10xa0years post-partum. We investigated the association between years since last full-term pregnancy at the time of diagnosis (≤10 or >10xa0years) and breast tumor subtype in a case series of premenopausal Hispanic women (nxa0=xa0627). Participants were recruited in the United States, Mexico, and Spain. Cases with known estrogen receptor (ER), progesterone receptor (PR), and HER2 status, with one or more full-term pregnancies ≥1xa0year prior to diagnosis were eligible for this analysis. Cases were classified into three tumor subtypes according to hormone receptor (HR+xa0=xa0ER+ and/or PR+; HR−xa0=xa0ER− and PR−) expression and HER2 status: HR+/HER2−, HER2+ (regardless of HR), and triple negative breast cancer. Case-only odds ratios (ORs) and 95xa0% confidence intervals (CIs) were calculated for HER2+ tumors in reference to HR+/HER2− tumors. Participants were pooled in a mixed-effects logistic regression model with years since pregnancy as a fixed effect and study site as a random effect. When compared to HR+/HER2− cases, women with HER2+ tumors were more likely be diagnosed in the post-partum period of ≤10xa0years (ORxa0=xa01.68; 95xa0% CI, 1.12–2.52). The effect was present across all source populations and independent of the HR status of the HER2+ tumor. Adjusting for age at diagnosis (≤45 or >45xa0years) did not materially alter our results (ORxa0=xa01.78; 95xa0% CI, 1.08–2.93). These findings support the novel hypothesis that factors associated with the post-partum breast, possibly hormonal, are involved in the development of HER2+ tumors.