Assessing Racial/Ethnic Disparities along the Breast Cancer Treatment Continuum

Ensuring equitable adjuvant treatment may alleviate the racial disparity in breast cancer mortality; yet little is known about factors that facilitate or impede treatment. This study assesses and examines racial/ethnic disparities in adjuvant breast cancer treatment offered, accepted, and initiated. The primary data came from a population-based study that included 989 females living in Chicago, age 30 to 79 years, who were diagnosed with first primary breast cancer in 2005–2008. Logistic regression using model-based standardization was used to estimate age-adjusted risk differences and path analyses were conducted to help explain the disparities. Chemotherapy treatment (CT) guidelines changed during the study period, and the association between race/ethnicity and treatment differed depending on which guideline was used to determine CT-eligibility. Among those for whom CT became discretionary, minority patients were more likely than non-Hispanic (nH) White patients to receive a CT recommendation but this was largely explained by tumor differences. There were no discernible racial/ethnic differences in radiation treatment (RT) recommendation and acceptance. However, among all RT-eligible patients, minority patients were less likely than nH White patients to receive RT (0.75 versus 0.74, p=0.01). This was explained by the higher use of mastectomy and lower breast tumor knowledge among minority patients. Compared to nH White patients (0.94), minority patients (0.80) were less likely to receive a recommendation for hormonal treatment (p=0.00). Tumor knowledge appears to be an important contributor of this disparity as well. Mastectomy patients may not be receiving guideline-adherent RT. In addition, a patient’s breast tumor knowledge may be protective against treatment underuse. These may present important avenues for disparity-reducing interventions

Barriers and Facilitators to HPV Vaccine Uptake Among US Rural Populations: A Scoping Review [Post-Print]

Author Post-print. Full text available June 2021.Purpose: Compared to US urban populations, rural residents have a higher incidence of HPV-related cancer and lower HPV vaccine coverage. This study determined what is known about barriers and facilitators to vaccine uptake in US rural settings. Methods: A scoping review was conducted to describe individual, interpersonal, organizational, and community/societal barriers and facilitators to HPV vaccine initiation and completion among US rural populations and to identify gaps in the current research. A systematic search was conducted using PubMed/MEDLINE and CINAHL databases. Results: A total of 1,083 abstracts were reviewed and 13 articles met the inclusion criteria. Major themes at the individual-level included caregiver and vaccine-recipient demographics, other immunizations received, pap test history, awareness/knowledge of cervical cancer, HPV vaccine, or HPV infection, attitudes and motivation to vaccinate, STD diagnosis, sexual behavior, cervical cancer history, contraceptive use, and cancer fatalism. Interpersonal themes focused on provider influence and communication, caregiver and peer influence, and social support for the caregiver. At the organizational-level, themes included health insurance, provider characteristics, school-based interventions, and provider/practice-based interventions. The only community/societal factor examined related to a social marketing campaign. Conclusion: Additional research is needed on interpersonal, organizational, and community/societal factors, as well as an expanded focus on rural males. Future studies should account for rural heterogeneity by expanding the geographic areas studied. Our findings detailing factors found to be associated with HPV vaccine uptake will help inform future clinical, health services, and community research, as well as interventions and policy efforts. Keywords: Disparities; HPV vaccine; HPV vaccine uptake; Human papillomavirus; Rural health. </p

Racial disparity in survival from estrogen and progesterone receptor-positive breast cancer: implications for reducing breast cancer mortality disparities

Introduction Non-Latina black breast cancer patients experience a shorter survival from breast cancer than their non-Latina white counterparts. We compared breast cancer-specific survival for the subset of black and white patients with estrogen and/or progesterone receptor-positive tumors that are generally targeted with endocrine therapy. Methods Using data collected from a population-based cohort of breast cancer patients from Chicago, IL, Kaplan–Meier survival curves and hazard functions were generated and proportional hazards models were estimated to determine the black/white disparity in time to death from breast cancer while adjusting for age at diagnosis, patient characteristics, treatment-related variables, and tumor grade and stage. Results In regression models, hazard of breast cancer death among ER/PR-positive patients was at least 4 times higher for black than for white patients in all models tested. Notably, even after adjusting for stage at diagnosis, tumor grade, and treatment variables (including initiation of systemic adjuvant therapies), the hazard ratio for death from ER/PR-positive breast cancer between black and white women was 4.39 (95% CI 1.76, 10.9, p = 0.001). Conclusions We observed a racial disparity in breast cancer survival for patients diagnosed with ER/PR-positive tumors that did not appear to be due to differences in tumor stage, grade, or therapy initiation in black patients, suggesting that there may be racial differences in the molecular characteristics of hormone receptor-positive tumors, such that ER/PR-positive tumors in black patients may be less responsive to standard treatments

Stigma and Cervical Cancer Prevention: A Scoping Review of the U.S. Literature

Cervical cancer is preventable through HPV vaccination and screening however, uptake falls below national targets. A scoping review was conducted to describe stigmas related to HPV infection and vaccination and cervical cancer and screening in the US. Results were organized into the domains proposed by Stangl and colleagues’ Health Stigma and Discrimination Framework. Common drivers of stigma were fear of social judgement and rejection, self-blame, and shame. Positive facilitators included social norms that provided motivation to receive HPV vaccination and screening. Gender and social norms were notable negative facilitators of stigma. HPV infection and cervical cancer resulted in stigma marking through the belief that both result from incautious behavior—either multiple sexual partners or failing to get screening. Stereotyping and prejudice were stigma practices attributed to HPV infection and cervical cancer through these same behaviors. Stigma experiences related to HPV infection, cervical cancer, and abnormal screening results included altered self-image based on perceived/anticipated stigma, as well as discrimination. This review advances understanding of the multiple dimensions of stigma associated with these outcomes in the US population. Three areas warrant additional consideration. Future studies should 1) assess how stigma dimensions affect uptake of cervical cancer preventions efforts; 2) focus on US women most affected by cervical cancer incidence and mortality to identify potential differences in these dimensions and tailor interventions accordingly; 3) include women from geographic areas of the US with high rates of cervical cancer to adapt interventions that address potential regional variations in resources and need. <br

Association of Genetic Ancestry with Breast Cancer in Ethnically Diverse Women from Chicago

<div><p>Introduction</p><p>Non-Hispanic (nH) Black and Hispanic women are disproportionately affected by early onset disease, later stage, and with more aggressive, higher grade and ER/PR negative breast cancers. The purpose of this analysis was to examine whether genetic ancestry could account for these variation in breast cancer characteristics, once data were stratified by self-reported race/ethnicity and adjusted for potential confounding by social and behavioral factors.</p><p>Methods</p><p>We used a panel of 100 ancestry informative markers (AIMs) to estimate individual genetic ancestry in 656 women from the “Breast Cancer Care in Chicago” study, a multi-ethnic cohort of breast cancer patients to examine the association between individual genetic ancestry and breast cancer characteristics. In addition we examined the association of individual AIMs and breast cancer to identify genes/regions that may potentially play a role in breast cancer disease disparities.</p><p>Results</p><p>As expected, nH Black and Hispanic patients were more likely than nH White patients to be diagnosed at later stages, with higher grade, and with ER/PR negative tumors. Higher European genetic ancestry was protective against later stage at diagnosis (OR 0.7 95%CI: 0.54–0.92) among Hispanic patients, and higher grade (OR 0.73, 95%CI: 0.56–0.95) among nH Black patients. After adjustment for multiple social and behavioral risk factors, the association with later stage remained, while the association with grade was not significant. We also found that the AIM SNP rs10954631 on chromosome 7 was associated with later stage (p = 0.02) and higher grade (p = 0.012) in nH Whites and later stage (p = 0.03) in nH Blacks.</p><p>Conclusion</p><p>Non-European genetic ancestry was associated with later stage at diagnosis in ethnic minorities. The relation between genetic ancestry and stage at diagnosis may be due to genetic factors and/or unmeasured environmental factors that are overrepresented within certain racial/ethnic groups.</p></div

Relations between genetic ancestry and breast cancer characteristics within racial/ethnic subgroups. Genetic ancestry divided into fifths within each subgroup.

+<p>p<0.20,</p><p>*p<0.10,</p><p>**p<0.05,</p><p>***p<0.01.</p><p>OR, odds ratio from logistic regression comparing the highest versus the lowest fifth of the subsample distribution.</p>a<p>Adjusted for health insurance, income, education, disadvantage, affluence, nulliparity, and age at first and last birth.</p><p>Relations between genetic ancestry and breast cancer characteristics within racial/ethnic subgroups. Genetic ancestry divided into fifths within each subgroup.</p

The distribution of European ancestry, West African ancestry, and Native American genetic ancestry stratified on self-reported race/ethnicity.

<p>The distribution of European ancestry, West African ancestry, and Native American genetic ancestry stratified on self-reported race/ethnicity.</p

Descriptive and tumor characteristics of the BCCC sample stratified by self-reported race/ethnicity.

<p>P-values for categorical variables are from χ² tests and from ANOVA for continuous variables for differences according to self-reported race/ethnicity.</p><p>Descriptive and tumor characteristics of the BCCC sample stratified by self-reported race/ethnicity.</p