Kangmin Zhu

Socioeconomic disparities and breast cancer hormone receptor status

PurposeRecent research, although inconsistent, indicates that socioeconomic status (SES) may be associated with hormone receptor (HR) status. This study aims to examine the association between SES and breast cancer HR status within and across racial/ethnic groups stratified by age at diagnosis and tumor stage.MethodsThe study subjects were 184,602 women with incident breast cancer diagnosed during 2004–2007 and identified from the National Cancer Institute’s Surveillance, Epidemiology and End Results program. Log-binomial regression assessed the risk of having breast tumors that were (1) HR-negative versus HR-positive and (2) HR-unknown versus HR-known between women who, at the time of diagnosis, were residing in high or medium poverty areas compared to low poverty areas.ResultsHigh poverty areas tended to have a greater prevalence of HR-negative tumors compared to more affluent areas. Although not always significant, this was observed among non-Hispanic white and Hispanic women regardless of age-tumor stage category, and only among young, non-Hispanic black women and non-Hispanic Asian/Pacific Islander women with regional and distant stage. High poverty areas also tended to have a greater prevalence of HR-unknown tumors compared to more affluent areas. Furthermore, significant trends between HR status and poverty level varied by race/ethnicity, age, and tumor stage.ConclusionsPoverty may be related to breast cancer negative and unknown HR status. These findings suggest the effects of non-genetic factors on biochemical features of breast cancer, as well as imply a clinical importance to improve HR measurement or recording for low socioeconomic breast cancer patients.

Breast reconstruction after mastectomy among Department of Defense beneficiaries by race

Postmastectomy breast reconstruction increased approximately 20% between 1998 and 2008 in the United States and has been found to improve body image, self‐esteem, and quality of life. These procedures, however, tend to be less common among minority women, which may be due to variations in health care access. The Department of Defense provides equal health care access, thereby affording an exceptional environment in which to assess whether racial variations persist when access to care is equal.

Trends in use of contralateral prophylactic mastectomy by racial/ethnic group and ER/PR status among patients with breast cancer: A SEER population-based study.

BACKGROUNDnWhile differences in CPM use between White and Black patients are well known, it is not clear whether CPM use differs by estrogen/progesterone receptor (ER/PR) status of tumors and whether racial/ethnic differences in the use are affected by ER/PR status, which varies between racial groups. The purpose of this study was to investigate whether CPM usage differs by racial/ethnic group and ER/PR status among patients in the Surveillance, Epidemiology, and End Results (SEER) data.nnnMETHODSnThe study subjects were women with histologically confirmed unilateral breast cancer who underwent breast surgery between 1998 and 2011. Age-adjusted CPM use as a proportion of all surgically treated patients or all patients who had mastectomy was analyzed by racial/ethnic group, tumor behavior, and ER/PR status. Temporal trends in age-adjusted CPM use were presented by ER/PR status and racial/ethnic group.nnnRESULTSnThe analyses stratified by ER/PR status showed significant racial/ethnic differences in age-adjusted CPM use with non-Hispanic White and non-Hispanic Asian/Pacific Islander (API) patients having the most and least CPM use. Age-adjusted CPM use was significantly higher for ER+/PR+ tumors than ER-/PR- ones for each race/ethnicity group among patients with mastectomy. However, among patients with any breast surgeries, the only difference was a higher proportion of CPM use for ER-/PR- tumors (8.6%) than ER+/PR+ tumors (8.0%) in non-Hispanic Whites. CPM use has increased over time in all racial/ethnic groups despite ER/PR status.nnnCONCLUSIONnCPM usage was lower not only in non-Hispanic Blacks, but also in non-Hispanic API and Hispanic patients compared to non-Hispanic White patients. CPM usage tended to be higher for ER+/PR+ tumors, but the results varied when different denominators (all mastectomies vs. all breast surgeries) were used.

Racial/ethnic differences in breast cancer survival by inflammatory status and hormonal receptor status: an analysis of the Surveillance, Epidemiology, and End Results data.

AbstractBackgroundnCompared to non-inflammatory breast cancer (non-IBC), inflammatory breast cancer (IBC) has less favorable survival and is more likely to be estrogen receptor (ER) and progesterone receptor (PR) negative. ER−/PR− tumors, regardless of histology, have less favorable survival. While black women are more likely to have IBC and ER−/PR− tumors than white women, it is unclear whether the racial disparity in survival is explained by these factors. The objective of this study was to assess racial/ethnic differences in breast cancer survival by inflammatory status and hormone receptor status.MethodsnThis study examined breast cancer mortality among non-Hispanic white (NHW), Hispanic white, black, and Asian/Pacific Islander (API) women diagnosed between 1990 and 2004 using the National Cancer Institute’s Surveillance, Epidemiology, and End Results data. Kaplan–Meier survival curves and Cox proportional hazard ratios (HRs) assessed the relationship between race/ethnicity and survival.ResultsBlack women had significantly poorer survival than NHW women regardless of inflammatory status and hormone receptor status. Compared to NHWs, the HRs for black women were 1.32 (95xa0% confidence interval (CI) 1.21–1.44), 1.43 (95xa0% CI 1.20–1.69), and 1.30 (95xa0% CI 1.16–1.47) for IBC, IBC with ER+/PR+, and with ER−/PR−, respectively. Similar HRs were found for non-IBC, non-IBC with ER+/PR−, and non-IBC with ER−/PR−. API women had significantly better survival than NHW women regardless of inflammatory status and hormone receptor status.ConclusionCompared to NHW women, black women had poorer survival regardless of inflammatory status and hormone receptor status and API women had better survival. These results suggest that factors other than inflammatory status and hormone receptor status may play a role in racial/ethnic disparities in breast cancer survival.

Socioeconomic Disparities in Colorectal Cancer Mortality in the United States, 1990–2007

United States colorectal cancer mortality rates have declined; however, disparities by socioeconomic status and race/ethnicity persist. The objective of this study was to describe the temporal association between colorectal cancer mortality and socioeconomic status by sex and race/ethnicity. Cancer mortality rates in the United States from 1990 to 2007, which were generated by the National Center for Health Statistics, and county-level socioeconomic status, which was estimated as the proportion of county residents living below the national poverty line based on 1990 US Census Bureau data, were obtained from the Surveillance, Epidemiology, and End Results program. The Kunst–Mackenbach relative index of inequality, which considers data across all poverty levels when comparing risks in the poorest (≥20xa0%) and richest counties (<10xa0%), was calculated as the measure of association. The study found that colorectal cancer mortality rates were significantly lower in the poorest counties than the richest counties during 1990–1992 among non-Hispanic whites, non-Hispanic black women and non-Hispanic API men. Over time though the tendency was for the poorest counties to have higher mortality rates. By 2003–2007 colorectal cancer mortality rates were significantly higher in the poorest than the richest counties among all sex-race/ethnicity groups. This disparity was most noticeable and appeared to be increasing most among Hispanic men. This suggests that socioeconomic disparities in colorectal cancer mortality were apparent after stratifying by sex and race/ethnicity and reversed over time. Further studies into the causes of these disparities would provide a basis for targeted cancer control interventions and allocation of public health resources.

Colorectal Prostate Skin Cancer Screening Among Hispanic White Non-Hispanic Men 2000–2005

Background : Hispanic men have lower colorectal, prostate, and skin cancer screening rates than white non-Hispanic men. Programs designed to increase screening rates, including the national Screen for Life campaign specifically for promoting colorectal cancer (CRC) screening, regional educational/research programs, and state cancer control programs, have been launched. Screen for Life and some intervention programs included educational materials in Spanish as well as English. Objective : To assess whether CRC as well as prostate and skin cancer screening rates among Hispanic and white non-Hispanic men changed between 2000 and 2005. Methods : Cancer screening rates were compared between 2000 and 2005 using the National Health Interview Survey data. The age ranges of the study subjects and definitions of cancer screening were site specific and based on the American Cancer Society recommendations. Results : Hispanic men were less likely to comply with cancer screening guidelines than white non-Hispanic men. However, significant increases in CRC endoscopic screening were observed in both ethnic groups. It increased 2.1-fold and 2.4-fold for Hispanics and white non-Hispanics, respectively (P Conclusion : Although cancer screening rates may be affected by multiple factors, our study suggested the intervention programs such as the Centers for Disease Control and Preventions national Screen for Life campaign may have raised CRC screening awareness and may contributed to the increase in endoscopic screening rates among both ethnic groups.

Breast conserving surgery versus mastectomy: the influence of comorbidities on choice of surgical operation in the Department of Defense health care system

BACKGROUNDnStudies on the effect of comorbidities on breast cancer operation have been limited and inconsistent. This study investigated whether pre-existing comorbidities influenced breast cancer surgical operation in an equal access health care system.nnnMETHODSnThis study was based on linked Department of Defense cancer registry and medical claims data. The study subjects were patients diagnosed with stage I to III breast cancer during 2001 to 2007. Logistic regression was used to determine if comorbidity was associated with operation type and time between diagnosis and operation.nnnRESULTSnBreast cancer patients with comorbidities were more likely to receive mastectomy (odds ratio [OR] = 1.27; 95% confidence interval [CI], 1.14 to 1.42) than breast conserving surgery plus radiation. Patients with comorbidities were also more likely to delay having operation than those without comorbidities (OR = 1.27; 95% CI, 1.14 to 1.41).nnnCONCLUSIONSnIn an equal access health care system, comorbidity was associated with having a mastectomy and with a delay in undergoing operation.

Survival among Black and White patients with renal cell carcinoma in an equal-access health care system

PurposeUnequal access to health care may be a reason for shorter survival among Black patients with renal cell carcinoma (RCC) than among their White counterparts. No studies have investigated survival disparity among RCC patients in an equal-access health care delivery system. This study aimed to examine racial differences in survival among clear cell RCC patients in the Department of Defense’s (DoD) Military Health System (MHS), which provides equal access to care to all persons.MethodsThe study used the DoD’s Automated Central Tumor Registry to identify 2056 White patients and 370 Black patients diagnosed with clear cell RCC between 1988 and 2004. The subjects were followed through 2007 with a median follow-up time of 4.8xa0years. Kaplan–Meier survival curves were compared and a Cox model was used to estimate the hazard ratios (HRs) associated with survival by race.ResultsDuring follow-up, 1,027 White and 158 Black patients died. The Kaplan–Meier curves showed that Black patients had more favorable overall survival than did White patients (log rank pxa0=xa00.031). After adjustment for demographic, tumor, and treatment variables, the Cox model showed no statistically significant racial difference overall (adjusted HR 1.07, 95xa0% CI 0.90–1.28) or stratified by age, sex or tumor stage. However, among patients who did not undergo surgery, Black patients had poorer survival than White patients.ConclusionsThe lack of racial difference in survival among RCC patients in the MHS may be related to equal access to health care. Improved access could reduce the survival disparity among RCC patients in the general population.

Chemotherapy Use and Survival Among Young and Middle-Aged Patients With Colon Cancer.

Importance Treatment options for patients with young-onset colon cancer remain to be defined and their effects on prognosis are unclear. Objective To investigate receipt of adjuvant chemotherapy by age category (18-49, 50-64, and 65-75 years) and assess whether age differences in chemotherapy matched survival gains among patients diagnosed as having colon cancer in an equal-access health care system. Design, Setting, and Participants This cohort study was based on linked and consolidated data from the US Department of Defense’s Central Cancer Registry and Military Heath System medical claims databases. There were 3143 patients aged 18 to 75 years with histologically confirmed primary colon adenocarcinoma diagnosed between 1998 and 2007. This study was conducted from December 2015 to August 2016. Exposures Patients who underwent surgery and postoperative systemic chemotherapy. Main Outcomes and Measures The primary outcome measure of the study was overall survival of patients who only received surgery and those who received both surgery and postoperative systemic chemotherapy. Results Of the 3143 patients, 1841 were men (58.6%). Young (18-49 years) and middle-aged (50-64 years) patients were 2 to 8 times more likely to receive postoperative systemic chemotherapy compared with older patients (65-75 years) across all tumor stages. Middle-aged patients with stage I (odds ratio, 5.04; 95% CI, 2.30-11.05) and stage II (odds ratio, 2.42; 95% CI, 1.58-3.72) disease were more likely to receive postoperative chemotherapy compared with older patients. Both groups were more likely to receive multiagent chemotherapy than were older patients (patients aged 18-49 years: odds ratio, 2.48; 95% CI, 1.42-4.32 and patients aged 50-64 years: odds ratio, 2.66; 95% CI, 1.70-4.18). Among patients who received surgery and postoperative systemic chemotherapy, no significant differences were observed in survival among age groups (the 95% CIs of hazard ratios included 1 for young and middle-aged patients compared with older patients for all tumor stages). Conclusions and Relevance In an equal-access health care system, we found potential overuse of chemotherapy among young and middle-aged adults with colon cancer. The addition of postoperative systemic chemotherapy did not result in matched survival improvement.

Surveillance mammography among female Department of Defense beneficiaries

Annual surveillance mammography is recommended after a diagnosis of breast cancer. Previous studies have suggested that surveillance mammography varies by demographics and initial tumor characteristics, which are related to an individuals access to health care. The Military Health System of the Department of Defense provides beneficiaries with equal access health care and thus offers an excellent opportunity to assess whether racial differences in surveillance mammography persist when access to care is equal.