Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System

Background. Racial differences in breast cancer survival may be in part due to variation in patterns of care. To better understand factors influencing survival disparities, we evaluated patterns of receipt of adjuvant chemotherapy among 2,234 women with invasive, nonmetastatic breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Methods. Sociodemographic and clinical information were obtained from linked datasets from the HFHS, Metropolitan Detroit Cancer Surveillance Systems, and U.S. Census. Comorbidity was measured using the Charlson comorbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index. Results. African American (AA) women were more likely than whites to have advanced tumors with more aggressive clinical features, to have more comorbidity and to be socioeconomically deprived. While in the unadjusted model, AAs were more likely to receive chemotherapy (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.02–1.46) and to have a delay in receipt of chemotherapy beyond 60 days (OR 1.68, 95% CI, 1.26–1.48), after multivariable adjustment there were no racial differences in receipt (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.73–1.43), or timing of chemotherapy (OR 1.18, 95 CI, 0.8–1.74). Conclusions. Societal factors and not race appear to have an impact on treatment delay among African American women with early breast cancer

The Burden of Chronic Health Conditions among Iraqi Refugees in Michigan

The vast majority of refugees in Michigan is from Iraq, and yet the health status of this population is not well defined. The purpose of this study was to describe chronic disease prevalence of Iraqi refugees and examine associations between sociodemographic characteristics and chronic disease. This study reviewed medical charts of 613 Iraqi refugees to examine the association between demographic characteristics and chronic conditions. The dependent variables were body mass index, non-fasting blood glucose, and history of hypertension and diabetes. The independent variables were birth place, age, sex, and smoking history. Men were 3.99 times (95% CI=1.88, 8.48) as likely as women to have abnormal non-fasting blood glucose levels. Compared to never smokers, former smokers were 3.19 times (95% CI=1.11, 9.13) as likely to have a history of diabetes. The findings will be used to develop tailored prevention interventions to prevent chronic conditions among refugees

Racial Differences in the Use of Adjuvant Chemotherapy for Breast Cancer in a Large Urban Integrated Health System

Background. Racial differences in breast cancer survival may be in part due to variation in patterns of care. To better understand factors influencing survival disparities, we evaluated patterns of receipt of adjuvant chemotherapy among 2,234 women with invasive, nonmetastatic breast cancer treated at the Henry Ford Health System (HFHS) from 1996 through 2005. Methods. Sociodemographic and clinical information were obtained from linked datasets from the HFHS, Metropolitan Detroit Cancer Surveillance Systems, and U.S. Census. Comorbidity was measured using the Charlson comorbidity index (CCI), and economic deprivation was categorized using a neighborhood deprivation index. Results. African American (AA) women were more likely than whites to have advanced tumors with more aggressive clinical features, to have more comorbidity and to be socioeconomically deprived. While in the unadjusted model, AAs were more likely to receive chemotherapy (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.02-1.46) and to have a delay in receipt of chemotherapy beyond 60 days (OR 1.68, 95% CI, 1.26-1.48), after multivariable adjustment there were no racial differences in receipt (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.73-1.43), or timing of chemotherapy (OR 1.18, 95 CI,. Conclusions. Societal factors and not race appear to have an impact on treatment delay among African American women with early breast cancer. Background Despite improvements in available options for breast cancer treatment, there continues to be a considerable gap in survival between African American (AA) and white women with breast cancer Adjuvant chemotherapy and hormonal therapy have had a dramatic impact on breast cancer survival, and in order to optimize longevity, it is critical for patients to receive treatment according to standard clinical guidelines International Journal of Breast Cancer Previous reports on patterns of care have indicated that AA women are less likely to receive standard breast cancer treatment compared with white women We hypothesized that racial disparities in breast cancer survival may be at least in part due to differences in the receipt of standard adjuvant chemotherapy as defined by national treatment guidelines. In order to address this question, we evaluated patterns of breast cancer care provided at the Henry Ford Health System (HFHS), a large integrated health system serving southeastern MI. The goal of this study was to assess patterns of adjuvant chemotherapy administration among women with invasive, nonmetastatic breast cancer comparing AA and white women, and focusing on receipt of standard chemotherapy, duration of treatment, and timing of treatment in relationship to diagnosis. Methods Study Design. This study consisted of a descriptive analysis of adjuvant chemotherapy received by AA and white women diagnosed with invasive, nonmetastatic breast cancer at the HFHS between January 1, 1996 and December 31, 2005. HFHS is a large urban integrated health system located in southeast Michigan founded in 1915 to provide for the health care needs of the city of Detroit and surrounding metropolitan area. HFHS currently consists of 5 hospitals, anchored by Henry Ford Hospital, a 903 bed tertiary care, research and teaching facility; and 36 ambulatory care facilities including 5 sites located within the city of Detroit, and 31 sites located in Wayne (outside of Detroit), Macomb, Oakland, and Washtenaw counties. A single lifetime medical record number (MRN) is used throughout the system to provide continuity of record keeping and medical care. For the purposes of this project, patient sociodemographic, clinical, and treatment information was derived through analyses of linked datasets using the HFHS administrative databases, the Metropolitan Detroit Cancer Surveillance System (MDCSS), and the U.S. Census Bureau. The MDCSS is home for the Detroit SEER registry, which registers all cancers of residents from Wayne, Oakland, and Macomb counties. In the current study, case records were matched from the SEER and HFHS databases using MRN, social security number (SSN), last name, and date of birth. Records that matched for only one variable were manually reviewed to look for character or punctuation errors in other nonmatched fields. Matching resulted in 3,630 record matches. We excluded matches with unknown American Joint Cancer Committee (AJCC) stage (n = 51); first breast surgery at another institution (n = 147); history of a prior malignancy within 6 months of breast cancer diagnosis (n = 52); duplicate records (n = 3); histology code indicating non-breast origin (n = 1); stage IV disease (n = 978), other race (n = 45); no definitive breast surgery (n = 52); and receipt of neoadjuvant chemotherapy (n = 67). These exclusions resulted in a study population of 2,234 (61.5%) white and AA women treated for invasive, nonmetastatic breast cancer at the HFHS. Measurement of Variables. Detailed information on breast cancer treatment, clinical, and socio-demographic data were derived from the HFHS and SEER database and information on neighborhood-level economic deprivation (see deprivation index below) was obtained form the U.S. Census Bureau. All primary breast surgery consisting of lumpectomy (partial mastectomy) or mastectomy (modified radical mastectomy, radical mastectomy, or simple mastectomy) and standard axillary lymph node dissection was performed at the HFHS. Guidelines from the National Comprehensive Cancer Network (NCCN) corresponding to the years of diagnosis were used to define standard adjuvant chemotherapy treatment recommendations according to AJCC stage Patient and clinical characteristics included race (from the medical record listing), age at diagnosis, tumor size, lymph node positivity, histology, grade, and estrogen and progesterone receptor (ER and PR) status. Insurance status was available from the HFHS records and was classified based on the most frequent insurance charged for each treatment visit, and categorized into 3 groups (private, Medicare, and other, including uninsured). Comorbidity was assessed using the Charlson comorbidity index (CCI) a prospectively verified method for classifying comorbid medical conditions which could affect the risk of mortality in longitudinal studies Statistical Analysis. The clinical and sociodemographic characteristics of AA and white women with invasive, nonmetastatic breast cancer were compared by chi-square tests for categorical variables and Student's t-tests for continuous variables. Separate analyses were conducted to determine racial differences in the use of standard chemotherapy (yes versus no), timing of chemotherapy as determined by the date of diagnosis and the date of chemotherapy initiation (dichotomized using the sample median, 60 days) for cases where detailed chemotherapy records were available and completion of standard chemotherapy (i.e., completing the NCCN recommended number of cycles of treatment). Odds ratios (ORs) for receipt of chemotherapy for AA versus white women and 95% confidence intervals (CIs) were estimated using unconditional logistic regression analyses. Race, age at diagnosis, tumor size, lymph node positivity, hormone receptor status, tumor grade, CCI, deprivation index, and insurance status were assessed individually and in multivariable adjusted models. Unconditional logistic regression was also used to estimate the odds of beginning chemotherapy within 60 days of the date of diagnosis. The analyses consisted of three models, first adjusting for clinical factors only (race, age, tumor size, lymph node positivity, hormone receptor status, tumor grade, and CCI), second adjusting for societal factors (race, deprivation index, and insurance status), and third adjusting for all listed variables. The purpose of performing three different models was to determine whether clinical versus societal factors had a greater impact on racial differences in receipt of adjuvant chemotherapy or in timing of chemotherapy. All regression models were run with and without a clustering correction for census tract. Results There were no significant racial differences in age at diagnosis adjuvant chemotherapy for AA women compared with white women. The average time from diagnosis to initiation of chemotherapy for white women was 67.9 days (S.D. 38.6) compared to 73.2 (S.D. 36.4) for AA women, P = 0.049. When time to adjuvant chemotherapy was stratified at 60 days (the sample median), white women were more likely to be treated prior to 60 days (55%) compared to AA women (43%), P < 0.001. Discussion While breast cancer survival rates continue to improve over time http://seer.cancer.gov/csr/1975 2008/, there remains a marked discrepancy in survival by race, Strengths of this study include the inclusion of women enrolled in a large integrated urban heath care system which provides uniform access to high-quality medical care. In addition, the linked HFHS and SEER database allowed for availability of detailed and accurate clinical, demographic, and treatment data including details on adjuvant chemotherapy received. Our measure of socioeconomic deprivation was a sophisticated measure developed through the linkage with U.S. Census data, however, the derived deprivation index was not based on factors specific to the individual patient such as income, education, or family support, and may therefore be subject to misclassification. In conclusion, race had no direct impact on receipt of adjuvant chemotherapy or timing of chemotherapy among a cohort of women treated at a large urban integrated health care system in Detroit. The fact that AA women were more likely to receive adjuvant chemotherapy in the unadjusted model was largely explained by the more advanced stage at diagnosis among AAs that suggests the need for better screening and access to early treatment interventions. Delay in receipt of chemotherapy among AA women was largely explained by societal factors which likely have a direct effect on access to care. However, the delay was on average less than one week and may not have had significant clinical impact. Nevertheless, it serves to remind health care providers of the importance of making health care accessible to all

Clinical Characteristics of Breast Cancers in African‐American Women with Benign Breast Disease: A Comparison to the Surveillance, Epidemiology, and End Results Program

Benign breast disease ( BBD ) is a very common condition, diagnosed in approximately half of all A merican women throughout their lifecourse. White women with BBD are known to be at substantially increased risk of subsequent breast cancer; however, nothing is known about breast cancer characteristics that develop after a BBD diagnosis in A frican‐ A merican women. Here, we compared 109 breast cancers that developed in a population of A frican‐ A merican women with a history of BBD to 10,601 breast cancers that developed in a general population of A frican‐ A merican women whose cancers were recorded by the M etropolitan D etroit C ancer S urveillance S ystem ( MDCSS population). Demographic and clinical characteristics of the BBD population were compared to the MDCSS population, using chi‐squared tests, F isher's exact tests, t ‐tests, and W ilcoxon tests where appropriate. K aplan– M eier curves and Cox regression models were used to examine survival. Women in the BBD population were diagnosed with lower grade (p = 0.02), earlier stage cancers (p = 0.003) that were more likely to be hormone receptor‐positive (p = 0.03) compared to the general metropolitan Detroit A frican‐ A merican population. In situ cancers were more common among women in the BBD cohort (36.7%) compared to the MDCSS population (22.1%, p < 0.001). Overall, women in the BBD population were less likely to die from breast cancer after 10 years of follow‐up (p = 0.05), but this association was not seen when analyses were limited to invasive breast cancers. These results suggest that breast cancers occurring after a BBD diagnosis may have more favorable clinical parameters, but the majority of cancers are still invasive, with survival rates similar to the general A frican‐ A merican population.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109284/1/tbj12331.pd

A Case-Control Study of Peripheral Blood Mitochondrial DNA Copy Number and Risk of Renal Cell Carcinoma

Background: Low mitochondrial DNA (mtDNA) copy number is a common feature of renal cell carcinoma (RCC), and may influence tumor development. Results: from a recent case-control study suggest that low mtDNA copy number in peripheral blood may be a marker for increased RCC risk. In an attempt to replicate that finding, we measured mtDNA copy number in peripheral blood DNA from a U.S. population-based case-control study of RCC. Methodology/Principal Findings: Relative mtDNA copy number was measured in triplicate by a quantitative real-time PCR assay using DNA extracted from peripheral whole blood. Cases (n = 603) had significantly lower mtDNA copy number than controls (n = 603; medians 0.85, 0.91 respectively; P = 0.0001). In multiple logistic regression analyses, the lowest quartile of mtDNA copy number was associated with a 60% increase in RCC risk relative to the highest quartile (OR = 1.6, 95% CI = 1.1–2.2; Ptrend = 0.009). This association remained in analyses restricted to cases treated by surgery alone (OR Q1 = 1.4, 95% CI = 1.0–2.1) and to localized tumors (2.0, 1.3–2.8). Conclusions/Significance: Our findings from this investigation, to our knowledge the largest of its kind, offer important confirmatory evidence that low mtDNA copy number is associated with increased RCC risk. Additional research is needed to assess whether the association is replicable in prospective studies

Risk factors for endometrial cancer in black and white women: a pooled analysis from the epidemiology of endometrial cancer consortium (E2C2)

Endometrial cancer (EC) is the most common gynecologic cancer in the United States. Over the last decade, the incidence rate has been increasing, with a larger increase among blacks. The aim of this study was to compare risk factors for EC in black and white women

Characterizing inflammatory breast cancer among Arab Americans in the California, Detroit and New Jersey Surveillance, Epidemiology and End Results (SEER) registries (1988–2008)

Introduction: Inflammatory breast cancer (IBC) is characterized by an apparent geographical distribution in incidence, being more common in North Africa than other parts of the world. Despite the rapid growth of immigrants to the United States from Arab nations, little is known about disease patterns among Arab Americans because a racial category is rarely considered for this group. The aim of this study was to advance our understanding of the burden of IBC in Arab ethnic populations by describing the proportion of IBC among different racial groups, including Arab Americans from the Detroit, New Jersey and California Surveillance, Epidemiology and End Results (SEER) registries.Methods: We utilized a validated Arab surname algorithm to identify women of Arab descent from the SEER registries. Differences in the proportion of IBC out of all breast cancer and IBC characteristics by race and menopausal status were evaluated using chi-square tests for categorical variables, t-tests and ANOVA tests for continuous variables, and log-rank tests for survival data. We modeled the association between race and IBC among all women with breast cancer using hierarchical logistic regression models, adjusting for individual and census tract-level variables.Results: Statistically significant differences in the proportion of IBC out of all breast cancers by race were evident. In a hierarchical model, adjusting for age, estrogen and progesterone receptor, human epidermal growth receptor 2, registry and census-tract level education, Arab-Americans (OR=1.5, 95% CI=1.2,1.9), Hispanics (OR=1.2, 95% CI=1.1,1.3), Non-Hispanic Blacks (OR=1.3, 95% CI=1.2, 1.4), and American Indians/Alaskans (OR=1.9, 95% CI=1.1, 3.4) had increased odds of IBC, while Asians (OR=0.6, 95% CI=0.6, 0.7) had decreased odds of IBC as compared to Non-Hispanic Whites.Conclusions: IBC may be more common among certain minority groups, including Arab American women. Understanding the descriptive epidemiology of IBC by race may generate hypotheses about risk factors for this aggressive disease. Future research should focus on etiologic factors that may explain these differences

Trends and racial disparities in aggressive end‐of‐life care for a national sample of women with ovarian cancer

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/168338/1/cncr33488.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168338/2/cncr33488_am.pd

Screening and follow-up for depression among Arab Americans

BACKGROUND: The authors compared proportions and associations of depression screening, major depression, and follow-up care of Arab Americans compared to non-Hispanic whites, non-Hispanic blacks, Asians, and Hispanics. METHODS: Administrative data was electronically abstracted from a large health system in metropolitan Detroit among 97,918 adult patients in 2014 and 2015. A valid and reliable surname list was used to identify Arab Americans. Using chi-squares, we examined the relationship between race/ethnicity and depression screening, major depression, and follow-up care. We calculated odds ratios (OR) and 95% confidence intervals (CI) to examine the relationship between the main independent variable of race/ethnicity and the dependent variables of depression screening and major depression while controlling for confounders. RESULTS: Arab American women were 23% less likely to be screened for depression compared to non-Hispanic white women (OR = 0.77; 95% CI = 0.70, 0.86). The age- and sex-adjusted proportions of major depression were 5.5% for Arab Americans compared to 7.0% for Hispanics, 6.0% for non-Hispanic blacks, 5.9% for non-Hispanic whites, and 1.5% for Asians. Arab Americans with major depression were less likely to follow up with a behavioral specialist and more likely to follow up with a primary care physician compared to other racial and ethnic groups. CONCLUSIONS: Our study adds to the discourse on depression care among Arab Americans by highlighting the existing disparities related to adequate screening and appropriate management of depression. Future studies should include information about the influences of acculturation, culture, stigma, family, and religion on depression care