Kendra Schwartz

Race, socioeconomic status and stage at diagnosis for five common malignancies

Background: African-Americans are more likely than Caucasians to be diagnosed at an advanced stage of colorectal, lung, breast, cervical, and prostate cancers. This study explores if racial differences in stage at diagnosis can be explained by socioeconomic status (SES) differences. Previous studies investigating this association have used aggregate SES indicators from census tract of residence; we used census block-group data, representing a smaller, potentially more homogenous group. Methods: We included all African-American and Caucasian invasive cancers of the colon and rectum, lung and bronchus, female breast, cervix uteri, and prostate that were diagnosed between January 1, 1988 and December 31, 1992 in the Detroit area. Stage of disease at diagnosis was grouped as local or non-local. An SES value was calculated for each case using aggregate 1990 US Census data for education, poverty status, and occupation specific to each cases census block-group. Logistic regression analysis was used to model the probability of non-local stage using SES, race, age group, and sex as covariates. Results: SES was an independent predictor of stage at diagnosis for each cancer site, with cases from the highest SES block-group more likely to present with local stage disease than those from the lowest SES group. Race independently predicted stage only for breast and prostate cancers; African-Americans presented with more advanced stage than Caucasians. Conclusions: Based on census block-group aggregate data, SES is an important predictor of stage at diagnosis, most likely accounting for much of the disparity in stage between African-Americans and Caucasians for colorectal, lung, and cervical cancers. Biological factors may play a role in racial disparities for breast and prostate cancer stage at diagnosis.

The Influence of Race, Ethnicity, and Individual Socioeconomic Factors on Breast Cancer Stage at Diagnosis

OBJECTIVES Previous research has generally found that racial/ethnic differences in breast cancer stage at diagnosis attenuate when measures of socioeconomic status are included in the analysis, although most previous research measured socioeconomic status at the contextual level. This study investigated the relation between race/ethnicity, individual socioeconomic status, and breast cancer stage at diagnosis. METHODS Women with stage 0 to III breast cancer were identified from population-based data from the Surveillance, Epidemiology, and End Results tumor registries in the Detroit and Los Angeles metropolitan areas. These data were combined with data from a mailed survey in a sample of White, Black, and Hispanic women (n=1700). Logistic regression identified factors associated with early-stage diagnosis. RESULTS Black and Hispanic women were less likely to be diagnosed with early-stage breast cancer than were White women (P< .001). After control for study site, age, and individual socioeconomic factors, the odds of early detection were still significantly less for Hispanic women (odds ratio [OR]=0.45) and Black women (OR = 0.72) than for White women. After control for the method of disease detection, the White/Black disparity attenuated to insignificance; the decreased likelihood of early detection among Hispanic women remained significant (OR=0.59). CONCLUSION The way in which racial/ethnic minority status and socioeconomic characteristics produce disparities in womens experiences with breast cancer deserves further research and policy attention.

Missed Opportunities for Type 2 Diabetes Mellitus Screening Among Women With a History of Gestational Diabetes Mellitus

OBJECTIVES We sought to determine rates and factors associated with screening for type 2 diabetes mellitus (DM) in women with a history of gestational diabetes mellitus. METHODS We retrospectively studied women with diagnosed gestational diabetes mellitus who delivered at a university-affiliated hospital (n=570). Data sources included medical and administrative record review. Main outcome measures were the frequency of any type of glucose testing at least 6 weeks after delivery and the frequency of recommended glucose testing. We assessed demographic data, past medical history, and prenatal and postpartum care characteristics. RESULTS Rates of glucose testing after delivery were low. Any type of glucose testing was performed at least once after 38% of deliveries, and recommended glucose testing was performed at least once after 23% of deliveries. Among women with at least 1 visit to the health care system after delivery (n=447), 42% received any type of glucose test at least once, and 35% received a recommended glucose test at least once. Factors associated with testing were being married, having a visit with an endocrinologist after delivery, and having more visits after delivery. CONCLUSIONS These findings suggest that most women with gestational diabetes mellitus are not screened for type 2 DM after delivery. Opportunities for DM prevention and early treatment are being missed.

Interplay of Race, Socioeconomic Status, and Treatment on Survival of Patients With Prostate Cancer

OBJECTIVES To compare overall and prostate cancer-specific survival, using the Detroit Surveillance, Epidemiology, and End Results registry data, among 8679 Detroit area black and white men with localized or regional stage prostate cancer diagnosed from 1988 to 1992 to determine whether racial disparities in long-term survival remained after adjusting for treatment type and socioeconomic status (SES). METHODS The cases were geocoded to the census block-group, and SES data were obtained from the 1990 U.S. Census. Cox proportional hazards regression analysis was used to estimate the hazard ratio of death from any cause. The median follow-up was 16.5 years. RESULTS Of the 7770 localized stage cases (22% black and 78% white) and 909 regional cases (24% black and 76% white), black men were more likely to receive nonsurgical treatment (P < .001) and to be of low SES (P < .0001). The survival analyses were stratified by stage. For both stages, black men had poorer survival than white men in the unadjusted model. The adjustment for age and tumor grade had little effect on the survival differences, but adjustment for SES and treatment removed the survival differences. CONCLUSIONS Low SES and nonsurgical treatment were associated with a greater risk of death among men with prostate cancer, explaining much of the survival disadvantage for black men with prostate cancer.

Correlates of between-surgeon variation in breast cancer treatments

Background:Determinants of between-surgeon variation in breast cancer treatment utilization are not well understood. Objectives:The objectives of this study were to evaluate variation in receipt of surgical treatment (ie, mastectomy or breast-conserving surgery with or without radiation) for women with stage I, II, or III breast cancer and receipt of breast reconstruction attributable to surgeons, and to assess factors associated with this between-surgeon variation. Methods:We surveyed all attending surgeons (n = 456) of a population-based sample of patients with breast cancer diagnosed in Detroit and Los Angeles during 2002 (n = 1844). Our analytic dataset linked data from 1477 patients with that of 311 surgeons. We used random-effects modeling to account for the multilevel dataset and evaluated 2 outcomes: 1) primary surgical treatment (mastectomy vs. BCS); and 2) receipt of reconstruction before being surveyed (yes vs. no). Independent variables included patient-related factors (clinical and demographic), surgeon-related factors (breast procedure volume, practice setting, and demographics), surgeon treatment recommendation, and referral propensity. Results:Surgeons explain some variation in use of both mastectomy and reconstruction (9.9% and 26%, respectively). Patient clinical factors and surgeon volume together explain approximately one-third of the between-surgeon variation in mastectomy. Patient factors and surgeon demographics explain approximately 60% of between-surgeon variation in reconstruction, and surgeon referral propensity explains an additional 15%. Conclusion:Our findings suggest that similar patients may get different treatment depending on their surgeon. Broader dissemination of guidelines coupled with increasing patient access to consultations before definitive surgery may reduce between-surgeon variation. Contributing factors such as patient–physician communication should be explored.

Hypertension and risk of renal cell carcinoma among white and black Americans.

Background: Renal cell carcinoma and hypertension (a well-established renal cancer risk factor) are both more frequent among blacks than whites in the United States. The association between hypertension and renal cell carcinoma has not been examined in black Americans. We investigated the hypertension–renal cancer association by race, and we assessed the role of hypertension in the racial disparity of renal cancer incidence. Methods: Participants were enrolled in a population-based case-control study in Detroit and Chicago during 2002–2007 (number of cases: 843 whites, 358 blacks; number of controls: 707 whites, 519 blacks). Participants reported their history of hypertension and antihypertensive drug use. We used unconditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for demographic characteristics, smoking, body mass index, and family history of cancer. Results: Hypertension doubled renal cancer risk (OR = 2.0 [CI = 1.7–2.5]) overall. For whites, the OR was 1.9 (CI = 1.5–2.4), whereas for blacks it was 2.8 (2.1–3.8) (P for interaction = 0.11). ORs increased with time after hypertension diagnosis (P for trend <0.001), reaching 4.1 (CI = 2.3–7.4) for blacks and 2.6 (CI = 1.7–4.1) for whites after 25 years. ORs for poorly controlled hypertension were 4.5 (CI = 2.3–8.8) for blacks and 2.1 (CI = 1.2–3.8) for whites. If these estimates correctly represent causal effects and if, hypothetically, hypertension could be prevented entirely among persons aged 50–79 years, the black/white disparity in renal cancer could be reversed among women and reduced by two-thirds among men. Conclusions: Hypertension is a risk factor for renal cancer among both blacks and whites, and might explain a substantial portion of the racial disparity in renal cancer incidence. Preventing and controlling hypertension might reduce renal cancer incidence, adding to the known benefits of blood pressure control for heart disease and stroke reduction, particularly among blacks.

Recall of age of weaning and other breastfeeding variables.

BackgroundMany studies of the impact of breastfeeding on child or maternal health have relied on data reported retrospectively. The goal of this study was to assess recall accuracy among breastfeeding mothers of retrospectively collected data on age of weaning, reasons for cessation, breast pain, lactation mastitis, and pumping.MethodsWomen in Michigan and Nebraska, U.S.A. were interviewed by telephone every 3 weeks during the first 3 months after the birth of their child, and mailed a questionnaire at 6 months. A subset was interviewed again by telephone approximately 1–3.5 years after the birth. The results for the three recall periods, collected 1994–1998, were compared using correlation, linear and Cox regression analysis, and sensitivity and specificity estimates.ResultsThe 184 participants were aged 18–42, mostly white (95%) and 63% had an older child. The age of weaning tended to be overestimated in interviews 1–3.5 years after birth compared to those within 3 weeks of the event, by approximately one month for 1–3.5 year recall and two weeks for 6-month recall (p < 0.001 in both cases). Recall accuracy of reasons for weaning varied greatly by reason, with mastitis and return to work having the most recall validity. The sensitivity of 1–3.5 year recall of mastitis was 80%, but was only 54% for nipple cracks or sores.ConclusionBreastfeeding duration among short-term breastfeeders tended to be somewhat overestimated when measured at 1–3.5 years post-partum. Reporting of other breastfeeding characteristics had variable reliability. Studies employing retrospective breastfeeding data should consider the possibility of such errors.

Contemporary Clinical Epidemiology of Renal Cell Carcinoma: Insight From a Population Based Case-Control Study

PURPOSE To clarify the contemporary clinical epidemiology of renal cell carcinoma we present trends in clinical presentation and treatment in patients enrolled in a population based case-control study. MATERIALS AND METHODS The National Cancer Institute performed a population based case-control study in metropolitan Detroit and Chicago from 2002 through 2007. In 1,136 patients with renal cell carcinoma who consented to an epidemiological interview and medical record review we ascertained detailed information on social and medical history, methods of renal cell carcinoma detection and diagnosis, cancer severity and treatment(s) received. From these data we assessed the demographic and cancer specific characteristics of study cases, and trends in clinical presentation, diagnosis and treatment. RESULTS Most patients with renal cell carcinoma had localized or regional tumors, including 52% with tumors 4 cm or less. The proportion of asymptomatic cases increased from 35% in 2002 to 50% in 2007 (p<0.001). Hypertension and diabetes were common in patients (58% and 17%, respectively) and 24% had at least 2 significant comorbid conditions at cancer diagnosis. While the use of laparoscopic surgery increased with time (p<0.001), fewer than 1/5 patients underwent nephron sparing surgery. CONCLUSIONS The proportion of patients presenting with small, asymptomatic renal cell carcinoma continues to increase. Most of these cases are still treated with radical nephrectomy, although increasingly via a laparoscopic approach. Since most patients with small renal cell carcinomas have 1 or more renal function relevant comorbidities, there is an imperative to increase the use of nephron sparing surgery.

Disentangling the effects of race on breast cancer treatment.

African Americans (AA) have higher mortality from breast cancer compared with white Americans (WA). Studies using population‐based cancer registries have attributed this to disparities in treatment after normalizing the AA and WA populations for differences in disease stage. However, those studies were hampered by lack of comorbidity data and limited information about systemic treatments. The objective of the current study was to investigate racial disparities in breast cancer treatment by conducting a comprehensive medical records review of women who were diagnosed with breast cancer at the Karmanos Cancer Institute (KCI) in Detroit, Michigan.

Trends in the stage specific incidence of prostate carcinoma in the Detroit metropolitan area: 1973-1994

Much of the recent increase in prostate carcinoma incidence has been attributed to screening with prostate specific antigen (PSA). Controversy exists as to whether this screening will ultimately impact prostate carcinoma mortality. Until adequate time elapses since PSA screening became widespread, or a randomized trial of PSA screening is completed, the effect of PSA screening on prostate carcinoma mortality cannot be determined. In the interim, stage specific prostate carcinoma incidence rates may provide an indication of the effect of PSA screening.